Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services after an Index Event

Montika Bush; Ross J. Simpson; Anna Kucharska-Newton; Gang Fang; Til Stürmer; M. Alan Brookhart

doi:10.1097/MLR.0000000000000923

Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services after an Index Event

Montika Bush, Ross J. Simpson, Anna Kucharska-Newton, Gang Fang, Til Stürmer, M. Alan Brookhart

Epidemiology

Research output: Contribution to journal › Article › peer-review

3 Scopus citations

Abstract

Background: Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. Methods: Medicare beneficiaries aged 65-95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. Results: At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%-14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%-15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%-52.7%) and 53.4% (95% CI, 53.1%-53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%-17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. Conclusions: In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.

Original language	English
Pages (from-to)	619-625
Number of pages	7
Journal	Medical Care
Volume	56
Issue number	7
DOIs	https://doi.org/10.1097/MLR.0000000000000923
State	Published - 2018

Bibliographical note

Funding Information:
Supported by a National Service Research Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 S000032.

Funding Information:
T.S.: received investigator-initiated research funding and support as Principal Investigator (R01 AG023178; R01 AG056479) from the National In-stitute on Aging (NIA), and as Co-Investigator (R01 CA174453; R01 HL118255, R21-HD080214) from the National Institutes of Health (NIH). He also received salary support as Director of the Comparative Effectiveness Research (CER) Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111), and as Director of the Center for Pharmacoepidemiology and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, Johnson & Johnson, and Novo Nordisk. The remaining authors declare no conflict of interest.

Funding Information:
Supported by a National Service Research Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 S000032. T.S.: received investigator-initiated research funding and support as Principal Investigator (R01 AG023178; R01 AG056479) from the National Institute on Aging (NIA), and as Co-Investigator (R01 CA174453; R01 HL118255, R21-HD080214) from the National Institutes of Health (NIH). He also received salary support as Director of the Comparative Effectiveness Research (CER) Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111), and as Director of the Center for Pharmacoepidemiology and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, Johnson & Johnson, and Novo Nordisk. The remaining authors declare no conflict of interest.

Publisher Copyright:
© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Keywords

Medicare administrative claims data
cardiac rehabilitation
guideline concordant care
post-acute MI health care
survival analysis method comparison

ASJC Scopus subject areas

Public Health, Environmental and Occupational Health

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1097/MLR.0000000000000923

Cite this

@article{fa7fddb9573a40dc80c6ce0cd2852bb9,

title = "Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services after an Index Event",

abstract = "Background: Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. Methods: Medicare beneficiaries aged 65-95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. Results: At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%-14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%-15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%-52.7%) and 53.4% (95% CI, 53.1%-53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%-17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. Conclusions: In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.",

keywords = "Medicare administrative claims data, cardiac rehabilitation, guideline concordant care, post-acute MI health care, survival analysis method comparison",

author = "Montika Bush and Simpson, {Ross J.} and Anna Kucharska-Newton and Gang Fang and Til St{\"u}rmer and Brookhart, {M. Alan}",

note = "Funding Information: Supported by a National Service Research Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 S000032. Funding Information: T.S.: received investigator-initiated research funding and support as Principal Investigator (R01 AG023178; R01 AG056479) from the National In-stitute on Aging (NIA), and as Co-Investigator (R01 CA174453; R01 HL118255, R21-HD080214) from the National Institutes of Health (NIH). He also received salary support as Director of the Comparative Effectiveness Research (CER) Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111), and as Director of the Center for Pharmacoepidemiology and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, Johnson & Johnson, and Novo Nordisk. The remaining authors declare no conflict of interest. Funding Information: Supported by a National Service Research Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 S000032. T.S.: received investigator-initiated research funding and support as Principal Investigator (R01 AG023178; R01 AG056479) from the National Institute on Aging (NIA), and as Co-Investigator (R01 CA174453; R01 HL118255, R21-HD080214) from the National Institutes of Health (NIH). He also received salary support as Director of the Comparative Effectiveness Research (CER) Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111), and as Director of the Center for Pharmacoepidemiology and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, Johnson & Johnson, and Novo Nordisk. The remaining authors declare no conflict of interest. Publisher Copyright: {\textcopyright} 2018 Wolters Kluwer Health, Inc. All rights reserved.",

year = "2018",

doi = "10.1097/MLR.0000000000000923",

language = "English",

volume = "56",

pages = "619--625",

number = "7",

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TY - JOUR

T1 - Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services after an Index Event

AU - Bush, Montika

AU - Simpson, Ross J.

AU - Kucharska-Newton, Anna

AU - Fang, Gang

AU - Stürmer, Til

AU - Brookhart, M. Alan

N1 - Funding Information: Supported by a National Service Research Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 S000032. Funding Information: T.S.: received investigator-initiated research funding and support as Principal Investigator (R01 AG023178; R01 AG056479) from the National In-stitute on Aging (NIA), and as Co-Investigator (R01 CA174453; R01 HL118255, R21-HD080214) from the National Institutes of Health (NIH). He also received salary support as Director of the Comparative Effectiveness Research (CER) Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111), and as Director of the Center for Pharmacoepidemiology and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, Johnson & Johnson, and Novo Nordisk. The remaining authors declare no conflict of interest. Funding Information: Supported by a National Service Research Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 S000032. T.S.: received investigator-initiated research funding and support as Principal Investigator (R01 AG023178; R01 AG056479) from the National Institute on Aging (NIA), and as Co-Investigator (R01 CA174453; R01 HL118255, R21-HD080214) from the National Institutes of Health (NIH). He also received salary support as Director of the Comparative Effectiveness Research (CER) Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111), and as Director of the Center for Pharmacoepidemiology and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, Johnson & Johnson, and Novo Nordisk. The remaining authors declare no conflict of interest. Publisher Copyright: © 2018 Wolters Kluwer Health, Inc. All rights reserved.

PY - 2018

Y1 - 2018

N2 - Background: Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. Methods: Medicare beneficiaries aged 65-95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. Results: At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%-14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%-15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%-52.7%) and 53.4% (95% CI, 53.1%-53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%-17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. Conclusions: In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.

AB - Background: Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. Methods: Medicare beneficiaries aged 65-95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. Results: At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%-14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%-15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%-52.7%) and 53.4% (95% CI, 53.1%-53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%-17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. Conclusions: In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.

KW - Medicare administrative claims data

KW - cardiac rehabilitation

KW - guideline concordant care

KW - post-acute MI health care

KW - survival analysis method comparison

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Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services after an Index Event

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

UN SDGs

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