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Quality of Care in the United States Territories, 1999–2012

Nuti, Sudhakar V. BA*; Wang, Yun PhD†,‡; Masoudi, Frederick A. MD, MSPH§; Nunez-Smith, Marcella MD, MHS∥,¶; Normand, Sharon-Lise T. PhD‡,#; Murugiah, Karthik MD**; Rodríguez-Vilá, Orlando MD, MMS††; Ross, Joseph S. MD, MHS†,∥,‡‡,§§; Krumholz, Harlan M. MD, SM†,**,§§

doi: 10.1097/MLR.0000000000000797
Brief Report

Background: Millions of Americans live in the US territories, but health outcomes and payments among Medicare beneficiaries in these territories are not well characterized.

Methods: Among Fee-for-Service Medicare beneficiaries aged 65 years and older hospitalized between 1999 and 2012 for acute myocardial infarction (AMI), heart failure (HF), and pneumonia, we compared hospitalization rates, patient outcomes, and inpatient payments in the territories and states.

Results: Over 14 years, there were 4,350,813 unique beneficiaries in the territories and 402,902,615 in the states. Hospitalization rates for AMI, HF, and pneumonia declined overall and did not differ significantly. However, 30-day mortality rates were higher in the territories for all 3 conditions: in the most recent time period (2008–2012), the adjusted odds of 30-day mortality were 1.34 [95% confidence interval (CI), 1.21–1.48], 1.24 (95% CI, 1.12–1.37), and 1.85 (95% CI, 1.71–2.00) for AMI, HF, and pneumonia, respectively; adjusted odds of 1-year mortality were also higher. In the most recent study period, inflation-adjusted Medicare in-patient payments, in 2012 dollars, were lower in the territories than the states, at $9234 less (61% lower than states), $4479 less (50% lower), and $4403 less (39% lower) for AMI, HF, and pneumonia hospitalizations, respectively (P<0.001 for all).

Conclusions and Relevance: Among Medicare Fee-for-Service beneficiaries, in 2008–2012 mortality rates were higher, or not significantly different, and hospital reimbursements were lower for patients hospitalized with AMI, HF, and pneumonia in the territories. Improvement of health care and policies in the territories is critical to ensure health equity for all Americans.

*Yale School of Medicine

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT

Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA

§Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO

Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine

Section of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT

#Department of Health Care Policy, Harvard Medical School, Boston, MA

**Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT

††Cardiology Section and the Medical Service, VA Caribbean Healthcare System, San Juan, PR

‡‡Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine

§§Department of Health Policy and Management, Yale School of Public Health, New Haven, CT

S.V.N. and K.M. were also affiliated with the Center for Outcomes Research and Evaluation during the time the work was conducted. This work was funded by the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.

H.M.K. chairs a cardiac scientific advisory board for United Health, is a participant/participant representative of the IBM Watson Health Life Sciences Board, is a member of the Element Science Advisory Board and the Aetna Physician Advisory Board, and is the founder of Hugo, a personal health information platform. J.S.R receives support from the Blue Cross and Blue Shield Association for projects to better understand medical technology, and from the Laura and John Arnold Foundation to support the Collaboration on Research Integrity and Transparency (CRIT) at Yale. J.S.R and H.M.K. are the recipients of research agreements from Medtronic and from Johnson & Johnson (Janssen), through Yale University, to develop methods of clinical trial data sharing and from Medtronic and the Food and Drug Administration, through Yale University, to develop methods for post-market surveillance of medical devices. H.M.K., J.S.R., and S.-L.T.N work under contract to the Centers for Medicare & Medicaid Services to develop and maintain performance measures. F.A.M. has a contract with the American College of Cardiology as the Senior Medical Officer of the National Cardiovascular Data Registries. M.N.-S. is supported by grant U24 MD006938 (Eastern Caribbean Health Outcomes Research Network) from the National Institute on Minority Health and Health Disparities. O.R.-V. is an employee of the Department of Veterans Affairs; the views expressed are his personal views and do not necessarily represent the views of the VA Caribbean Healthcare System, the Department of Veterans Affairs, or the United States Government. Neither the National Institute on Minority Health and Health Disparities nor the Department of Veterans Affairs had a role in study design; in the collection, analysis, and interpretation of data; in writing the report; and in the decision to submit the article for publication. The remaining authors declare no conflict of interest.

Reprints: Harlan M. Krumholz, MD, SM, 1 Church Street, Suite 200, New Haven, CT 06510. E-mail: harlan.krumholz@yale.edu.

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