Lack Of Access To Specialists Associated With Mortality And Preventable Hospitalizations Of Rural Medicare Beneficiaries

Background Frailty is a key determinant of health status and outcomes of health care interventions in older adults that is not readily measured in Medicare data. This study aimed to develop and validate a claims-based frailty index (CFI). Methods We used data from Medicare Current Beneficiary Survey 2006 (development sample: n = 5,593) and 2011 (validation sample: n = 4,424). A CFI was developed using the 2006 claims data to approximate a survey-based frailty index (SFI) calculated from the 2006 survey data as a reference standard. We compared CFI to combined comorbidity index (CCI) in the ability to predict death, disability, recurrent falls, and health care utilization in 2007. As validation, we calculated a CFI using the 2011 claims data to predict these outcomes in 2012. Results The CFI was correlated with SFI (correlation coefficient: 0.60). In the development sample, CFI was similar to CCI in predicting mortality ( C statistic: 0.77 vs. 0.78), but better than CCI for disability, mobility impairment, and recurrent falls (C statistic: 0.62–0.66 vs. 0.56–0.60). Although both indices similarly explained the variation in hospital days, CFI outperformed CCI in explaining the variation in skilled nursing facility days. Adding CFI to age, sex, and CCI improved prediction. In the validation sample, CFI and CCI performed similarly for mortality (C statistic: 0.71 vs. 0.72). Other results were comparable to those from the development sample. Conclusion A novel frailty index can measure the risk for adverse health outcomes that is not otherwise quantified using demographic characteristics and traditional comorbidity measures in Medicare data.

Question During 2013-2016, were there differences in the prevalence of obesity and severe obesity by demographics and urbanization level among US adults? Findings In this cross-sectional analysis that included 10 792 adults aged 20 years or older, differences were found in the prevalence of obesity and severe obesity by age group, race and Hispanic origin, and education level. The prevalence of obesity was significantly greater among women living in nonmetropolitan statistical areas (non-MSAs; 47.2%) compared with women living in large MSAs (38.1%), and the prevalence of severe obesity in non-MSAs was higher than in large MSAs among men (9.9% vs 4.1%, respectively) and women (13.5% vs 8.1%, respectively). Meaning Differences in age group, race and Hispanic origin, education level, or smoking status were not related to the differences in the prevalence of obesity and severe obesity by urbanization level. Importance Differences in obesity by sex, age group, race and Hispanic origin among US adults have been reported, but differences by urbanization level have been less studied. Objectives To provide estimates of obesity by demographic characteristics and urbanization level and to examine trends in obesity prevalence by urbanization level. Design, Setting, and Participants Serial cross-sectional analysis of measured height and weight among adults aged 20 years or older in the 2001-2016 National Health and Nutrition Examination Survey, a nationally representative survey of the civilian, noninstitutionalized US population. Exposures Sex, age group, race and Hispanic origin, education level, smoking status, and urbanization level as assessed by metropolitan statistical areas (MSAs; large: ≥1 million population). Main Outcomes and Measures Prevalence of obesity (body mass index [BMI] ≥30) and severe obesity (BMI ≥40) by subgroups in 2013-2016 and trends by urbanization level between 2001-2004 and 2013-2016. Results Complete data on weight, height, and urbanization level were available for 10 792 adults (mean age, 48 years; 51% female [weighted]). During 2013-2016, 38.9% (95% CI, 37.0% to 40.7%) of US adults had obesity and 7.6% (95% CI, 6.8% to 8.6%) had severe obesity. Men living in medium or small MSAs had a higher age-adjusted prevalence of obesity compared with men living in large MSAs (42.4% vs 31.8%, respectively; adjusted difference, 9.8 percentage points [95% CI, 5.1 to 14.5 percentage points]); however, the age-adjusted prevalence among men living in non-MSAs was not significantly different compared with men living in large MSAs (38.9% vs 31.8%, respectively; adjusted difference, 4.8 percentage points [95% CI, −2.9 to 12.6 percentage points]). The age-adjusted prevalence of obesity was higher among women living in medium or small MSAs compared with women living in large MSAs (42.5% vs 38.1%, respectively; adjusted difference, 4.3 percentage points [95% CI, 0.2 to 8.5 percentage points]) and among women living in non-MSAs compared with women living in large MSAs (47.2% vs 38.1%, respectively; adjusted difference, 4.7 percentage points [95% CI, 0.2 to 9.3 percentage points]). Similar patterns were seen for severe obesity except that the difference between men living in large MSAs compared with non-MSAs was significant. The age-adjusted prevalence of obesity and severe obesity also varied significantly by age group, race and Hispanic origin, and education level, and these patterns of variation were often different by sex. Between 2001-2004 and 2013-2016, the age-adjusted prevalence of obesity and severe obesity significantly increased among all adults at all urbanization levels. Conclusions and Relevance In this nationally representative survey of adults in the United States, the age-adjusted prevalence of obesity and severe obesity in 2013-2016 varied by level of urbanization, with significantly greater prevalence of obesity and severe obesity among adults living in nonmetropolitan statistical areas compared with adults living in large metropolitan statistical areas. This national survey study uses National Health and Nutrition Examination Survey data to examine trends in obesity and severe obesity among adults aged 20 years or older by age, sex, race, ethnicity, education level and urbanization level between 2001 and 2016.