Description
- Abstract:
- Introduction: Falls among older adults are common, costly, and preventable, yet uptake of screening and multifactorial interventions is limited. This dissertation (1) develops and validates a Medicare claims-based fall risk prediction model, (2) evaluates whether participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) increases delivery of fall-related preventive services, and (3) tests whether MSSP participation reduces fall-related healthcare encounters. Methods: We assembled a 5% random sample of community-dwelling fee-for-service Medicare beneficiaries aged ≥65 years from 2011–2018. Chapter 1 fit logistic models with repeated LASSO selection to predict next-year falls identified by three fall identification algorithms (ECO, AUR, ECDC), using prior-year demographics, chronic conditions, assistive devices, and healthcare utilization. Chapters 2 and 3 estimated the effects of attribution to the MSSP using the Callaway-Sant’Anna staggered difference-in-differences approach with doubly robust estimation, “not-yet-treated” controls, and beneficiary-clustered standard errors. We assessed the impact of the MSSP on fall risk screening, osteoporosis screening, and fall-related healthcare encounters across the inpatient, outpatient, ED, SNF, HHA, and observation settings. Results: The cohort included 10,676,150 beneficiaries (mean age 74.7; 56% female). Prediction models achieved strong discrimination (AUCs: ECO 0.776; AUR 0.744; ECDC 0.706) with good calibration. Experiencing a fall in the prior year was the strongest predictor. MSSP attribution increased fall risk screening by 3.42 percentage points (≈96% over the ACO pre-contract mean) with no overall change in osteoporosis screening. MSSP attribution was associated with higher fall-related inpatient (ATT≈0.0047) and SNF (ATT≈0.0016) admissions, with no meaningful association for ER, outpatient, observation, or HHA encounters. Increases were concentrated among females, beneficiaries aged 65-84, and those with the highest baseline fall risk, and were larger for beneficiaries in ACOs with low pre-MSSP screening rates. Conclusions: Our Medicare claims-based models can reliably stratify fall risk at population scale. Within the MSSP, incentives effectively raised fall risk screening but did not translate into short-term reductions in fall-related healthcare utilization. Aligning incentives with outcome measures (e.g., fall-related hospitalizations) and supporting delivery of multifactorial risk-reduction interventions may be necessary to convert greater fall risk screening into fewer fall-related injuries.
- Notes:
- Thesis (Ph. D.)--Brown University, 2025
Citation
Baird, Courtney Elizabeth,
"The Impact of the Medicare Shared Savings Program on Fall Prevention Services and Falls Among Community-Dwelling Older Adults"
(2025).
Public Health Theses and Dissertations.
Brown Digital Repository. Brown University Library.
https://repository.library.brown.edu/studio/item/bdr:cxred8dk/
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Public Health Theses and Dissertations
Theses and Dissertations for the Public Health department....