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Atkinson MK, Saghafian S. Who should see the patient? on deviations from preferred patient-provider assignments in hospitals. Health Care Manag Sci 2023:10.1007/s10729-022-09628-x. [PMID: 37103616 DOI: 10.1007/s10729-022-09628-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 12/22/2022] [Indexed: 04/28/2023]
Abstract
In various organizations including hospitals, individuals are not forced to follow specific assignments, and thus, deviations from preferred task assignments are common. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from preferred assignments as needed. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children's hospital), and generate insights into whether and when hospital administrators should disallow such flexibility. We do so by identifying 73 top medical diagnoses and using detailed patient-level electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a survey of medical experts and utilized it to identify the preferred provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from preferred provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by 30-day readmissions and adverse events), and cost (measured by total charges). We find that deviating from preferred assignments is beneficial for task types (patients' diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we observe that deviations are either detrimental or yield no tangible benefits, and thus, hospitals should try to eliminate them (e.g., by developing and enforcing assignment guidelines). To understand the causal mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a "no free lunch" theorem: while for some task types, deviations are beneficial for certain performance outcomes, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators, we also consider counterfactual scenarios corresponding to imposing the preferred assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing the preferred assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.
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Affiliation(s)
- Mariam K Atkinson
- Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, Boston, MA, 02115, USA
| | - Soroush Saghafian
- Harvard Kennedy School, Harvard University, Cambridge, MA, 02138, USA.
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2
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Horvat O, Halgato T, Stojšić-Milosavljević A, Paut Kusturica M, Kovačević Z, Bukumiric D, Tomas A. Identification of patient-related, healthcare-related and knowledge-related factors associated with inadequate blood pressure control in outpatients: a cross-sectional study in Serbia. BMJ Open 2022; 12:e064306. [PMID: 36323484 PMCID: PMC9639095 DOI: 10.1136/bmjopen-2022-064306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To determine rate of blood pressure (BP) control and to analyse patient-related, medication-related and healthcare system-related factors associated with poor BP control in outpatients with hypertension (HT). DESIGN Cross-sectional study. SETTING Two study sites with different levels of healthcare (primary healthcare (PHC) and secondary level of healthcare (SHC)) in Vojvodina, Northern Serbia. PARTICIPANTS A total of 581 patients (response rate 96.8%) visiting their primary care physician between July 2019 and June 2020 filled out a pretested semistructured questionnaire and had a BP reading during their regular appointments. PRIMARY AND SECONDARY OUTCOME MEASURES Data on demographics, medication, BP control (target systolic BP≤140 mm Hg and∕ or diastolic BP≤90 mm Hg) and knowledge on HT was collected. Based on the median of knowledge score, patients were classified as having poor, average and adequate knowledge. RESULTS Majority of the respondents (74.9%) had poorly controlled BP and had HT longer than 10 years. Larger number of patients at PHC site was managed with monotherapy while at the SHC majority received three or more antihypertensive drugs. Respondents from SHC showed a significantly lower knowledge score (9, 2-15) compared with the respondents from PHC (11, 4-15, p=0.001). The share of respondents with adequate knowledge on HT was significantly higher in the group with good BP control (26% and 9.2%, respectively). In a multivariate regression analysis, factors associated with poor BP control were knowledge (B=-1.091; p<0001), number of drugs (B=0536; p<0001) and complications (B=0898; p=0004). CONCLUSIONS Poor BP control is common in outpatients in Serbia, irrespective of the availability of different levels of healthcare. Patients with poor knowledge on HT, with complications of HT and those with multiple antihypertensive drugs, were at particular risk of poor BP control. Our study could serve as a basis for targeted interventions to improve HT management.
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Affiliation(s)
- Olga Horvat
- Department of Pharmacology and Toxicology, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
| | - Tinde Halgato
- Health Center "Dr Janoš Hadži" Bačka Topola, Novi Sad, Serbia
| | - Anastazija Stojšić-Milosavljević
- Department of Pharmacology and Toxicology, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
- Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia, University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
| | - Milica Paut Kusturica
- Department of Pharmacology and Toxicology, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
| | - Zorana Kovačević
- Department of Veterinary Medicine, Faculty of Agriculture, University of Novi Sad, Novi Sad, Serbia
| | - Dragica Bukumiric
- Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia, University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
| | - Ana Tomas
- Department of Pharmacology and Toxicology, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
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Yang S, Zhou M, Liao J, Ding X, Hu N, Kuang L. Association between Primary Care Utilization and Emergency Room or Hospital Inpatient Services Utilization among the Middle-Aged and Elderly in a Self-Referral System: Evidence from the China Health and Retirement Longitudinal Study 2011-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912979. [PMID: 36232279 PMCID: PMC9564952 DOI: 10.3390/ijerph191912979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 05/09/2023]
Abstract
With rapid economic growth and aging, hospital inpatient and emergency services utilization has grown rapidly, and has emphasized an urgent requirement to adjust and optimize the structure of health service utilization. Studies have shown that primary care is an effective way to reduce inpatient and emergency room (ER) service utilization. This study aims to examine whether middle-aged and elderly individuals who selected primary care outpatient services in the last month had less ER and hospital inpatient service utilization than those who selected hospitals outpatient services via the self-referral system. Data were obtained from four waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS). We pooled respondents who had outpatient visits and were aged 45 years and above. We used logistic regressions to explore the association between types of outpatient and ER visits or hospitalization, and then used zero-truncated negative binomial regression to examine the impact of outpatient visit types on the number of hospitalizations and the length of hospitalization days. A trend test was used to explore the trend of outpatient visit types and the ER or hospital inpatient services utilization with the increase in outpatient visits. Among the 7544 respondents in CHARLS, those with primary care outpatient visits were less likely to have ER visits (adjusted OR = 0.141, 95% CI: 0.101-0.194), hospitalization (adjusted OR = 0.623, 95% CI: 0.546-0.711), and had fewer hospitalization days (adjusted IRR = 0.886, 95% CI: 0.81-0.969). The trend test showed that an increase in the number of total outpatient visits was associated with a lower hospitalizations (p = 0.006), but a higher odds of ER visits (p = 0.023). Our findings suggest that policy makers need to adopt systematic policies that focus on restructuring and balancing the structure of resources and service utilization in the three-tier healthcare system.
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Affiliation(s)
- Siman Yang
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
| | - Mengping Zhou
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, 17177 Stockholm, Sweden
| | - Jingyi Liao
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
| | - Xinxin Ding
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
| | - Nan Hu
- Department of Biostatistics, FIU Robert Stempel College of Public Health and Social Work, Miami, FL 33199, USA
- Department of Family and Preventive Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Correspondence: (N.H.); (L.K.)
| | - Li Kuang
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
- Correspondence: (N.H.); (L.K.)
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Sakowski JA, Song PH. The Extent Hospital Organizational Factors Influence Inpatient Care Delivery: A Case Study Looking at Knee and Hip Replacement Surgery. Health Serv Insights 2022; 15:11786329221109303. [PMID: 35813564 PMCID: PMC9260580 DOI: 10.1177/11786329221109303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
There is a body of Implementation and Dissemination research describing the importance of "context"-the characteristics describing the setting where a process or innovation occurs-when evaluating delivery, outcomes and cost of health services. These contextual factors, which can occur at the system, organization, or provider level, may either facilitate or erect barriers to the utilization of evidence-based practices and the outcomes achieved. This paper examines the influence of organizational structure and operating environment characteristics of where inpatient health care is delivered, controlling for patient and provider characteristics, on health services delivery and outcomes achieved. We used inpatient cost-of-care to represent the bundle of services provided to patients receiving primary knee and hip replacement procedures. Data includes patient level data from discharge records for 62 140 knee replacements and 42 392 hip replacements from the 2015 AHRQ Healthcare Cost and Utilization Project State Inpatient Discharge database and hospital characteristics from the 2015 American Hospital Association survey. Multi-level linear estimation models controlling for patient and payer characteristics were employed to assess the impact of specific organizational and operating environment factors. We found that although patient and payer characteristics significantly impacted the inpatient cost of care, there is significant variation between hospitals and among physicians within a hospital beyond what can be explained by patient, payer and local price effect characteristics. Organizational and physician characteristics that had the most significant impact on cost of care included the volume of services provided, urban location, and for-profit ownership. These factors can inform future policy and program design and evaluation.
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Affiliation(s)
- Julie Ann Sakowski
- Associate Professor of Health Care
Management, Appalachian State University, Boone, NC, USA
| | - Paula H Song
- Richard M. Bracken Professor and Chair,
Department of Health Administration, Virginia Commonwealth University, Richmond, VA,
USA
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Stephenson AL, Sullivan EE, Hoffman AR. Primary care physician leaders’ perspectives on opportunities and challenges in healthcare leadership: a qualitative study. BMJ LEADER 2022; 7:28-32. [PMID: 37013883 DOI: 10.1136/leader-2022-000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/11/2022] [Indexed: 11/04/2022]
Abstract
BackgroundThere is an increasing demand for physicians to assume leadership roles in hospitals, health systems, clinics and community settings, given the documented positive outcomes of physician leadership and the systemic shifts towards value-based care. The purpose of this study is to examine how primary care physicians (PCPs) perceive and experience leadership roles. Better understanding how PCPs perceive leadership affords the opportunity to influence changes in primary care training in order to more adequately prepare and support physicians for current and future leadership roles.MethodsThis study used qualitative interviews, conducted from January to May 2020. The participants included 27 PCPs, recruited via the Harvard Medical School Center for Primary Care newsletters and through snowball sampling techniques. Participants worked in 22 different organisations, including major urban health systems, corporate pharmacy, public health departments and academic medical centres.ResultsUsing content analysis and qualitative comparative analysis methodologies, three major themes and seven subthemes emerged from the interviews. The primary themes included the advantage PCPs have in leadership positions, the lack of leadership training and development, and disincentives to leading.ConclusionsWhile PCPs perceive primary care to hold a unique position that would incline them towards leadership, the lack of training and other noted disincentives are barriers to leadership. Therefore, health organisations should seek to invest in, better train and promote PCPs in leadership.
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Affiliation(s)
- Amber L Stephenson
- David D. Reh School of Business, Clarkson University, Schenectady, New York, USA
| | - Erin E Sullivan
- Sawyer School of Business, Suffolk University, Boston, Massachusetts, USA
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron R Hoffman
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
- Atrius Health, Boston, Massachusetts, USA
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Resource Use Among Diabetes Patients Who Mainly Visit Primary Care Physicians Versus Medical Specialists: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:283-289. [PMID: 33796983 PMCID: PMC8811114 DOI: 10.1007/s11606-021-06710-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND It is not uncommon for medical specialists to predominantly care for patients with certain chronic conditions rather than primary care physicians (PCPs), yet the resource implications from such patterns of care are not well understood. OBJECTIVE To assess resource use of diabetes patients who predominantly visit a PCP versus a medical specialist. DESIGN Retrospective cohort study of diabetes patients aging into the traditional Medicare program. Patients were attributed to a PCP or medical specialist annually based on a preponderance of ambulatory care visits and categorized according to whether attribution changed year to year. Propensity score weighting was used to balance baseline demographic characteristics, diabetes complications, and underlying health conditions between patients attributed to PCPs and to medical specialists. Spending and utilization were measured up to 3 patient-years. SUBJECTS A total of 141,558 patient-years. MAIN MEASURES Total visits, unique physicians, hospital admissions, emergency department visits, procedures, imaging, and tests. KEY RESULTS Each year, roughly 70% of patients maintained attribution to a PCP and 15% to a medical specialist relative to the previous year. After propensity weighting, patients continuously attributed to a PCP versus medical specialist from 1 year to the next had lower average total payer payments ($10,326 [SD $57,386] versus $14,971 [SD $74,112], P<0.0001) and lower total patient out-of-pocket payments ($1,707 [SD $6,020] versus $2,443 [SD $7,984], P<0.0001). Rates of hospitalization, emergency department visits, procedures, imaging, and tests were lower among patients attributed to PCPs as well. CONCLUSIONS Older adults with diabetes who receive more of their ambulatory care from a PCP instead of a medical specialist show evidence of lower resource use.
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Vader K, Ashcroft R, Bath B, Décary S, Deslauriers S, Desmeules F, Donnelly C, Perreault K, Richardson J, Wojkowski S, Miller J. Physiotherapy Practice in Primary Health Care: A Survey of Physiotherapists in Team-Based Primary Care Organizations in Ontario. Physiother Can 2022; 74:86-94. [PMID: 35185252 PMCID: PMC8816364 DOI: 10.3138/ptc-2020-0060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 01/03/2023]
Abstract
Purpose: This study describes (1) the current state of physiotherapy practice in team-based primary care organizations in Ontario, (2) the perceived barriers to and facilitators of providing physiotherapy services, and (3) recommendations for improving how these services are provided. Method: This was a cross-sectional, web-based survey. We analyzed the responses using descriptive statistics and summative content analysis. Results: A total of 66 responses were received, and 61 were included in the final analysis. The respondents reported that most of their practice was directed toward musculoskeletal care, followed by multi-system, neurological, and cardiorespiratory conditions, and that most of their direct patient care was focused on in-person, one-to-one assessment or follow-up. Frequently identified barriers to providing physiotherapy services included a lack of space, resources, time, and equipment. The most common facilitators were support from management, recognition and support from other health care providers about the value and role of physiotherapists, and appropriate referrals from other health care providers. The most common recommendation was to increase the physiotherapist-to-patient ratio at primary care sites. Conclusions: Physiotherapists provide care to diverse populations in team-based primary care, which is influenced by specific barriers and facilitators. Our results highlight opportunities for physiotherapists in this context, such as increasing the provision of first-contact care and group-based interventions.
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Affiliation(s)
- Kyle Vader
- School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada, Chronic Pain Clinic, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Rachelle Ashcroft
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Brenna Bath
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Simon Décary
- Research Centre in Primary Care in Health and Social Services, Université Laval, Quebec City, Quebec, Canada
| | - Simon Deslauriers
- Department of Rehabilitation, Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Université Laval, Quebec City, Quebec, Canada
| | - François Desmeules
- School of Rehabilitation, Université de Montréal, Montreal, Quebec, Canada
| | - Catherine Donnelly
- School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
| | - Kadija Perreault
- Department of Rehabilitation, Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Université Laval, Quebec City, Quebec, Canada
| | - Julie Richardson
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Wojkowski
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Jordan Miller
- School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
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Ganguli I, McGlave C, Rosenthal MB. National Trends and Outcomes Associated With Presence and Type of Usual Clinician Among Older Adults With Multimorbidity. JAMA Netw Open 2021; 4:e2134798. [PMID: 34846529 PMCID: PMC8634053 DOI: 10.1001/jamanetworkopen.2021.34798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults. OBJECTIVE To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending. DESIGN, SETTING, AND PARTICIPANTS This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021. MAIN OUTCOMES AND MEASURES Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics. RESULTS A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1). CONCLUSIONS AND RELEVANCE In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire McGlave
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Huang J, Wang L, Liu S, Zhang T, Liu C, Zhang Y. The Path Analysis of Family Doctor's Gatekeeper Role in Shanghai, China: A Structural Equation Modeling (SEM) Approach. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:469580211009667. [PMID: 33870745 PMCID: PMC8058791 DOI: 10.1177/00469580211009667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Studies globally have provided substantial evidence that PHC could conduct doctor-visiting behaviors, control medical expense, and improve population health. This study aimed to map how family doctor (FD) in Shanghai achieved gate-keeper goals including health management, medical expense control, and conducting ordered doctor-visiting behavior. A total of 2754 and 1995 valid questionnaires were collected in 2013 and 2016 respectively in Shanghai. The data were analyzed using structural equation modeling (SEM). Invariance analysis was also performed for 2 waves of data. We found that the coefficient of cognition on health management (β5 = 0.26, P < .05) was larger than that of signing with FD (β4 = 0.06, P < .05). SEM model also showed that first-contact at community health service center (CHSC) had a positive effect on health management (β6 = 0.30, P < .05), and the latter also affected health management results positively (β8 = 0.39, P < .05), suggesting that the path for FD was through first-contact and health management. Besides, the gate-keeper role of medical expense control was significant through the first-contact (β10 = −0.12, P < .05) mediation rather than health management (β9 = 0.03, P > .05). The model fit was acceptable (RMSEA = 0.033). A “cognition-behavior-outcomes (health and medical expense)” path of FD’s gate-keeper role was found. It is necessary to consolidate FD contracted services rather than reimbursement discount the latter of which is proved to be unsustainable.
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Affiliation(s)
- Jiaoling Huang
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Luan Wang
- Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Shanshan Liu
- Pudong Institute for Health Development, Shanghai, China
| | - Tao Zhang
- Jinyang Community Health Service Center of Pudong New Area, Shanghai, China
| | - Chengjun Liu
- Fudan University, Shanghai, China.,Eye and Dental Diseases Prevention & Treatment of Pudong New Area, Shanghai, China
| | - Yimin Zhang
- Pudong Institute for Health Development, Shanghai, China
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Farias AJ, Toledo G, Ochoa CY, Hamilton AS. Racial/Ethnic Disparities in Patient Experiences With Health Care in Association With Earlier Stage at Colorectal Cancer Diagnosis: Findings From the SEER-CAHPS Data. Med Care 2021; 59:295-303. [PMID: 33528232 DOI: 10.1097/mlr.0000000000001514] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Racial/ethnic minorities are more likely to be diagnosed at a later stage of colorectal cancer (CRC). Therefore, our objective was to identify whether racial/ethnic differences in patient experiences (PE) with health care are associated with stage at CRC diagnosis. METHODS The authors used the National Cancer Institute Surveillance, Epidemiology and End Results registry data linked with the Consumer Assessment of Healthcare Providers and Systems to conduct a retrospective cohort analysis. They examined composite measures from surveys to assess 3 domains: patient-centeredness, timeliness, and realized access. Multivariable logistic regression was used to determine the association between PE with care and earlier stage at diagnosis. RESULTS Of the 9211 patients, 31.1% non-Hispanic White, 27.2% non-Hispanic Black (NHB), 32.3% Hispanic, and 36.4% Asian were diagnosed with early stage cancer. Compared with non-Hispanic White patients, for the timeliness domain, Hispanic [β=-2.82; 95% confidence interval (CI), -5.42 to -0.39] and Asian (β=-6.65; 95% CI, -9.44 to -3.87) patients had significant lower adjusted mean score for getting care quickly. For the realized access domain, Asian (β=-5.78; 95% CI, -8.51 to -3.05) and NHB patients (β=-3.18; 95% CI, -5.50 to -0.87) had significantly lower adjusted mean score for getting needed prescription drugs compared with non-Hispanic White patients. Among NHB patients, a 5-Unit increase in getting needed care quickly was associated with higher odds of earlier CRC stage at diagnosis (odds ratio, 1.06; 95% CI, 1.01-1.10). CONCLUSION There are racial/ethnic disparities in PE with timeliness and realized access to care preceding a CRC diagnosis. Among NHB patients, poor experiences with timeliness and realized access of care may be associated with later stage at diagnosis.
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Affiliation(s)
- Albert J Farias
- Department of Preventive Medicine
- Gehr Family Center for Health System Science, Keck School of Medicine of the University of Southern California, Los Angeles, CA
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Vaughan L, Bardsley M, Bell D, Davies M, Goddard A, Imison C, Melnychuk M, Morris S, Rafferty AM. Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.
Objective
To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.
Methods
The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.
Results
In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.
Limitations
Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.
Conclusions
The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.
Future work
The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.
Study registration
This study is registered as Integrated Research Application System project ID 191393.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
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12
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Miskulin D. Characterizing Comorbidity in Dialysis Patients: Principles of Measurement and Applications in Risk Adjustment and Patient Care. Perit Dial Int 2020. [DOI: 10.1177/089686080502500403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Comorbid conditions are highly prevalent in dialysis patients and are significant predictors of mortality and other adverse outcomes. Accordingly, it is important to account for differences in comorbid illness burden among groups of dialysis patients being compared. At present, there is no consensus on what conditions matter, how each should be defined, and what weights each carries when defining an individual's risk or case-mix severity. A number of comorbidity instruments, generic or disease specific, have been employed in dialysis populations. They differ by the representation and definition of conditions as well as instrument scoring. No instrument has been found to be superior to another in terms of predictive accuracy for mortality, and accuracy across the board is low. Further studies are needed to determine whether improvements would be found with the use of more specifically defined items and through assignment of item weights based on relationships for outcomes specifically in a dialysis population. The roles of other factors in risk prediction, such as markers of nutritional status, inflammation, or other physiological parameters, relative to comorbid conditions also need to be defined. Outcomes other than mortality are likely to identify different factors and/or different relationships than those noted for mortality, which also require study. Comorbidity is important for risk adjusting comparative analyses in nonrandomized trials and quality of care assessments and may, in future, influence payment for dialysis services. Efforts to improve the management of comorbid illnesses are needed. Comorbid conditions must be documented accurately and uniformly in all dialysis patients to enable these applications.
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Affiliation(s)
- Dana Miskulin
- Division of Nephrology, New England Medical Center, Boston, Massachusetts, USA
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13
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Farias AJ, Ochoa CY, Toledo G, Bang SI, Hamilton AS, Du XL. Racial/ethnic differences in patient experiences with health care in association with earlier stage at breast cancer diagnosis: findings from the SEER-CAHPS data. Cancer Causes Control 2020; 31:13-23. [PMID: 31797123 PMCID: PMC7443934 DOI: 10.1007/s10552-019-01254-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/25/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Black women are more likely to be diagnosed with later stage breast cancer compared to white women due to biological or access to care factors. Therefore, our objective was to identify whether racial/ethnic differences in patient experiences with healthcare are associated with stage at diagnosis. METHODS We used the SEER registry data linked with patient surveys from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) completed prior to the diagnosis date. We examined responses about various aspects of their care such as the ability to get needed care, and to get care quickly. We used multivariable linear regression to examine racial/ethnic differences in patient experiences, and a multivariable ordinal logistic regression to determine the association between patient experiences and earlier stage at diagnosis. RESULTS Of the 10,144 patients, 80.7% were non-Hispanic white, 7.6% black, 7.1% Hispanic, and 4.6% Asian. After controlling for potential confounders, black patients had significantly lower mean scores for getting care quickly (β = - 2.78), getting needed care (β = - 2.26), getting needed prescription drugs (β = - 3.83), and lower ratings of their health care (β = - 2.33) compared to white patients. More importantly, we found that black patients who reported a 1-unit increase in rating of their experiences with customer service (OR 1.04, 95% CI 1.01-1.06) and the ability to get care quickly (OR 1.03, 1.01-1.05) had higher odds of earlier stage breast cancer. CONCLUSION Racial/ethnic minorities reported poorer patient experiences with care preceding a diagnosis of breast cancer. Better ratings among black patients were associated with earlier stage at diagnosis.
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Affiliation(s)
- Albert J Farias
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, USA.
- Gehr Family Center for Health System Science, Keck School of Medicine of the University of Southern California, Los Angeles, USA.
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, 1200 N. Soto St., Suite 318B, Los Angeles, CA, 90032, USA.
| | - Carol Y Ochoa
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Gabriela Toledo
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Soo-In Bang
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Xianglin L Du
- Department of Epidemiology, Human Genetics and Environmental Science, School of Public Health, University of Texas Health Science Center At Houston, Houston, USA
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14
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Mohan D, Wallace DJ, Kerti SJ, Angus DC, Rosengart MR, Barnato AE, Yealy DM, Fischhoff B, Chang CC, Kahn JM. Association of Practitioner Interfacility Triage Performance With Outcomes for Severely Injured Patients With Fee-for-Service Medicare Insurance. JAMA Surg 2019; 154:e193944. [PMID: 31642889 PMCID: PMC6813581 DOI: 10.1001/jamasurg.2019.3944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/29/2019] [Indexed: 12/16/2022]
Abstract
Importance Despite evidence that treatment of severely injured patients at trauma centers is associated with reduced mortality, nearly half of all such patients are treated at nontrauma centers (undertriaged). Little is known about whether interfacility undertriage occurs because of practitioner decision-making or institutional and regional factors. Objectives To assess the associations between variation in triage practitioners at nontrauma centers and between practitioner-level variation and patient outcomes after injury. Design, Setting, and Participants This retrospective cohort study used Medicare claims data from severely injured patients presenting to nontrauma centers and the practitioners who evaluated them in the emergency department from January 1, 2010, to October 15, 2015. Data analysis was performed from January 15, 2018, to March 21, 2019. Main Outcomes and Measures Proportion of variation in undertriage associated with practitioners, practitioner rates of undertriage, practitioner characteristics associated with undertriage, and 30-day case-fatality rate. Results A total of 124 008 severely injured patients (mean [SD] age, 81 [8.4] years; 67 253 [54.2%] female) and the 25 376 practitioners (5564 [21.9%] female) who evaluated the patients in the emergency department of nontrauma centers were included in the study. Undertriage occurred among 85 403 patients (68.9%), with 40.6% of total variation associated with practitioners, 37.8% with hospitals, and 6.7% with regions. Compared with physicians with National Provider Identification (NPI) enumeration before 2007, those with an NPI enumerated between 2007 and 2010 had an undertriage risk ratio (RR) of 0.98 (95% CI, 0.97-0.99), and those with an NPI enumerated after 2010 had an undertriage RR of 0.96 (95% CI, 0.94-0.99). Hospitals with neurosurgeons had an undertriage RR of 1.51 (95% CI, 1.45-1.57) compared with those that did not; hospitals with spine surgeons had an undertriage RR of 1.10 (95% CI, 1.06-1.13); hospitals with general surgeons had an undertriage RR of 1.13 (95% CI, 1.09-1.17). Compared with practitioners who undertriaged 25% or less of patients, a statistically significant increase was found in the odds of death for patients treated by practitioners with a triage rate of less than 25% to 50% (odds ratio [OR], 1.08; 95% CI, 1.05-1.20) and less than 50% to 75% undertriage (OR, 1.12; 95% CI, 1.09-1.26) but not undertriage at greater than 75% (OR, 1.03, 95% CI, 1.00-1.18). In sensitivity analyses to adjust for unmeasured confounding, the association between triage practices and the case fatality rate became monotonic; compared with patients treated by practitioners with an undertriage rate of 25% or less, the odds of case fatality were 1.13 (95% CI, 1.05-1.21; P = .001) among patients treated by practitioners with undertriage rates less than 25% to 50%, 1.22 (95% CI, 1.13-1.32; P < .001) for patients treated by practitioners with undertriage rates less than 50% to 75%, and 1.20 (95% CI, 1.10-1.30; P < .001) for patients treated by practitioners with undertriage rates greater than 75%. Conclusions and Relevance The findings suggest that individual practitioner practices are an important source of variation in triage and represent a potential locus of intervention to reduce preventable deaths after injury.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David J. Wallace
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samantha J. Kerti
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amber E. Barnato
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Environmental Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Chung-Chou Chang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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15
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Hamandi B, Law N, Alghamdi A, Husain S, Papadimitropoulos EA. Clinical and economic burden of infections in hospitalized solid organ transplant recipients compared with the general population in Canada - a retrospective cohort study. Transpl Int 2019; 32:1095-1105. [PMID: 31144787 DOI: 10.1111/tri.13467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/05/2019] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
Abstract
Infections continue to be a major cause of post-transplant morbidity and mortality, requiring increased health services utilization. Estimates on the magnitude of this impact are relatively unknown. Using national administrative databases, we compared mortality, acute care health services utilization, and costs in solid organ transplant (SOT) recipients to nontransplant patients using a retrospective cohort of hospitalizations in Canada (excluding Manitoba/Quebec) between April-2009 and March-2014, with a diagnosis of pneumonia, urinary tract infection (UTI), or sepsis. Costs were analyzed using multivariable linear regression. We examined 816 324 admissions in total: 408 352 pneumonia; 328 066 UTI's; and 128 275 sepsis. Unadjusted mean costs were greater in SOT compared to non-SOT patients with pneumonia [(C$14 923 ± C$29 147) vs. (C$11 274 ± C$18 284)] and sepsis [(C$23 434 ± C$39 685) vs. (C$20 849 ± C$36 257)]. Mortality (7.6% vs. 12.5%; P < 0.001), long-term care transfer (5.3% vs. 16.5%; P < 0.001), and mean length of stay (11.0 ± 17.7 days vs. 13.1 ± 24.9 days; P < 0.001) were lower in SOT. More SOT patients could be discharged home (63.2% vs. 44.3%; P < 0.001), but required more specialized care (23.5% vs. 16.1%; P < 0.001). Adjusting for age and comorbidities, hospitalization costs for SOT patients were 10% (95% CI: 8-12%) lower compared to non-SOT patients. Increased absolute hospitalization costs for these infections are tempered by lower adjusted costs and favorable clinical outcomes.
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Affiliation(s)
- Bassem Hamandi
- Department of Pharmacy, University Health Network, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Nancy Law
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Ali Alghamdi
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Emmanuel A Papadimitropoulos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Eli Lilly & Company, Toronto, ON, Canada
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16
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Gelinne A, Thakrar R, Tranmer BI, Durham SR, Jewell RP, Penar PL, Lollis SS. Differential Patterns of Referral to Neurosurgery: A Comparison of Allopathic Physicians, Osteopathic Physicians, Nurse Practitioners, Physician Assistants, and Chiropractors. World Neurosurg 2019; 126:e564-e569. [PMID: 30831280 DOI: 10.1016/j.wneu.2019.02.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Rising cost and limited resources remain major challenges to U.S. health care and neurosurgery in particular. To ensure an efficient and cost-effective health care system, it is important that referrals to neurosurgery clinics are appropriate, and that referred patients have a reasonably high probability of requiring surgical intervention or, at a minimum, ongoing neurosurgical follow-up. This retrospective study tests the null hypothesis that the probability of a referred patient requiring surgery is independent of referring provider credentials and referring service specialty. METHODS A database of all patients referred to the neurosurgery clinic from 2015 through 2018 (n = 5677) was reviewed; the database included referring provider, referring provider specialty, number of subsequent clinic visits, and outcome of surgery or no surgery. Associations between categorical variables were tested using a χ2 analysis with post hoc relative risk (RR) calculations and binary logistical regression. RESULTS Compared with patients referred by allopathic physicians, patients referred by osteopathic physicians (RR, 0.63; 95% confidence interval [CI], 0.48-0.84) and those referred by nurse practitioners (RR, 0.66; 95% CI, 0.51-0.86) were significantly less likely to require surgery. Probability of surgical intervention also varied by referrer specialty. Patients referred by neurologists required surgery 35% of the time, whereas patients referred by family practitioners required surgery 19% of the time, and patients referred by pediatricians required surgery only 7% of the time (P < 0.01). Binary logistic regression revealed that referrals from nurse practitioners and osteopathic physicians were independently associated with a decreased probability of surgical intervention. CONCLUSIONS Our data strengthen the concept of having interdisciplinary teams led by physicians at the primary care level to ensure appropriate referrals. Training and adherence to guidelines must continually be reinforced to ensure proper referrals.
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Affiliation(s)
- Aaron Gelinne
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Raj Thakrar
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Bruce I Tranmer
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Susan R Durham
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Ryan P Jewell
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Paul L Penar
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - S Scott Lollis
- Division of Neurological Surgery, University of Vermont Medical Center, Burlington, Vermont, USA.
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17
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Mungroop TH, Geerts BF, Veelo DP, Pawlik TM, Bonnet A, Lesurtel M, Reyntjens KM, Noji T, Liu C, Jonas E, Wu CL, de Santibañes E, Abu Hilal M, Hollmann MW, Besselink MG, van Gulik TM. Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists. Surgery 2019; 165:337-344. [DOI: 10.1016/j.surg.2018.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/17/2018] [Accepted: 08/12/2018] [Indexed: 02/07/2023]
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18
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Feldman K, Johnson RA, Chawla NV. The State of Data in Healthcare: Path Towards Standardization. JOURNAL OF HEALTHCARE INFORMATICS RESEARCH 2018; 2:248-271. [PMID: 35415409 PMCID: PMC8982788 DOI: 10.1007/s41666-018-0019-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 12/23/2022]
Abstract
Coupled with the rise of data science and machine learning, the increasing availability of digitized health and wellness data has provided an exciting opportunity for complex analyses of problems throughout the healthcare domain. Whereas many early works focused on a particular aspect of patient care, often drawing on data from a specific clinical or administrative source, it has become clear such a single-source approach is insufficient to capture the complexity of the human condition. Instead, adequately modeling health and wellness problems requires the ability to draw upon data spanning multiple facets of an individual's biology, their care, and the social aspects of their life. Although such an awareness has greatly expanded the breadth of health and wellness data collected, the diverse array of data sources and intended uses often leave researchers and practitioners with a scattered and fragmented view of any particular patient. As a result, there exists a clear need to catalogue and organize the range of healthcare data available for analysis. This work represents an effort at developing such an organization, presenting a patient-centric framework deemed the Healthcare Data Spectrum (HDS). Comprised of six layers, the HDS begins with the innermost micro-level omics and macro-level demographic data that directly characterize a patient, and extends at its outermost to aggregate population-level data derived from attributes of care for each individual patient. For each level of the HDS, this manuscript will examine the specific types of constituent data, provide examples of how the data aid in a broad set of research problems, and identify the primary terminology and standards used to describe the data.
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Affiliation(s)
- Keith Feldman
- Department of Computer Science and Engineering, University of Notre Dame, Notre Dame, IN 46656 USA
- iCeNSA, University of Notre Dame, Notre Dame, IN 46656 USA
| | - Reid A. Johnson
- Department of Computer Science and Engineering, University of Notre Dame, Notre Dame, IN 46656 USA
- iCeNSA, University of Notre Dame, Notre Dame, IN 46656 USA
| | - Nitesh V. Chawla
- Department of Computer Science and Engineering, University of Notre Dame, Notre Dame, IN 46656 USA
- iCeNSA, University of Notre Dame, Notre Dame, IN 46656 USA
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19
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The Role of Patient Navigators in Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 23:276-282. [PMID: 28079645 PMCID: PMC5381478 DOI: 10.1097/phh.0000000000000512] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CONTEXT People living with human immunodeficiency virus (HIV) (PLWH) who are most at risk for falling out of HIV primary care and detectable viral loads include homeless and unstably housed individuals and those codiagnosed with behavioral health disorders. The patient-centered medical home (PCMH) is a model that promotes provision of comprehensive, patient-centered, accessible, coordinated, and quality care for patients. This initiative provided patient navigation to HIV-positive homeless and unstably housed individuals codiagnosed with a mental health or substance use disorder as a means to create an adapted PCMH to meet the specific needs of this population. OBJECTIVE The purpose of this analysis was to characterize the roles and responsibilities of patient navigators as part of an effort to create a medical home for homeless and unstably housed PLWH with behavioral health comorbidities. DESIGN Eighty-one in-depth interviews with clinic staff and 2 focus groups with patient navigators were conducted. Content analysis was performed to identify key roles and responsibilities of the patient navigators. RESULTS Patient navigators played an important role in creating a PCMH by working with clients to schedule and complete appointments, develop comprehensive care plans, forging critical relationships with providers both within and outside of health care systems, providing holistic support to increase patient self-management, and assisting in achieving housing stability. CONCLUSIONS It may be necessary to adapt the traditional PCMH model to effectively meet the social, behavior health, and medical needs of homeless and unstably housed PLWH with behavioral health comorbidities. A patient navigator who can invest time in supporting and connecting these patients to needed services may be a key component in creating an effective PCMH for this population. These findings highlight the roles and tasks of patient navigators that may contribute to developing a PCMH specific to homeless and unstably housed PLWH with mental health and substance use comorbidities. Implementation of such a model has the potential to improve health outcomes (such as retention in care and viral suppression) for particularly vulnerable PLWH and thereby reduce the burden of HIV infection.
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20
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Skrepnek GH, Mills JL, Lavery LA, Armstrong DG. Health Care Service and Outcomes Among an Estimated 6.7 Million Ambulatory Care Diabetic Foot Cases in the U.S. Diabetes Care 2017; 40:936-942. [PMID: 28495903 DOI: 10.2337/dc16-2189] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 04/19/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate ambulatory clinical cases of diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs) in the U.S. from 2007 to 2013 and to assess outcomes of emergency department or inpatient (ED/IP) admission, number of clinic visits per year, and physician time spent per visit. RESEARCH DESIGN AND METHODS A cross-sectional historical cohort analysis was conducted by using the nationally representative Centers for Disease Control and Prevention National Ambulatory Medical Care Survey data from 2007 to 2013, including patients age ≥18 years with diabetes and either DFIs or DFUs. Study outcomes were analyzed by using generalized linear models controlling for key demographics and chronic conditions. RESULTS Across the estimated 5.6 billion ambulatory care visits between 2007 and 2013, 784.8 million involved diabetes and ∼6.7 million (0.8%) were for DFUs (0.3%) or DFIs (0.5%). Relative to other ambulatory clinical cases, multivariable analyses indicated that DFUs were associated with a 3.4 times higher odds of direct ED/IP admission (CI 1.01-11.28; P = 0.049), 2.1 times higher odds of referral to another physician (CI 1.14-3.71; P = 0.017), 1.9 times more visits in the past 12 months (CI 1.41-2.42; P < 0.001), and 1.4 times longer time spent per visit with the physician (CI 1.03-1.87; P = 0.033). DFIs were independently associated with a 6.7 times higher odds of direct ED referral or IP admission (CI 2.25-19.51; P < 0.001) and 1.5 times more visits in the past 12 months (CI 1.14-1.90; P = 0.003). CONCLUSIONS This investigation of an estimated 6.7 million diabetic foot cases indicates markedly greater risks for both ED/IP admissions and number of outpatient visits, with DFUs also associated with a higher odds of referrals to other physicians and longer physician visit times.
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Affiliation(s)
- Grant H Skrepnek
- College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Joseph L Mills
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lawrence A Lavery
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David G Armstrong
- Division of Vascular and Endovascular Surgery and Southern Arizona Limb Salvage Alliance, Department of Surgery, University of Arizona College of Medicine, Tucson, AZ
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21
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Edwards ST, Landon BE. Seeking Value in Healthcare: The Importance of Generalists as Primary Care Physicians. J Am Geriatr Soc 2017; 65:1900-1901. [PMID: 28555721 DOI: 10.1111/jgs.14937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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22
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O'Neill DE, Southern DA, Norris CM, O'Neill BJ, Curran HJ, Graham MM. Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment & outcome. BMC Health Serv Res 2017; 17:354. [PMID: 28511683 PMCID: PMC5433046 DOI: 10.1186/s12913-017-2294-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 05/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background Specialized cardiology services have contributed to reduced mortality in acute coronary syndromes (ACS). We sought to evaluate the outcomes of ACS patients admitted to non-cardiology services in Southern Alberta. Methods Retrospective chart review performed on all troponin-positive patients in the Calgary Health Region identified those diagnosed with ACS by their attending team. Patients admitted to non-cardiology and cardiology services were compared, using linked data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry and the Strategic Clinical Network for Cardiovascular Health and Stroke. Results From January 1, 2007 to December 31, 2008, 2105 ACS patients were identified, with 1636 (77.7%) admitted to cardiology and 469 (22.3%) to non-cardiology services. Patients admitted to non-cardiology services were older, had more comorbidities, and rarely received cardiology consultation (5.1%). Cardiac catheterization was underutilized (5.1% vs 86.4% in cardiology patients (p < 0.0001)), as was evidence-based pharmacotherapy (p < 0.0001). Following adjustment for baseline comorbidities, 30-day through 4-year mortality was significantly higher on non-cardiology vs. cardiology services (49.1% vs. 11.0% respectively at 4-years, p < 0.0001). Conclusion In a large ACS population in the Calgary Health Region, 25% were admitted to non-cardiology services. These patients had worse outcomes, despite adjustment for baseline risk factor differences. Although many patients were appropriately admitted to non-cardiology services, the low use of investigations and secondary prevention medications may contribute to poorer patient outcome. Further research is required to identify process of care strategies to improve outcomes and lessen the burden of illness for patients and the health care system.
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Affiliation(s)
- Deirdre E O'Neill
- Division of Cardiology and Department of Medicine, and Mazankowski Alberta Heart Insitute, University of Alberta, Edmonton, Canada
| | - Danielle A Southern
- Department of Public Health Sciences, University of Calgary, Calgary, Canada
| | - Colleen M Norris
- Division of Cardiology and Department of Medicine, and Mazankowski Alberta Heart Insitute, University of Alberta, Edmonton, Canada
| | - Blair J O'Neill
- Division of Cardiology and Department of Medicine, and Mazankowski Alberta Heart Insitute, University of Alberta, Edmonton, Canada
| | - Helen J Curran
- Division of Cardiology and Department of Medicine, Dalhousie University, Halifax, Canada
| | - Michelle M Graham
- Division of Cardiology and Department of Medicine, and Mazankowski Alberta Heart Insitute, University of Alberta, Edmonton, Canada. .,Division of Cardiology, University of Alberta, 2C2 WMC, 8440 112 St, Edmonton, AB, T6G 2B7, Canada.
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Julio Ceitlin on The development of family medicine in Latin America (2006). Fam Med 2016. [DOI: 10.1201/9781315365305-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fortinsky RH, Wasson JH. How do physicians diagnose dementia? Evidence from clinical vignette responses. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153331759701200202] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined how a sample of family practitioners, general internists, and osteopathic physicians practicing in the state of Maine (N=353) diagnose symptoms of cognitive dysfunction. Physicians' reported diagnostic approaches were compared to American and Canadian expert panel recommendations, and were associated with their sociodemographic and office practice characteristics. Sample members responded to a self-administered questionnaire, which was completed in response to a clinical vignette describing a patient with either mild symptoms or more progressive symptoms of cognitive dysfunction. Results showed that 59 percent of respondents would perform a formal cognitive status test and 32 percent would perform a depression screening test; both types of tests are recommended by American and Canadian expert panels. Adjusting for other factors, female physicians were twice as likely as males to perform a depression screening test (OR=2.04; 95 percent C1=1.13-3.67). Most respondents (87 percent) would order at least three of four recommended laboratory tests, and 59 percent would order a computerized tomography (CT) scan, even though expert guidelines are ambiguous about the value of CT scans in diagnostic workups. Diagnostic approaches were not significantly affected by plans to refer patients to other physicians for additional testing. Practicing physicians should be encouraged to perform recommended nueropsychological and mental status tests when patients present with symptoms of cognitive dysfunction.
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Affiliation(s)
- Richard H. Fortinsky
- General Internal Medicine and Health Care Research, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, Ohio
| | - John H. Wasson
- Center for the Aging, Dartmouth Medical School, Hanover New Hampshire
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Kane RL. Commentary. Med Care Res Rev 2016. [DOI: 10.1177/107755879705400305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bazzoli GJ, Dynan L, Burns LR, Yap C. Two Decades of Organizational Change in Health Care: What Have we Learned? Med Care Res Rev 2016; 61:247-331. [PMID: 15358969 DOI: 10.1177/1077558704266818] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 1980s and 1990s witnessed a substantial wave of organizational restructuring among hospitals and physicians, as health providers rethought their organizational roles given perceived market imperatives. Mergers, acquisitions, internal restructuring, and new interorganizational relationships occurred at a record pace. Matching this was a large wave of study and discourse among health services researchers, industry experts, and consultants to understand the causes and consequences of organizational change. In many cases, this literature provides mixed signals about what was accomplished through these organizational efforts. The purpose of this review is to synthesize this diverse literature. This review examines studies of horizontal consolidation and integration of hospitals, horizontal consolidation and integration of physician organizations, and integration and relationship development between physicians and hospitals. In all, around 100 studies were examined to assess what was learned through two decades of research on organizational change in health care.
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van Hoof SJM, Spreeuwenberg MD, Kroese MEAL, Steevens J, Meerlo RJ, Hanraets MMH, Ruwaard D. Substitution of outpatient care with primary care: a feasibility study on the experiences among general practitioners, medical specialists and patients. BMC FAMILY PRACTICE 2016; 17:108. [PMID: 27506455 PMCID: PMC4979105 DOI: 10.1186/s12875-016-0498-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 07/21/2016] [Indexed: 01/17/2023]
Abstract
Background Reinforcing the gatekeeping role of general practitioners (GPs) by embedding specialist knowledge into primary care is seen as a possibility for stimulating a more sustainable healthcare system and avoiding unnecessary referrals to outpatient care. An intervention called Primary Care Plus (PC+) was developed to achieve these goals. The objective of this study is to gain insight into: (1) the content and added value of PC+ consultations according to stakeholders, and (2) patient satisfaction with PC+ compared to outpatient care. Methods A feasibility study was conducted in the southern part of the Netherlands between April 2013 and January 2014. Data was collected using GP, medical specialist and patient questionnaires. Patient characteristics and medical specialty data were collected through the data system of a GP referral department. Results GPs indicated that they would have referred 85.4 % of their PC+ patients to outpatient care in the hypothetical case that PC+ was not available. Medical specialists indicated that about one fifth of the patients needed follow-up in outpatient care and 75.9 % of the consultations were of added value to patient care. The patient satisfaction results appear to be in favour of PC+. Conclusion PC+ seems to be a feasible intervention to be implemented on a larger scale, because it has the potential to prevent unnecessary hospital referrals. PC+ will be evaluated on a larger scale regarding the effects on health outcomes, quality of care and costs (Triple Aim principle).
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Affiliation(s)
- Sofie J M van Hoof
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Marieke D Spreeuwenberg
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands. .,Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands.
| | - Mariëlle E A L Kroese
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jessie Steevens
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Ronald J Meerlo
- Primary Care Organisation Care In Development ZIO, Wilhelminasingel 81, 6221 BG, Maastricht, The Netherlands
| | - Monique M H Hanraets
- Department of Patient and Care, Academic Hospital Maastricht azM, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Azizi F, Mehran L, Amouzegar A, Alamdari S, Subetki I, Saadat N, Moini S, Sarvghadi F. Prevalent Practices of Thyroid Diseases During Pregnancy Among Endocrinologists, Internists and General Practitioners. Int J Endocrinol Metab 2016; 14:e29601. [PMID: 27274337 PMCID: PMC4894079 DOI: 10.5812/ijem.29601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/16/2015] [Accepted: 06/21/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Maternal thyroid disease in pregnancy is associated with adverse impact on both mother and fetus. Both the American thyroid association and the endocrine society have recently published guidelines for the management of thyroid disease in pregnancy. OBJECTIVES The objective of this survey was to assess and compare the current practices of various East-Asian physicians in the screening and management of thyroid disease in pregnancy. MATERIALS AND METHODS Completed survey questionnaires were collected from 112 physicians of six East-Asian countries. The survey was based on clinical case scenarios, asking questions about the clinical practices related to diagnosis and management of thyroid disease during pregnancy. Reponses from 76 endocrinologists and 33 internists and general practitioners (generalists) were analyzed. RESULTS There were minor differences in treatment preferences for Graves' disease in pregnancy and tests to monitor antithyroid drugs between endocrinologists and generalists; the major difference being targeted free thyroxin, and also thyroxin, depicted in the upper end of normal range, by the majority of endocrinologist and within the normal range, by generalists. Compared to generalists, endocrinologists perform more targeted screening and are more familiar with its risk factors. Predominantly, endocrinologists increase levothyroxine dose in hypothyroid women, upon confirmation of pregnancy and also indicate full dose in a pregnant woman, diagnosed with overt hypothyroidism, and treat thyroid peroxidase antibody positive or negative pregnant women with thyroid stimulating hormone (2.5 - 5 mU/L), as compared to generalists. CONCLUSIONS There is wide variation in the clinical practices of screening and management of thyroid disorders during pregnancy in East-Asia, with many clinicians, in particular general practitioners, not adhering to clinical practice guidelines, unfortunately.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Ladan Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Ladan Mehran, Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, P. O. Box: 19395-4763, Tehran, IR Iran. Tel: +98-2122409309, Fax: +98-2122402463, E-mail:
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Shahram Alamdari
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Medical Research Development Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Imam Subetki
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Navid Saadat
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Siamak Moini
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Farzaneh Sarvghadi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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Patient cost-sharing and insurance arrangements are associated with hospital readmissions after abdominal surgery: Implications for access and quality health care. Surgery 2015; 159:919-29. [PMID: 26477477 DOI: 10.1016/j.surg.2015.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Readmission rates after operative procedures are used increasingly as a measure of hospital care quality. Patient access to care may influence readmission rates. The objective of this study was to determine the relationship between patient cost-sharing, insurance arrangements, and the risk of postoperative readmissions. METHODS Using the MarketScan Research Database (n = 121,002), we examined privately insured, nonelderly patients who underwent abdominal surgery in 2010. The main outcome measures were risk-adjusted unplanned readmissions within 7 days and 30 days of discharge. Odds of readmissions were compared with multivariable logistic regression models. RESULTS In adjusted models, $1,284 increase in patient out-of-pocket payments during index admission (a difference of one standard deviation) was associated with 19% decrease in the odds of 7-day readmission (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.78-0.85) and 17% decrease in the odds of 30-day readmission (OR 0.83, 95% CI 0.81-0.86). Patients in the noncapitated point-of-service plans (OR 1.19, 95% CI 1.07-1.33), preferred provider organization plans (OR 1.11, 95% CI 1.03-1.19), and high-deductible plans (OR 1.12, 95% CI 1.00-1.26) were more likely to be readmitted within 30 days compared with patients in the capitated health maintenance organization and point-of-service plans. CONCLUSION Among privately insured, nonelderly patients, increased patient cost-sharing was associated with lower odds of 7-day and 30-day readmission after abdominal surgery. Insurance arrangements also were significantly associated with postoperative readmissions. Patient cost sharing and insurance arrangements need consideration in the provision of equitable access for quality care.
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Cohen SM, Kim J, Roy N, Courey M. Delayed otolaryngology referral for voice disorders increases health care costs. Am J Med 2015; 128:426.e11-8. [PMID: 25460527 DOI: 10.1016/j.amjmed.2014.10.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the accepted role of laryngoscopy in assessing patients with laryngeal/voice disorders, controversy surrounds its timing. This study sought to determine how increased time from first primary care to first otolaryngology outpatient visit affected the health care costs of patients with laryngeal/voice disorders. METHODS Retrospective analysis of a large, national administrative claims database was performed. Patients had an International Classification of Diseases, 9(th) Revision-coded diagnosis of a laryngeal/voice disorder; initially saw a primary care physician and, subsequently, an otolaryngologist as outpatients; and provided 6 months of follow-up data after the first otolaryngology evaluation. The outpatient health care costs accrued from the first primary care outpatient visit through the 6 months after the first otolaryngology outpatient visit were determined. RESULTS There were 260,095 unique patients who saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 8999 (3.5%) subsequently seeing an otolaryngologist and with 6 months postotolaryngology follow-up data. A generalized linear regression model revealed that, compared with patients who saw an otolaryngologist ≤1 month after the first primary care visit, patients in the >1-month and ≤3-months and >3-months time periods had relative mean cost increases of $271.34 (95% confidence interval $115.95-$426.73) and $711.38 (95% confidence interval $428.43-$993.34), respectively. CONCLUSIONS Increased time from first primary care to first otolaryngology evaluation is associated with increased outpatient health care costs. Earlier otolaryngology examination may reduce health care expenditures in the evaluation and management of patients with laryngeal/voice disorders.
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Affiliation(s)
- Seth M Cohen
- Duke Voice Care Center, Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC.
| | - Jaewhan Kim
- Division of Public Health & Study Design and Biostatistics Center, University of Utah, Salt Lake City
| | - Nelson Roy
- Department of Communication Sciences and Disorders, Division of Otolaryngology-Head & Neck Surgery (Adjunct), University of Utah, Salt Lake City
| | - Mark Courey
- Department of Otolaryngology-Head & Neck Surgery, University of California - San Francisco
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Lichtenberg FR. The Effect of Pharmaceutical Innovation on the Functional Limitations of Elderly Americans: Evidence from the 2004 National Nursing Home Survey. ACTA ACUST UNITED AC 2015; 23:73-101. [DOI: 10.1108/s0731-2199(2012)0000023006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Multi-stage methodology to detect health insurance claim fraud. Health Care Manag Sci 2015; 19:249-60. [DOI: 10.1007/s10729-015-9317-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 01/07/2015] [Indexed: 11/26/2022]
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Bekelis K, Fisher ES, Labropoulos N, Zhou W, Skinner J. Variations in the intensive use of head CT for elderly patients with hemorrhagic stroke. Radiology 2014; 275:188-95. [PMID: 25353250 DOI: 10.1148/radiol.14141362] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the variability in head computed tomographic (CT) scanning in patients with hemorrhagic stroke in U.S. hospitals, its association with mortality, and the number of different physicians consulted. MATERIALS AND METHODS The study was approved by the Committee for the Protection of Human Subjects at Dartmouth College. A retrospective analysis of the Medicare fee-for-service claims data was performed for elderly patients admitted for hemorrhagic stroke in 2008-2009, with 1-year follow-up through 2010. Risk-adjusted primary outcome measures were mean number of head CT scans performed and high-intensity use of head CT (six or more head CT scans performed in the year after admission). We examined the association of high-intensity use of head CT with the number of different physicians consulted and mortality. RESULTS A total of 53 272 patients (mean age, 79.6 years; 31 377 women [58.9%]) with hemorrhagic stroke were identified in the study period. The mean number of head CT scans conducted in the year after admission for stroke was 3.4; 8737 patients (16.4%) underwent six or more scans. Among the hospitals with the highest case volume (more than 50 patients with hemorrhagic stroke), risk-adjusted rates ranged from 8.0% to 48.1%. The correlation coefficient between number of physicians consulted and rates of high-intensity use of head CT was 0.522 (P < .01) for all hospitals and 0.50 (P < .01) for the highest-volume hospitals. No improvement in 1-year mortality was found for patients undergoing six or more head CT scans (odds ratio, 0.84; 95% confidence interval: 0.69, 1.02). CONCLUSION High rates of head CT use for patients with hemorrhagic stroke are frequently observed, without an association with decreased mortality. A higher number of physicians consulted was associated with high-intensity use of head CT.
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Affiliation(s)
- Kimon Bekelis
- From the Section of Neurosurgery (K.B.) and Department of Medicine (E.S.F.), Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03755; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (E.S.F., W.Z., J.S.); Geisel School of Medicine (E.S.F.) and Department of Economics (J.S.), Dartmouth College, Hanover, NH; and Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY (N.L.)
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Comparison of the use of downstream tests after exercise treadmill testing by cardiologists versus noncardiologists. Am J Cardiol 2014; 114:305-11. [PMID: 24874162 DOI: 10.1016/j.amjcard.2014.04.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 04/24/2014] [Accepted: 04/24/2014] [Indexed: 01/20/2023]
Abstract
Although exercise treadmill testing (ETT) is a useful initial test for patients with suspected cardiovascular (CV) disease, there is concern regarding the use of downstream imaging tests especially in the setting of equivocal or positive ETTs. Patients with no history of coronary artery disease who underwent ETT between 2009 and 2010 were prospectively included. Referring physicians were categorized as cardiologists and noncardiologists. Downstream tests included nuclear perfusion imaging, coronary computed tomography angiography, stress echocardiography, stress magnetic resonance, and invasive coronary angiography performed up to 6 months after the ETT. Patients were followed for CV death, myocardial infarction, and coronary revascularization for a median of 2.7 years. Among 3,656 patients, the ETT were negative in 2,876 (79%), positive in 132 (3.6%), and inconclusive in 643 (18%). Cardiologists ordered less downstream tests than noncardiologists (9.5% vs 12.2%, p=0.02), with less noninvasive tests (5.9% vs 10.4%, p<0.0001) and more invasive angiography (3.6% vs 1.8%, p<0.0001). After adjustment for confounding, patients evaluated by cardiologists were less likely to undergo additional testing after equivocal (odds ratio: 0.65, p=0.02) or positive ETT results (odds ratio: 0.39, p=0.02), whereas after negative ETT, the odds ratio was 1.7 (p=0.06). There was no difference in the rate of adverse CV events between patients referred by cardiologists versus noncardiologists. In conclusion, patients referred for ETT by cardiologists are less likely to undergo additional testing, particularly noninvasive tests, than those referred by noncardiologists. The lower rate of tests is driven by a lower rate of tests after positive or inconclusive ETT.
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Hamandi B, Husain S, Humar A, Papadimitropoulos EA. Impact of infectious disease consultation on the clinical and economic outcomes of solid organ transplant recipients admitted for infectious complications. Clin Infect Dis 2014; 59:1074-82. [PMID: 25009289 DOI: 10.1093/cid/ciu522] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There has been a paucity of data on the healthcare resource utilization of infectious disease-related complications in solid organ transplant recipients. The aims of this study were to report the clinical and economic burden of infectious disease-related complications, along with the impact of infectious disease consultation. METHODS This cohort study evaluated patients requiring admission to a tertiary-care center during 2007, 2008, and 2011. Propensity score matching was used to estimate the effects of patient demographics, comorbidities, and transplant- and infection-related factors on 28-day hospital survival, length of stay (LOS), and medical costs. RESULTS Infectious disease-related complications occurred in 603 of 1414 (43%) admissions in 306 of 531 (58%) patients. Unadjusted 28-day mortality did not differ between those who received infectious disease consultations vs those who did not (2.9% vs 3.6%, P = .820), however, after propensity score matching, infectious disease consultation resulted in significantly greater 28-day survival estimates (hazard ratio = 0.33; log-rank P = .026), and reduced 30-day rehospitalization rates (16.9% vs 23.9%, P = .036). The median LOS and hospitalization costs were significantly increased for patients receiving an infectious disease consultation than in those managed by the attending team alone (7.0 vs 5.0 days, P = .002, and $9652 vs $6192, P = .003). However, the median LOS (5.5 vs 5.1 days, P = .31) and hospitalization costs ($8106 vs $6912, P = .63) did not differ significantly among those receiving an early infectious disease consultation (<48 hours) vs no consultation, respectively. CONCLUSIONS Infectious disease consultation in recipients of solid organ transplant is associated with increased LOS and hospitalization costs but decreased mortality and reduced rehospitalization rates. Early consultation with infectious disease specialists decreases healthcare resource utilization compared with delayed referrals.
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Affiliation(s)
| | - Shahid Husain
- Transplant Infectious Diseases, University Health Network
| | - Atul Humar
- Transplant Infectious Diseases, University Health Network
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Kruger JF, Chen AH, Rybkin A, Leeds K, Frosch DL, Goldman LE. Clinician perspectives on considering radiation exposure to patients when ordering imaging tests: a qualitative study. BMJ Qual Saf 2014; 23:893-901. [DOI: 10.1136/bmjqs-2013-002773] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Payment mechanism and GP self-selection: capitation versus fee for service. ACTA ACUST UNITED AC 2014; 14:143-60. [DOI: 10.1007/s10754-014-9143-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 03/03/2014] [Indexed: 11/30/2022]
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Stange KC, Etz RS, Gullett H, Sweeney SA, Miller WL, Jaén CR, Crabtree BF, Nutting PA, Glasgow RE. Metrics for assessing improvements in primary health care. Annu Rev Public Health 2014; 35:423-42. [PMID: 24641561 PMCID: PMC6360939 DOI: 10.1146/annurev-publhealth-032013-182438] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.
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A systematic review of medical practice variation in OECD countries. Health Policy 2013; 114:5-14. [PMID: 24054709 DOI: 10.1016/j.healthpol.2013.08.002] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 05/24/2013] [Accepted: 08/02/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Major variations in medical practice have been documented internationally. Variations raise questions about the quality, equity, and efficiency of resource allocation and use, and have important implications for health care and health policy. OBJECTIVE To perform a systematic review of the peer-reviewed literature on medical practice variations in OECD countries. METHODS We searched MEDLINE to find publications on medical practice variations in OECD countries published between 2000 and 2011. We present an overview of the characteristics of published studies as well as the magnitude of variations for select high impact conditions. RESULTS A total of 836 studies were included. Consistent with the gray literature, there were large variations across regions, hospitals and physician practices for almost every condition and procedure studied. Many studies focused on high-impact conditions, but very few looked at the causes or outcomes of medical practice variations. CONCLUSION While there were an overwhelming number of publications on medical practice variations the coverage was broad and not often based on a theoretical construct. Future studies should focus on conditions and procedures that are clinically important, policy relevant, resource intensive, and have high levels of public awareness. Further study of the causes and consequences of variations is important.
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The effect of medical malpractice liability on rate of referrals received by specialist physicians. HEALTH ECONOMICS POLICY AND LAW 2013; 8:453-75. [PMID: 23527533 DOI: 10.1017/s1744133113000157] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Using nationally representative data from the United States, this paper analyzed the effect of a state’s medical malpractice environment on referral visits received by specialist physicians. The analytic sample included 12,839 ambulatory visits to specialist care doctors in office-based settings in the United States during 2003–2007. Whether the patient was referred for the visit was examined for its association with the state’s malpractice environment, assessed by the frequency and severity of paid medical malpractice claims, medical malpractice insurance premiums and an indicator for whether the state had a cap on non-economic damages. After accounting for potential confounders such as economic or professional incentives within practices, the analysis showed that statutory caps on non-economic damages of $250,000 were significantly associated with lower likelihood of a specialist receiving referrals, suggesting a potential impact of a state’s medical malpractice environment on physicians’ referral behavior.
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Phillips RL, Bazemore AW. Primary care and why it matters for U.S. health system reform. Health Aff (Millwood) 2013; 29:806-10. [PMID: 20439865 DOI: 10.1377/hlthaff.2010.0020] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The term primary care is widely used as if it were consistently defined or well understood. In fact, neither is the case. This paper offers a definition of primary care derived from historical perspectives-from both the United States and abroad. We discuss the evidence for primary care's important functions and international experiences with primary care. We also describe how and why the United States has deviated from this fuller realization of primary care, as well as the steps needed to achieve primary care and health outcomes on a par with those of other developed countries. These include doubling primary care financing to 10-12 percent of total health care spending--a step that would be likely to pay for itself via resulting reductions in overall health spending.
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Friedberg MW, Hussey PS, Schneider EC. Primary care: a critical review of the evidence on quality and costs of health care. Health Aff (Millwood) 2013; 29:766-72. [PMID: 20439859 DOI: 10.1377/hlthaff.2010.0025] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite contentious debate over the new national health care reform law, there is an emerging consensus that strengthening primary care will improve health outcomes and restrain the growth of health care spending. Policy discussions imply three general definitions of primary care: a specialty of medical providers, a set of functions served by a usual source of care, and an orientation of health systems. We review the empirical evidence linking each definition of primary care to health care quality, outcomes, and costs. The available evidence most directly supports initiatives to increase providers' ability to serve primary care functions and to reorient health systems to emphasize delivery of primary care.
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Primary care physician shortage, healthcare reform, and convenient care: challenge meets opportunity? South Med J 2013; 105:576-80. [PMID: 23128798 DOI: 10.1097/smj.0b013e31826f5bc5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Choi YJ, Ko BS, Cho KH, Lee JH. Concept, values, current status and prospect of primary care in Korea. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2013. [DOI: 10.5124/jkma.2013.56.10.856] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Yong-Jun Choi
- Department of Social and Preventive Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | | | - Kyung-Hee Cho
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae-Ho Lee
- Department of Family Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
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Burns LR, Goldsmith JC, Sen A. Horizontal and vertical integration of physicians: a tale of two tails. Adv Health Care Manag 2013; 15:39-117. [PMID: 24749213 DOI: 10.1108/s1474-8231(2013)0000015009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway. DESIGN/METHODOLOGY APPROACH: We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models. FINDINGS The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners. RESEARCH LIMITATIONS While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization. RESEARCH IMPLICATIONS Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices. PRACTICAL IMPLICATIONS Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats. ORIGINALITY/VALUE This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.
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Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med 2012; 38:1886-96. [PMID: 22940755 PMCID: PMC3684418 DOI: 10.1007/s00134-012-2661-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/11/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To explore norms of decision making regarding life-sustaining treatments (LSTs) at two academic medical centers (AMCs) that contribute to their opposite extremes of end-of-life ICU use. METHODS We conducted a 4-week mixed methods case study at each AMC in 2008-2009 involving direct observation of patient care during rounds in the main medical ICU, semi-structured interviews with staff, patients, and families, and collection of artifacts (e.g., patient lists, standardized forms). We compared patterns of decision making regarding initiation, continuation, and withdrawal of LST using tests of proportions and grounded theory analysis of field note and interview transcripts. RESULTS We observed 80 patients [26 (32.5 %) ≥65 years old] staffed by 4 attendings, and interviewed 23 staff and 3 patients/families at the low-intensity AMC (LI-AMC), and observed 73 patients [26 (35.6 %) ≥65 years old] staffed by 4 attending physicians and interviewed 26 staff and 4 patients/families at the high-intensity AMC (HI-AMC). LST initiation among patients over 65 was similar, except feeding tubes (0 % LI-AMC versus 31 % HI-AMC, p = 0.002). The LI-AMC was more likely to use a time-limited trial of LST, followed by withdrawal (27 vs. 8 %, p = 0.01) and to have a known outcome of death (31 vs. 4 %, p < 0.001). We identified qualitative differences in goals of LST, the determination of "dying," concern about harms of commission versus omission, and physician self-efficacy for LST decision making. CONCLUSIONS Time-limited trials of LST at the LI-AMC and open-ended use of LST at the HI-AMC explain some of the AMCs' nationally profiled differences in end-of-life ICU use.
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Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. ACTA ACUST UNITED AC 2012; 172:163-70. [PMID: 22271124 DOI: 10.1001/archinternmed.2011.722] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Physician referrals play a central role in ambulatory care in the United States; however, little is known about national trends in physician referrals over time. The objective of this study was to assess changes in the annual rate of referrals to other physicians from physician office visits in the United States from 1999 to 2009. METHODS We analyzed nationally representative cross-sections of ambulatory patient visits in the United States, using a sample of 845 243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2009, focusing on the decade from 1999 to 2009. The main outcome measures were survey-weighted estimates of the total number and percentage of visits resulting in a referral to another physician across several patient and physician characteristics. RESULTS From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician increased from 4.8% to 9.3% (P < .001), a 94% increase. The absolute number of visits resulting in a physician referral increased 159% nationally during this time, from 41 million to 105 million. This trend was consistent across all subgroups examined, except for slower growth among physicians with ownership stakes in their practice (P = .02) or those with the majority of income from managed care contracts (P = .007). Changes in referral rates varied according to the principal symptoms accounting for patients' visits, with significant increases noted for visits to primary care physicians from patients with cardiovascular, gastrointestinal, orthopedic, dermatologic, and ear/nose/throat symptoms. CONCLUSIONS The percentage and absolute number of ambulatory visits resulting in a referral in the United States grew substantially from 1999 to 2009. More research is necessary to understand the contribution of rising referral rates to costs of care.
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Affiliation(s)
- Michael L Barnett
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02215, USA
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Allard M, Jelovac I, Léger PT. Treatment and referral decisions under different physician payment mechanisms. JOURNAL OF HEALTH ECONOMICS 2011; 30:880-893. [PMID: 21782263 DOI: 10.1016/j.jhealeco.2011.05.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 05/26/2011] [Accepted: 05/31/2011] [Indexed: 05/31/2023]
Abstract
This paper analyzes and compares the incentive properties of some common payment mechanisms for GPs, namely fee for service (FFS), capitation and fundholding. It focuses on gatekeeping GPs and it specifically recognizes GPs heterogeneity in both ability and altruism. It also allows inappropriate care by GPs to lead to more serious illnesses. The results are as follows. Capitation is the payment mechanism that induces the most referrals to expensive specialty care. Fundholding may induce almost as much referrals as capitation when the expected costs of GPs care are high relative to those of specialty care. Although driven by financial incentives of different nature, the strategic behaviors associated with fundholding and FFS are very much alike. Finally, whether a regulator should use one or another payment mechanism for GPs will depend on (i) his priorities (either cost-containment or quality enhancement) which, in turn, depend on the expected cost difference between GPs care and specialty care, and (ii) the distribution of profiles (diagnostic ability and altruism levels) among GPs.
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