Association between primary care practice characteristics and emergency department use in a medicaid managed care organization

Healthcare utilisation by diabetic patients in Denmark: the role of primary care in reducing emergency visits

Improving the management of diabetic patients is receiving increasing attention in the health policy agenda due to increasing prevalence in the population and raising pressure on healthcare resources. This paper examines the determinants of healthcare services utilisation in patients with type-2 diabetes, investigating the potential substitution effect of general practice visits on the utilisation of emergency department visits. By using rich longitudinal data from Denmark and a bivariate econometric model, our analysis highlights primary care services that are more effective in preventing emergency department visits and socioeconomic groups of patients with a weak substitution response. Our results suggest that empowering primary care services, such as preventive assessment visits, may contribute to reducing emergency department visits significantly. Moreover, special attention should be devoted to vulnerable groups, such as patients from low socioeconomic background and older patients, who may find more difficult achieving a large substitution response.

Is the emergency department used as a substitute or a complement to primary care in Medicaid?

Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.

Emergency department utilization, admissions, and revisits in the United States (New York), Canada (Ontario), and New Zealand: A retrospective cross-sectional analysis

BACKGROUND

Emergency department (ED) utilization is a significant concern in many countries, but few population-based studies have compared ED use. Our objective was to compare ED utilization in New York (United States), Ontario (Canada), and New Zealand (NZ).

METHODS

A retrospective cross-sectional analysis of all ED visits between January 1, 2016, and September 30, 2017, for adults ≥18 years using data from the State Emergency Department and Inpatient Databases (New York), the National Ambulatory Care Reporting System and Discharge Abstract Data (Ontario), and the National Non-Admitted Patient Collection and the National Minimum Data Set (New Zealand). Outcomes included age- and sex-standardized per-capita ED utilization (overall and stratified by neighborhood income), ED disposition, and ED revisit and hospitalization within 30 days of ED discharge.

RESULTS

There were 10,998,371 ED visits in New York, 8,754,751 in Ontario, and 1,547,801 in New Zealand. Patients were older in Ontario (mean age 51.1 years) compared to New Zealand (50.3) and New York (48.7). Annual sex- and age-standardized per-capita ED utilization was higher in Ontario than New York or New Zealand (443.2 vs. 404.0 or 248.4 visits per 1000 population/year, respectively). In all countries, ED utilization was highest for residents of the lowest income quintile neighborhoods. The proportion of ED visits resulting in hospitalization was higher in New Zealand (34.5%) compared to New York (20.8%) and Ontario (12.8%). Thirty-day ED revisits were higher in Ontario (27.0%) than New Zealand (18.6%) or New York (21.4%).

CONCLUSIONS

Patterns of ED utilization differed widely across three high-income countries. These differences highlight the varying approaches that our countries take with respect to urgent visits, suggest opportunities for shared learning through international comparisons, and raise important questions about optimal approaches for all countries.

Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy

Background

Frequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs.

Methods

The analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors.

Results

A total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p < 0.001).

Conclusion

The FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.

The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data

Background

To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions.

Methods

Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017.

Results

The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center.

Conclusion

Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

Impact of Statewide Mandatory Medicaid Managed Care (SMMC) Programs on Hospital Obstetric Outcomes

The state of Florida implemented mandatory managed care for Medicaid enrollees via the Statewide Medicaid Managed Care (SMMC) program in April of 2014. The objective of this study was to examine the impact of the implementation of the SMMC program on the access to care and quality of maternal care for Medicaid enrollees, as measured by several hospital obstetric outcomes. The primary data source for this retrospective observational study was the Hospital Cost and Utilization Project (HCUP) all-payer State ED (SED) visit and State Inpatient Databases (SIDs) from 2010 to 2017. The primary health outcomes for obstetric care were primary cesarean, preterm birth, postpartum preventable ED visits, postpartum preventable readmissions, and vaginal delivery after cesarean (VBAC) rates. Using difference-in-differences (DID) estimation, selected health outcomes were examined for Florida residents with Medicaid beneficiaries (treatment) and the commercially insured population (comparison), before and after the implementation of SMMC. Improvement in disparities for racial/ethnic minority Medicaid enrollees was estimated relative to whites, compared to the relative change among commercially insured patients. From the DID estimation, the findings showed that SMMC is statistically significantly associated with a higher reduction in primary cesarean rates, preterm births, preventable postpartum ED visits, and readmissions among Medicaid beneficiaries relative to their commercially insured counterparts. However, this study did not find any significant reduction in racial/ethnic disparities in obstetric outcomes. In general, this study highlights the impact of SMMC implementation on obstetric outcomes in Florida and provides important insights and potential scope for improvement in obstetric care quality and associated racial/ethnic disparities.

Weekend Versus Weekday Asthma-Related Emergency Department Utilization

OBJECTIVE

To assess variation in asthma-related emergency department (ED) use between weekends and weekdays.

METHODS

Cross-sectional administrative claims-based analysis using California 2016 Medicaid data and Vermont 2016 and Massachusetts 2015 all-payer claims databases. We defined ED use as the rate of asthma-related ED visits per 100 child-years. A weekend visit was a visit on Saturday or Sunday, based on date of ED visit claim. We used negative binomial regression and robust standard errors to assess variation between weekend and weekday rates, overall and by age group.

RESULTS

We evaluated data from 398,537 patients with asthma. The asthma-related ED visit rate was slightly lower on weekends (weekend: 18.7 [95% confidence interval (CI): 18.3-19.0], weekday: 19.6 [95% CI, 19.3-19.8], P < .001). When stratifying by age group, 3- to 5-year-olds had higher rates of asthma-related ED visits on weekends than weekdays (weekend: 33.7 [95% CI, 32.6-34.7], weekday: 29.8 [95% CI, 29.1-30.5], P < .001) and 12- to 17-year-olds had lower rates of ED visits on weekends than weekdays (weekend: 13.0 [95% CI: 12.5-13.4], weekday: 16.3 [95% CI: 15.9-16.7], P < .001). In the other age groups (6-11, 18-21 years) there were not statistically significant differences between weekend and weekday rates (P > .05).

CONCLUSIONS

In this multistate analysis of children with asthma, we found limited overall variation in pediatric asthma-related ED utilization on weekends versus weekdays. These findings suggest that increasing access options during the weekend may not necessarily decrease asthma-related ED use.

Emergency Department Patient Navigator Program Demonstrates Reduction in Emergency Department Return Visits and Increase in Follow-up Appointment Adherence

BACKGROUND

An estimated 56% of emergency department (ED) visits are avoidable. One motivation for return visits is patients' perception of poor access to timely outpatient care. Efforts to facilitate access may help reduce preventable ED visits. We aimed to analyze whether an ED patient navigator (PN) program improved adherence with outpatient appointments and reduced ED return visits.

METHODS

We performed a retrospective analysis of patients evaluated and discharged from two EDs from October 2016 to December 2019. Using propensity score matching, an intervention case group was matched against two control groups - patients similar to the case group who presented either (1) pre-PN intervention or (2) post-PN intervention and did not receive intervention. The four outcomes included 72-h return ED visits, 30-day return ED visits, overall ED utilization, as well as the intervention group's adherence rates to PN-scheduled outpatient appointments. From 482,896 charts, propensity matching led to a total of 14,295 patients in each group.

RESULTS

PN intervention decreased both acute and subacute ED return visits. Compared to both pre-PN and post-PN controls, navigated patients had a decrease in 72-h and 30-day return visits from 2% to 1% and 7% to 4% (p < 0.001) respectively. Navigated patients also had outpatient appointment adherence rates of 74-80% compared to the estimated national average of 25-56%. While there was no difference in mean ED utilization between the intervention group and pre-PN control group, mean ED utilization was found to be higher in the intervention group compared to the post-PN control group with 0.62 visits compared to 0.38 mean visits (p < 0.001).

CONCLUSIONS

By facilitating access to post-ED care, PNs may reduce avoidable ED utilization and improve outpatient follow-up adherence. While overall ED utilization did not change, this may be due to the overall vulnerability of the navigated group which is the goal PN intervention group.

Characteristics of Emergency Department Patient Visits Referred for Follow-Up Medical Care After Discharge, National Hospital Ambulatory Medicare Care Survey—United States, 2018

Objective

To describe characteristics of a nationally representative sample of patient visits that ended with a referral for follow-up medical care after discharge from hospital emergency department (ED) visits.

Methods

We used 2018 National Hospital Ambulatory Medical Care Survey data to identify patient characteristics associated with higher rates of visits with referrals for follow-up medical care after ED discharge from nonfederal short-stay and general hospitals throughout the United States. Referral included categories of all disposition variables that indicated referral to a source of care consistent with the patient’s clinical condition at ED discharge.

Results

Approximately 97 million of 130 million visits (29 700/100 000 US resident population) were referred for follow-up medical care during 2018. Visit referral rates were higher among females (33 100) than among males (26 300/100 000 population); higher among Black patients (61 700) than among White patients (25 600/100 000 population); highest in the South (33 200/100 000 population); and similar rates in Nonmetropolitan (29 900/100 000 population) and Metropolitan Statistical Areas (30 200/100 000 population). Visit referral rates were higher for patients with Medicaid/Children's Health Insurance Program (CHIP) (66 900) than those with Medicare (31 500) or private insurance (14 000/100 000 population). Abnormal clinical findings and injuries were the discharge diagnoses most often referred for follow-up medical care.

Conclusion

Higher visit referral rates were observed among female sex, non-Hispanic Black race, Medicaid/CHIP, abnormal clinical findings, and injuries. Future studies might reveal reasons that prompted higher referral rates among various patients’ characteristics.

Factors Associated With Increased Emergency Department Utilization in Patients With Acute Optic Neuritis

BACKGROUND

Symptoms of acute vision loss and eye pain may lead patients with optic neuritis to seek care in the emergency department (ED). Given the availability of lower cost alternatives for providing medical care for optic neuritis, this study aimed to identify factors associated with higher ED utilization.

METHODS

Subjects with acute optic neuritis were identified through a chart review of adults with International Classification of Diseases-9 (ICD-9) or ICD-10 codes for optic neuritis with corresponding gadolinium contrast enhancement of the optic nerve on MRI in the medical record research repository of a tertiary care institution. Subjects were grouped based on the number of ED visits (0-1 and 2-3) within 2 months of either ICD code or MRI. Demographics, characteristics of disease presentation, type and location of medical care, testing (chest imaging, lumbar puncture, optical coherence tomography, spine MRI, visual field, and laboratory tests), treatment, provider specialty of follow-up visits, and duration of care were extracted from the medical record.

RESULTS

Of 30 acute optic neuritis subjects (age 41 ± 16 years, range 18-76, 53% [16/30] female), 19 had 0-1 ED visit and 11 had 2-3 ED visits. Most subjects were Caucasian, non-Hispanic (47%), followed by Asian (23%), Hispanic/Latino (17%), Black (10%), and others (3%). Subjects had an initial clinical encounter primarily in the outpatient setting (63%) as compared with the ED (37%). The median time from symptom onset to initial clinical encounter was 4 days with a range of 0-13. Subjects were mostly insured through a private insurance (60%), followed by Medicare/Medicaid (23%) and uninsured (17%). Fewer ED visits were associated with an initial clinical encounter in an outpatient setting (P = 0.02, chi-square), but not residential distance from the hospital or insurance type. Subjects with a higher number of ED visits were more likely to be of Hispanic/Latino ethnicity (P = 0.047, Fisher exact). There was no significant difference in the ophthalmic, radiologic, or laboratory testing performed in both groups. Both groups presented in a similar time frame with similar symptoms and clinical signs. Treatment was similar in both groups.

CONCLUSIONS

Subjects with their first clinical encounter for optic neuritis in the ED had more visits to the ED overall when compared with those first seen in an outpatient setting and thus strategies aimed at facilitating outpatient care may help reduce unnecessary ED visits, although some, such as insurance status, may be difficult to modify. Further study in a larger sample is needed to refine these observations.

Association between service scope of primary care facilities and patient outcomes: a retrospective study in rural Guizhou, China

BACKGROUND

Extending service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about association between service scope of PCFs with patient outcomes are available. This study aims to investigate association between service scope of PCFs and patient outcomes.

METHODS

A multistage, stratified clustered sampling method was used to collect information about service scope of PCFs from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from local information system of New Rural Cooperation Medical Scheme. Service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were (1) level of inpatient institutions, (2) length of stay, (3) per capita total health cost, (4) per capita out-of-pocket cost, (5) reimbursement ratio, (6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordinal regression model were conducted to identify association between service scope of PCFs and patient outcomes.

RESULTS

On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2 % [-6.5 %, -5.9 %], city-level hospitals (-1.9 % [-2.0 %, -1.8 %]), and provincial hospitals (-2.1 % [-2.2 %, -2.0 %]), smaller rate of 30-day readmission (-0.5 % [-0.7 %, -0.2 %]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3 % [1.9 %, 2.8 %]) than their counterparts from communities with PCFs of least service scope.

CONCLUSIONS

Service scope of PCFs varied a lot in rural Guizhou, China. Greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending service scope of PCFs is cost-effective and sustainable.

How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study

BACKGROUND

The retirement of a family physician can represent a challenge in accessibility and continuity of care for patients. In this population-based, longitudinal cohort study, we assess whether and how long it takes for patients to find a new majority source of primary care (MSOC) when theirs retires, and we investigate the effect of demographic and clinical characteristics on this process.

METHODS

We used provincial health insurance records to identify the complete cohort of patients whose majority source of care left clinical practice in either 2007/2008 or 2008/2009 and then calculated the number of days between their last visit with their original MSOC and their first visit with their new one. We compared the clinical and sociodemographic characteristics of patients who did and did not find a new MSOC in the three years following their original physician's retirement using Chi-square and Fisher's exact test. We also used Cox proportional hazards models to determine the adjusted association between patient age, sex, socioeconomic status, location and morbidity level (measured using Johns Hopkins' Aggregated Diagnostic Groupings), and time to finding a new primary care physician. We produce survival curves stratified by patient age, sex, income and morbidity.

RESULTS

Fifty-four percent of patients found a new MSOC within the first 12 months following their physician's retirement. Six percent of patients still had not found a new physician after 36 months. Patients who were older and had higher levels of morbidity were more likely to find a new MSOC and found one faster than younger, healthier patients. Patients located in more urban regional health authorities also took longer to find a new MSOC compared to those in rural areas.

CONCLUSIONS

Primary care physician retirements represent a potential threat to accessibility; patients followed in this study took more than a year on average to find a new MSOC after their physician retired. Providing programmatic support to retiring physicians and their patients, as well as addressing shortages of longitudinal primary care more broadly could help to ensure smoother retirement transitions.

Comparison between primary care service delivery in Malaysia and other participating countries of the QUALICOPC project: a cross-sectional study

OBJECTIVES

Most countries including Malaysia have set goals to incorporate a strong primary care into the healthcare system. The aim of this study was to evaluate the strength of service delivery process dimensions in Malaysia and compare it with England, the Netherlands, Spain, North Macedonia, Romania and Turkey which participated in the Quality and Costs of Primary Care (QUALICOPC) study.

METHODS

This cross-sectional study utilised the QUALICOPC study data on primary care performance, which was conducted in 2011-2013 (QUALICOPC in Europe Australia, New Zealand and Canada) and 2015-2016 (Malaysia). A standardised questionnaire was completed by primary care practitioners from participating countries. Multilevel regression analysis and composite scores were constructed to compare the performance of primary care on four process dimensions: accessibility, comprehensiveness, continuity of care and coordination.

RESULTS

The high-income countries with strong primary care performed better in comprehensiveness, continuity and coordination but poorer in accessibility to services compared with upper-middle-income countries. Among the upper-middle-income countries, Malaysia scored the best in comprehensiveness and coordination. None of the studied countries were having consistent performance over all indicators either in their respective best or worst primary care services delivery dimensions.

CONCLUSIONS

There is a wide variation in primary care services delivery across and within the studied countries. The findings indicate room for quality improvement activities to strengthen primary healthcare services. This includes addressing current healthcare challenges in response to the population health needs which are essential for more integrated and efficient primary care services delivery.

First Nations emergency care in Alberta: descriptive results of a retrospective cohort study

Background

Worse health outcomes are consistently reported for First Nations people in Canada. Social, political and economic inequities as well as inequities in health care are major contributing factors to these health disparities. Emergency care is an important health services resource for First Nations people. First Nations partners, academic researchers, and health authority staff are collaborating to examine emergency care visit characteristics for First Nations and non-First Nations people in the province of Alberta.

Methods

We conducted a population-based retrospective cohort study examining all Alberta emergency care visits from April 1, 2012 to March 31, 2017 by linking administrative data. Patient demographics and emergency care visit characteristics for status First Nations persons in Alberta, and non-First Nations persons, are reported. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage and Acuity Scale). Means, medians, standard deviations and interquartile ranges describe continuous variables (e.g., age).

Results

The dataset contains 11,686,288 emergency care visits by 3,024,491 unique persons. First Nations people make up 4% of the provincial population and 9.4% of provincial emergency visits. The population rate of emergency visits is nearly 3 times higher for First Nations persons than non-First Nations persons. First Nations women utilize emergency care more than non-First Nations women (54.2% of First Nations visits are by women compared to 50.9% of non-First Nations visits). More First Nations visits end in leaving without completing treatment (6.7% v. 3.6%).

Conclusions

Further research is needed on the impact of First Nations identity on emergency care drivers and outcomes, and on emergency care for First Nations women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06415-2.

A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost

INTRODUCTION

Reducing costly and harmful ED use by patients classified as high need, high cost is a priority across health care systems. The purpose of this systematic review was to evaluate the impact of various primary care and payment models on ED use and overall costs in patients classified as high need, high cost.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was performed from January 2000 to March 2020 in 3 databases. Two reviewers independently appraised articles for quality. Studies were eligible if they evaluated models implemented in the primary care setting and in patients classified as high need, high cost in the United States. Outcomes included all-cause and preventable ED use and overall health care costs.

RESULTS

In the 21 articles included, 4 models were evaluated: care coordination (n = 8), care management (n = 7), intensive primary care (n = 4), and alternative payment models (n = 2). Statistically significant reductions in all-cause ED use were reported in 10 studies through care coordination, alternative payment models, and intensive primary care. Significant reductions in overall costs were reported in 5 studies, and 1 reported a significant increase. Care management and care coordination models had mixed effects on ED use and overall costs.

DISCUSSION

Studies that significantly reduced ED use had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Identifying primary care models that effectively enhance access to care and improve ongoing chronic disease management is imperative to reduce costly and harmful ED use in patients classified as high need, high cost.

Do access, quality and cost of general practice affect emergency department use?

Limited access, poor experience, and high out-of-pocket (OOP) costs of primary care services may lead to avoidable emergency department (ED) presentations. But, the evidence has been limited with most of the studies using surveys conducted in EDs. Using detailed health survey data of Australian women linked to multiple administrative datasets, we extend the literature by estimating the effects of access, costs, and experience of general practice (GP) services on the probability of ED attendance while accounting for a large set of health and socioeconomic covariates. Our findings suggest that improvements in access to primary care services can significantly reduce the demand for low acuity ED presentations. We also show that the impact of increased accessibility of GP services is expected to be the highest for socioeconomic vulnerable populations and patients whose access is the poorest. This evidence can be useful for the design of targeted policies aimed at improving access to doctors in particular areas that are socioeconomically disadvantaged and where medical skill shortages are significant. However, policies aimed at reduction in primary care OOP costs or improvement in the perception of GP quality are less likely to be effective in reducing the number of non-urgent ED presentations.

Will policy to constrain GP referrals damage health? Evidence using practice level NHS emergency admissions administrative data

Attempts to control hospital expenditure by managing down General Practitioner (GP) referrals are reoccurring features of UK health policy. However, despite the best efforts of GPs to benchmark referral criteria, patient health may be damaged and other costs created by constraining referrals to targets. This paper adopts an indirect method to indicate whether rationing practice referrals may damage population health by distorting the use of health resources away from patients' interests. We utilise a comprehensive database at practice level that allows us to explore the relationship between referrals and emergency admissions, using a panel fixed effects model of admissions that allows for the endogeneity of referrals. We find that practice referrals are positively and partially correlated with emergency admissions, which is consistent with time-varying practice-level sickness shocks driving the relationship between referrals and emergency care, rather than shocks to the practice willingness to refer, or to system reforms. In this environment, government policy to constrain referrals may make the elective care less responsive to practice-level variations in illness, and thereby lower health.

Prescribing practices of migraine-specific pharmacotherapy associated with emergency department use for migraine

OBJECTIVE

This study compared migraine medication prescribing between patients with a migraine diagnosis who used versus did not use the emergency department (ED) for migraine.

BACKGROUND

Headache is the fifth most common chief complaint for ED visits nationwide and the third most common potentially avoidable ED diagnosis in the University of Colorado Health system. The reasons some patients use the ED for migraine management while others do not and whether some ED admissions might be preventable remain unclear.

METHODS

This retrospective cohort study identified adults with migraine-related diagnoses within 1 year before the index date of July 1, 2018 and compared patient characteristics and migraine medication prescribing patterns between those who did or did not have a subsequent migraine-related ED encounter the following year. ED admission notes were manually reviewed to identify potentially preventable circumstances that led to the ED visit. The primary outcome was the proportion of patients with an active triptan prescription at the index date.

RESULTS

Of the 3843 patients identified, 35 patients (0.9%) had a migraine-related ED encounter. Of these, 17/35 (49%) had an active triptan prescription compared to 1360/3808 (36%) of non-ED utilizers (p = 0.114), OR 1.22 (95% CI 0.61-2.45). More ED utilizers had an active prescription for opioids (11/35 [31%] vs. 663/3808 [17%], p = 0.030) and migraine preventive therapy (19/35 [54%] vs. 1149/3808 [30%], p = 0.002), and neurology referrals (20/35 [57%] vs. 654/3808 [17%], p < 0.001) compared to non-ED utilizers. The most common circumstance for migraine-related ED visits was nonresponse to migraine abortive medications administered at home.

CONCLUSIONS

Triptan prescribing did not differ between ED utilizers and non-ED utilizers for migraine. Overall, less than half of the total patient population had a triptan prescribed. More ED utilizers had neurology referrals, prescriptions for opioids and preventive therapies, and a history of previous ED visit for any reason, which may be markers for higher disease severity or behavior patterns. Future research and interventions to reduce migraine-related ED use could target high-risk patients such as those with previous ED visits for any indication and neurology referrals.

Frequent use of emergency departments and chronic conditions in ageing societies: a retrospective analysis based in Italy

Background

Most western countries are facing relevant demographic changes, and the percentage of older people is destined to rise in the next decades. This fact is likely to affect the sustainability of healthcare systems significantly, mainly due to the connected issue of chronicity.

Methods

In this paper, using an extensive and comprehensive administrative dataset, we analyse the phenomenon of frequent use of emergency departments (ED) in the oldest region in Europe (i.e. Liguria) over 4 years (2013–2016). Two alternative approaches are used to define categories of ED users based on the intensity and frequency of accesses and splitting patients into different age groups.

Results

Results allow identifying clinical and socio-demographic risk-factors connected to different levels of ED utilisation and highlight the influential role played by chronic conditions (particularly mental disorders, respiratory diseases) and by multiple chronic conditions.

Conclusions

The study aims at representing an informative tool to support policy-makers in setting proper policies addressed, on the one side, towards the potentially preventable frequent users and, on the other, towards those accessing due to complex medical conditions. The results can help in building a warning system to help general practitioners in the identification of potential frequent users and to develop preventive policies.

Medicaid managed care and preventable emergency department visits in the United States

Objectives

In the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use.

Methods

Using data from the 2003–2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting.

Results

We found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy.

Conclusions

Within the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE

The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs).

RESEARCH DESIGN AND METHODS

Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models.

RESULTS

PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001).

CONCLUSIONS

Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review

Access to after-hours primary care is problematic in many developed countries, leading patients to instead visit the emergency department for non-urgent conditions. However, emergency department utilization for conditions treatable in primary care settings may contribute to emergency department overcrowding and increased health system costs. This systematic review examines the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency department and primary care utilization. We performed a systematic review on the impact of improved access to after-hours primary and searched CINAHL, EMBASE, MEDLINE, and Scopus. We identified 20 studies that examined the impact of improved access to after-hours primary care on ED utilization and 6 studies that examined the impact on primary care utilization. Improved access to after-hours primary care was associated with increased primary care utilization, but had a mixed effect on emergency department utilization, with limited evidence of a reduction in non-urgent and semi-urgent emergency department visits. Although our review suggests that improved access to after-hours primary care may limit emergency department utilization by shifting patient care from the emergency department back to primary care, rigorous research in a given institutional context is required before introducing any initiative to improve access to after-hours primary care.

What explains the regional variation in the use of general practitioners in Australia?

BACKGROUND

Regional variation in the use of health care services is widespread. Identifying and understanding the sources of variation and how much variation is unexplained can inform policy interventions to improve the efficiency and equity of health care delivery.

METHODS

We examined the regional variation in the use of general practitioners (GPs) using data from the Social Health Atlas of Australia by Statistical Local Area (SLAs). 756 SLAs were included in the analysis. The outcome variable of GP visits per capita by SLAs was regressed on a series of demand-side factors measuring population health status and demographic characteristics and supply-side factors measuring access to physicians. Each group of variables was entered into the model sequentially to assess their explanatory share on regional differences in GP usage.

RESULTS

Both demand-side and supply-side factors were found to influence the frequency of GP visits. Specifically, areas in urban regions, areas with a higher percentage of the population who are obese, who have profound or severe disability, and who hold concession cards, and areas with a smaller percentage of the population who reported difficulty in accessing services have higher GP usage. The availability of more GPs led to higher use of GP services while the supply of more specialists reduced use. 30.56% of the variation was explained by medical need. Together, both need-related and supply-side variables accounted for 32.24% of the regional differences as measured by the standard deviation of adjusted GP-consultation rate.

CONCLUSIONS

There was substantial variation in GP use across Australian regions with only a small proportion of them being explained by population health needs, indicating a high level of unexplained clinical variation. Supply factors did not add a lot to the explanatory power. There was a lot of variation that was not attributable to the factors we could observe. This could be due to more subtle aspects of population need or preferences and therefore warranted. However, it could be due to practice patterns or other aspects of supply and be unexplained. Future work should try to explain the remaining unexplained variation.

Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan

PURPOSE

The quality of health care, including primary care, is influenced by the context in which care is delivered. We investigated the association between primary care practice location and patient experience with a focus on differences between hospital-based practices and community-based office practices.

METHODS

We conducted a cross-sectional study in a primary care practice-based research network in Japan among 25 participating facilities: 6 small and medium-sized hospitals and 19 community-based offices. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness with respect to services available, comprehensiveness with respect to services provided, and community orientation.

RESULTS

Analyses were based on 1,725 primary care patients. After adjustment for possible confounders and clustering within facilities, compared with community-based office practices, hospital-based practices were associated with poorer patient experience of community orientation (adjusted mean difference = -5.76; 95% CI, -10.35 to -1.17). In contrast, hospital-based practices were associated with comparatively better patient experience of first contact (adjusted mean difference = 15.43; 95% CI, 5.13 to 25.72).

CONCLUSIONS

Our study elucidates differences in the strengths and challenges of primary care between hospital-based practices and community-based office practices, with a focus on patient centeredness. Improving community orientation in hospital-based practices and improving accessibility, including out-of-hours care, in community-based office practices may enhance the quality of primary care and promote standardization of care across settings.

How Are Patients Accessing Primary Care Within the Patient-Centered Medical Home? Results From the Veterans Health Administration

The patient-centered medical home (PCMH) expands access by providing care same-day, by phone, and after hours; however, little is known about which patients seek these services. We examined the association of patient, clinical, and local economic characteristics with the self-reported use of 5 routine and nonroutine ways to access primary care within the Veterans Health Administration. We identified sets of characteristics, including gender- and age-specific, racial and ethnic, and socioeconomic differences of how veterans report seeking primary care. As the PCMH model develops, it will be important to further understand the differential demand for these services to optimize patient-centered access.

Substituting emergency services: primary care vs. hospital care

Overcrowding in emergency departments (EDs) is inefficient, especially if it is caused by inappropriate visits for which primary care physicians could be equally effective as a hospital ED. Our paper investigates the extent to which both ambulatory ED visits and inpatient ED admissions are substitutes for primary care emergency services (PCES) in Germany. We use extensive longitudinal data and fixed effects models. Moreover, we add interaction terms to investigate the influence of various determinants on the strength of the substitution. Our results show significant substitution between PCES and ambulatory ED visits. Regarding the determinants, we find the largest substitution for younger patients. The more accessible the hospital ED is, the significantly larger the substitution. Moreover, substitution is larger among better-educated patients. For inpatient ED admission, we find significant substitution that is eight times smaller than the substitution for ambulatory ED visits. With regard to the determinants, we find the strongest substitution for non-urgent, short-stay admission and elderly patients. Countries with no gate-keeping system (such as Germany) have difficulties redirecting the patients streaming to EDs. Our estimated elasticities can help policy makers to resolve this issue, as our findings indicate where incentivizing the utilization of PCES is particularly effective.

The Impact of Medicaid Managed Care on Health Service Utilization Among Adults With Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) are frequent users of health services. We examined how their service utilization of emergency department (ED), inpatient hospitalization, and primary care physicians changed as they transitioned from fee-for-service to Medicaid managed care (MMC). Our results showed that MMC reduced the utilization of all of these services. A substantial decrease in ED visits was associated with the reduction in visits due to mental/behavioral health conditions and conditions that could be nonemergent and manageable with the community-based health services. These findings suggest that health service utilization of people with IDD is related not only to their health needs, but also to the delivery model that provides their health services.

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

BACKGROUND

The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.

OBJECTIVE

To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).

DESIGN

Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects.

PARTICIPANTS

A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.

MAIN MEASURES

Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.

KEY RESULTS

Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.

CONCLUSIONS

Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.

Low and Higher Wage Workers Report No Differences in Four Barriers to Primary Care Access

Lower wage workers, known to seek more care in the emergency department (ED), may encounter more barriers to timely outpatient primary care. This study aimed to identify differences in self-reported delays in care related to 4 modifiable barriers (phone availability, appointment wait time, in-clinic wait time, and limited service hours) across self-reported wage and to examine the relationship between these care delays and self-reported ED use. The authors examined data from the 2011-2015 National Health Interview Surveys for 58,298 self-identified full-time workers. Multivariable logistic models with geographical region and year fixed effects were used to test the association of wage group and barriers to care. In addition, the multiplicative and additive interaction effects upon self-reported ED use were tested. No association was observed between wage level and barrier to timely care. Lower wage workers (<$25,000 vs. >$75,000/yr.; OR 1.53, 95% CI 1.20-1.94, P = 0.001) and those reporting any of the 4 barriers to care (OR 1.99, 95% CI 1.71-1.94, P < 0.001) were more likely to report 2 or more ED visits in the past year. Multiplicative effects were not statistically significant. Additive interaction effects of wage and barriers were only significant among workers with wages $35,000-$44,999 annually (vs. >$75,000: relative excess risk coef. 1.23, 95% CI 0.07-2.38, P = 0.037) for 2 or more ED visits in past year. Although these modifiable barriers may explain the differences in repeat ED use for workers earning $35,000-$44,999 annually, these barriers do not explain disparities in ED use between highest and lowest wage workers.

Emergency Department and Primary Care Use in Massachusetts 5 Years After Health Reform

OBJECTIVE

Conceptually, access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions. We sought to identify characteristics of insured Massachusetts residents associated with PCS ED use, and compare such use for public versus private insurees.

POPULATION AND SETTING

People under age 65 in the Massachusetts All-Payer Claims Data, 2011-2012.

STUDY DESIGN

Retrospective, observational analysis of PCS ED use with nonurgent, urgent/primary care treatable, and urgent/potentially avoidable visits being considered PCS. We predicted utilization in 2012 using multivariable regression models and data available in 2011 administrative records.

PRINCIPAL FINDINGS

Among 2,269,475 nonelderly Massachusetts residents, 40% had public insurance. Among public insurees, PCS ED use was higher than for private (mean, 36.5 vs. 9.0 per 100 persons; adjusted risk ratio, 2.53; 95% confidence limits, 2.49-2.56), while having any primary care visit was less common (70% vs. 83%), as was having any visit to one's own (attributed) primary care provider (38% vs. 44%).

CONCLUSIONS

Public insurance was associated with less access to primary care and more PCS ED use; statewide labor shortages and low reimbursement rates from public insurance may have provided inadequate access to care that might otherwise have helped reduce PCS ED use.

Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial

Introduction:

Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization.

Methods:

We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input.

Results:

2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures.

Discussion:

A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs.

Conclusion:

Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.

The Effect of a Primary Care Provider Incentive Program on Pediatric Emergency Medicine Visits

OBJECTIVE

The aim of the study was to analyze the effect of a financial incentive program targeting primary care providers (PCPs) with the goal of decreasing emergency department (ED) utilization.

METHODS

We performed a retrospective cohort analysis in a single health maintenance organization comparing ED visit/1000 member-months before and after the physician incentive program in 2009. We compared the median ED visit rate between physicians who did (PIP) and did not participate (non-PIP) from 2009 to 2012. We used 2008 data as a baseline study period to compare the ED visit rate between PIP and non-PIP providers to detect any inherent difference between the 2 groups.

RESULTS

A total of 1376 PCPs were enrolled. A total of US $18,290,817 was spent in total on incentives. Overall, the median ED visit rate for all providers was statistically significantly lower during the study period (baseline period, study period: 56.36 ED visits/1000 member-months vs 45.82, respectively, P < 0.001). During the baseline period in our fully adjusted linear regression for degree, specialty, education, and board status, PIP versus non-PIP visits were not statistically significantly different (P = 0.17). During the study period in our fully adjusted model, we found that PIP had statistically significant fewer ED visits compared with non-PIP (P = 0.02). In a subgroup analysis of providers who did and did not receive an incentive payment, in the fully adjusted linear regression, providers who received any payment had statistically significant fewer ED visits/1000 member-months (P < 0.001). In addition, we found in the fully adjusted analysis that those providers who received at least 1 incentive payment for meeting after-hours criteria had statistically significantly fewer ED visits/1000 member-months (P < 0.001).

CONCLUSIONS

A financial incentive program to provide PCPs with specific targets and goals to decrease pediatric ED utilization can decrease ED visits.

Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia

PURPOSE

Providing care in alternative (non-office) locations and outside office hours are important elements of access and comprehensiveness of primary care. We examined the trends in and determinants of the services provided in a cohort of primary care physicians in British Columbia, Canada.

METHODS

We used physician-level payments for all primary care physicians practicing in British Columbia from 2006-2007 through 2011-2012. We examined the association between physician demographics and practice characteristics and payment for care in alternative locations and after hours across rural, urban, and metropolitan areas using longitudinal mixed-effects models.

RESULTS

The proportion of physicians who provided care in alternative locations and after hours declined significantly during the period, in rural, urban, and metropolitan practices. Declines ranged from 5% for long-term care facility visits to 22% for after-hours care. Female physicians, and those in the oldest age category, had lower odds of providing care at alternative locations and for urgent after-hours care. Compared with those practicing in metropolitan centers, physicians working in rural areas had significantly higher odds of providing care both in alternative locations and after hours.

CONCLUSION

Care provided in non-office locations and after office hours declined significantly during the study period. Jurisdictions where providing these services are not mandated, and where similar workforce demographic shifts are occurring, may experience similar accessibility challenges.

Precision of provider licensure data for mapping member accessibility to Medicaid managed care provider networks

BACKGROUND

In July 2018, the Centers for Medicare and Medicaid Services (CMS) updated its Medicaid Managed Care (MMC) regulations that govern network and access standards for enrollees. There have been few published studies of whether there is accurate geographic information on primary care providers to monitor network adequacy.

METHODS

We analyzed a sample of nurse practitioner (NP) and physician address data registered in the state labor, licensing, and regulation (LLR) boards and the National Provider Index (NPI) using employment location data contained in the patient-centered medical home (PCMH) data file. Our main outcome measures were address discordance (%) at the clinic-level, city, ZIP code, and county spatial extent and the distance, in miles, between employment location and the LLR/NPI address on file.

RESULTS

Based on LLR records, address information provided by NPs corresponded to their place of employment in 5% of all cases. NP address information registered in the NPI corresponded to their place of employment in 64% of all cases. Among physicians, the address information provided in the LLR and NPI corresponded to the place of employment in 64 and 72% of all instances. For NPs, the average distance between the PCMH and the LLR address was 21.5 miles. Using the NPI, the distance decreased to 7.4 miles. For physicians, the average distance between the PCMH and the LLR and NPI addresses was 7.2 and 4.3 miles.

CONCLUSIONS

Publicly available data to forecast state-wide distributions of the NP workforce for MMC members may not be reliable if done using state licensure board data. Meaningful improvements to correspond with MMC policy changes require collecting and releasing information on place of employment.

Implementation of an Asthma Self-Management Education Guideline in the Emergency Department: A Feasibility Study

Patients often present to emergency departments (EDs) for the management of chronic asthma. Because of the nature of ED care, national guideline recommendations for asthma education are generally not initiated in the ED. There is evidence that asthma education can have a positive effect on patient outcomes (; ). This study examines the feasibility of implementing an asthma self-management guideline in a tertiary care center ED. Despite protocol utilization by physicians (87%), nurse practitioners and physician assistants (66.7%), and nurses (41.7%), total compliance with national guideline was accomplished in only 25.93% of cases. Barriers to protocol implementation included staff education, high workload, rapid turnover, and competing initiatives within the department. Linear regression analysis identified high daily census as a predictor of protocol noncompliance (p = 0.033).

Postpartum Hospital Utilization among Massachusetts Women with Intellectual and Developmental Disabilities: A Retrospective Cohort Study

Objectives This study examined the risk of postpartum hospital admissions and emergency department (ED) visits among US women with intellectual and developmental disabilities (IDD). Methods We used the 2002-2012 Pregnancy to Early Life Longitudinal Data System and identified deliveries to women with and without IDD. Women with IDD (n = 1104) or case subjects were identified from the International Classification of Diseases and Related Health Problems 9th Revision (ICD-9 CM) codes. The study primary outcome measures were any postpartum hospital admission and any ED visit during three critical postpartum periods (1-42, 43-90, and 1-365 days). We conducted unadjusted and adjusted survival analysis using Cox proportional hazard models to compare the occurrence of first hospital admission or ED visits between women with and without IDD. Results We found that women with IDD had markedly higher rates of postpartum hospital admissions and ED visits during the critical postpartum periods (within 1-42, 43-90, and 91-365 days) after a childbirth. Conclusion for Practice Given the heightened risk of pregnancy complications and adverse birth outcomes and the findings of this study, there is an urgent need for clinical guidelines related to the frequency and timing of postpartum care among new mothers with IDD. Further, this study provides evidence of the need for evidence-based interventions for new mothers with IDD to provide preventive care and routine assessments that would identify and manage complications for both the mother and the infant outside of the traditional postpartum health care framework.

Medicaid Managed Care in Florida and Racial and Ethnic Disparities in Preventable Emergency Department Visits

BACKGROUND

In an effort to address health care spending growth, coordinate care, and improve access to primary care in the Medicaid program, Florida implemented the Statewide Mandatory Managed Care (SMMC) program in May of 2014.

OBJECTIVES

The objective of this study is to investigate the impact of implementation of mandatory managed care in Medicaid on the preventable emergency department (ED) utilizations, with a focus on racial/ethnic minorities.

RESEARCH DESIGN

The primary data source is the universe of Florida ED visit and inpatient discharge data from 2010 to 2015, maintained by the Florida Agency for Health Care Administration. We adopt the New York University Billing's ED Classification Algorithm to create measures for preventable ED visits. Using difference-in-differences estimation, we examine preventable ED visits for Florida residents aged 18-64 with a primary payer of Medicaid (treatment group) and private health insurance (control group) pre-SMMC and post-SMMC reform.

RESULTS

Our findings show that SMMC is statistically significantly associated with more reductions in preventable ED visits among non-Hispanic African American (incidence rate ratio=0.81; 95% confidence interval, 0.70-0.94) and Hispanic (incidence rate ratio=0.72; 95% CI, 0.60-0.87) Medicaid enrollees relative to their white counterparts. We also find significant reduction of racial/ethnic disparities only in counties with above median preimplementation Medicaid managed care penetration rate.

CONCLUSIONS

Our findings suggest that implementation of Medicaid mandatory managed care in Florida is associated with reduced racial/ethnic disparities in preventable ED visits.

Do Financial Incentives Influence GPs' Decisions to Do After-hours Work? A Discrete Choice Labour Supply Model

This paper analyses doctors' supply of after-hours care (AHC), and how it is affected by personal and family circumstances as well as the earnings structure. We use detailed survey data from a large sample of Australian General Practitioners (GPs) to estimate a structural, discrete choice model of labour supply and AHC. This allows us to jointly model GPs' decisions on the number of daytime-weekday working hours and the probability of providing AHC. We simulate GPs' labour supply responses to an increase in hourly earnings, both in a daytime-weekday setting and for AHC. GPs increase their daytime-weekday working hours if their hourly earnings in this setting increase, but only to a very small extent. GPs are somewhat more likely to provide AHC if their hourly earnings in that setting increase, but again, the effect is very small and only evident in some subgroups. Moreover, higher earnings in weekday-daytime practice reduce the probability of providing AHC, particularly for men. Increasing GPs' earnings appears to be at best relatively ineffective in encouraging increased provision of AHC and may even prove harmful if incentives are not well targeted. Copyright © 2017 John Wiley & Sons, Ltd.

The impact of improving access to primary care

OBJECTIVES

To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014).

STUDY DESIGN AND METHODS

Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs.

RESULTS

The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P < 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (-43% vs -5%, P < 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub-group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P < 0.001) across the study period.

CONCLUSIONS

The potential for long-term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.

Key factors of case management interventions for frequent users of healthcare services: a thematic analysis review

OBJECTIVE

The aim of this paper was to identify the key factors of case management (CM) interventions among frequent users of healthcare services found in empirical studies of effectiveness.

DESIGN

Thematic analysis review of CM studies.

METHODS

We built on a previously published review that aimed to report the effectiveness of CM interventions for frequent users of healthcare services, using the Medline, Scopus and CINAHL databases covering the January 2004-December 2015 period, then updated to July 2017, with the keywords 'CM' and 'frequent use'. We extracted factors of successful (n=7) and unsuccessful (n=6) CM interventions and conducted a mixed thematic analysis to synthesise findings. Chaudoir's implementation of health innovations framework was used to organise results into four broad levels of factors: (1) ,environmental/organisational level, (2) practitioner level, (3) patient level and (4) programme level.

RESULTS

Access to, and close partnerships with, healthcare providers and community services resources were key factors of successful CM interventions that should target patients with the greatest needs and promote frequent contacts with the healthcare team. The selection and training of the case manager was also an important factor to foster patient engagement in CM. Coordination of care, self-management support and assistance with care navigation were key CM activities. The main issues reported by unsuccessful CM interventions were problems with case finding or lack of care integration.

CONCLUSIONS

CM interventions for frequent users of healthcare services should ensure adequate case finding processes, rigorous selection and training of the case manager, sufficient intensity of the intervention, as well as good care integration among all partners. Other studies could further evaluate the influence of contextual factors on intervention impacts.

Online Reviews as Health Data: Examining the Association Between Availability of Health Care Services and Patient Star Ratings Exemplified by the Yelp Academic Dataset

BACKGROUND

There have been public health interventions that aim to reduce barriers to health care access by extending opening hours of health care facilities. However, the impact of opening hours from the patient's perspective is not well understood.

OBJECTIVE

This study aims to investigate the relationship between temporal accessibility of health care services and how patients rate the providers on Yelp, an online review website that is popular in the United States. Using crowdsourced open Internet data, such as Yelp, can help circumvent the traditional survey method.

METHODS

From Yelp's limited academic dataset, this study examined the pattern of visits to health care providers and performed a secondary analysis to examine the association between patient rating (measured by Yelp's rating) and temporal accessibility of health care services (measured by opening hours) using ordinal logistic regression models. Other covariates included were whether an appointment was required, the type of health care service, the region of the health care service provider, the number of reviews the health care service provider received in the past, the number of nearby competitors, the mean rating of competitors, and the standard deviation of competitors' ratings.

RESULTS

From the 2085 health care service providers identified, opening hours during certain periods, the type of health care service, and the variability of competitors' ratings showed an association with patient rating. Most of the visits to health care service providers took place between normal working hours (9 AM-5 PM) from Sunday to Thursday, and the least on Saturday. A model fitted to the entire sample showed that increasing hours during normal working hours on Monday (OR 0.926, 95% CI 0.880-0.973, P=0.03), Saturday (OR 0.897, 95% CI 0.860-0.935, P<0.001), Sunday (OR 0.904, 95% CI 0.841-0.970, P=0.005), and outside normal working hours on Friday (OR 0.872, 95% CI 0.760-0.998, P=0.048) was associated with receiving lower ratings. But increasing hours during outside normal working hours on Sunday was associated with receiving higher ratings (OR 1.400, 95% CI 1.036-1.924, P=0.03). There were also observed differences in patient ratings among the health care services types, but not geographically or by appointment requirement.

CONCLUSIONS

This study shows that public health interventions, especially those involving opening hours, could use crowdsourced open Internet data to enhance the evidence base for decision making and evaluation in the future. This study illustrates one example of how Yelp data could be used to understand patient experiences with health care services, making a case for future research for exploring online reviews as a health dataset.

A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial

Few interventions to improve asthma outcomes have targeted low-income minority adults. Even fewer have focused on the real-world practice where care is delivered. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, to facilitate and maintain access to chronic care for adults with moderate or severe asthma and prevalent co-morbidities recruited from clinics serving low-income urban neighborhoods. We describe the planning, design, methodology (informed by patient and provider focus groups), baseline results, and challenges of an ongoing randomized controlled trial of 312 adults of a PA intervention implemented in a variety of practices. The PA coaches, models, and assists participants with preparations for a visit with the asthma clinician; attends the visit with permission of participant and provider; and confirms participants' understanding of what transpired at the visit. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients' unique social and administrative barriers to carrying out medical advice and transfer of information between providers and patients. PA activities are individualized, take account of comorbidities, and are generalizable to other chronic diseases. PAs are recent college graduates interested in health-related careers, research experience, working with patients, and generally have the same race/ethnicity distribution as potential participants. We test whether the PA intervention, compared to usual care, is associated with improved and sustained asthma control and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) relative to baseline. Mediators and moderators of the PA-asthma outcome relationship are examined along with the intervention's cost-effectiveness.

Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter?

CONTEXT

Overutilization and overreliance on Emergency Departments (EDs) as a usual source of care can lead to unnecessarily high costs and undesirable consequences, such as a gap in care coordination and inadequate provision of preventive care.

OBJECTIVE

To identify factors associated with multiple ED visits by patients, in particular, the impact of primary care physicians (PCPs) on their patients' multiple ED visit rates.

DESIGN

Geisinger Health Plan claims data among adult patients who averaged more than 1 ED visit within a 12-month period between 2013 and 2014 were obtained (N = 20,351).

MAIN OUTCOME MEASURES

Rate of ED visits. Three linear regression models using patient characteristics and utilization patterns as covariates along with PCP fixed effects were estimated to explain the variation in the multiple ED visit rates.

RESULTS

Multiple ED visits were significantly associated with younger age (18-39 years), having Medicaid insurance, and greater comorbidity. Higher rates of physician office visits and inpatient admissions were also associated with higher rates of multiple ED visits. Accounting for PCP characteristics only marginally improved the explained variation (R² increased from 0.14 to 0.16).

CONCLUSIONS

Multiple ED visit patterns are likely driven by patients' health conditions and care needs rather than by their PCPs. Multiple ED visits also appear to be complementary, rather than substitutionary, to PCP visits, suggesting that PCP-focused interventions aimed at reducing ED use are unlikely to have a major impact.

Pediatric Gastrostomy Tube Placement: Lessons Learned from High-performing Institutions through Structured Interviews

INTRODUCTION

Gastrostomy tube (GT) placement is one of the most common operations performed in children, and it is plagued by high complication rates. Previous studies have shown variation in readmission and emergency room visit rates across different children's hospitals, with both low and high outliers. There is an opportunity to learn how to optimize outcomes by identifying practices at high-performing institutions.

METHODS

Surgeons and nurses routinely involved in GT care at 8 high-performing pediatric centers were identified. We conducted structured interviews focusing on the approach to GT education, technical aspects of GT placement, and postoperative management. Summary statistics were performed on quantitative data, and the open-ended responses were analyzed by 2 independent reviewers using content analysis.

RESULTS

Several common practices among high-performing centers were identified (standardized approach to education, availability by phone and in clinic to manage GT-related issues, and empowering families to feel confident with troubleshooting and dealing with GT problems). There was substantial variation in operative technique and postoperative care. The participants expressed that technical aspects of operative placement and postoperative management of feedings and common complications are not as important as education, availability, and empowerment in optimizing outcomes.

CONCLUSIONS

We have identified common themes among pediatric centers with favorable outcomes after GT placement. Identifying which components of GT care are associated with optimal outcomes is critical to our understanding of current practice and may help identify opportunities to improve care quality.

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.