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Awtry JA, Abernathy JH, Wu X, Yang J, Zhang M, Hou H, Kaneko T, de la Cruz KI, Stakich-Alpirez K, Yule S, Cleveland JC, Shook DC, Fitzsimons MG, Harrington SD, Pagani FD, Likosky DS. Evaluating the Impact of Operative Team Familiarity on Cardiac Surgery Outcomes: A Retrospective Cohort Study of Medicare Beneficiaries. Ann Surg 2024; 279:891-899. [PMID: 37753657 PMCID: PMC10965508 DOI: 10.1097/sla.0000000000006100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To associate surgeon-anesthesiologist team familiarity (TF) with cardiac surgery outcomes. BACKGROUND TF, a measure of repeated team member collaborations, has been associated with improved operative efficiency; however, examination of its relationship to clinical outcomes has been limited. METHODS This retrospective cohort study included Medicare beneficiaries undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), or both (CABG+SAVR) between January 1, 2017, and September 30, 2018. TF was defined as the number of shared procedures between the cardiac surgeon and anesthesiologist within 6 months of each operation. Primary outcomes were 30- and 90-day mortality, composite morbidity, and 30-day mortality or composite morbidity, assessed before and after risk adjustment using multivariable logistic regression. RESULTS The cohort included 113,020 patients (84,397 CABG; 15,939 SAVR; 12,684 CABG+SAVR). Surgeon-anesthesiologist dyads in the highest [31631 patients, TF median (interquartile range)=8 (6, 11)] and lowest [44,307 patients, TF=0 (0, 1)] TF terciles were termed familiar and unfamiliar, respectively. The rates of observed outcomes were lower among familiar versus unfamiliar teams: 30-day mortality (2.8% vs 3.1%, P =0.001), 90-day mortality (4.2% vs 4.5%, P =0.023), composite morbidity (57.4% vs 60.6%, P <0.001), and 30-day mortality or composite morbidity (57.9% vs 61.1%, P <0.001). Familiar teams had lower overall risk-adjusted odds of 30-day mortality or composite morbidity [adjusted odds ratio (aOR) 0.894 (0.868, 0.922), P <0.001], and for SAVR significantly lower 30-day mortality [aOR 0.724 (0.547, 0.959), P =0.024], 90-day mortality [aOR 0.779 (0.620, 0.978), P =0.031], and 30-day mortality or composite morbidity [aOR 0.856 (0.791, 0.927), P <0.001]. CONCLUSIONS Given its relationship with improved 30-day cardiac surgical outcomes, increasing TF should be considered among strategies to advance patient outcomes.
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Affiliation(s)
- Jake A. Awtry
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Boston, MA
| | - James H. Abernathy
- Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiaoting Wu
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Jie Yang
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Hechuan Hou
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University in St Louis/Barnes-Jewish Hospital, St. Louis, MO
| | - Kim I. de la Cruz
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Korana Stakich-Alpirez
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
| | - Steven Yule
- School of Surgery, University of Edinburgh, Scotland, UK
| | - Joseph C. Cleveland
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Douglas C. Shook
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Michael G. Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Donald S. Likosky
- Department of Cardiac Surgery, Section of Health Services Research and Quality, Michigan Medicine, Ann Arbor, MI
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Matthews LJ, Damberg CL, Zhang S, Escarce JJ, Gibson CB, Schuler M, Popescu I. Within-Physician Differences in Patient Sharing Between Primary Care Physicians and Cardiologists Who Treat White and Black Patients With Heart Disease. J Am Heart Assoc 2023; 12:e030653. [PMID: 37982233 PMCID: PMC10727292 DOI: 10.1161/jaha.123.030653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Black-White disparities in heart disease treatment may be attributable to differences in physician referral networks. We mapped physician networks for Medicare patients and examined within-physician Black-White differences in patient sharing between primary care physicians and cardiologists. METHODS AND RESULTS Using Medicare fee-for-service files for 2016 to 2017, we identified a cohort of Black and White patients with heart disease and the primary care physicians and cardiologists treating them. To ensure the robustness of within-physician comparisons, we restricted the sample to regional health care markets (ie, hospital referral regions) with at least 10 physicians sharing ≥3 Black and White patients. We used claims to construct 2 race-specific physician network measures: degree (number of cardiologists with whom a primary care physician shares patients) and transitivity (network tightness). Measures were adjusted for Black-White differences in physician panel size and calculated for all settings (hospital and office) and for office settings only. Of 306 US hospital referral regions, 226 and 145 met study criteria for all settings and office setting analyses, respectively. Black patients had more cardiology encounters overall (6.9 versus 6.6; P<0.001) and with unique cardiologists (3.0 versus 2.6; P<0.001), but fewer office encounters (31.7% versus 41.1%; P<0.001). Primary care physicians shared Black patients with more cardiologists than White patients (mean differential degree 23.4 for all settings and 3.6 for office analyses; P<0.001 for both). Black patient-sharing networks were less tightly connected in all but office settings (mean differential transitivity -0.2 for all settings [P<0.001] and near 0 for office analyses [P=0.74]). CONCLUSIONS Within-physician Black-White differences in patient sharing exist and may contribute to disparities in cardiac care.
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Affiliation(s)
| | | | | | | | | | | | - Ioana Popescu
- RAND CorporationSanta MonicaCA
- David Geffen School of Medicine at UCLALos AngelesCA
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Lin SC, Hammond G, Esposito M, Majewski C, Foraker RE, Joynt Maddox KE. Segregated Patterns of Hospital Care Delivery and Health Outcomes. JAMA HEALTH FORUM 2023; 4:e234172. [PMID: 37991783 PMCID: PMC10665978 DOI: 10.1001/jamahealthforum.2023.4172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/29/2023] [Indexed: 11/23/2023] Open
Abstract
Importance Residential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care. Objective To characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes. Design, Setting, and Participants This cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023. Exposures Dissimilarity index and isolation index for HRRs. Main Outcomes and Measures Health outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes. Results This study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients. Conclusions and Relevance This cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.
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Affiliation(s)
- Sunny C. Lin
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Gmerice Hammond
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
| | | | - Cassandra Majewski
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Randi E. Foraker
- Division of General Medical Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | - Karen E. Joynt Maddox
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
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HSUAN CHARLEEN, CARR BRENDANG, VANNESS DAVID, WANG YINAN, LESLIE DOUGLASL, DUNHAM ELEANOR, ROGOWSKI JEANNETTEA. A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks. Milbank Q 2023; 101:74-125. [PMID: 36919402 PMCID: PMC10037699 DOI: 10.1111/1468-0009.12609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [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] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Kim KD, Funk RJ, Hou H, Airhart A, Nassar K, Pagani FD, Zhang M, Chandanabhumma PP, Aaronson KD, Chenoweth CE, Hider A, Cabrera L, Likosky DS. Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset. Circ Cardiovasc Qual Outcomes 2022; 15:e008592. [PMID: 36065815 PMCID: PMC9489640 DOI: 10.1161/circoutcomes.121.008592] [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: 11/16/2022]
Abstract
BACKGROUND Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008). CONCLUSIONS Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.
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Affiliation(s)
- K. Dennie Kim
- Strategy, Ethics, and Entrepreneurship, Darden School of Business, University of Virginia, Charlottesville, VA
| | - Russell J. Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Khalil Nassar
- University Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - P. Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Ahmad Hider
- University of Michigan Medical School, Ann Arbor, MI
| | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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McDermott J, Wang H, DeLia D, Sweeney M, Bayasi M, Unger K, Stein DE, Al-Refaie WB. Impact of Clinician Linkage on Unequal Access to High-Volume Hospitals for Colorectal Cancer Surgery. J Am Coll Surg 2022; 235:99-110. [PMID: 35703967 DOI: 10.1097/xcs.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Understanding drivers of persistent surgical disparities remains an important area of cancer care delivery and policy. The degree to which clinician linkages contribute to disparities in access to quality colorectal cancer surgery is unknown. Using hospital surgical volume as a proxy for quality, the study team evaluated how clinician linkages impact access to colorectal cancer surgery at high-volume hospitals (HVHs). STUDY DESIGN Maryland's Health Services Cost Review Commission was used to evaluate 6,909 patients who underwent colon or rectal cancer operations from 2013 to 2018. Two linkages based on patient sharing were examined separately for colon and rectal cancer surgery: (1) from primary care clinicians to specialists (gastroenterologist or medical oncologist) and (2) from specialists to surgeons (general or colorectal). A referral link was defined as 9 or more shared patients between 2 clinicians. Adjusted regression models examined associations between referral links and odds of receiving colon or rectal cancer operations at HVHs. RESULTS The cohort included 5,645 colon and 1,264 rectal cancer patients across 52 hospitals. Every additional referral link between a primary care clinician and a specialist connected to a HVH was associated with a 12% and 14% increased likelihood of receiving colon (odds ratio [OR] 1.12, CI 1.07 to 1.17) and rectal (OR 1.14, CI 1.08 to 1.20]) cancer operations at a HVH, respectively. Every additional referral link between a specialist and a surgeon at a HVH was associated with at least a 25% increased likelihood of receiving colon (OR 1.28, CI 1.20 to 1.36) and rectal (OR 1.25, CI 1.15 to 1.36) cancer operation at a HVH. CONCLUSIONS Patients of clinicians with linkages to HVHs are more likely to have their colorectal cancer operations at these hospitals. These findings suggest that policy interventions targeting clinician relationships are an important step in providing equitable surgical care.
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Affiliation(s)
- James McDermott
- From the David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA (McDermott)
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
| | - Haijun Wang
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
| | - Derek DeLia
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - Matthew Sweeney
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
| | - Mohammed Bayasi
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - Keith Unger
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - David E Stein
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
| | - Waddah B Al-Refaie
- the MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC (McDermott, Wang, Sweeney, Al-Refaie)
- the MedStar Health Research Institute, Washington, DC (Wang, DeLia, Stein, Al-Refaie)
- the Department of Surgery, MedStar-Georgetown University Hospital Washington, DC (DeLia, Bayasi, Unger, Al-Refaie)
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Ssegujja E, Ddumba I, Andipatin M. Health workers' social networks and their influence in the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000798. [PMID: 36962455 PMCID: PMC10021602 DOI: 10.1371/journal.pgph.0000798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Health workers' peer networks are known to influence members' behaviours and practices while translating policies into service delivery. However, little remains known about the extent to which this remains true within interventions aimed at addressing the stillbirth burden in low-resource settings like Uganda. The objective of this study was to examine the health workers' social networks and their influence on the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. A qualitative exploratory design was adopted on a purposively selected sample of 16 key informants. The study was conducted in Mukono district among sub-national health systems, managers, health facility in-charges, and frontline health workers. Data was collected using semi-structured interview guides in a face-to-face interview with respondents. The analysis adopted a thematic approach utilising Atlas. ti software for data management. Participants acknowledged that workplace social networks were influential during the implementation of policies to address stillbirth. The influence exerted was in form of linkage with other services, caution, and advice regarding strict adherence to policy recommendations perhaps reflective of the level of trust in providers' ability to adhere to policy provisions. At the district health management level and among non-state actors, support in perceived areas of weak performance in policy implementation was observed. In addition, timely initiation of contact and subsequent referral was another aspect where health workers exerted influence while translating policies to address the stillbirth burden. While the level of support from among network peers was observed to influence health workers' adoption and implementation of strategies to address the stillbirth burden, different mechanisms triggered subsequent response and level of adherence to recommended policy aspects. Drawing from the elicited responses, we infer that health workers' social networks influence the direction and extent of success in policy implementation to address the stillbirth burden at the subnational level.
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Affiliation(s)
- Eric Ssegujja
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Faculty of Community and Health Sciences, School of Public Health, University of the Western Cape, Cape Town, Republic of South Africa
| | - Isaac Ddumba
- Department of Health, Mukono District Local Government, Mukono, Uganda
| | - Michelle Andipatin
- Faculty of Community and Health Sciences, Department of Psychology, University of the Western Cape, Cape Town, Republic of South Africa
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Cohen-Mekelburg S, Yu X, Costa D, Hofer TP, Krein S, Hollingsworth J, Wiitala W, Saini S, Zhu J, Waljee A. Variation in Provider Connectedness Associates With Outcomes of Inflammatory Bowel Diseases in an Analysis of Data From a National Health System. Clin Gastroenterol Hepatol 2021; 19:2302-2311.e1. [PMID: 32798705 PMCID: PMC9131729 DOI: 10.1016/j.cgh.2020.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBD) often require multidisciplinary care with tight coordination among providers. Provider connectedness, a measure of the relationship among providers, is an important aspect of care coordination that has been linked to higher quality care. We aimed to assess variation in provider connectedness among medical centers, and to understand the association between this established measure of care coordination and outcomes of patients with IBD. METHODS We conducted a national cohort study of 32,949 IBD patients with IBD from 2005 to 2014. We used network analysis to examine provider connectedness, defined using network properties that measure the strength of the collaborative relationship, team cohesiveness, and between-facility collaborations. We used multilevel modeling to examine variations in provider connectedness and association with patient outcomes. RESULTS There was wide variation in provider connectedness among facilities in complexity, rural designation, and volume of patients with IBD. In a multivariable model, patients followed in a facility with team cohesiveness (odds ratio, 0.38; 95% CI, 0.16-0.88) and where providers often collaborated with providers outside their facility (odds ratio, 0.48; 95% CI, 0.31-0.75) were less likely to have clinically active disease, defined by a composite of outpatient flare, inpatient flare, and IBD-related surgery. CONCLUSIONS A national study found evidence for heterogeneity in patient-sharing among IBD care teams. Patients with IBD seen at health centers with higher provider connectedness appear to have better outcomes. Understanding provider connectedness is a step toward designing network-based interventions to improve coordination and quality of care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, Ann Arbor, Michigan; Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Xianshi Yu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Deena Costa
- Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sarah Krein
- VA Center for Clinical Management Research, Ann Arbor, Michigan, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John Hollingsworth
- Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Wyndy Wiitala
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer Saini
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Akbar Waljee
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, VA Center for Clinical Management Research, Ann Arbor, Michigan, Institute of Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Nemesure MD, Schwedhelm TM, Sacerdote S, O’Malley AJ, Rozema LR, Moen EL. A measure of local uniqueness to identify linchpins in a social network with node attributes. APPLIED NETWORK SCIENCE 2021; 6:56. [PMID: 34938853 PMCID: PMC8691752 DOI: 10.1007/s41109-021-00400-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/02/2021] [Indexed: 06/14/2023]
Abstract
Network centrality measures assign importance to influential or key nodes in a network based on the topological structure of the underlying adjacency matrix. In this work, we define the importance of a node in a network as being dependent on whether it is the only one of its kind among its neighbors' ties. We introduce linchpin score, a measure of local uniqueness used to identify important nodes by assessing both network structure and a node attribute. We explore linchpin score by attribute type and examine relationships between linchpin score and other established network centrality measures (degree, betweenness, closeness, and eigenvector centrality). To assess the utility of this measure in a real-world application, we measured the linchpin score of physicians in patient-sharing networks to identify and characterize important physicians based on being locally unique for their specialty. We hypothesized that linchpin score would identify indispensable physicians who would not be easily replaced by another physician of their specialty type if they were to be removed from the network. We explored differences in rural and urban physicians by linchpin score compared with other network centrality measures in patient-sharing networks representing the 306 hospital referral regions in the United States. We show that linchpin score is uniquely able to make the distinction that rural specialists, but not rural general practitioners, are indispensable for rural patient care. Linchpin score reveals a novel aspect of network importance that can provide important insight into the vulnerability of health care provider networks. More broadly, applications of linchpin score may be relevant for the analysis of social networks where interdisciplinary collaboration is important.
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Affiliation(s)
- Matthew D. Nemesure
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
| | - Thomas M. Schwedhelm
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
| | | | - A. James O’Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
| | - Luke R. Rozema
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
| | - Erika L. Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
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Toumi A, DiGennaro C, Vahdat V, Jalali MS, Gazelle GS, Chhatwal J, Kelz RR, Lubitz CC. Trends in Thyroid Surgery and Guideline-Concordant Care in the United States, 2007-2018. Thyroid 2021; 31:941-949. [PMID: 33280499 PMCID: PMC8215427 DOI: 10.1089/thy.2020.0643] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: The American Thyroid Association (ATA) published the 2015 Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, recommending a shift to less aggressive diagnostic, surgical, and postoperative treatment strategies. At the same time and perhaps related to the new guidelines, there has been a shift to outpatient thyroid surgery. The aim of the current study was to assess physician adherence to these recommendations by identifying and quantifying temporal trends in the rates and indications for thyroid procedures in the inpatient and outpatient settings. Methods: Using the IBM® MarketScan® Commercial database, we identified employer-insured patients in the United States who underwent outpatient and inpatient thyroid surgery from 2007 to 2018. Thyroid surgery was classified as total thyroidectomy (TT), thyroid lobectomy (TL), or a completion thyroidectomy. The surgical indication diagnosis was also determined and classified as either benign or malignant thyroid disease. We compared outpatient and inpatient trends in surgery between benign and malignant thyroid disease both before and after the release of the 2015 ATA guidelines. Results: A total of 220,088 patients who underwent thyroid surgery were included in the analysis. Approximately 80% of TLs were performed in the outpatient setting versus 70% of TTs. Longitudinal analysis showed a statistically significant changepoint for TT proportion occurring in November 2015. The proportion of TT as compared with TL decreased from 80% in September 2015 to 39% by December 2018. For thyroid cancer, there is an increasing trend in performing TL over TT, increasing from 17% in 2015 to 28% by the end of 2018. Conclusions: There was a significant changepoint occurring in November 2015 in the operative and management trends for benign and malignant thyroid disease.
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Affiliation(s)
- Asmae Toumi
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine DiGennaro
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Vahab Vahdat
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad S. Jalali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - G. Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel R. Kelz
- Department of Surgery, Center for Surgery and Health Economics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carrie C. Lubitz
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Surgical Oncology, Harvard Medical School, Boston, Massachusetts, USA
- Address correspondence to: Carrie C. Lubitz, MD, MPH, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA 02114, USA
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Hollingsworth JM, Yu X, Yan PL, Yoo H, Telem DA, Yankah EN, Zhu J, Waljee AK, Nallamothu BK. Provider Care Team Segregation and Operative Mortality Following Coronary Artery Bypass Grafting. Circ Cardiovasc Qual Outcomes 2021; 14:e007778. [PMID: 33926210 PMCID: PMC8137653 DOI: 10.1161/circoutcomes.120.007778] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/08/2023] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies have shown that Black patients die more frequently following coronary artery bypass grafting than their White counterparts for reasons not fully explained by disease severity or comorbidity. To examine whether provider care team segregation within hospitals contributes to this inequity, we analyzed national Medicare data. METHODS Using national Medicare data, we identified beneficiaries who underwent coronary artery bypass grafting at hospitals where this procedure was performed on at least 10 Black and 10 White patients between 2008 and 2014 (n=12 646). After determining the providers who participated in their perioperative care, we examined the extent to which Black and White patients were cared for by unique networks of provider care teams within the same hospital. We then evaluated whether a lack of overlap in composition of the provider care teams treating Black versus White patients (ie, high segregation) was associated with higher 90-day operative mortality among Black patients. RESULTS The median level of provider care team segregation was high (0.89) but varied across hospitals (interquartile range, 0.85-0.90). On multivariable analysis, after controlling for patient-, hospital-, and community-level differences, mortality rates for White patients were comparable at hospitals with high and low levels of provider care segregation (5.4% [95% CI, 4.7%-6.1%] versus 5.8% [95% CI, 4.7%-7.0%], respectively; P=0.601), while Black patients treated at high-segregation hospitals had significantly higher mortality than those treated at low-segregation hospitals (8.3% [95% CI, 5.4%-12.4%] versus 3.3% [95% CI, 2.0%-5.4%], respectively; P=0.017). The difference in mortality rates for Black and White patients treated at low-segregation hospitals was nonsignificant (-2.5%; P=0.098). CONCLUSIONS Black patients who undergo coronary artery bypass grafting at a hospital with a higher level of provider care team segregation die more frequently after surgery than Black patients treated at a hospital with a lower level.
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Affiliation(s)
| | - Xianshi Yu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Phyllis L. Yan
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Hyesun Yoo
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Dana A. Telem
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | | | - Ji Zhu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Akbar K. Waljee
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Brahmajee K. Nallamothu
- Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Dispersion in the hospital network of shared patients is associated with less efficient care. Health Care Manage Rev 2020; 47:88-99. [PMID: 33298805 DOI: 10.1097/hmr.0000000000000295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood. PURPOSE We examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination. METHODOLOGY/APPROACH We used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates. RESULTS In multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes. CONCLUSION Dispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care. PRACTICE IMPLICATIONS Hospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.
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Geissler KH, Lubin B, Ericson KMM. The association between patient sharing network structure and healthcare costs. PLoS One 2020; 15:e0234990. [PMID: 32569294 PMCID: PMC7307780 DOI: 10.1371/journal.pone.0234990] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/05/2020] [Indexed: 11/19/2022] Open
Abstract
STUDY QUESTION While physician relationships (measured through shared patients) are associated with clinical and utilization outcomes, the extent to which this is driven by local or global network characteristics is not well established. The objective of this research is to examine the association between local and global network statistics with total medical spending and utilization. DATA SOURCE Data used are the 2011 Massachusetts All Payer Claims Database. STUDY DESIGN The association between network statistics and total medical spending and utilization (using standardized prices) is estimated using multivariate regression analysis controlling for patient demographics and health status. DATA COLLECTION We limit the sample to continuously enrolled commercially insured patients in Massachusetts in 2011. PRINCIPAL FINDINGS Mean patient age was 45 years, and 56.3% of patients were female. 73.4% were covered by a health maintenance organization. Average number of visits was 5.43, with average total medical spending of $4,911 and total medical utilization of $4,252. Spending was lower for patients treated by physicians with higher degree (p<0.001), eigenvector centrality (p<0.001), clustering coefficient (p<0.001), and measures reflecting the normalized degree (p<0.001) and eigenvector centrality (p<0.001) of specialists connected to a patient's PCP. Spending was higher for patients treated by physicians with higher normalized degree, which accounts for physician specialty and patient panel size (p<0.001). Results were similar for utilization outcomes, although magnitudes differed indicating patients may see different priced physicians. CONCLUSIONS Generally, higher values of network statistics reflecting local connectivity adjusted for physician characteristics are associated with increased costs and utilization, while higher values of network statistics reflecting global connectivity are associated with decreased costs and utilization. As changes in the financing and delivery system advance through policy changes and healthcare consolidation, future research should examine mechanisms through which this structure impacts outcomes and potential policy responses to determine ways to reduce costs while maintaining quality and coordination of care. WHAT THIS STUDY ADDS It is unknown whether local and global measures of physician network connectivity associated with spending and utilization for commercially insured patients?In this social network analysis, we found generally higher values of network statistics reflecting local connectivity are associated with increased costs and utilization, while higher values of network statistics reflecting global connectivity are associated with decreased costs and utilization.Understanding how to influence local and global physician network characteristics may be important for reducing costs while maintaining quality.
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Affiliation(s)
- Kimberley H. Geissler
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, United States of America
| | - Benjamin Lubin
- Information Systems, Boston University Questrom School of Business, Boston, MA, United States of America
| | - Keith M. Marzilli Ericson
- Information Systems, Boston University Questrom School of Business, Boston, MA, United States of America
- Gehr Center for Health Systems Science, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States of America
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Gandré C, Beauguitte L, Lolivier A, Coldefy M. Care coordination for severe mental health disorders: an analysis of healthcare provider patient-sharing networks and their association with quality of care in a French region. BMC Health Serv Res 2020; 20:548. [PMID: 32552821 PMCID: PMC7298939 DOI: 10.1186/s12913-020-05173-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For patients with multiple and complex health needs, such as those suffering from mental health disorders, outcomes are determined by the combined actions of the care providers they visit and their interactions. Care coordination is therefore essential. However, little is known on links between hospitals providing psychiatric care and community-based care providers which could serve as a basis for the creation of formal mental care networks supported by recent policies. In this context, we first aimed to identify and characterize existing types of healthcare provider patient-sharing networks for severe mental health disorders in one French region. Second, we aimed to analyse the association between their characteristics and the quality of the care they provide. METHODS Patient flows among healthcare providers involved in treating severe mental health disorders in the Provence-Alpes-Côte-d'Azur region were extracted from the French national health data system, which contains all billing records from the social health insurance. Healthcare provider networks that have developed around public and private non-profit hospitals were identified based on shared patients with other providers (hospitals, community-based psychiatrists, general practitioners and nurses). Hierarchical clustering was conducted to create a typology of the networks. Indicators of quality of care, encompassing multiple complementary dimensions, were calculated across these networks and linked to their characteristics using multivariable methods. RESULTS Three main types of existing healthcare provider networks were identified. They were either networks strongly organized around the main hospital providing psychiatric care; scattered networks involving numerous and diverse healthcare providers; or medically-oriented networks involving mainly physician providers. Few significant associations between the structure and composition of healthcare provider networks and indicators of quality of care were found. CONCLUSIONS Our findings provide a basis to develop explicit structuring of mental care based on pre-existing working relationships but suggest that healthcare providers' patient-sharing patterns were not the main driver of optimal care provision in the context explored. The shift towards a stronger integration of health and social care in the mental health field might impact these results but is currently not observable in the administrative data available for research purpose which should evolve to include social care.
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Affiliation(s)
- Coralie Gandré
- Institut de recherche et documentation en économie de la santé (IRDES), 117 bis rue Manin, 75019, Paris, France.
| | - Laurent Beauguitte
- UMR Géographie-cités, Centre National de la Recherche Scientifique, Paris, France
| | - Alexandre Lolivier
- Institut de recherche et documentation en économie de la santé (IRDES), 117 bis rue Manin, 75019, Paris, France
| | - Magali Coldefy
- Institut de recherche et documentation en économie de la santé (IRDES), 117 bis rue Manin, 75019, Paris, France
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Rolls KD, Hansen MM, Jackson D, Elliott D. Intensive care nurses on social media: An exploration of knowledge exchange on an intensive care virtual community of practice. J Clin Nurs 2020; 29:1381-1397. [PMID: 31856353 PMCID: PMC7328784 DOI: 10.1111/jocn.15143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/31/2019] [Accepted: 10/18/2019] [Indexed: 11/28/2022]
Abstract
Aims and objectives To explore the nature of knowledge exchange on a multi‐disciplinary Australasian intensive care virtual community of practice, “ICUConnect.” Background Current organisational structures and cultures constrain the social networks of healthcare professionals, limiting access to contemporary best practice knowledge. While virtual communities can facilitate knowledge and clinical expertise exchange in professional networks, their effectiveness has not been established. Design A sequential mixed‐methods design with a quantitative core and qualitative supplementary component was used to explore the content of discussions from an intensive care virtual community. SRQR has been used to report this study. Methods Email archives of an intensive care listserv (2003–2013) were mined using a two‐stage sampling technique to identify discussion threads (with >2 posts) concerning ventilator or airway practices (cluster) and two sets of 20 threads (stratified across years). Summative content analysis was used to examine both manifest and latent content. Results Forty threads containing 326 emails posted by 133 individuals from 80 organisations were analysed. Nurses contributed 68% (55% were in clinical leadership roles) and physicians 27%. Three subject areas were identified: clinical practices (71%); equipment (23%); and clinical governance (6%). “Knowledge‐requested” and “knowledge‐supplied” posts were categorised as follows: experiential and explicit (33% and 16%, respectively); experiential (27% and 35%); or explicit (40% and 17%). Knowledge supplied was also categorised as “know‐how” (20%); “know‐why” (5%) or “no knowledge” exchanged (6%). The central construct of virtual community work was identified with six elements that facilitated participation and knowledge exchange including: (a) the discussion thread; (b) sharing of artefacts; (c) community; (d) cordiality; (e) maven work; and (f) promotion of the VC. Members asked questions to benchmark their practice, while those who answered were focused on ensuring that best practices were delivered. Conclusions ICUConnect reflected characteristics of a virtual community of practice, enabling key benefits for members and the broader Australasian intensive care community, especially access to best practice knowledge from clinical experts. Relevance to clinical practice This study demonstrated that a practice‐based VC can function effectively as a VCoP to establish an effective professional network where members have access to up‐to‐date best practice knowledge. Healthcare organisations could leverage VCs to support the professional development of HCPs and ensure that local clinical practices are based on contemporaneous knowledge. Participation by nurses in these communities facilitates individual professional development and access to important clinical knowledge and expertise, and ultimately reinforcing the unique position of nursing in delivering effective, consistent high‐quality patient care.
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Affiliation(s)
- Kaye Denise Rolls
- Centre for Applied Nursing Research, University of Wollongong, Liverpool, NSW, Australia.,AVATAR, Griffith University Menzies Health, Nathan, Australia.,Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Debra Jackson
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Doug Elliott
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
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Chandanabhumma PP, Fetters MD, Pagani FD, Malani PN, Hollingsworth JM, Funk RJ, Aaronson KD, Zhang M, Kormos RL, Chenoweth CE, Shore S, Watt TMF, Cabrera L, Likosky DS. Understanding and Addressing Variation in Health Care-Associated Infections After Durable Ventricular Assist Device Therapy: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e14701. [PMID: 31909721 PMCID: PMC6996720 DOI: 10.2196/14701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/26/2019] [Accepted: 10/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Durable ventricular assist device (VAD) therapy is reserved for patients with advanced heart failure who have a poor estimated 1-year survival. However, despite highly protocolized management processes, patients are at a unique risk for developing a health care-associated infection (HAI). Few studies have examined optimal strategies for HAI prevention after durable VAD implantation, despite variability in rates across centers and their impact on short- and long-term outcomes. OBJECTIVE The objective of this study is to develop recommendations for preventing the most significant HAIs after durable VAD implantation. The study has 3 specific aims: (1) identify determinants of center-level variability in HAI rates, (2) develop comprehensive understanding of barriers and facilitators for achieving low center-level HAI rates, and (3) develop and disseminate a best practices toolkit for preventing HAIs that accommodates various center contexts. METHODS This is a sequential mixed methods study starting with a cross-sectional assessment of current practices. To address aim 1, we will conduct (1) a systematic review of HAI prevention studies and (2) in-depth quantitative analyses using administrative claims, in-depth clinical data, and organizational surveys of VAD centers. For aim 2, we will apply a mixed methods patient tracer assessment framework to conduct semistructured interviews, field observations, and document analysis informed by findings from aim 1 at 5 high-performing (ie, low HAIs) and 5 low-performing (ie, high HAI) centers, which will be examined using a mixed methods case series analysis. For aim 3, we will build upon the findings from the previous aims to develop and field test an HAI preventive toolkit, acquire stakeholder input at an annual cardiac surgical conference, disseminate the final version to VAD centers nationwide, and conduct follow-up surveys to assess the toolkit's adoption. RESULTS The project was funded by the Agency for Healthcare Research and Quality in 2018 and enrollment for the overall project is ongoing. Data analysis is currently under way and the first results are expected to be submitted for publication in 2019. CONCLUSIONS This mixed methods study seeks to quantitatively assess the determinants of HAIs across clinical centers and qualitatively identify the context-specific facilitators and barriers for attaining low HAI rates. The mixed data findings will be used to develop and disseminate a stakeholder-acceptable toolkit of evidence-based HAI prevention recommendations that will accommodate the specific contexts and needs of VAD centers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/14701.
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Affiliation(s)
- P Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Michael D Fetters
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Preeti N Malani
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | | | - Russell J Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN, United States
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Robert L Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Supriya Shore
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Lourdes Cabrera
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
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A Decomposition Method to Assess the Contributions of Geographic and Nongeographic Factors to White-Black Disparities in Health Care. Med Care 2019; 58:e16-e22. [DOI: 10.1097/mlr.0000000000001252] [Citation(s) in RCA: 2] [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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Popescu I, Huckfeldt P, Pane JD, Escarce JJ. Contributions of Geography and Nongeographic Factors to the White-Black Gap in Hospital Quality for Coronary Heart Disease: A Decomposition Analysis. J Am Heart Assoc 2019; 8:e011964. [PMID: 31787056 PMCID: PMC6912970 DOI: 10.1161/jaha.119.011964] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Differences in hospital proximity and nongeographic factors affect disparities in hospital quality for heart disease, but their relative contributions are unknown. The current study quantifies the influences of these factors on the white‐black gap in high‐ and low‐quality hospital use for acute myocardial infarction (AMI) and coronary artery bypass grafting (CABG) surgery. Methods and Results We used Medicare claims to identify fee‐for‐service Medicare beneficiaries aged 65 and older hospitalized during 2009–2011 with AMI (n=384 443) and CABG (n=71 411). Hospital quality was measured using publicly available AMI mortality rates. In national and regional analyses, we used conditional multinomial logit models to estimate the white‐black gap in high‐ and low‐quality hospital use and decompose the gap into geographic and nongeographic contributions. Overall, more whites used high‐quality hospitals for both conditions (34.8% versus 32.4% for AMI; 39.0% versus 29.9% for CABG; P<0.001), but after accounting for distance to hospitals, the white‐black gap was significant only for CABG (9.1%; P<0.001). The nongeographic component was significant for both conditions (3.4% for AMI and 7.7% for CABG; P<0.001) and accounted for nearly the entire gap for CABG. In contrast, hospital geographic proximity was not significant. In regional analyses, white beneficiaries had higher rates of high‐quality hospital use in the Northeast (CABG) and South (AMI and CABG), whereas black had higher rates of high‐quality hospital use in the Midwest (AMI). Conclusions White‐black differences in high‐quality hospital use were significant for CABG and related to nongeographic factors. Interventions should consider health system and contextual reasons for these disparities.
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Affiliation(s)
- Ioana Popescu
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at UCLALos AngelesCA
- RAND CorporationSanta MonicaCA
| | - Peter Huckfeldt
- University of Minnesota School of Public HealthMinneapolisMN
| | | | - José J. Escarce
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at UCLALos AngelesCA
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20
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Johnson A. Understanding Why Black Patients Have Worse Coronary Heart Disease Outcomes: Does the Answer Lie in Knowing Where Patients Seek Care? J Am Heart Assoc 2019; 8:e014706. [PMID: 31787054 PMCID: PMC6912985 DOI: 10.1161/jaha.119.014706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amber Johnson
- University of Pittsburgh School of Medicine Pittsburgh PA
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21
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Rolls KD, Hansen MM, Jackson D, Elliott D. Why Health Care Professionals Belong to an Intensive Care Virtual Community: Qualitative Study. J Med Internet Res 2019; 21:e14068. [PMID: 31687936 PMCID: PMC6864486 DOI: 10.2196/14068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/26/2019] [Accepted: 08/31/2019] [Indexed: 11/23/2022] Open
Abstract
Background Clinical practice variation that results in poor patient outcomes remains a pressing problem for health care organizations. Some evidence suggests that a key factor may be ineffective internal and professional networks that limit knowledge exchange among health care professionals. Virtual communities have the potential to overcome professional and organizational barriers and facilitate knowledge flow. Objective This study aimed to explore why health care professionals belong to an exemplar virtual community, ICUConnect. The specific research objectives were to (1) understand why members join a virtual community and remain a member, (2) identify what purpose the virtual community serves in their professional lives, (3) identify how a member uses the virtual community, and (4) identify how members used the knowledge or resources shared on the virtual community. Methods A qualitative design, underpinned by pragmatism, was used to collect data from 3 asynchronous online focus groups and 4 key informant interviews, with participants allocated to a group based on their posting behaviors during the previous two years—between September 1, 2012, and August 31, 2014: (1) frequent (>5 times), (2) low (≤5 times), and (3) nonposters. A novel approach to focus group moderation, based on the principles of traditional focus groups, and e-moderating was developed. Thematic analysis was undertaken, applying the Diffusion of Innovation theory as the theoretical lens. NCapture (QRS International) was used to extract data from the focus groups, and NVivo was used to manage all data. A research diary and audit trail were maintained. Results There were 27 participants: 7 frequent posters, 13 low posters, and 7 nonposters. All participants displayed an external orientation, with the majority using other social media; however, listservs were perceived to be superior in terms of professional compatibility and complexity. The main theme was as follows: “Intensive care professionals are members of ICUConnect because by being a member of a broader community they have access to credible best-practice knowledge.” The virtual community facilitated access to all professionals caring for the critically ill and was characterized by a positive and collegial online culture. The knowledge found was credible because it was extensive and because the virtual community was moderated and sponsored by a government agency. This enabled members to benchmark and improve their unit practices and keep up to date. Conclusions This group of health care professionals made a strategic decision to be members of ICUConnect, as they understood that to provide up-to-date clinical practices, they needed to network with colleagues in other facilities. This demonstrated that a closed specialty-specific virtual community can create a broad heterogeneous professional network, overcoming current ineffective networks that may adversely impact knowledge exchange and creation in local practice settings. To address clinical practice variation, health care organizations can leverage low-cost social media technologies to improve interprofessional and interorganizational networks.
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Affiliation(s)
- Kaye Denise Rolls
- Centre for Applied Nursing Research, University of Western Sydney, Liverpool, Australia.,Ingham Institute for Medical Research, Liverpool, Australia.,South Western Sydney Local Health District, Liverpool, Australia.,University of Technology Sydney, Sydney, Australia
| | | | - Debra Jackson
- University of Technology Sydney, Sydney, Australia.,Oxford Health, NHS Foundation Trust, Oxford, United Kingdom.,Ngangk Yira Research Centre for Aboriginal Health & Social Equity, Murdoch University, Perth, Australia
| | - Doug Elliott
- University of Technology Sydney, Sydney, Australia
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22
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Austin AM, Carmichael DQ, Bynum JPW, Skinner JS. Measuring racial segregation in health system networks using the dissimilarity index. Soc Sci Med 2019; 240:112570. [PMID: 31585377 PMCID: PMC6810808 DOI: 10.1016/j.socscimed.2019.112570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/12/2019] [Accepted: 09/24/2019] [Indexed: 11/28/2022]
Abstract
Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).
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Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon.
| | - Donald Q Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor MI, USA; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor MI, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon; Dartmouth College, Hanover, NH, USA; Department of Economics, Dartmouth College, Hanover NH, USA
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23
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Chen LM, Nallamothu BK, Spertus JA, Tang Y, Chan PS. Racial Differences in Long-Term Outcomes Among Older Survivors of In-Hospital Cardiac Arrest. Circulation 2019; 138:1643-1650. [PMID: 29987159 DOI: 10.1161/circulationaha.117.033211] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Black patients have worse in-hospital survival than white patients after in-hospital cardiac arrest (IHCA), but less is known about long-term outcomes. We sought to assess among IHCA survivors whether there are additional racial differences in survival after hospital discharge and to explore potential reasons for differences. METHODS This was alongitudinal study of patients ≥65 years of age who had an IHCA and survived until hospital discharge between 2000 and 2011 from the national Get With The Guidelines-Resuscitation registry whose data could be linked to Medicare claims data. Sequential hierarchical modified Poisson regression models evaluated the proportion of racial differences explained by patient, hospital, and unmeasured factors. Our exposure was black or white race. Our outcome was survival at 1, 3, and 5 years. RESULTS Among 8764 patients who survived to discharge, 7652 (87.3%) were white and 1112 (12.7%) were black. Black patients with IHCA were younger, more frequently female, sicker with more comorbidities, less likely to have a shockable initial cardiac arrest rhythm, and less likely to be evaluated with coronary angiography after initial resuscitation. At discharge, black patients were also more likely to have at least moderate neurological disability and less likely to be discharged home. Compared with white patients and after adjustment only for hospital site, black patients had lower 1-year (43.6% versus 60.2%; relative risk [RR], 0.72), 3-year (31.6% versus 45.3%; RR, 0.71), and 5-year (23.5% versus 35.4%; RR, 0.67; all P<0.001) survival. Adjustment for patient factors explained 29% of racial differences in 1-year survival (RR, 0.80; 95% confidence interval, 0.75-0.86), and further adjustment for hospital treatment factors explained an additional 17% of racial differences (RR, 0.85; 95% confidence interval, 0.80-0.92). Approximately half of the racial difference in 1-year survival remained unexplained, and the degree to which patient and hospital factors explained racial differences in 3-year and 5-year survival was similar. CONCLUSIONS Black survivors of IHCA have lower long-term survival compared with white patients, and about half of this difference is not explained by patient factors or treatments after IHCA. Further investigation is warranted to better understand to what degree unmeasured but modifiable factors such as postdischarge care account for unexplained disparities.
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Affiliation(s)
- Lena M Chen
- Division of General Medicine (L.M.C.), University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy and Institute for Healthcare Policy and Innovation (L.M.C., B.K.N.), University of Michigan, Ann Arbor.,Department of Internal Medicine (L.M.C., B.K.N.), University of Michigan, Ann Arbor
| | - Brahmajee K Nallamothu
- Center for Healthcare Outcomes & Policy and Institute for Healthcare Policy and Innovation (L.M.C., B.K.N.), University of Michigan, Ann Arbor.,Department of Internal Medicine (L.M.C., B.K.N.), University of Michigan, Ann Arbor.,Division of Cardiovascular Medicine (B.K.N.), University of Michigan, Ann Arbor.,Veterans Affairs Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, MI (B.K.N.)
| | - John A Spertus
- Saint Luke's Mid-America Heart Institute, Kansas City, MO (J.A.S., Y.T., P.S.C.).,University of Missouri, Kansas City (J.A.S., P.S.C.)
| | - Yuanyuan Tang
- Saint Luke's Mid-America Heart Institute, Kansas City, MO (J.A.S., Y.T., P.S.C.)
| | - Paul S Chan
- Saint Luke's Mid-America Heart Institute, Kansas City, MO (J.A.S., Y.T., P.S.C.).,University of Missouri, Kansas City (J.A.S., P.S.C.)
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24
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Qi AC, Butler AM, Joynt Maddox KE. The Role Of Social Risk Factors In Dialysis Facility Ratings And Penalties Under A Medicare Quality Incentive Program. Health Aff (Millwood) 2019; 38:1101-1109. [DOI: 10.1377/hlthaff.2018.05406] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Andrew C. Qi
- Andrew C. Qi is a medical student at the Washington University School of Medicine, in Saint Louis, Missouri
| | - Anne M. Butler
- Anne M. Butler is an instructor of medicine at the Washington University School of Medicine, in Saint Louis
| | - Karen E. Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in Saint Louis
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25
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Everson J, Adler-Milstein J, Ryan AM, Hollingsworth JM. Hospitals Strengthened Relationships With Close Partners After Joining Accountable Care Organizations. Med Care Res Rev 2018; 77:549-558. [PMID: 30541401 DOI: 10.1177/1077558718818336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The strategies that hospitals participating in Medicare Accountable Care Organizations (ACOs) use to achieve quality and cost containment goals are poorly understood. One possibility is that participating hospitals could try to influence where their patients receive care. To test this hypothesis, we examined whether a hospital's participation in a Medicare ACO was associated with changes in its patterns of patient sharing with other hospitals. Between 2010 and 2014, patient sharing across hospitals increased 23.3%. After controlling for hospital and regional factors, patient sharing increased 4.4% more at ACO hospitals than non-ACO hospitals (p = .001 for difference). This increase occurred disproportionately among hospitals with which ACO hospitals already shared a high proportion of their patients prior to participation, and among hospitals in ACOs characterized as physician-hospital collaborations. The increased sharing of patients among closely affiliated hospitals may serve to achieve ACO quality and cost containment goals through increased interorganizational coordination.
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Affiliation(s)
- Jordan Everson
- Vanderbilt University School of Medicine, Nashville, TN, USA
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26
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Tannenbaum SS, Soulos PR, Herrin J, Pollack CE, Xu X, Christakis NA, Forman HP, Yu JB, Killelea BK, Wang SY, Gross CP. Surgeon peer network characteristics and adoption of new imaging techniques in breast cancer: A study of perioperative MRI. Cancer Med 2018; 7:5901-5909. [PMID: 30444005 PMCID: PMC6308117 DOI: 10.1002/cam4.1821] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 11/28/2022] Open
Abstract
Background Perioperative MRI has disseminated into breast cancer practice despite equivocal evidence. We used a novel social network approach to assess the relationship between the characteristics of surgeons’ patient‐sharing networks and subsequent use of MRI. Methods We identified a cohort of female patients with stage 0‐III breast cancer from the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database. We used claims data from these patients and non‐cancer patients from the 5% Medicare sample to identify peer groups of physicians who shared patients during 2004‐2006 (T1). We used a multivariable hierarchical model to identify peer group characteristics associated with uptake of MRI in T2 (2007‐2009) by surgeons who had not used MRI in T1. Results Our T1 sample included 15 149 patients with breast cancer, treated by 2439 surgeons in 390 physician groups. During T1, 9.1% of patients received an MRI; the use of MRI varied from 0% to 100% (IQR 0%, 8.5%) across peer groups. After adjusting for clinical characteristics, patients treated by surgeons in groups with a higher proportion of primary care physicians (PCPs) in T1 were less likely to receive MRI in T2 (OR = 0.81 for 10% increase in PCPs, 95% CI = 0.71, 0.93). Surgeon transitivity (ie, clustering of surgeons) was significantly associated with MRI receipt (P = 0.013); patients whose surgeons were in groups with higher transitivity in T1 were more likely to receive MRI in T2 (OR = 1.29 for 10% increase in clustering, 95% CI = 1.06, 1.58). Conclusion The characteristics of a surgeon's peer network are associated with their patients’ subsequent receipt of perioperative MRI.
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Affiliation(s)
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeph Herrin
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Health Research & Educational Trust, Chicago, Illinois
| | - Craig E Pollack
- Johns Hopkins School of Medicine, Baltimore, Maryland.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Xiao Xu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Nicholas A Christakis
- Department of Sociology, Yale University, New Haven, Connecticut.,Yale Institute for Network Science and Human Nature Lab, Yale University, New Haven, Connecticut
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - James B Yu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Brigid K Killelea
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Department of Surgery, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Center, New Haven, Connecticut
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, Connecticut.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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27
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Affordable Care Act's Medicaid Expansion and Use of Regionalized Surgery at High-Volume Hospitals. J Am Coll Surg 2018; 227:507-520.e9. [DOI: 10.1016/j.jamcollsurg.2018.08.693] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/31/2018] [Accepted: 08/22/2018] [Indexed: 01/26/2023]
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28
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Onnela JP, O’Malley AJ, Keating NL, Landon BE. Comparison of physician networks constructed from thresholded ties versus shared clinical episodes. APPLIED NETWORK SCIENCE 2018; 3:28. [PMID: 30839809 PMCID: PMC6214299 DOI: 10.1007/s41109-018-0084-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/13/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To compare standard methods for constructing physician networks from patient-physician encounter data with a new method based on clinical episodes of care. DATA SOURCE We used data on 100% of traditional Medicare beneficiaries from 51 nationally representative geographical regions for the years 2005-2010. STUDY DESIGN We constructed networks of physicians based on their shared patients. In the fixed-threshold networks and adaptive-threshold networks, we included data on all patient-physician encounters to form the physician-physician ties, and then subsequently thresholded some proportion of the strongest ties. In contrast, in the episode-based approach, only those patient-physician encounters that occurred within shared clinical episodes treating specific conditions contributed towards physician-physician ties. DATA COLLECTION/EXTRACTION METHODS We extracted clinical episodes in the Medicare data and investigated structural properties of the patient-sharing networks of physicians, temporal dynamics of their ties, and temporal stability of network communities across the two approaches. PRINCIPAL FINDINGS The episode-based networks accentuated ties between primary care physicians (PCPs) and medical specialists, had ties that were more likely to reappear in the future, and appeared to have more fluid community structure. CONCLUSIONS Constructing physician networks around shared episodes of care is a clinically sound alternative to previous approaches to network construction that does not require arbitrary decisions about thresholding. The resulting networks capture somewhat different aspects of patient-physician encounters.
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Affiliation(s)
- Jukka-Pekka Onnela
- Harvard T.H. Chan School of Public Health, Harvard University, 655 Huntington Avenue, Boston, MA USA
| | - A. James O’Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH USA
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
- Division of Primary Care and General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
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29
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DuGoff EH, Fernandes-Taylor S, Weissman GE, Huntley JH, Pollack CE. A scoping review of patient-sharing network studies using administrative data. Transl Behav Med 2018; 8:598-625. [PMID: 30016521 PMCID: PMC6086089 DOI: 10.1093/tbm/ibx015] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
There is a robust literature examining social networks and health, which draws on the network traditions in sociology and statistics. However, the application of social network approaches to understand the organization of health care is less well understood. The objective of this work was to examine approaches to conceptualizing, measuring, and analyzing provider patient-sharing networks. These networks are constructed using administrative data in which pairs of physicians are considered connected if they both deliver care to the same patient. A scoping review of English language peer-reviewed articles in PubMed and Embase was conducted from inception to June 2017. Two reviewers evaluated article eligibility based upon inclusion criteria and abstracted relevant data into a database. The literature search identified 10,855 titles, of which 63 full-text articles were examined. Nine additional papers identified by reviewing article references and authors were examined. Of the 49 papers that met criteria for study inclusion, 39 used a cross-sectional study design, 6 used a cohort design, and 4 were longitudinal. We found that studies most commonly theorized that networks reflected aspects of collaboration or coordination. Less commonly, studies drew on the strength of weak ties or diffusion of innovation frameworks. A total of 180 social network measures were used to describe the networks of individual providers, provider pairs and triads, the network as a whole, and patients. The literature on patient-sharing relationships between providers is marked by a diversity of measures and approaches. We highlight key considerations in network identification including the definition of network ties, setting geographic boundaries, and identifying clusters of providers, and discuss gaps for future study.
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Affiliation(s)
- Eva H DuGoff
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, USA
| | - Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Gary E Weissman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Hospital of the University of Pennsylvania, Pulmonary, Allergy, and Critical Care Division, Philadelphia, PA, USA
| | - Joseph H Huntley
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig Evan Pollack
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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30
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Physician referral patterns and racial disparities in total hip replacement: A network analysis approach. PLoS One 2018; 13:e0193014. [PMID: 29462180 PMCID: PMC5819779 DOI: 10.1371/journal.pone.0193014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background Efforts to reduce racial disparities in total hip replacement (THR) have focused mainly on patient behaviors. While these efforts are no doubt important, they ignore the potentially important role of provider- and system-level factors, which may be easier to modify. We aimed to determine whether the patterns of interaction among physicians around THR episodes differ in communities with low versus high concentrations of black residents. Materials and methods We analyzed national Medicare claims from 2008 to 2011, identifying all fee-for-service beneficiaries who underwent THR. Based on physician encounter data, we then mapped the physician referral networks at the hospitals where beneficiaries’ procedures were performed. Next, we measured two structural properties of these networks that could affect care coordination and information sharing: clustering, and the number of external ties. Finally, we estimated multivariate regression models to determine the relationship between the concentration of black residents in the community [as measured by the hospital service area (HSA)] served by a given network and each of these 2 network properties. Results Our sample included 336,506 beneficiaries (mean age 76.3 ± SD), 63.1% of whom were women. HSAs with higher concentrations of black residents tended to be more impoverished than those with lower concentrations. While HSAs with higher concentrations of black residents had, on average, more acute care beds and medical specialists, they had fewer surgeons per capita than those with lower concentrations. After adjusting for these differences, we found that HSAs with higher concentrations of black residents were served by physician referral networks that had significantly higher within-network clustering but fewer external ties. Conclusions We observed differences in the patterns of interaction among physicians around THR episodes in communities with low versus high concentrations of black residents. Studies investigating the impact of these differences on access to quality providers and on THR outcomes are needed.
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Brunson JC, Laubenbacher RC. Applications of network analysis to routinely collected health care data: a systematic review. J Am Med Inform Assoc 2018; 25:210-221. [PMID: 29025116 PMCID: PMC6664849 DOI: 10.1093/jamia/ocx052] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/18/2017] [Accepted: 04/23/2017] [Indexed: 01/21/2023] Open
Abstract
Objective To survey network analyses of datasets collected in the course of routine operations in health care settings and identify driving questions, methods, needs, and potential for future research. Materials and Methods A search strategy was designed to find studies that applied network analysis to routinely collected health care datasets and was adapted to 3 bibliographic databases. The results were grouped according to a thematic analysis of their settings, objectives, data, and methods. Each group received a methodological synthesis. Results The search found 189 distinct studies reported before August 2016. We manually partitioned the sample into 4 groups, which investigated institutional exchange, physician collaboration, clinical co-occurrence, and workplace interaction networks. Several robust and ongoing research programs were discerned within (and sometimes across) the groups. Little interaction was observed between these programs, despite conceptual and methodological similarities. Discussion We use the literature sample to inform a discussion of good practice at this methodological interface, including the concordance of motivations, study design, data, and tools and the validation and standardization of techniques. We then highlight instances of positive feedback between methodological development and knowledge domains and assess the overall cohesion of the sample.
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32
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Examining Healthcare Segregation Among Racial and Ethnic Minorities Receiving Spine Surgical Procedures in the State of Florida. Spine (Phila Pa 1976) 2017; 42:1917-1922. [PMID: 28542099 DOI: 10.1097/brs.0000000000002251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This was a retrospective review of the Florida Inpatient Dataset (2011-2014). OBJECTIVE To examine healthcare segregation among African American and Hispanic patients treated with one of four common spine surgical procedures. SUMMARY OF BACKGROUND DATA Racial and ethnic minorities are known to be at increased risk of adverse events after spine surgery. Healthcare segregation has been proposed as a source for these disparities, but has not been systematically examined for patients undergoing spine surgery. METHODS African American, Hispanic, and White patients who underwent one of the four lumbar spine surgical procedures under study were included. Volume cut-offs were previously established for surgical providers and hospitals. Surgeons and hospitals were dichotomized based on these metrics as low- or high-volume providers. Multivariable logistic regression analysis was used to determine the likelihood of patients receiving surgery from a low volume provider, adjusting for sociodemographic and clinical characteristics. RESULTS African Americans were found to be at significantly increased odds of receiving surgery from a low-volume surgeon (P < 0.001) and were significantly more likely to receive surgery at a low-volume hospital (P < 0.007) for all procedures except decompression (P = 0.56). Like findings were encountered for Hispanic patients. Hispanic patients were 55% to three-times more likely to receive surgery from a low-volume surgeon depending on the procedure and 28% to 56% more likely to be treated at a low-volume hospital. African Americans were 34% to 82% more likely to receive surgery from a low-volume surgeon depending on the procedure and 10% to 17% more likely to be treated at a low-volume hospital. CONCLUSION The results of this work identify the phenomenon of racial and ethnic healthcare segregation among low-volume providers for lumbar spine procedures in the State of Florida. This may be a contributing factor to the increased risk of adverse events after spine surgery known to exist among minorities. LEVEL OF EVIDENCE 3.
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Everson J, Funk RJ, Kaufman SR, Owen-Smith J, Nallamothu BK, Pagani FD, Hollingsworth JM. Repeated, Close Physician Coronary Artery Bypass Grafting Teams Associated with Greater Teamwork. Health Serv Res 2017; 53:1025-1041. [PMID: 28474343 DOI: 10.1111/1475-6773.12703] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine whether observed patterns of physician interaction around shared patients are associated with higher levels of teamwork as perceived by physicians. DATA SOURCES/STUDY SETTING Michigan Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) procedures at 24 hospitals in the state between 2008 and 2011. STUDY DESIGN We assessed hospital teamwork using the teamwork climate scale in the Safety Attitudes Questionnaire. After aggregating across CABG discharges at these hospitals, we mapped the physician referral networks (including both surgeons and nonsurgeons) that served them and measured three network properties: (1) reinforcement, (2) clustering, and (3) density. We then used multilevel regression models to identify associations between network properties and teamwork at the hospitals on which the networks were anchored. PRINCIPAL FINDINGS In hospitals where physicians repeatedly cared for patients with the same colleagues, physicians perceived better teamwork (β-reinforcement = 3.28, p = .003). When physicians who worked together also had other colleagues in common, the reported teamwork was stronger (β clustering = 1.71, p = .001). Reported teamwork did not change when physicians worked with a higher proportion of other physicians at the hospital (β density = -0.58, p = .64). CONCLUSION In networks with higher levels of reinforcement and clustering, physicians perceive stronger teamwork, perhaps because the strong ties between them create a shared understanding; however, sharing patients with more physicians overall (i.e., density) did not lead to stronger teamwork. Clinical and organizational leaders may consider designing the structure of clinical teams to increase interactions with known colleagues and repeated interactions between providers.
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Affiliation(s)
- Jordan Everson
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Russell J Funk
- Department of Strategic Management and Entrepreneurship, University of Minnesota Carlson School of Management, Minneapolis, MN
| | - Samuel R Kaufman
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Jason Owen-Smith
- Department of Sociology, University of Michigan College of Literature, Sciences, and the Arts, Ann Arbor, MI
| | - Brahmajee K Nallamothu
- Department of Internal Medicine in the Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI
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Meese KA, Borkowski NM. It Takes a Village to Deliver Effective and Efficient Care. Anesth Analg 2017; 124:1717-1720. [DOI: 10.1213/ane.0000000000001980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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