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Sengupta S, Anand A, Lopez R, Weleff J, Wang PR, Bellar A, Attaway A, Welch N, Dasarathy S. Emergency services utilization by patients with alcohol-associated hepatitis: An analysis of national trends. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:98-109. [PMID: 38193831 PMCID: PMC10783841 DOI: 10.1111/acer.15223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/10/2023] [Accepted: 11/03/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Hospitalization and mortality in patients with alcohol-associated hepatitis (AH), a severe form of liver disease, continue to increase over time. Given the severity of the illness, most hospitalized patients with AH are admitted from the emergency department (ED). However, there are no data on ED utilization by patients with AH. Thus, the Nationwide Emergency Department Sample (NEDS) dataset was analyzed to determine the ED utilization for AH. METHODS Temporal trends (2016-2019) and outcomes of ED visits for AH were determined. Primary or secondary AH diagnoses were based on coding priority. Numbers of patients evaluated in the ED, severity of disease, complications of liver disease, and discharge disposition were analyzed. Crude and adjusted rates were examined, and temporal trends evaluated using logistic regression with orthogonal polynomial contrasts for each year. RESULTS There were 466,014,370 ED visits during 2016-2019, of which 448,984 (0.096%) were for AH, 85.0% of which required hospitalization. The rate of visits for AH (primary and secondary) between 2016 and 2019 increased from 85 to 106.8/100,000 ED visits. The rate of secondary AH increased more than the rate of primary AH (from 68.6 to 86.5 vs. from 16.4 to 20.3/100,000 ED visits). Patients aged 45-64 years had the highest rate of ED visits for AH, which decreased during the study period, while the rate of ED visits for AH increased in those aged 25-44 years (from 38.5% to 42.9%). The severity of disease (ascites, hepatic encephalopathy, and acute kidney injury) also increased over time. Medicaid and private insurance were the most common payors for patients seeking care in the ED for AH. CONCLUSIONS Temporal trends show an overall increase in ED utilization rates for AH, more patients requiring hospitalization, and an increase in the proportion of younger patients presenting to the ED with AH.
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Affiliation(s)
- Shreya Sengupta
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Akhil Anand
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, USA
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rocio Lopez
- Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, USA
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, New Haven, CT, 06511, USA
| | - Philip R Wang
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Annette Bellar
- Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Attaway
- Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Nicole Welch
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
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Rich EC, Peris K, Luhr M, Ghosh A, Molinari L, O'Malley AS. Association of the Range of Outpatient Services Provided by Primary Care Physicians with Subsequent Health Care Costs and Utilization. J Gen Intern Med 2023; 38:3414-3423. [PMID: 37580638 PMCID: PMC10682337 DOI: 10.1007/s11606-023-08363-5] [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: 02/17/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Broader primary care practice range of services (ROS), defined as the diversity of professional services delivered, is associated with lower utilization. ROS provided by individual primary care physicians (PCPs) varies considerably with unclear implications for patients. OBJECTIVES Create a PCP-ROS measure covering six categories of outpatient services, including expanded codes for mental health counseling services and point of care ultrasound (POCUS) technology in physician offices. Determine whether PCP-ROS is associated with total Medicare expenditures, inpatient admissions, acute hospital utilization (AHU), and emergency department (ED) visits. Examine physician and practice characteristics associated with PCP-ROS. DESIGN Retrospective cohort study. PARTICIPANTS 4,569,711 Medicare fee-for-service beneficiaries and 27,008 PCPs observed during the evaluation of the Comprehensive Primary Care Plus (CPC +) initiative. MEASUREMENTS PCP-ROS, hospitalizations, AHU (includes observation stays as well as inpatient admissions), ED visits, and total Medicare expenditures. RESULTS Physicians varied substantially in the range of services provided. Broader PCP-ROS was significantly, independently associated with 1 - 3% lower Medicare expenditures (p ≤ 0.01), inpatient admissions (p ≤ 0.027), AHU (p ≤ 0.025), and ED visit rates (p ≤ 0.000). PCP-ROS score was associated with improved patient outcomes, independent of physician provision of procedures (such as laceration repair or skin excisions). Physicians in practice sites affiliated with a hospital or health system had narrower PCP-ROS than independent physicians by 0.3 to 0.4 (p < 0.001). Internal medicine specialty was associated with narrower PCP-ROS than family medicine by 0.3 (p < 0.001). CONCLUSIONS Patients cared for by primary care physicians who provide a broader range of services subsequently experience lower acute care utilization and expenditures than do those cared for by physicians with narrower ROS. Practice leaders and professional associations should consider how best to ensure that primary care physicians efficiently and effectively provide the office-based professional services most needed by their patients.
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O'Reilly-Jacob M, Chapman J, Subbiah SV, Perloff J. Estimating the Primary Care Workforce for Medicare Beneficiaries Using an Activity-Based Approach. J Gen Intern Med 2023; 38:2898-2905. [PMID: 37081305 PMCID: PMC10593719 DOI: 10.1007/s11606-023-08206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/07/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The enumeration of the primary care workforce relies on potentially inaccurate specialty designations sourced from licensure registries and clinician surveys. OBJECTIVE To use an activity-based measure of primary care to estimate the number of physicians, nurse practitioners (NPs), and physician assistants (PAs) providing primary care to Medicare beneficiaries. DESIGN Observational study using Medicare fee-for-service (FFS) claims data. SUBJECTS All clinicians in the US billing Medicare in 2019 and their fee-for-service Medicare patients. MAIN MEASURES We construct three measures that together distinguish primary care from specialty clinicians: (1) presence of evaluation and management (E&M) services in a setting consistent with primary care, (2) the dispersion of clinical care across International Classification of Diseases-10 (ICD-10) chapters, and (3) the extent of provided services that are atypical of primary care (e.g., surgical procedure). We apply parameters to the measures to identify the clinicians likely providing primary care and compare the resulting classifications across provider type. KEY RESULTS Of physicians with at least 50 Medicare beneficiaries, 19-22% provide primary care. Of medical generalists (i.e., family medicine, internal medicine) with at least 50 beneficiaries, 61-68% provide primary care. We estimate that 40-45% of NPs and 27-30% of PAs meeting the panel size threshold are primary care providers in FFS Medicare. CONCLUSIONS Our findings suggest that based on a primary care practice style, the number of primary care physicians in FFS Medicare is likely smaller than conventional estimates. However, compared to prior estimates, the number of primary care NPs is larger and the number of PAs is similar.
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Affiliation(s)
| | - John Chapman
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | | | - Jennifer Perloff
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
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Khazen M, Abu Ahmad W, Spolter F, Golan-Cohen A, Merzon E, Israel A, Vinker S, Rose AJ. Greater temporal regularity of primary care visits was associated with reduced hospitalizations and mortality, even after controlling for continuity of care. BMC Health Serv Res 2023; 23:777. [PMID: 37474968 PMCID: PMC10360299 DOI: 10.1186/s12913-023-09808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Previous studies have shown that more temporally regular primary care visits are associated with improved patient outcomes. OBJECTIVE To examine the association of temporal regularity (TR) of primary care with hospitalizations and mortality in patients with chronic illnesses. Also, to identify threshold values for TR for predicting outcomes. DESIGN Retrospective cohort study. PARTICIPANTS We used data from the electronic health record of a health maintenance organization in Israel to study primary care visits of 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease). MAIN MEASURES We calculated TR for each patient during a two-year period (2016-2017), and divided patients into quintiles based on TR. Outcomes (hospitalization, death) were observed in 2018-2019. Covariates included the Bice-Boxerman continuity of care score, demographics, and comorbidities. We used multivariable logistic regression to examine TR's association with hospitalization and death, controlling for covariates. KEY RESULTS Compared to patients receiving the most regular care, patients receiving less regular care had increased odds of hospitalization and mortality, with a dose-response curve observed across quintiles (p for linear trend < 0.001). For example, patients with the least regular care had an adjusted odds ratio of 1.40 for all-cause mortality, compared to patients with the most regular care. Analyses stratified by age, sex, ethnic group, area-level SES, and certain comorbid conditions did not show strong differential associations of TR across groups. CONCLUSIONS We found an association between more temporally regular care in antecedent years and reduced hospitalization and mortality of patients with chronic illness in subsequent years, after controlling for covariates. There was no clear threshold value for temporal regularity; rather, more regular primary care appeared to be better across the entire range of the variable.
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Affiliation(s)
- Maram Khazen
- Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem Campus, Jerusalem, Israel.
- Department of Health Systems Management, The Max Stern Yezreel Valley College, Yezreel Valley, Israel.
| | - Wiessam Abu Ahmad
- Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem Campus, Jerusalem, Israel
| | - Faige Spolter
- Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem Campus, Jerusalem, Israel
| | - Avivit Golan-Cohen
- Leumit Health Services, Research Institute, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv, Israel
| | - Eugene Merzon
- Leumit Health Services, Research Institute, Tel Aviv, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Ariel Israel
- Leumit Health Services, Research Institute, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv, Israel
| | - Shlomo Vinker
- Leumit Health Services, Research Institute, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv, Israel
| | - Adam J Rose
- Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Ein Kerem Campus, Jerusalem, Israel
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Petersen DM, O'Malley AS, Felland L, Peebles V, Rittenhouse DR, Powell RE, Rich EC, Sarwar R, Sorensen A, Hoag S, Finucane M, Lipman E, Gellar J, Machta RM, Keith RE. Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators. Ann Fam Med 2023; 21:313-321. [PMID: 37487736 PMCID: PMC10365870 DOI: 10.1370/afm.2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 07/26/2023] Open
Abstract
PURPOSE Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. METHODS We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. RESULTS The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. CONCLUSIONS The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Erin Lipman
- University of Washington, Seattle, Washington
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Endalamaw A, Erku D, Khatri RB, Nigatu F, Wolka E, Zewdie A, Assefa Y. Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review. Arch Public Health 2023; 81:100. [PMID: 37268966 DOI: 10.1186/s13690-023-01116-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/23/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC. METHODS We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens. RESULTS A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers. CONCLUSIONS There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia.
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Daniel Erku
- School of Public Health, The University of Queensland, Brisbane, Australia
- Centre for Applied Health Economics, School of Medicine, Griffith University, Brisbane, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Resham B Khatri
- School of Public Health, The University of Queensland, Brisbane, Australia
- Health Social Science and Development Research Institute, Kathmandu, Nepal
| | - Frehiwot Nigatu
- International Institute for Primary Health Care in Ethiopia, Addis Ababa, Ethiopia
| | - Eskinder Wolka
- International Institute for Primary Health Care in Ethiopia, Addis Ababa, Ethiopia
| | - Anteneh Zewdie
- International Institute for Primary Health Care in Ethiopia, Addis Ababa, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
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O'Malley AS, Rich EC, Ghosh A, Palakal M, Rose T, Swankoski K, Peikes D, McCall N. Medicare beneficiaries with more comprehensive primary care physicians report better primary care. Health Serv Res 2023; 58:264-270. [PMID: 36527443 PMCID: PMC10012239 DOI: 10.1111/1475-6773.14119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.
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Zhang H, Wu Y, Sun W, Li W, Huang X, Sun T, Wu M, Huang Z, Chen S. How does people-centered integrated care in medical alliance in China promote the continuity of healthcare for internal migrants: The moderating role of respect. Front Public Health 2023; 10:1030323. [PMID: 36684939 PMCID: PMC9845872 DOI: 10.3389/fpubh.2022.1030323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/06/2022] [Indexed: 01/05/2023] Open
Abstract
Background Continuity is crucial to the health care of the internal migrant population and urgently needs improvements in China. Chinese government is committed to promoting healthcare continuity by improving the people-centered integrated care (PCIC) model in medical alliances. However, little is known about the driving mechanisms for continuity. Methods We created the questionnaire for this study by processes of a literature research, telephone interviews, two rounds of Delphi consultation. Based on the combination of quota sampling and judgment sampling, we collected 765 valid questionnaires from developed region and developing region in Zhejiang Province. Structural equation models were used to examined whether the attributes of PCIC (namely coordination, comprehensiveness, and accessibility of health care) associated with continuity, and explored the moderated mediating role of respect. Results The result of SEM indicated that coordination had direct effect on continuity, and also had mediating effect on continuity via comprehensiveness and accessibility. The hierarchical linear regression analysis showed that the interactive items of coordination and respect had a positive effect on the comprehensiveness (β = 0.132), indicating that respect has positive moderating effect on the relationship between coordination and comprehensiveness. The simple slope test indicated that in the developed region, coordination had a significant effect on comprehensiveness for both high respect group(β = 0.678) and low respect group (β = 0.508). The moderated mediation index was statistically significant in developed areas(β = 0.091), indicating that respect had moderated mediating effect on the relationship between coordination and continuity via comprehensiveness of healthcare in the developed region; however, the moderated mediation effect was not significant in the developing region. Conclusion Such regional differences of the continuity promoting mechanism deserve the attention of policy-makers. Governments and health authorities should encourage continuity of healthcare for migrants through improving the elements of PCIC-coordination, comprehensiveness and accessibility of healthcare, shaping medical professionalism of indiscriminate respect, and empowering migrants to have more autonomy over selection of services and decisions about their health.
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Affiliation(s)
- Hao Zhang
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Yan Wu
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Wei Sun
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Wuge Li
- Department of Clinical Medicine, School of Clinical Medicine, Hangzhou Medical College, Hangzhou, China
| | - Xianhong Huang
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Tao Sun
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Mengjie Wu
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Zhen Huang
- Department of Health Policy and Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Shanquan Chen
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Gao J, Moran E, Grimm R, Toporek A, Ruser C. The Effect of Primary Care Visits on Total Patient Care Cost: Evidence From the Veterans Health Administration. J Prim Care Community Health 2022; 13:21501319221141792. [PMID: 36564889 PMCID: PMC9793026 DOI: 10.1177/21501319221141792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Since the 1980s, primary care (PC) in the US has been recognized as the backbone of healthcare providing comprehensive care to complex patients, coordinating care among specialists, and rendering preventive services to contain costs and improve clinical outcomes. However, the effect of PC visits on total patient care cost has been difficult to quantify. OBJECTIVE To assess the effect of PC visits on total patient care cost. METHODS This is a retrospective study of over 5 million patients assigned to a PC provider in the Veterans Health Administration (VHA) in each of the 4 fiscal years (FY 2016-2019). The main outcome of interest is total annual patient care cost. We assessed the effect of primary care visits on total patient care cost first by descriptive statistics, and then by multivariate regressions adjusting for severity of illness and other confounders. We conducted in-depth sensitivity analyses to validate the findings. RESULTS On average, each additional in-person PC visit was associated with a total cost reduction of $721 (per patient per year). The first PC visit was associated with the largest savings, $3976 on average, and a steady diminishing return was observed. Further, the higher the patient risk (severity of illness), the larger the cost reduction: Among the top 10% of high-risk patients, the first PC in-person visit was associated with a reduction of $16 406 (19%). CONCLUSIONS These findings, substantiated by our exhaustive sensitivity analyses, suggest that expanding PC capacity can significantly reduce overall health care costs and improve patient care outcomes given the former is a strong proxy of the latter.
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Affiliation(s)
- Jian Gao
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement,Jian Gao, Department of Veterans Affairs,
Office of Productivity, Efficiency and Staffing, Office of Analytics and
Performance Improvement, 67 Veterans Way, Albany, NY 12208, USA.
| | - Eileen Moran
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | | | - Andrew Toporek
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | - Christopher Ruser
- VACT Healthcare System, Yale University
School of Medicine, New Haven, CT, USA
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Shin E, Fleming C, Ghosh A, Javadi A, Powell R, Rich E. Assessing patient, physician, and practice characteristics predicting the use of low-value services. Health Serv Res 2022; 57:1261-1273. [PMID: 36054345 PMCID: PMC9643094 DOI: 10.1111/1475-6773.14053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices. DATA SOURCES This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018. STUDY DESIGN We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level. DATA COLLECTION/EXTRACTION METHODS The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites. PRINCIPAL FINDINGS Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level. CONCLUSIONS Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.
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Abstract
BACKGROUND Understanding what drives fragmented ambulatory care (care spread across multiple providers without a dominant provider) can inform the design of future interventions to reduce unnecessary fragmentation. OBJECTIVES To identify the characteristics of beneficiaries, primary care physicians, primary care practice sites, and geographic markets that predict highly fragmented ambulatory care in the United States. RESEARCH DESIGN Cross-sectional analysis of Medicare claims data for beneficiaries attributed to primary care physicians and practices in 2018. We used hierarchical linear models with random intercepts and an extensive list of explanatory variables to predict the likelihood of high fragmentation. SUBJECTS A total of 3,540,310 Medicare fee-for-service beneficiaries met the inclusion criteria, attributed to 26,344 primary care physicians in 9300 practice sites, and 788 geographic markets. MEASURES We defined high care fragmentation as a reversed Bice-Boxerman Index score above 0.85. RESULTS Explanatory variables explained only 6% of the variation in highly fragmented care. Unobserved differences between primary care physicians, between practice sites, and between markets together accounted for 4%. Instead, 90% of the variation in high fragmentation was unobserved residual variance. We identified the characteristics of beneficiaries (age, reason for original Medicare entitlement, and dually eligible for Medicaid insurance), physicians (comprehensiveness of care), and practices (size, being part of a system/hospital) that had small associations with high fragmentation. CONCLUSIONS Variation in fragmentation was not explained by observed beneficiary, primary care provider, practice site, or market characteristics. Instead, the aggregate behavior of diverse health care providers beyond primary care, along with unmeasured patient preferences and behaviors, seem to be important predictors.
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Fleming C, Shin E, Powell R, Poznyak D, Javadi A, Burkhart C, Ghosh A, Rich EC. Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med 2022; 37:3453-3461. [PMID: 35668238 PMCID: PMC9550936 DOI: 10.1007/s11606-022-07654-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/03/2022] [Indexed: 11/25/2022]
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13
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Gao J, Moran E, Woolhandler S, Toporek A, Wilper AP, Himmelstein DU. Primary Care's Effects on Costs in the US Veterans Health Administration, 2016-2019: an Observational Cohort Study. J Gen Intern Med 2022; 37:3289-3294. [PMID: 34608563 PMCID: PMC9550907 DOI: 10.1007/s11606-021-07140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care's effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. OBJECTIVE To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). DESIGN Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. PARTICIPANTS In total, 6,009,973 VHA patients in fiscal year (FY) 2019-5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP-and similar numbers in FYs 2016-2018. MAIN MEASURES Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients' demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. KEY RESULTS Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare's spending for VHA patients yielded similar results. CONCLUSIONS In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.
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Affiliation(s)
- Jian Gao
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Eileen Moran
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, NY, USA
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - Andrew Toporek
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Andrew P Wilper
- Boise Veterans Affairs Medical Center, Boise, ID, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - David U Himmelstein
- City University of New York at Hunter College, New York, NY, USA.
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA.
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Fraze TK, Lewis VA, Wood A, Newton H, Colla CH. Configuration and Delivery of Primary Care in Rural and Urban Settings. J Gen Intern Med 2022; 37:3045-3053. [PMID: 35266129 PMCID: PMC9485295 DOI: 10.1007/s11606-022-07472-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 02/22/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are concerns about the capacity of rural primary care due to potential workforce shortages and patients with disproportionately more clinical and socioeconomic risks. Little research examines the configuration and delivery of primary care along the spectrum of rurality. OBJECTIVE Compare structure, capabilities, and payment reform participation of isolated, small town, micropolitan, and metropolitan physician practices, and the characteristics and utilization of their Medicare beneficiaries. DESIGN Observational study of practices defined using IQVIA OneKey, 2017 Medicare claims, and, for a subset, the National Survey of Healthcare Organizations and Systems (response rate=47%). PARTICIPANTS A total of 27,716,967 beneficiaries with qualifying visits who were assigned to practices. MAIN MEASURES We characterized practices' structure, capabilities, and payment reform participation and measured beneficiary utilization by rurality. KEY RESULTS Rural practices were smaller, more primary care dominant, and system-owned, and had more beneficiaries per practice. Beneficiaries in rural practices were more likely to be from high-poverty areas and disabled. There were few differences in patterns of outpatient utilization and practices' care delivery capabilities. Isolated and micropolitan practices reported less engagement in quality-focused payment programs than metropolitan practices. Beneficiaries cared for in more rural settings received fewer recommended mammograms and had higher overall and condition-specific readmissions. Fewer beneficiaries with diabetes in rural practices had an eye exam. Most isolated rural beneficiaries traveled to more urban communities for care. CONCLUSIONS While most isolated Medicare beneficiaries traveled to more urban practices for outpatient care, those receiving care in rural practices had similar outpatient and inpatient utilization to urban counterparts except for readmissions and quality metrics that rely on services outside of primary care. Rural practices reported similar care capabilities to urban practices, suggesting that despite differences in workforce and demographics, rural patterns of primary care delivery are comparable to urban.
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Affiliation(s)
- Taressa K Fraze
- Department of Family and Community Medicine, Healthforce Center, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
| | - Valerie A Lewis
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Wood
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Helen Newton
- School of Public Health, Yale University, New Haven, CT, USA
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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Introducing Parenting Support in Primary Care: Professionals’ Perspectives on the Implementation of a Positive Parenting Program. JOURNAL OF PREVENTION 2022; 43:241-255. [PMID: 35286544 PMCID: PMC9021089 DOI: 10.1007/s10935-021-00664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/11/2022]
Abstract
While positive parenting programs are an initiative aligned with the Family-Centered Care model and the Council of Europe’s Recommendation on Positive Parenting, implementation in healthcare centers remains a challenge. The aims of this study were to (1) investigate how the hybrid version (online course plus face-to-face activities) of the program “Gain Health & Wellbeing From 0 to 3” was implemented in Spain from professionals’ perspective, and (2) explore the perceived impact of this hybrid version of the program on the implementers’ professional development. We used a qualitative mixed-methods design that included focus groups and surveys. Fifty professionals from 17 centers completed the survey on professional development. Thirty-one of these also participated in the focus groups to address the first aim. The key themes identified from the focus group were professional training, parent recruitment, program features, organizational issues, parental responses, and program sustainability. Survey results related to positive professional impact fit nicely with subthemes concerning collaboration with parents, parental needs, center coordination, and future expectations. The perceived relevance of the parenting program and its positive impact on the implementers’ professional development were potential predictors for the adoption and sustainability of the program in the public health system.
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Primary Care Practices Providing a Broader Range of Services Have Lower Medicare Expenditures and Emergency Department Utilization. J Gen Intern Med 2021; 36:2796-2802. [PMID: 33782897 PMCID: PMC8390710 DOI: 10.1007/s11606-021-06728-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
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Li Z, Shi M, He R, Zhang M, Zhang C, Xiong X, Zhang L, Li B. Association between service scope of primary care facilities and patient outcomes: a retrospective study in rural Guizhou, China. BMC Health Serv Res 2021; 21:885. [PMID: 34454504 PMCID: PMC8400844 DOI: 10.1186/s12913-021-06877-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Extending service scope of primary care facilities (PCFs) has been widely concerned in China. However, no current data about association between service scope of PCFs with patient outcomes are available. This study aims to investigate association between service scope of PCFs and patient outcomes. METHODS A multistage, stratified clustered sampling method was used to collect information about service scope of PCFs from rural Guizhou, China. Claim data of 299,633 inpatient cases covered by 64 PCFs were derived from local information system of New Rural Cooperation Medical Scheme. Service scope of PCFs was collected with self-administrated questionnaires. Primary outcomes were (1) level of inpatient institutions, (2) length of stay, (3) per capita total health cost, (4) per capita out-of-pocket cost, (5) reimbursement ratio, (6) 30-day readmission. A total of 64 PCFs were categorized into five groups per facility-level service scope scores. Generalized linear regression models, logistic regression model, and ordinal regression model were conducted to identify association between service scope of PCFs and patient outcomes. RESULTS On average, the median service scope score of PCFs was 20, with wide variation across PCFs. After controlling for demographic and clinical characteristics, patients living in communities with PCFs of greatest service scope (Quintile V vs. I) tended to have smaller rates of admission by county-level hospitals (-6.2 % [-6.5 %, -5.9 %], city-level hospitals (-1.9 % [-2.0 %, -1.8 %]), and provincial hospitals (-2.1 % [-2.2 %, -2.0 %]), smaller rate of 30-day readmission (-0.5 % [-0.7 %, -0.2 %]), less total health cost (-201.8 [-257.9, -145.8]) and out-of-pocket cost (-210.2 [-237.2, -183.2]), and greater reimbursement ratio (2.3 % [1.9 %, 2.8 %]) than their counterparts from communities with PCFs of least service scope. CONCLUSIONS Service scope of PCFs varied a lot in rural Guizhou, China. Greater service scope was associated with a reduction in secondary and tertiary hospital admission, reduced total cost and out-of-pocket cost, and 30-day readmission and increased reimbursement ratio. These results raised concerns about access to care for patients discharged from hospitals, which suggests potential opportunities for cost savings and improvement of quality of care. However, further evidence is warranted to investigate whether extending service scope of PCFs is cost-effective and sustainable.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Meng Shi
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Ruibo He
- School of Finance and Public Administration, Hubei University of Economics, Wuhan, Hubei China
| | - Mei Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Chi Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Xinyu Xiong
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Boyang Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
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Galanter W, Eguale T, Gellad W, Lambert B, Mirica M, Cashy J, Salazar A, Volk LA, Falck S, Shilka J, Van Dril E, Jarrett J, Zulueta J, Fiskio J, Orav J, Norwich D, Bennett S, Seger D, Wright A, Linder JA, Schiff G. Personal Formularies of Primary Care Physicians Across 4 Health Care Systems. JAMA Netw Open 2021; 4:e2117038. [PMID: 34264328 PMCID: PMC8283562 DOI: 10.1001/jamanetworkopen.2021.17038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE More conservative prescribing has the potential to reduce adverse drug events and patient harm and cost; however, no method exists defining the extent to which individual clinicians prescribe conservatively. One potential domain is prescribing a more limited number of drugs. Personal formularies-defined as the number and mix of unique, newly initiated drugs prescribed by a physician-may enable comparisons among clinicians, practices, and institutions. OBJECTIVES To develop a method of defining primary care physicians' personal formularies and examine how they differ among primary care physicians at 4 institutions; evaluate associations between personal formularies and patient, physician, and practice site characteristics; and empirically derive and examine the variability of the top 200 core drugs prescribed at the 4 sites. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at 4 US health care systems among 4655 internal and family medicine physicians and 4 930 707 patients who had at least 1 visit to these physicians between January 1, 2017, and December 31, 2018. EXPOSURES Personal formulary size was defined as the number of unique, newly initiated drugs. MAIN OUTCOMES AND MEASURES Personal formulary size and drugs used, physician and patient characteristics, core drugs, and analysis of selected drug classes. RESULTS The study population included 4655 primary care physicians (2274 women [48.9%]; mean [SD] age, 48.5 [4.4] years) and 4 930 707 patients (16.5% women; mean [SD] age, 51.9 [8.3] years). There were 41 378 903 outpatient prescriptions written, of which 9 496 766 (23.0%) were new starts. Institution median personal formulary size ranged from 150 (interquartile range, 82.0-212.0) to 296 (interquartile range, 230.0-347.0) drugs. In multivariable modeling, personal formulary size was significantly associated with panel size (total number of unique patients with face-to-face encounters during the study period; 1.2 medications per 100 patients), physician's total number of encounters (5.7 drugs per 10% increase), and physician's sex (-6.2 drugs per 100 patients for female physicians). There were 1527 unique, newly prescribed drugs across the 4 sites. Fewer than half the drugs (626 [41.0%]) were used at every site. Physicians' prescribing of drugs from a pooled core list varied from 0% to 100% of their prescriptions. CONCLUSIONS AND RELEVANCE Personal formularies, measured at the level of individual physicians and institutions, reveal variability in size and mix of drugs. Similarly, defining a list of commonly prescribed core drugs in primary care revealed interphysician and interinstitutional differences. Personal formularies and core medication lists enable comparisons and may identify outliers and opportunities for safer and more appropriate prescribing.
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Affiliation(s)
- William Galanter
- Department of Medicine, University of Illinois at Chicago, Chicago
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago
| | | | - Walid Gellad
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - John Cashy
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - Suzanne Falck
- Department of Medicine, University of Illinois at Chicago, Chicago
| | - John Shilka
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - Elizabeth Van Dril
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - Jennie Jarrett
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - John Zulueta
- Department of Psychiatry, University of Illinois at Chicago, Chicago
| | | | - John Orav
- Mass General Brigham, Boston, Massachusetts
| | | | | | | | | | - Jeffrey A. Linder
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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O'Malley AS, Rich EC, Shang L, Rose T, Ghosh A, Poznyak D, Peikes D, Niedzwiecki M. Practice-site-level measures of primary care comprehensiveness and their associations with patient outcomes. Health Serv Res 2020; 56:371-377. [PMID: 33197047 DOI: 10.1111/1475-6773.13599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To develop two practice-site-level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician-level measures. DATA SOURCES Medicare fee-for-service claims. STUDY DESIGN We calculated practice-site-level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices' attributed beneficiaries' 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs' comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice-site and PCP-level measures with outcomes. PRINCIPAL FINDINGS The measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P < .01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P < .05); 8.84 (3.0%) fewer hospitalizations (P < .001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P < .01). PCP comprehensiveness varied more within than between practices. CONCLUSIONS More comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice-site level comprehensiveness measures had strong construct and predictive validity; PCP-level measures were more precise.
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Affiliation(s)
- Ann S O'Malley
- Mathematica Policy Research, Washington, District of Columbia, USA
| | - Eugene C Rich
- Mathematica Policy Research, Washington, District of Columbia, USA
| | - Lisa Shang
- Mathematica Policy Research, Windsor Mill, Maryland, USA
| | - Tyler Rose
- Mathematica Policy Research, Ann Arbor, Michigan, USA
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20
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Li Z, Hung P, He R, Zhang L. Association between direct government subsidies and service scope of primary care facilities: a cross-sectional study in China. Int J Equity Health 2020; 19:135. [PMID: 32778111 PMCID: PMC7418383 DOI: 10.1186/s12939-020-01248-7] [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: 05/11/2020] [Accepted: 07/29/2020] [Indexed: 12/01/2022] Open
Abstract
Background Comprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health. However, the scope of primary care services has still been in decline in China. Studies on the factors for primary care service scope have centred on human resources and infrastructure; the role of direct government subsidies (DGS) on services scope of primary care facilities were left unanswered. This study aimed to explore the association between the DGS and services scope of primary care facilities in China. Methods A multi-stage, clustered cross-sectional survey using self-administrated questionnaire was conducted among primary care facilities of 36 districts/counties in China. A total of 770 primary care facilities were surveyed with 757 (98.3%) valid respondents. Of the 757 primary care facilities, 469 (62.0%) provided us detailed information of financial revenue and DGS from 2009 to 2016. Therefore, 469 primary care facilities from 31 counties/districts were included in this study. Sasabuchi-Lind-Mehlum tests and multivariate regression models were used to examine the inverted U-shaped relationship between the DGS and service scope. Results Of 469 PCFs, 332 (70.8%) were township health centres. Proportion of annul DGS to FR arose from 26.5% in 2009 to 50.5% in 2016. At the low proportion of DGS to financial revenue, an increase in DGS was associated with an increased service scope of primary care facilities, whereas the proportion of DGS to financial revenue over 42.5% might cause narrowed service scope (P = 0.023, 95% CI 11.59–51.74%); for the basic medical care dimension, the cut point is 42.6%. However, association between DGS and service scope of public health by primary care facilities is statistically insignificant. Conclusion While the DGS successfully achieved equalization of basic preventive and public health services, the disproportionate proportion of DGS to financial revenue is associated with narrowed service scope, which might cause underutilization of primary care and distorted incentive structure of primary care. Future improvements of DGS should focus on the incentive of broader basic medical services provision, such as clarifying service scope of primary care facilities and strategic procurement with a performance-based subsidies system to determine resource allocation.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Research Center for Rural Health Services, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, Hubei, China.,Arnold School of Public Health, University of South Carolina, Columbia, 29205, SC, USA
| | - Peiyin Hung
- Arnold School of Public Health, University of South Carolina, Columbia, 29205, SC, USA
| | - Ruibo He
- School of Finance and Public Administration, Hubei University of Economics, Wuhan, 430205, Hubei, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China. .,Research Center for Rural Health Services, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, Hubei, China.
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21
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Chang ET, Zulman DM, Nelson KM, Rosland AM, Ganz DA, Fihn SD, Piegari R, Rubenstein LV. Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA Netw Open 2020; 3:e208120. [PMID: 32597993 PMCID: PMC7324956 DOI: 10.1001/jamanetworkopen.2020.8120] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described. OBJECTIVE To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA). DESIGN, SETTING, AND PARTICIPANTS This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019. EXPOSURES Risk of hospitalization and assignment to general vs specialized primary care. MAIN OUTCOME AND MEASURES High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care). RESULTS The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall. CONCLUSIONS AND RELEVANCE The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.
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Affiliation(s)
- Evelyn T. Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karin M. Nelson
- Seattle-Denver Health Services Research & Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington
- General Internal Medicine Service, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A. Ganz
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- VA Greater Los Angeles Geriatric Research, Education and Clinical Center, Los Angeles, California
- UCLA Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles, California
| | - Stephan D. Fihn
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Rebecca Piegari
- VA Office of Clinical Systems Development & Evaluation, Washington, DC
| | - Lisa V. Rubenstein
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
- Fielding School of Public Health, UCLA, Los Angeles, California
- RAND Corporation, Santa Monica, California
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Flaegel K, Brandt B, Goetz K, Steinhaeuser J. Which procedures are performed by general internists practicing primary care in Germany? - a cross-sectional study. BMC FAMILY PRACTICE 2020; 21:73. [PMID: 32349681 PMCID: PMC7191754 DOI: 10.1186/s12875-020-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/02/2020] [Indexed: 11/25/2022]
Abstract
Background Due to differences of residency training programs’ emphases – inpatient vs office-based – internal medicine and family medicine residents consistently reported differences in preparedness to care for common adult conditions. Study’s aim was to add knowledge about procedures that a) are performed by general internists working in primary care and b) should be learned during residency in general internists’ appraisal. Methods A cross-sectional postal survey was carried out by using a questionnaire that comprised 90 procedures relevant in primary care. Each procedure implied the two questions “Do you perform this procedure in your own practice?” and “How important do you think it is to learn this procedure during residency?” The final questionnaire was sent to 1002 general internists working in primary care in Germany in May 2015. Data analysis was performed using SPSS Version 24.0 (SPSS inc., IBM). Next to descriptive statistics subgroup analyses were performed using cross tabulation and Chi-square tests for evaluation of differences in the performance of most frequently performed procedures in urban or rural areas as well as by male or female physicians. Results Twenty-eight percent of sent questionnaires (276/1002) could be included in analysis. Mean age of participants was 52 years with 13 years of practice experience; 40% were female. Twenty-nine (32%) of 90 given procedures were performed by at least half of the participants, foremost technical diagnostics, punctures, procedures of the integument and resuscitation. After Bonferroni correction, five of those procedures were performed by more male than female physicians and two procedures by more physicians working in a rural practice than physicians practicing in an urban location. Moreover, 46 (51%) procedures were assessed as important to learn during residency by at least 50% of participants. Conclusions General internists working in German primary care perform a narrow scope of procedures offered by primary care physicians. In order to provide best ambulatory care for patients, residency training programs must ensure training in procedures that are necessary for providing high quality care. Therefore, a consensus aligned with patients’ and health-systems’ needs on procedures required for working as a general internist in primary care is necessary.
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Affiliation(s)
- Kristina Flaegel
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Bettina Brandt
- Department of General Practice/Primary Care, Hamburg University Medical School, Martinistraße 52, 20246, Hamburg, Germany
| | - Katja Goetz
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jost Steinhaeuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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23
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Ho V, Tapaneeyakul S, Metcalfe L, Vu L, Short M. Using Medicare data to measure vertical integration of hospitals and physicians. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2020; 20:1-12. [PMID: 32099524 PMCID: PMC7036068 DOI: 10.1007/s10742-020-00207-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/08/2020] [Accepted: 01/22/2020] [Indexed: 11/12/2022]
Abstract
Researchers, healthcare providers, and policy makers have become increasingly interested in the cost and quality effects of vertical integration (VI) between hospitals and physicians. However, tracking VI is often financially costly. Because the Medicare Data on Provider Practice and Specialty (MD-PPAS) annual dataset may be more cost-effective for researchers to access than private data sources, we examine the accuracy of MD-PPAS in identifying VI by comparing it to physician and hospital affiliations reported in Blue Cross Blue Shield Texas (BCBSTX) PPO claims data for 2014-2016. The BCBSTX data serve as a gold standard, because physician-hospital affiliations are based on the insurer's provider contract information. We merged the two datasets using the physician National Provider Identifier (NPI), then determined what percentage of physicians had the same Tax Identification Number (TIN) in both sources, and whether the TIN implied the physician belonged to a physician- or hospital-owned practice. We found that 71.3% of successfully matched NPIs reported the same TIN, and 95.1% of patient-level observations were attributed to organizations with the same ownership type in both datasets, regardless of TIN. We compared regression estimates of patient-level annual spending on an indicator variable for physician versus hospital ownership for the primary attributed physician and found that estimates were within one percentage point whether one determined VI based on the BCBSTX or the MD-PPAS data. The results suggest that MD-PPAS, which costs less to obtain than from a for-profit data source, can be used to reliably track VI between hospitals and physicians.
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Affiliation(s)
- Vivian Ho
- Baker Institute for Public Policy, Rice University, 6100 Main Street, MS 22, Houston, TX 77005 USA
- Department of Economics, Rice University, Houston, TX USA
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Sasathorn Tapaneeyakul
- Baker Institute for Public Policy, Rice University, 6100 Main Street, MS 22, Houston, TX 77005 USA
| | | | - Lan Vu
- Blue Cross Blue Shield of Texas, Richardson, TX USA
| | - Marah Short
- Baker Institute for Public Policy, Rice University, 6100 Main Street, MS 22, Houston, TX 77005 USA
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24
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Geissler KH. Differences in referral patterns for rural primary care physicians from 2005 to 2016. Health Serv Res 2019; 55:94-102. [PMID: 31845328 DOI: 10.1111/1475-6773.13244] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine differences in referral patterns in a nationally representative sample between primary care physicians (PCP) practicing in rural vs nonrural areas and changes over time. STUDY DESIGN Using the 2005-2016 National Ambulatory Medical Care Survey and multivariate logit regression models, I compare referral patterns of PCPs in rural vs nonrural areas. DATA COLLECTION Multiple years of data were combined. PRINCIPAL FINDINGS A PCP visit was 1.9 percentage points (95% confidence interval: 0.1 pp, 3.8 pp) more likely to result in a referral in nonrural areas than rural areas, controlling for physician and patient characteristics, a 17 percent increase. This difference is driven by a widening gap in referral rates between nonrural and rural areas over time, with large differences in later periods. The regression-adjusted predicted probability of a PCP visit resulting in a referral was 71 percent higher in nonrural than rural areas in 2013-2014 and 92 percent higher in 2015-2016. CONCLUSIONS Recognizing that the optimal PCP referral rate is unknown, referrals are less common in rural areas with a widening gap in recent years. This difference may reflect specialist availability, distance to care, or patient preferences. As changes occur to health care financing and delivery, continuing to monitor practice patterns is important to ensure patients are receiving appropriate levels of care across geographic regions.
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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, Massachusetts
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25
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Comparing Comprehensiveness in Primary Care Specialties and Their Effects on Healthcare Costs and Hospitalizations in Medicare Beneficiaries. J Gen Intern Med 2019; 34:2708-2710. [PMID: 31520228 PMCID: PMC6854125 DOI: 10.1007/s11606-019-05338-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 08/06/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
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26
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Myers CR, Chang C, Mirvis D, Stansberry T. The macroeconomic benefits of Tennessee APRNs having full practice authority. Nurs Outlook 2019; 68:155-161. [PMID: 31685235 DOI: 10.1016/j.outlook.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/08/2019] [Accepted: 09/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND To-date, advocacy efforts to advance full practice authority for APRNs have primarily stressed arguments based on evidence on the cost effectiveness and quality of APRN-provided care, as well as the improved care access and patient satisfaction these providers offer. PURPOSE The economic impact analysis forecasts the additional job and economic output associated with granting Tennessee APRNs full practice authority. METHODS The IMPLAN software and a variety of data inputs were used to estimate the direct, indirect, and induced economic impact on jobs, labor income, value-added benefits, total output, and tax revenues. FINDINGS From a 2017 baseline, the cumulative impact of granting Tennessee APRNs full practice authority is a net gain of 25,536 jobs and $3.2 billion in economic impact. DISCUSSION Granting Tennessee APRNs full practice authority would confer substantial economic benefits and employment opportunities to the state.
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Affiliation(s)
- Carole R Myers
- College of Nursing and Department of Public Health, University of Tennessee, Knoxville, TN.
| | - Cyril Chang
- Methodist Le Bonheur Center for Healthcare Economics, The University of Memphis, The Fogelman College of Business and Economics, Memphis, TN
| | - David Mirvis
- College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN; Methodist LeBonheur Center for Healthcare Economics, The Fogelman College of Business and Economics, The University of Memphis, Memphis, TN
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27
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O'Malley AS, Rich EC, Shang L, Rose T, Ghosh A, Poznyak D, Peikes D. New approaches to measuring the comprehensiveness of primary care physicians. Health Serv Res 2019; 54:356-366. [PMID: 30613955 DOI: 10.1111/1475-6773.13101] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To develop claims-based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost. DATA SOURCES AND STUDY SETTING A total of 5359 PCPs caring for over 1 million Medicare fee-for-service beneficiaries from 1404 practices. STUDY DESIGN We developed Medicare claims-based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs' comprehensiveness in 2013 with their beneficiaries' emergency department, hospitalizations rates, and ambulatory care-sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering. PRINCIPAL FINDINGS Each measure varied across PCPs and had low correlation with the other measures-as intended, they capture different aspects of comprehensiveness. For patients whose PCPs' comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, -$17.4 (-2.2 percent); hospitalizations, -5.5 (-1.9 percent); emergency department (ED) visits, -16.3 (-2.4 percent); new problem management: total Medicare expenditures, -$13.3 (-1.7 percent); hospitalizations, -7.0 (-2.4 percent); ED visits, -19.7 (-2.9 percent); range of services: ED visits, -17.1 (-2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates. CONCLUSIONS These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.
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Affiliation(s)
- Ann S O'Malley
- Mathematica Policy Research, Washington, District of Columbia
| | - Eugene C Rich
- Mathematica Policy Research, Washington, District of Columbia
| | - Lisa Shang
- Mathematica Policy Research, Baltimore, Maryland
| | - Tyler Rose
- Mathematica Policy Research, Ann Arbor, Michigan
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