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Chang ET, Huynh A, Yoo C, Yoon J, Zulman DM, Ong MK, Klein M, Eng J, Roy S, Stockdale SE, Jimenez EE, Denietolis A, Needleman J, Asch SM. Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis. J Gen Intern Med 2024:10.1007/s11606-024-08923-3. [PMID: 39075268 DOI: 10.1007/s11606-024-08923-3] [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: 01/11/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.
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Affiliation(s)
- Evelyn T Chang
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Alexis Huynh
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Caroline Yoo
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Jean Yoon
- VHA Health Economics Resource Center (HERC), Menlo Park, CA, USA
- Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA
| | - Donna M Zulman
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael K Ong
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Klein
- Department of Medicine, VHA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Jessica Eng
- On Lok Program of All-Inclusive Care for the Elderly (PACE), San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Sudip Roy
- VHA Salisbury Healthcare System, Salisbury, NC, USA
| | - Susan E Stockdale
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
| | - Elvira E Jimenez
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Behavioral Neurology, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Angela Denietolis
- VHA Office of Primary Care, 810 Vermont Ave, Washington, DC, 20420, USA
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven M Asch
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [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] [Received: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Shen M, Osman K, Blumenthal DM, DeMuth K, Liu Y. Home Heart Hospital Associated With Reduced Hospitalizations and Costs Among High-Cost Patients With Cardiovascular Disease. Clin Cardiol 2024; 47:e24302. [PMID: 38874052 PMCID: PMC11177177 DOI: 10.1002/clc.24302] [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: 02/13/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND There is no widely accepted care model for managing high-need, high-cost (HNHC) patients. We hypothesized that a Home Heart Hospital (H3), which provides longitudinal, hospital-level at-home care, would improve care quality and reduce costs for HNHC patients with cardiovascular disease (CVD). OBJECTIVE To evaluate associations between enrollment in H3, which provides longitudinal, hospital-level at-home care, care quality, and costs for HNHC patients with CVD. METHODS This retrospective within-subject cohort study used insurance claims and electronic health records data to evaluate unadjusted and adjusted annualized hospitalization rates, total costs of care, part A costs, and mortality rates before, during, and following H3. RESULTS Ninety-four patients were enrolled in H3 between February 2019 and October 2021. Patients' mean age was 75 years and 50% were female. Common comorbidities included congestive heart failure (50%), atrial fibrillation (37%), coronary artery disease (44%). Relative to pre-enrollment, enrollment in H3 was associated with significant reductions in annualized hospitalization rates (absolute reduction (AR): 2.4 hospitalizations/year, 95% confidence interval [95% CI]: -0.8, -4.0; p < 0.001; total costs of care (AR: -$56 990, 95% CI: -$105 170, -$8810; p < 0.05; and part A costs (AR: -$78 210, 95% CI: -$114 770, -$41 640; p < 0.001). Annualized post-H3 total costs and part A costs were significantly lower than pre-enrollment costs (total costs of care: -$113 510, 95% CI: -$151 340, -$65 320; p < 0.001; part A costs: -$84 480, 95% CI: -$121 040, -$47 920; p < 0.001). CONCLUSIONS Longitudinal home-based care models hold promise for improving quality and reducing healthcare spending for HNHC patients with CVD.
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Affiliation(s)
- Michael Shen
- Novolink Health (Previously Duxlink Health), A Division of Cardiovascular Associates of America, Sunrise, Florida, USA
| | - Kareem Osman
- University of California Los Angeles David Geffen School of Medicine, Department of Medicine, Los Angeles, California, USA
| | - Daniel M Blumenthal
- Novocardia, A Division of Cardiovascular Associates of America, Celebration, Florida, USA
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kaelin DeMuth
- Philadelphia College of Osteopathic Medicine South Georgia, Moultrie, Georgia, USA
| | - Yixiang Liu
- Novolink Health (Previously Duxlink Health), A Division of Cardiovascular Associates of America, Sunrise, Florida, USA
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Giannitrapani KF, Holliday JR, McCaa MD, Stockdale S, Bergman AA, Katz ML, Zulman DM, Rubenstein LV, Chang ET. Meeting high-risk patient pain care needs through intensive primary care: a secondary analysis. BMJ Open 2024; 14:e080748. [PMID: 38167288 PMCID: PMC10773401 DOI: 10.1136/bmjopen-2023-080748] [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: 10/09/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM. DESIGN Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients. SETTING Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions. PARTICIPANTS Staff and high-risk PC patients in the VA. INTERVENTION A multisite randomised PC-based IM programme for high-risk patients. OUTCOME MEASURES (a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain. RESULTS Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned. CONCLUSIONS Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams.
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Affiliation(s)
- Karleen F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Jesse R Holliday
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
| | - Matthew D McCaa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Alicia A Bergman
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Marian L Katz
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | | | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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Hojat LS, Wilson BM, Perez F, Mojica MF, Singer ME, Bonomo RA, Epstein LH. Association of COVID-19 coinfection with increased mortality among patients with Pseudomonas aeruginosa bloodstream infection in the Veterans Health Administration system. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e237. [PMID: 38156202 PMCID: PMC10753479 DOI: 10.1017/ash.2023.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 12/30/2023]
Abstract
Objective Pseudomonas aeruginosa bloodstream infection (PA-BSI) and COVID-19 are independently associated with high mortality. We sought to demonstrate the impact of COVID-19 coinfection on patients with PA-BSI. Design Retrospective cohort study. Setting Veterans Health Administration. Patients Hospitalized patients with PA-BSI in pre-COVID-19 (January 2009 to December 2019) and COVID-19 (January 2020 to June 2022) periods. Patients in the COVID-19 period were further stratified by the presence or absence of concomitant COVID-19 infection. Methods We characterized trends in resistance, treatment, and mortality over the study period. Multivariable logistic regression and modified Poisson analyses were used to determine the association between COVID-19 and mortality among patients with PA-BSI. Additional predictors included demographics, comorbidities, disease severity, antimicrobial susceptibility, and treatment. Results A total of 6,714 patients with PA-BSI were identified. Throughout the study period, PA resistance rates decreased. Mortality decreased during the pre-COVID-19 period and increased during the COVID-19 period. Mortality was not significantly different between pre-COVID-19 (24.5%, 95% confidence interval [CI] 23.3-28.6) and COVID-19 period/COVID-negative (26.0%, 95% CI 23.5-28.6) patients, but it was significantly higher in COVID-19 period/COVID-positive patients (47.2%, 35.3-59.3). In the modified Poisson analysis, COVID-19 coinfection was associated with higher mortality (relative risk 1.44, 95% CI 1.01-2.06). Higher Charlson Comorbidity Index, higher modified Acute Physiology and Chronic Health Evaluation score, and no targeted PA-BSI treatment within 48 h were also predictors of higher mortality. Conclusions Higher mortality was observed in patients with COVID-19 coinfection among patients with PA-BSI. Future studies should explore this relationship in other settings and investigate potential SARS-CoV-2 and PA synergy.
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Affiliation(s)
- Leila S. Hojat
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brigid M. Wilson
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Federico Perez
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Case Western Reserve University, Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Maria F. Mojica
- Case Western Reserve University, Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
- Departments of Pathology, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mendel E. Singer
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Robert A. Bonomo
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Case Western Reserve University, Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Departments of Pathology, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lauren H. Epstein
- Infectious Diseases, US Department of Veterans Affairs Medical Center, Decatur, GA, USA
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Blonigen D, Hyde J, McInnes DK, Yoon J, Byrne T, Ngo T, Smelson D. Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial. Contemp Clin Trials 2023; 125:107065. [PMID: 36572239 DOI: 10.1016/j.cct.2022.107065] [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] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Homelessness is a strong determinant of acute care service utilization (inpatient hospitalization, emergency department visits) among US adults. Data analytics, peer support, and patient-centered approaches can collectively offer high-quality care for homeless patients who frequently utilize acute care ("super utilizers"). However, few outpatient programs have integrated these components and tested their effectiveness for this patient population. OBJECTIVE To test the effectiveness and implementation potential of a novel intervention that integrates data analytics with peers trained in whole health coaching ("Peer Whole Health") to reduce use of acute care among homeless adults. METHODS Using a randomized controlled trial design at two US Veterans Health Administration Medical Centers, we plan to enroll 220 veterans in primary care on VHA's Homeless Registry who are flagged on a super-utilizer clinical dashboard. Participants will complete a baseline interview, be randomized to Enhanced Usual Care (EUC; primary care and data analytics) or EUC plus 18 sessions of Peer Whole Health over 6 months, and be re-interviewed at 3, 6, and 9 months. Qualitative interviews with primary care staff and patients will identify facilitators and barriers to more widespread implementation of the intervention. DISCUSSION The primary hypothesis is that those who receive the intervention will have fewer total days of all-cause hospitalization. If confirmed, the findings can provide healthcare systems that serve homeless super-utilizers with a high-value approach to care that can be integrated into primary care services and reduce overall costs for these patients. CLINICAL TRIAL REGISTRATION The study is registered with ClinicalTrials.gov (NCT05176977).
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Affiliation(s)
- Daniel Blonigen
- HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
| | - Justeen Hyde
- HSR&D Center for Healthcare Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | - D Keith McInnes
- HSR&D Center for Healthcare Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA, USA; Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Jean Yoon
- HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Thomas Byrne
- HSR&D Center for Healthcare Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA, USA
| | - Tu Ngo
- VA Bedford HealthCare System, Bedford, MA, USA
| | - David Smelson
- HSR&D Center for Healthcare Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA, USA; Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
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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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Atkins D, Makridis CA, Alterovitz G, Ramoni R, Clancy C. Developing and Implementing Predictive Models in a Learning Healthcare System: Traditional and Artificial Intelligence Approaches in the Veterans Health Administration. Annu Rev Biomed Data Sci 2022; 5:393-413. [PMID: 35609894 DOI: 10.1146/annurev-biodatasci-122220-110053] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Predicting clinical risk is an important part of healthcare and can inform decisions about treatments, preventive interventions, and provision of extra services. The field of predictive models has been revolutionized over the past two decades by electronic health record data; the ability to link such data with other demographic, socioeconomic, and geographic information; the availability of high-capacity computing; and new machine learning and artificial intelligence methods for extracting insights from complex datasets. These advances have produced a new generation of computerized predictive models, but debate continues about their development, reporting, validation, evaluation, and implementation. In this review we reflect on more than 10 years of experience at the Veterans Health Administration, the largest integrated healthcare system in the United States, in developing, testing, and implementing such models at scale. We report lessons from the implementation of national risk prediction models and suggest an agenda for research. Expected final online publication date for the Annual Review of Biomedical Data Science, Volume 5 is August 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- David Atkins
- Office of Research and Development, Department of Veterans Affairs, Washington, DC, USA;
| | - Christos A Makridis
- National Artificial Intelligence Institute, Department of Veterans Affairs, Washington, DC, USA
| | - Gil Alterovitz
- National Artificial Intelligence Institute, Department of Veterans Affairs, Washington, DC, USA
| | - Rachel Ramoni
- Office of Research and Development, Department of Veterans Affairs, Washington, DC, USA;
| | - Carolyn Clancy
- Office of Discovery, Education and Affiliate Networks, Department of Veterans Affairs, Washington, DC, USA
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Montori VM. Removing the blindfold: The centrality of care in caring for patients with multiple chronic conditions. Health Serv Res 2021; 56 Suppl 1:969-972. [PMID: 34378207 PMCID: PMC8515218 DOI: 10.1111/1475-6773.13865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Victor M. Montori
- Knowledge and Evaluation Research UnitMayo ClinicRochesterMinnesotaUSA
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