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Kern LM, Lau JD, Rajan M, Rhodes JD, Casalino LP, Colantonio LD, Pinheiro LC, Safford MM. Associations among claims-based care fragmentation, self-reported gaps in care coordination, and self-reported adverse events. BMC Health Serv Res 2024; 24:1045. [PMID: 39256705 PMCID: PMC11389281 DOI: 10.1186/s12913-024-11440-y] [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: 03/15/2024] [Accepted: 08/14/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Fragmentation of care (that is, the use of multiple ambulatory providers without a dominant provider) may increase the risk of gaps in communication among providers. However, it is unclear whether people with fragmented care (as measured in claims) perceive more gaps in communication among their providers. It is also unclear whether people who perceive gaps in communication experience them as clinically significant (that is, whether they experience adverse events that they attribute to poor coordination). METHODS We conducted a longitudinal study using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including a survey on perceptions of healthcare (2017-2018) and linked fee-for-service Medicare claims (for the 12 months prior to the survey) (N = 4,296). We estimated correlation coefficients to determine associations between claims-based and self-reported numbers of ambulatory visits and ambulatory providers. We then used logistic regression to determine associations between claims-based fragmentation (measured with the reversed Bice-Boxerman Index [rBBI]) and self-reported gaps in care coordination and, separately, between claims-based fragmentation and self-reported adverse events that the respondent attributed to poor coordination. RESULTS The correlation coefficient between claims-based and self-report was 0.37 for the number of visits and 0.38 for the number of providers (p < 0.0001 for each). Individuals with high fragmentation by claims (rBBI ≥ 0.85) had a 23% increased adjusted odds of reporting any gap in care coordination (95% CI 3%, 48%) and, separately, a 61% increased adjusted odds of reporting an adverse event that they attributed to poor coordination (95% CI 11%, 134%). CONCLUSIONS Medicare beneficiaries with claims-based fragmentation also report gaps in communication among their providers. Moreover, these gaps appear to be clinically significant, with beneficiaries reporting adverse events that they attribute to poor coordination.
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Affiliation(s)
- Lisa M Kern
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA.
| | - Jennifer D Lau
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | - Mangala Rajan
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | - J David Rhodes
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lawrence P Casalino
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | | | - Laura C Pinheiro
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | - Monika M Safford
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
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Lampe D, Grosser J, Gensorowsky D, Witte J, Muth C, van den Akker M, Dinh TS, Greiner W. The Relationship of Continuity of Care, Polypharmacy and Medication Appropriateness: A Systematic Review of Observational Studies. Drugs Aging 2023; 40:473-497. [DOI: 10.1007/s40266-023-01022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 03/29/2023]
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Leniz J, Gulliford M, Higginson IJ, Bajwah S, Yi D, Gao W, Sleeman KE. Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia. Br J Gen Pract 2022; 72:BJGP.2021.0715. [PMID: 35817583 PMCID: PMC9282808 DOI: 10.3399/bjgp.2021.0715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/02/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Reducing hospital admissions among people dying with dementia is a policy priority. AIM To explore associations between primary care contacts, continuity of primary care, identification of palliative care needs, and unplanned hospital admissions among people dying with dementia. DESIGN AND SETTING This was a retrospective cohort study using the Clinical Practice Research Datalink linked with hospital records and Office for National Statistics data. Adults (>18 years) who died between 2009 and 2018 with a diagnosis of dementia were included in the study. METHOD The association between GP contacts, Herfindahl-Hirschman Index continuity of care score, palliative care needs identification before the last 90 days of life, and multiple unplanned hospital admissions in the last 90 days was evaluated using random-effects Poisson regression. RESULTS In total, 33 714 decedents with dementia were identified: 64.1% (n = 21 623) female, mean age 86.6 years (SD 8.1), mean comorbidities 2.2 (SD 1.6). Of these, 1894 (5.6%) had multiple hospital admissions in the last 90 days of life (increase from 4.9%, 95% confidence interval [CI] = 4.2 to 5.6 in 2009 to 7.1%, 95% CI = 5.7 to 8.4 in 2018). Participants with more GP contacts had higher risk of multiple hospital admissions (incidence risk ratio [IRR] 1.08, 95% CI = 1.05 to 1.11). Higher continuity of care scores (IRR 0.79, 95% CI = 0.68 to 0.92) and identification of palliative care needs (IRR 0.66, 95% CI = 0.56 to 0.78) were associated with lower frequency of these admissions. CONCLUSION Multiple hospital admissions among people dying with dementia are increasing. Higher continuity of care and identification of palliative care needs are associated with a lower risk of multiple hospital admissions in this population, and might help prevent these admissions at the end of life.
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Affiliation(s)
- Javiera Leniz
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Martin Gulliford
- Department of Population Health Sciences, Faculty of Life Science & Medicine, King's College London, London
| | - Irene J Higginson
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Sabrina Bajwah
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Deokhee Yi
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Wei Gao
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Katherine E Sleeman
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
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Mirabal-Beltran R, Hawks-Cuellar M, Powell TW, Strobino DM. Women's perceptions of provider communication on birth options after cesarean: A qualitative study. Res Nurs Health 2022; 45:173-182. [PMID: 34791690 DOI: 10.1002/nur.22196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 11/09/2022]
Abstract
In the United States, Hispanic and non-Hispanic Black women are more likely to have a repeat cesarean birth (RCB) than non-Hispanic White women. The underrepresentation of Hispanic women and women with previous cesarean births in prior studies has resulted in a limited understanding of the reasons for this disparity. This study used in-depth interviews to investigate the perceptions of 27 Hispanic and non-Hispanic Black and White women about the communication that took place with their providers about their birth options after a previous cesarean. The roles of cultural norms and trust in providers in communication about RCBs were also explored. Results suggest that patient-provider communication and trust of providers for Hispanic and non-Hispanic Black and White women may influence their perception of choice, uptake of information, and ability to make an informed choice regarding birth options. Findings have implications for providers and healthcare management systems who need to account for and attempt to address these differences as they directly affect women's birth outcomes.
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Affiliation(s)
- Roxanne Mirabal-Beltran
- Department of Professional Nursing Practice, Georgetown University School of Nursing and Health Studies, Washington, District of Columbia, USA
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michelle Hawks-Cuellar
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Terrinieka W Powell
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Donna M Strobino
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Chhatre S, Malkowicz SB, Jayadevappa R. Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients. Prostate 2021; 81:1310-1319. [PMID: 34516667 DOI: 10.1002/pros.24228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022]
Abstract
Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.
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Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA
| | - S Bruce Malkowicz
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ravishankar Jayadevappa
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Barrera L, Oviedo D, Silva A, Tovar D, Méndez F. Continuity of Care and the Control of High Blood Pressure at Colombian Primary Care Services. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:469580211047043. [PMID: 34620003 PMCID: PMC8511938 DOI: 10.1177/00469580211047043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Continuity of care (COC) has been associated with lower mortality and
hospitalizations and higher high blood pressure (HBP) control rates. This
evidence mainly came from high income countries. We aimed to identify conditions
associated with controlled HBP, particularly COC, in primary care services
(PCSs) affiliated to two health insurances in Colombia, a low-median income
country. A longitudinal observational study was carried out using clinical
records of hypertensive adults >18 years with ≥4 clinic visits attending a
contributive and a subsidized PCS in Cali (Colombia) between 2013 and 2014.
Subsidized PCSs were for unemployment people and those at low socio-economic
position and contributive for formal workers. COC was measured using the Bice
and Boxerman index. Logistic regression models were performed to quantify the
relation between COC and controlled HBP (blood pressure <140/90 mmHg).
Between 2013 and 2014, among 8797 hypertensive people identified, 1358 were
included: 935 (68.8%) and 423 (31.1%) from the contributive and subsidized PCSs,
respectively. 856 (62.3%) were women and had a mean age of 67.7 years (SD 11.7).
All people were on antihypertensive treatment. Over the study period, 522
(38.4%) people had controlled HBP, 410 (43.9%) in the contributive and 112
(26.5%) in subsidized PCSs. An increase in 1 unit of the COC index is associated
with a 161% higher probability of having HBP controlled (OR, 2.61; 95% CI,
1.25–5.44). The odds of having controlled HBP increased as the number of visits
rose; for example, people at the fourth visit had a 34% (OR, 1.34; 95% CI,
1.08–1.66) higher probability of reaching the target. Continuity of care was
positively associated with controlled HBP. The strengthening of COC can improve
the observed low HBP control rates and reduce health inequalities.
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Affiliation(s)
- Lena Barrera
- School of Medicine, Prevention and Control of Chronic Diseases Group, PRECEC, Faculty of Health. 28006Universidad Del Valle, Cali, Colombia.,School of Public Health, Prevention and Control of Chronic Diseases Group, PRECEC, Faculty of Health. 469604Universidad Del Valle, Cali, Colombia
| | - Diana Oviedo
- School of Medicine, Prevention and Control of Chronic Diseases Group, PRECEC, Faculty of Health. 28006Universidad Del Valle, Cali, Colombia
| | - Alvaro Silva
- School of Medicine, Prevention and Control of Chronic Diseases Group, PRECEC, Faculty of Health. 28006Universidad Del Valle, Cali, Colombia.,Caja de Compensación Familiar Del Valle Del Cauca-Comfandi, Cali, Colombia
| | - Diego Tovar
- School of Statistics, Prevention and Control of Chronic Diseases Group, PRECEC, Faculty of Health, 28006Universidad Del Valle, Cali, Colombia
| | - Fabián Méndez
- School of Public Health, Prevention and Control of Chronic Diseases Group, PRECEC, Faculty of Health. 469604Universidad Del Valle, Cali, Colombia
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Johnston KJ, Mittler J, Hockenberry JM. Patient social risk factors and continuity of care for Medicare beneficiaries. Health Serv Res 2020; 55:445-456. [PMID: 32037553 DOI: 10.1111/1475-6773.13272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To identify patient social risk factors associated with Continuity of Care (COC) index. DATA SOURCES/STUDY SETTING Medicare Current Beneficiary Survey (MCBS), the Dartmouth Institute, and Area Resource File for 2006-2013. STUDY DESIGN We use regression methods to assess the effect of patient social risk factors on COC after adjusting for medical complexity. In secondary analyses, we assess the effect of social risk factors on annual utilization of physicians and specialists for evaluation and management (E&M). DATA COLLECTION/EXTRACTION METHODS We retrospectively identified 59 499 patient years for Medicare beneficiaries with one year of enrollment and three or more E&M visits. PRINCIPAL FINDINGS After adjustment for medical complexity, individual-level social risk factors such as lack of education, low income, and living alone are all associated with better patient COC (P < .05). Similarly, area-level social risk factors such as living in areas that are nonurban or high poverty, as well as in areas with low specialist or high primary care physician supply, are all associated with better patient COC (P < .05). We found the opposite pattern of associations between these same risk factors and annual patient utilization of physicians and specialists (P < .05). CONCLUSIONS Medicare patients with multiple social risk factors have consistently better COC; these same social risk factors are associated with reduced patient-realized access to specialist physician care.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
| | - Jessica Mittler
- Department of Health Administration, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Qiu C, Chen S, Yao Y, Zhao Y, Xin Y, Zang X. Adaption and validation of Nijmegen continuity questionnaire to recognize the influencing factors of continuity of care for hypertensive patients in China. BMC Health Serv Res 2019; 19:79. [PMID: 30696430 PMCID: PMC6352379 DOI: 10.1186/s12913-019-3915-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 01/17/2019] [Indexed: 12/05/2022] Open
Abstract
Background Continuity of care (COC) has become a primary point of concern for care providers in both developed and developing countries, which is regarded as the “cornerstone of care” and an “essential element” of good health care. A robust and proper instrument is of necessity to identify problems and evaluate intervention aimed at improving continuity of care. This study aimed to adapt Nijmegen continuity questionnaire (NCQ) into a Chinese version (NCQ-C) and to delineate the status of COC as well as explore its influencing factors for hypertensive patients in China. Methods A forward-back-translation procedure was adopted for the determination of the adaption of NCQ. Then a total of 448 patients completed questionnaires and 24-h ambulatory blood pressure monitoring (ABPM). Proper indexes were calculated to test the reliability and validity of NCQ-C. Logistic analysis were used to detect the influencing factors of COC. Results The NCQ-C had excellent intraclass correlation coefficient of 0.855 and internal consistency of seven dimensions varied from 0.907 to 0.944. The item-content validity index ranged from 0.71 to 1.00. For construct validity, seven-factor structure was confirmed as original questionnaire and all the fit indices indicated acceptable levels. Gender, education level, medical insurance and frequency of family visits, blood pressure level, depression status as well as general health perception were demonstrated to be statistically related to COC. Conclusions In addition, all the parameters of ABPM were negatively significant with COC. The NCQ-C has shown acceptable level of reliability and validity. The related factors of COC should arouse care providers’ attention.
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Affiliation(s)
- Chen Qiu
- School of Nursing, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin, China
| | - Shixiang Chen
- School of Nursing, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin, China
| | - Ying Yao
- Department of Emergency, Tianjin Medical University General Hospital, Tianjin, China
| | - Yue Zhao
- School of Nursing, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin, China
| | - Yi Xin
- Department of Cardiology, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiaoying Zang
- School of Nursing, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin, China.
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Continuity of Care in Older Adults With Multiple Chronic Conditions: How Well Do Administrative Measures Correspond With Patient Experiences? J Healthc Qual 2018; 40:120-128. [DOI: 10.1097/jhq.0000000000000051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Waibel S, Vargas I, Coderch J, Vázquez ML. Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system. BMC Health Serv Res 2018; 18:257. [PMID: 29631622 PMCID: PMC5891958 DOI: 10.1186/s12913-018-3042-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 03/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background In the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain). Methods We conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data. Results Patients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship. Conclusions Consistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists. Electronic supplementary material The online version of this article (10.1186/s12913-018-3042-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sina Waibel
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Av. Tibidabo 21, 08022, Barcelona, Spain. .,Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Av. de Can Domènech 737, 08193, Bellaterra (Cerdanyola de Vallès), Spain.
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Av. Tibidabo 21, 08022, Barcelona, Spain
| | - Jordi Coderch
- Grup de Recerca en Serveis Sanitaris i Resultats en Salut, Serveis de Salut Integrats Baix Empordà, Carrer Hospital 17-19 Edifici Fleming, 17230, Palamós, Spain
| | - María-Luisa Vázquez
- Grup de Recerca en Serveis Sanitaris i Resultats en Salut, Serveis de Salut Integrats Baix Empordà, Carrer Hospital 17-19 Edifici Fleming, 17230, Palamós, Spain
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Johnston KJ, Hockenberry JM. Are Two Heads Better Than One or Do Too Many Cooks Spoil the Broth? The Trade-Off between Physician Division of Labor and Patient Continuity of Care for Older Adults with Complex Chronic Conditions. Health Serv Res 2017; 51:2176-2205. [PMID: 27891605 DOI: 10.1111/1475-6773.12600] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the effects of physician division of labor and patient continuity of care (COC) on the care quality and outcomes of older adults with complex chronic conditions. DATA SOURCES/STUDY SETTING Seven years (2006-2012) of panel data from the Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Regression models were used to estimate the effect of the specialty-type of physicians involved in annual patient evaluation and management, as well as patient COC, on simultaneous care processes and following year outcomes. DATA COLLECTION/EXTRACTION METHODS Multiyear cohorts of Medicare beneficiaries with diabetes and/or heart failure were retrospectively identified to create a panel of 15,389 person-year observations. PRINCIPAL FINDINGS Involvement of both primary care physicians and disease-relevant specialists is associated with better compliance with process-of-care guidelines, but patients seeing disease-relevant specialists also receive more repeat cardiac imaging (p < .05). Patient COC is associated with less repeat cardiac imaging and compliance with some recommended care processes (p < .05), but the effects are small. Receiving care from a disease-relevant specialist is associated with lower rates of following year functional impairment, institutionalization in long-term care, and ambulatory care sensitive hospitalization (p < .05). CONCLUSIONS Annual involvement of disease-relevant specialists in the care of beneficiaries with complex chronic conditions leads to more resource use but has a beneficial effect on outcomes.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St Louis, MO
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
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12
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Radhakrishnan A, Grande D, Ross M, Mitra N, Bekelman J, Stillson C, Pollack CE. When Primary Care Providers (PCPs) Help Patients Choose Prostate Cancer Treatment. J Am Board Fam Med 2017; 30:298-307. [PMID: 28484062 PMCID: PMC5870832 DOI: 10.3122/jabfm.2017.03.160359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/30/2017] [Accepted: 02/06/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The role of primary care providers (PCPs) in decision making around cancer care remains largely unknown. We evaluated how frequently men with localized prostate cancer report receiving help from their PCP about their treatment, and whether those men who do are less likely to receive definitive treatment. METHODS We mailed surveys to men newly diagnosed with localized prostate cancer between 2012 and 2014 in the greater Philadelphia region. Participants were asked whether their PCP helped decide how to treat their cancer. The outcome was receipt of definitive treatment (either radical prostatectomy or radiotherapy). RESULTS A total of 2386 men responded (adjusted response rate, 51.1%). Among these men, 38.2% reported receiving help from their PCP regarding choosing a treatment, and 79.6% received definitive treatment. In adjusted analyses, non-Hispanic black men (odds ratio, 1.76; 95% confidence interval, 1.37-2.27) were more likely than non-Hispanic white men to report receiving help from their PCP. However, men who did receive help were not more likely to forgo definitive treatment overall (P = .58) or in the subgroups of men who may be least likely to benefit from definitive treatment. CONCLUSIONS Though a substantial proportion of men reported receiving help from their PCP about prostate cancer treatment, these discussions were not associated with different treatment patterns. Further effort is needed to determine how to optimize the role of PCPs in supporting patients to make preference-sensitive cancer decisions.
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Affiliation(s)
- Archana Radhakrishnan
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP).
| | - David Grande
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP)
| | - Michelle Ross
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP)
| | - Nandita Mitra
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP)
| | - Justin Bekelman
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP)
| | - Christian Stillson
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP)
| | - Craig Evan Pollack
- From the Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD (AR, CEP); the Division of General Internal Medicine, Hospital of the University of Pennsylvania Philadelphia (DG, CS); the Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania (MR, NM); the Department of Radiation Oncology, Hospital of the University of Pennsylvania (JB); and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (CEP)
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Loganathan SK, Hasche JC, Koenig KT, Haffer SC, Uchendu US. Racial and Ethnic Differences in Satisfaction with Care Coordination Among VA and non-VA Medicare Beneficiaries. Health Equity 2017; 1:50-60. [PMID: 30283835 PMCID: PMC6071882 DOI: 10.1089/heq.2016.0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose: Patients who have multiple sources of care are at risk for fragmented and uncoordinated care, which can lead to poorer outcomes. Veteran Medicare beneficiaries who use the Veterans Health Administration (VHA) system (VA users), particularly racial/ethnic minorities, often have complex medical conditions that may require care from multiple sources, leaving them especially vulnerable to the effects of fragmented care. We examined racial/ethnic differences in the level of satisfaction with care coordination among Medicare beneficiaries, comparing those who do and do not use the VHA healthcare system. Methods: We conducted a retrospective, pooled, cross-sectional study of Medicare beneficiaries using the 2009-2011 Medicare Current Beneficiary Survey. The outcomes are self-reported satisfaction with care items related to three dimensions of care coordination: (1) integrated care, (2) care continuity, and (3) follow-up care. We present descriptive statistics and use generalized linear models to examine racial/ethnic differences across VA and non-VA users, after accounting for other demographic characteristics, health status, functional limitations, insurance coverage, and geographic variation. Results: VA users are more likely to be very satisfied with receiving both integrated and follow-up care compared with non-VA users. Despite the existence of significant racial/ethnic disparities in the likelihood of being very satisfied with receiving well-coordinated care in the larger Medicare population, racial/ethnic minority VA users are just as likely as White non-Hispanics to be very satisfied with receiving well-coordinated care. Conclusions: Future research should continue to study care coordination among VA users and reasons for preferring the VA over other healthcare systems, especially among racial/ethnic minority groups.
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Affiliation(s)
| | | | | | - Samuel C. Haffer
- Data and Policy Analytics Group, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Uchenna S. Uchendu
- United States Department of Veterans Affairs, Office of Health Equity, Washington DC
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Sveréus S, Larsson K, Rehnberg C. Clinic continuity of care, clinical outcomes and direct costs for COPD in Sweden: a population based cohort study. Eur Clin Respir J 2017; 4:1290193. [PMID: 28326179 PMCID: PMC5345579 DOI: 10.1080/20018525.2017.1290193] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/13/2017] [Indexed: 11/24/2022] Open
Abstract
Introduction: In this study we investigate whether clinic level continuity of care (COC) for individuals with chronic obstructive pulmonary disease (COPD) is associated with better health care outcomes and lower costs in a Swedish setting. Methods: Individuals with COPD (N = 20,187) were identified through ICD-10 codes in all Stockholm County health care registries in 2007-2011 (59% female, 40% in the age group 65-74 years). We followed the individuals prospectively for 365 days after their first outpatient visit in 2012. Individual associations between COC and incidence of any hospitalization or emergency department visit and total costs for health care and pharmaceuticals were quantified by regression analysis, controlling for age, sex, comorbidity and number of visits. Clinic level COC was measured through the Bice-Boxerman COC index, grouped into quintiles. Results: At baseline, 26% of the individuals had been hospitalized at least once and 73% had dispensed at least seven prescription drugs (23% at least 16) in the last year. Patients in the lowest COC quintile (Q1) had higher probabilities of any hospitalization and any emergency department visit compared to those in Q5 (odds ratio 2.17 [95% CI 1.95-2.43] and 2.06 [1.86-2.28], respectively). Patients in Q1 also on average had 58% [95% CI: 52-64] higher costs. Conclusion: The findings show robust associations between clinic level COC and outcomes. These results verify the importance of COC, and suggest that clinic level COC is of relevance to both better outcomes for COPD patients and more efficient use of resources.
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Affiliation(s)
- Sofia Sveréus
- Department of Learning, Informatics, Management & Ethics (LIME), Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Centre for Health Economics, Informatics and Health Services, Stockholm County Council, Stockholm, Sweden
| | - Kjell Larsson
- National Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management & Ethics (LIME), Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
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15
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Amjad H, Carmichael D, Austin AM, Chang CH, Bynum JPW. Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare. JAMA Intern Med 2016; 176:1371-8. [PMID: 27454945 PMCID: PMC5061498 DOI: 10.1001/jamainternmed.2016.3553] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. OBJECTIVE To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. DESIGN, SETTING, AND PARTICIPANTS This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. EXPOSURES Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. MAIN OUTCOMES AND MEASURES Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). RESULTS Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. CONCLUSIONS AND RELEVANCE Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.
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Affiliation(s)
- Halima Amjad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Donald Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Chiang-Hua Chang
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Nyweide DJ, Bynum JPW. Relationship Between Continuity of Ambulatory Care and Risk of Emergency Department Episodes Among Older Adults. Ann Emerg Med 2016; 69:407-415.e3. [PMID: 27520592 DOI: 10.1016/j.annemergmed.2016.06.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/18/2016] [Accepted: 06/15/2016] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE We determine whether visit patterns indicative of higher continuity are related to a lower risk of presenting at the emergency department (ED) among older adults. METHODS This study was a survival analysis between 2011 and 2013 of a 20% random sample of fee-for-service Medicare beneficiaries aged 66 years or older. Ambulatory visit patterns were measured starting in 2011 for up to 24 months using 2 continuity metrics measured on a 0 to 1 scale-Continuity of Care (COC) score and the Usual Provider Continuity (UPC) score. The composite outcome of an ED episode was defined as occurrence of an ED visit with discharge home, an observation stay, or hospital admission. Time-dependent Cox proportional hazards regression models controlled for patient demographic characteristics, comorbidities, previous use, and regional factors, with censoring for death or occurrence of the composite outcome. In a secondary analysis, continuity was measured in the 12 months preceding an ED episode to test whether it was associated with type of ED episode. RESULTS The relative rate of ED episodes decreased approximately 1% for every 0.1-point increase in the COC score (adjusted hazard ratio 0.99; 95% confidence interval 0.99 to 0.99; P<.001) and 2% for every 0.1-point increase in the UPC score (adjusted hazard ratio 0.98; 95% CI 0.98 to 0.99; P<.001), or up to a 10% lower rate between the lowest and highest COC score and a 20% lower rate for the UPC score. Among beneficiaries with an ED episode, higher continuity was associated with a 1% lower risk of observation stay but a 3% to 4% higher risk of hospital admission relative to an ED visit with discharge home. CONCLUSION Ambulatory visit patterns exhibiting more continuity were associated with a lower rate of ED utilization for older adults with fee-for-service Medicare coverage. The association of higher continuity with lower risk of ED use but differences in outcome when an ED visit does occur may reflect more appropriate referral to the ED when outpatient management is no longer adequate.
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Affiliation(s)
- David J Nyweide
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD.
| | - Julie P W Bynum
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
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