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Biscione FM, Domingues da Silva J. Representation of the hierarchical and functional structure of an ambulatory network of medical consultations through Social Network Analysis, with an emphasis on the role of medical specialties. PLoS One 2024; 19:e0290596. [PMID: 38359023 PMCID: PMC10868750 DOI: 10.1371/journal.pone.0290596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/16/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Ambulatory Health Care Networks (Amb-HCN) are circuits of patient referral and counter-referral that emerge, explicitly or spontaneously, between doctors who provide care in their offices. Finding a meaningful analytical representation for the organic and hierarchical functioning of an Amb-HCN may have managerial and health policymaking implications. We aimed to characterize the structural and functional topology of an Amb-HCN of a private health insurance provider (PHIP) using objective metrics from graph theory. METHODS This is a cross-sectional quantitative study with a secondary data analysis study design. A Social Network Analysis (SNA) was conducted using office visits performed between April 1, 2021 and May 15, 2022, retrieved from secondary administrative claim databases from a PHIP in Belo Horizonte, Southeastern Brazil. Included were beneficiaries of a healthcare plan not restricting the location or physician caring for the patient. A directional and weighted network was constructed, where doctors were the vertices and patient referrals between doctors, within 7-45 days, were the network edges. Vertex-level SNA measures were calculated and grouped into three theoretical constructs: patient follow-up (aimed at assessing the doctor's pattern of patient follow-up); relationship with authorities (which assessed whether the doctor is an authority or contributes to his or her colleague's authority status); and centrality (aimed at positioning the doctor relative to the network graph). To characterize physician profiles within each dimension based on SNA metrics results, a K-means cluster analysis was conducted. The resulting physician clusters were assigned labels that sought to be representative of the observed values of the vertex metrics within the clusters. FINDINGS Overall, 666,263 individuals performed 3,863,222 office visits with 4,554 physicians. A total of 577 physicians (12.7%) had very low consultation productivity and contributed very little to the network (i.e., about 1.1% of all referrals made or received), being excluded from subsequent doctor profiles analysis. Cluster analysis found 951 (23.9%) doctors to be central in the graph and 1,258 (31.6%) to be peripheral; 883 (22.2%) to be authorities and 266 (6.7%) as seeking authorities; 3,684 (92.6%) mostly shared patients with colleagues, with patient follow-up intensities ranging from weak to strong. Wide profile dispersion was observed among specialties and, more interestingly, within specialties. Non-primary-care medical specialties (e.g., cardiology, endocrinology etc.) were associated with central profile in the graph, while surgical specialties predominated in the periphery, along with pediatrics. Only pediatrics was associated with strong and prevalent (i.e., low patient sharing pattern) follow-up. Many doctors from internal medicine and family medicine had unexpectedly weak and shared patient follow-up profiles. Doctor profiles exhibited pairwise relationships with each other and with the number of chronic comorbidities of the patients they treated. For example, physicians identified as authorities were frequently central and treated patients with more comorbidities. Ten medical communities were identified with clear territorial and specialty segregation. CONCLUSIONS Viewing the Amb-HCN as a social network provided a topological and functional representation with potentially meaningful and actionable emerging insights into the most influential actors and specialties, functional hierarchies, factors that lead to self-constituted medical communities, and dispersion from expected patterns within medical specialties.
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Affiliation(s)
- Fernando Martín Biscione
- Department of Data Science in Healthcare, Healthcare Superintendence, Unimed-Belo Horizonte Healthcare Plan, Belo Horizonte, Minas Gerais State, Brazil
| | - Juliano Domingues da Silva
- Department of Administration, Center for Socioeconomic Studies, State University of Maringá, Maringá, Paraná State, Brazil
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Iashchenko I, Flemming R, Franke S, Sundmacher L. Do physician networks with standardized audit and feedback deliver better quality care for older patients compared to regular care?: a quasi-experimental study using claims data from Bavaria, Germany. Eur J Public Health 2023; 33:981-986. [PMID: 37563087 PMCID: PMC10710359 DOI: 10.1093/eurpub/ckad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Physician networks (PNs) are a recent development in Germany, designed to improve the coordination and quality of healthcare. We compared the performance of PNs that use a standardized system of audit and feedback to that of regular care. METHODS We analysed a large sample of claims data from Bavaria, Germany, using nearest-neighbour propensity score matching. Patients who had ambulatory care-sensitive conditions (ACSCs) and were enrolled in PNs were matched with control patients receiving regular care. We examined potentially avoidable hospitalizations related to the 13 most common ACSCs (primary endpoints), as well as processes-of-care indicators for disease prevention, pharmacotherapy and coordination of care. RESULTS There were no significant differences in rates of potentially avoidable hospitalizations between the two groups. However, the networks showed higher vaccination rates, increased participation in disease management programmes, and more frequent use of referrals when consulting specialist physicians. On average, network patients visited a greater number of specialists and had lower continuity of care compared to patients receiving regular care. Polypharmacy and PRISCUS-list prescriptions were more prevalent in the networks. CONCLUSIONS PNs using audit and feedback do not appear to perform better than regular care in preventing hospitalizations due to ACSCs. However, they do perform better in disease prevention measures while showing inconclusive results for care coordination and pharmacotherapy. Further research is needed to understand effective collaboration among providers and its impact on the quality of care within PNs.
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Affiliation(s)
- Iryna Iashchenko
- Department of Sport and Health Sciences, Technical University of Munich, Munich 80992, Germany
| | - Ronja Flemming
- Department of Sport and Health Sciences, Technical University of Munich, Munich 80992, Germany
| | - Sebastian Franke
- Department of Sport and Health Sciences, Technical University of Munich, Munich 80992, Germany
| | - Leonie Sundmacher
- Department of Sport and Health Sciences, Technical University of Munich, Munich 80992, Germany
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Wang SY, Larrain N, Groene O. Can peer effects explain prescribing appropriateness? a social network analysis. BMC Med Res Methodol 2023; 23:252. [PMID: 37898770 PMCID: PMC10613382 DOI: 10.1186/s12874-023-02048-7] [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: 05/17/2022] [Accepted: 09/25/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Optimizing prescribing practices is important due to the substantial clinical and financial costs of polypharmacy and an increasingly aging population. Prior research shows the importance of social relationships in driving prescribing behaviour. Using social network analysis, we examine the relationship between a physician practices' connectedness to peers and their prescribing performance in two German regions. METHODS We first mapped physician practice networks using links established between two practices that share 8 or more patients; we calculated network-level (density, average path length) and node-level measures (degree, betweenness, eigenvector). We defined prescribing performance as the total number of inappropriate medications prescribed or appropriate medications not prescribed (PIMs) to senior patients (over the age of 65) during the calendar year 2016. We used FORTA (Fit fOR The Aged) algorithm to classify medication appropriateness. Negative binomial regression models estimate the association between node-level measures and prescribing performance of physician practices controlling for patient comorbidity, provider specialization, percentage of seniors in practice, and region. We conducted two sensitivity analyses to test the robustness of our findings - i) limiting the network mapping to patients younger than 65; ii) limiting the network ties to practices that share more than 25 patients. RESULTS We mapped two patient-sharing networks including 436 and 270 physician practices involving 28,508 and 20,935 patients and consisting of 217,126 and 154,274 claims in the two regions respectively. Regression analyses showed a practice's network connectedness as represented by degree, betweenness, and eigenvector centrality, is significantly negatively associated with prescribing performance (degree-bottom vs. top quartile aRR = 0.04, 95%CI: 0.035,0.045; betweenness-bottom vs. top quartile aRR = 0.063 95%CI: 0.052,0.077; eigenvector-bottom vs. top quartile aRR = 0.039, 95%CI: 0.034,0.044). CONCLUSIONS Our study provides evidence that physician practice prescribing performance is associated with their peer connections and position within their network. We conclude that practices occupying strategic positions at the edge of networks with advantageous access to novel information are associated with better prescribing outcomes, whereas highly connected practices embedded in insulated information environments are associated with poor prescribing performance.
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Affiliation(s)
- Sophie Y Wang
- Hamburg Center for Health Economics, Esplanade 36, 20354, Hamburg, Germany.
- OptiMedis AG, Buchardstraße 17, 20095, Hamburg, Germany.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Nicolas Larrain
- Hamburg Center for Health Economics, Esplanade 36, 20354, Hamburg, Germany
- Employment, Labour and Social Affairs, Health Division, OECD, 2 Rue André Pascal, Cedex 16, 75775, Paris, France
| | - Oliver Groene
- OptiMedis AG, Buchardstraße 17, 20095, Hamburg, Germany
- Faculty of Management, Economics and Society, University of Witten, Alfred-Herrhausen-Straße 50, 58455, HerdeckeWitten, Germany
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Schüttig W, Flemming R, Mosler CH, Leve V, Reddemann O, Schultz A, Brua E, Brittner M, Meyer F, Pollmanns J, Martin J, Czihal T, von Stillfried D, Wilm S, Sundmacher L. Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany. BMC Health Serv Res 2022; 22:1015. [PMID: 35945585 PMCID: PMC9364554 DOI: 10.1186/s12913-022-08327-1] [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] [Received: 12/17/2021] [Accepted: 07/13/2022] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients. METHODS Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients. RESULTS The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure. CONCLUSION Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.
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Affiliation(s)
- Wiebke Schüttig
- Chair of Health Economics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany. .,Department for Health Services Management, Ludwig-Maximilian-University Munich, Munich, Germany.
| | - Ronja Flemming
- Chair of Health Economics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany.,Department for Health Services Management, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Christiane Höhling Mosler
- AOK Health Insurance Rhineland / Hamburg, Kasernenstraße 61, 40213, Duesseldorf, Germany.,University Hospital Düsseldorf, Office of Quality Management and Patient Safety, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Verena Leve
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Olaf Reddemann
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Annemarie Schultz
- Regional Association of Statutory Health Insurance Physicians Hamburg, Humboldtstraße 56, 22083, Hamburg, Germany
| | - Emmanuelle Brua
- Regional Association of Statutory Health Insurance Physicians Hamburg, Humboldtstraße 56, 22083, Hamburg, Germany
| | - Matthias Brittner
- Regional Association of Statutory Health Insurance Physicians Westphalia Lip, Robert-Schimrigk-Straße 4-6, 44141, Dortmund, Germany
| | - Frank Meyer
- Regional Association of Statutory Health Insurance Physicians Westphalia Lip, Robert-Schimrigk-Straße 4-6, 44141, Dortmund, Germany
| | - Johannes Pollmanns
- Regional Association of Statutory Health Insurance Physicians North Rhine, Tersteegenstraße 9, 40474, Duesseldorf, Germany
| | - Johnannes Martin
- Regional Association of Statutory Health Insurance Physicians North Rhine, Tersteegenstraße 9, 40474, Duesseldorf, Germany
| | - Thomas Czihal
- Zentralinstitut für die Kassenärztliche Versorgung in der Bundesrepublik Deutschland, Salzufer 8, 10587, Berlin, Germany
| | - Dominik von Stillfried
- Zentralinstitut für die Kassenärztliche Versorgung in der Bundesrepublik Deutschland, Salzufer 8, 10587, Berlin, Germany
| | - Stefan Wilm
- Institute of General Practice (ifam), Centre for Health and Society (chs), Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Leonie Sundmacher
- Chair of Health Economics, Technical University of Munich, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany.,Department for Health Services Management, Ludwig-Maximilian-University Munich, Munich, Germany
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