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Tekeste R, Grant M, Newton P, Davis NL, Tekeste M, Carter R. Prevalence of Medical Mistrust and Its Impact on Patient Satisfaction in Pediatric Caregivers. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02165-z. [PMID: 39240453 DOI: 10.1007/s40615-024-02165-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/18/2024] [Accepted: 08/29/2024] [Indexed: 09/07/2024]
Abstract
Racial minorities report lower perceived quality of care received compared to non-Hispanic White Americans, resulting in racial disparities in patient satisfaction. Medical mistrust, defined as a lack of confidence in the medical establishment and the intentions of medical personnel, is more prevalent among racial minority groups and is associated with poorer health outcomes. This study examines the prevalence and racial differences of patient/caregiver medical mistrust and its relationship to patient satisfaction among the pediatric patient population at a large urban academic medical center. A cross-sectional anonymous survey was conducted for caregivers of pediatric families seen at an urban tertiary care facility, including demographic information, the Patient Satisfaction Questionnaire (PSQ), and the Group-Based Medical Mistrust Scale (GBMMS). Linear regressions and mediation analyses were performed, examining race-based medical mistrust and associations with patient satisfaction. Sixty-seven surveys (67% Black/African American, 24% White) were completed. Black/African American participants reported higher levels of medical mistrust (M = 2.29, SD = 0.88 vs. M = 1.37, SD = 0.50; p < .001), which was associated with lower patient satisfaction (p < .001). In a parallel mediation analysis, disaggregating the GBMMS into three subscales, a significant indirect relationship emerged between race and patient satisfaction via the subscale lack of support from healthcare providers (95% CI [- 1.52, - .02], p < .05). Black/African American participants were more likely to have medical mistrust, and greater medical mistrust was significantly associated with lower patient satisfaction. Black/African American participants were significantly more likely to perceive lower support from healthcare providers which, in turn, was associated with lower patient satisfaction. These findings identify potential areas for intervention to improve Black/African American patients' experience with healthcare.
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Affiliation(s)
- R Tekeste
- Mercy Medical Center, Baltimore, MD, USA
| | - M Grant
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - P Newton
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - N L Davis
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - R Carter
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA.
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Johnson C, Ingraham MK, Stafford SR, Guilamo-Ramos V. Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid. Nurs Outlook 2024; 72:102191. [PMID: 38781773 DOI: 10.1016/j.outlook.2024.102191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/18/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Medicaid payment reforms and delivery model innovations are needed to fully transform U.S. healthcare structuring and provision. PURPOSE To synthesize nurse-led models of care and their implications for improving health care access, quality, and reducing costs for Medicaid recipients. METHODS A critical review of the literature regarding nurse-led models and implications for addressing social determinants of health (SDOH), adopting population health approaches, managing complex care, and integrating behavioral and physical health care within Medicaid. DISCUSSION Three interrelated findings emerged (a) investing in dynamic nurse-led models is important for mitigating SDOH and adopting value-based care, (b) regulations preventing nurses from practicing at the fullest extent of their training and licensure limit clinical impact and value, and (c) directed payments can establish value-based expectations for Medicaid managed care. CONCLUSION Adoption of a nurse-led model of care has the potential to advance the goals of reducing inequity and promoting whole-person health within Medicaid and nationally.
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Affiliation(s)
- Celia Johnson
- Institute for Policy Solutions, Johns Hopkins School of Nursing, Washington, DC; Center for Latino Adolescent and Family Health, Johns Hopkins School of Nursing, Baltimore, MD
| | | | - Stephen R Stafford
- Institute for Policy Solutions, Johns Hopkins School of Nursing, Washington, DC; Center for Latino Adolescent and Family Health, Johns Hopkins School of Nursing, Baltimore, MD
| | - Vincent Guilamo-Ramos
- Institute for Policy Solutions, Johns Hopkins School of Nursing, Washington, DC; Center for Latino Adolescent and Family Health, Johns Hopkins School of Nursing, Baltimore, MD; Presidential Advisory Council on HIV/AIDS, U.S. Department of Health and Human Services, Washington, DC.
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Wernli KJ, Haupt EC, Chawla N, Osuji T, Shen E, Smitherman AB, Casperson M, Kirchhoff AC, Zebrack BJ, Keegan THM, Kushi L, Baggett C, Kaddas HK, Ruddy KJ, Sauder CAM, Wun T, Figueroa Gray M, Chubak J, Nichols H, Hahn EE. Emergency Department Use in Adolescent and Young Adult Cancer Early Survivors from 2006 to 2020. J Adolesc Young Adult Oncol 2024. [PMID: 38682323 DOI: 10.1089/jayao.2023.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Purpose: Understanding emergency department (ED) use in adolescent and young adult (AYA) survivors could identify gaps in AYA survivorship. Methods: We conducted a cohort study of 7925 AYA survivors (aged 15-39 years at diagnosis) who were 2-5 years from diagnosis in 2006-2020 at Kaiser Permanente Southern California. We calculated ED utilization rates overall and by indication of the encounter (headache, cardiac issues, and suicide attempts). We estimated rate changes by survivorship year and patient factors associated with ED visit using a Poisson model. Results: Cohort was 65.4% women, 45.8% Hispanic, with mean age at diagnosis at 31.3 years. Overall, 38% of AYA survivors had ≥1 ED visit (95th percentile: 5 ED visits). Unadjusted ED rates declined from 374.2/1000 person-years (PY) in Y2 to 327.2 in Y5 (p change < 0.001). Unadjusted rates declined for headache, cardiac issues, and suicide attempts. Factors associated with increased ED use included: age 20-24 at diagnosis [relative risk (RR) = 1.30, 95% CI 1.09-1.56 vs. 35-39 years]; female (RR = 1.27, 95% CI 1.11-1.47 vs. male); non-Hispanic Black race/ethnicity (RR 1.64, 95% CI 1.38-1.95 vs. non-Hispanic white); comorbidity (RR = 1.34, 95% CI 1.16-1.55 for 1 and RR 1.80, 95% CI 1.40-2.30 for 2+ vs. none); and public insurance (RR = 1.99, 95% CI 1.70-2.32 vs. private). Compared with thyroid cancer, cancers associated with increased ED use were breast (RR = 1.45, 95% CI 1.24-1.70), cervical (RR = 2.18, 95% CI 1.76-2.71), colorectal (RR = 2.34, 95% CI 1.94-2.81), and sarcoma (RR = 1.39, 95% CI 1.03-1.88). Conclusion: ED utilization declined as time from diagnosis elapsed, but higher utilization was associated with social determinants of health and cancer types.
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Affiliation(s)
- Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Eric C Haupt
- Kaiser Permanente Southern California, Pasadena, California, USA
| | - Neetu Chawla
- Veteran's Affairs Los Angeles County, Los Angeles, California, USA
| | - Thearis Osuji
- Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ernest Shen
- Kaiser Permanente Southern California, Pasadena, California, USA
| | - Andrew B Smitherman
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Anne C Kirchhoff
- Department of Pediatrics, Huntsman Cancer Institute and the University of Utah, Salt Lake City, Utah, USA
| | - Bradley J Zebrack
- School of Social Work, University of Michigan, Ann Arbor, Michigan, USA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Lawrence Kushi
- Division of Research, Kaiser Permanente, Northern California, Oakland, California, USA
| | - Christopher Baggett
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Heydon K Kaddas
- Department of Pediatrics, Huntsman Cancer Institute and the University of Utah, Salt Lake City, Utah, USA
| | - Kathryn J Ruddy
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Candice A M Sauder
- Division of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - Theodore Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | | | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Hazel Nichols
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Erin E Hahn
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Kaiser Permanente Southern California, Pasadena, California, USA
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Denham A, Hill EL, Raven M, Mendoza M, Raz M, Veazie PJ. Is the emergency department used as a substitute or a complement to primary care in Medicaid? HEALTH ECONOMICS, POLICY, AND LAW 2024; 19:73-91. [PMID: 37870129 DOI: 10.1017/s1744133123000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.
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Affiliation(s)
- Alina Denham
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA
| | - Elaine L Hill
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA
| | - Maria Raven
- Department of Emergency Medicine, School of Medicine, University of California, San Francisco, USA
| | - Michael Mendoza
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA
- Department of Family Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, USA
| | - Mical Raz
- Department of History, University of Rochester, Rochester, USA
- Department of Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, USA
| | - Peter J Veazie
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA
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Shearer E, Bundorf MK. Changes in emergency department use associated with Medicaid expansion under the Affordable Care Act: A comparison of waiver and traditional expansion states. J Am Coll Emerg Physicians Open 2023; 4:e13060. [PMID: 37915356 PMCID: PMC10616539 DOI: 10.1002/emp2.13060] [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: 04/27/2023] [Revised: 09/24/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To determine whether changes in emergency department use associated with Medicaid expansions differed between states undergoing waiver and traditional expansions. Methods Design: This study was a cross-sectional difference-in-difference and event studies of Medicaid Expansion among states that expanded during or after 2014. Setting: We used a nationally representative cross-sectional survey from all 50 United States and the District of Columbia from 2010 to 2016. Participants: Adults aged 19-65 years with incomes <138% of the federal poverty level were included. Main Outcomes and Measures: Main outcomes were self-reported emergency department (ED) utilization in the last 12 months. Results Individuals in states across all expansion types were not more likely to report any ED use in the previous year (2.8 percentage point increase [0.0-5.5], P = 0.052) but were more likely to report visiting an ED 2 times or more in the previous year (2.0 [0.0-4.1], P = 0.049) than those in non-expansion states. Individuals in states undergoing traditional expansions likewise were not more likely to report any ED use (2.2 [-0.7 to 1.5], P = 0.136) but were more likely to report visiting an ED 2 times or more in the previous year (2.3 [0.1-4.4], P = 0.038). Conversely, individuals in waiver states were more likely to report increase in any ED use (5.6 [0.3-11.0], P = 0.038), but were not more likely to report use of EDs 2 times or more in the previous year (0.8 [-3.2-4.9], P = 0.688). The differences between traditional and waiver states in any ED use and ED use 2 times or more in the previous 12 months were not statistically significant (P = 0.215 and P = 0.501, respectively). Conclusions Three years after expanding Medicaid under the Affordable Care Act, there is little evidence of differences between traditional and waiver expansion states in changes in any ED use or intensive ED use. Future studies should investigate longer term changes in ED use.
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Affiliation(s)
- Emily Shearer
- Department of Emergency MedicineAlpert School of Medicine at Brown UniversityProvidenceRhode IslandUSA
| | - M. Kate Bundorf
- Sanford School of Public PolicyDuke UniversityDurhamNorth CarolinaUSA
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Bakare O, Akintujoye IA, Gbemudu PE, Mbaezue RN, Akinbolade AO, Olopade S. Medicaid Coverage and Emergency Department Utilization in Southeastern Pennsylvania. Cureus 2023; 15:e45464. [PMID: 37859924 PMCID: PMC10584275 DOI: 10.7759/cureus.45464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
Overutilization of the emergency department (ED) is a significant problem in the United States (US), characterized mainly by patients with non-emergent conditions seeking care in a setting designed specifically for acute care. This has significantly increased healthcare costs in the US, a country with one of the most expensive healthcare systems in the world. ED overutilization was also found to be high among people with Medicaid coverage, especially since the Affordable Care Act was enacted with an expansion in Medicaid coverage. Using the 2018 South Eastern Pennsylvania (SEPA) Household Health Survey, we identified a significant bivariate relationship between emergency department visits and the following predictor variables: sex, race, education, employment status, 150% poverty level, and Medicaid recipient. Using a multivariable logistic regression model, Medicaid recipients had higher odds of presenting to the ED than non-Medicaid recipients [odds ratio (OR): 2.863, 95% confidence interval (CI): 2.164, 3.788]. Black people (OR: 1.647, 95% CI: 1.411, 1.923) and Native Americans (OR: 2.985, 95% CI: 1.536, 5.800) had higher odds than Whites. Respondents without a high school diploma had higher odds than college graduates (OR: 1.647, 95% CI: 1.96, 2.273). Respondents below the 150% poverty line had higher odds than those at or above the 150% poverty level (OR: 1.651, 95% CI: 1.386, 1.968). Unemployed respondents had higher odds than full-time employed respondents (OR: 1.703, 95% CI: 1.488, 1.953) or part-time (OR: 1.259, 95% CI: 1.036, 1.529). No difference was observed between the sexes. Addressing ED overutilization should take a multi-faceted approach with the ultimate goal of improving access to primary care.
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Affiliation(s)
- Olusegun Bakare
- Internal Medicine-Pediatrics, Tulane University School of Medicine, New Orleans, USA
| | | | - Paul E Gbemudu
- Internal Medicine-Pediatrics, Tulane University School of Medicine, New Orleans, USA
| | | | | | - Segun Olopade
- Medicine and Surgery, Igbinedion University Teaching Hospital, Okada, NGA
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Unger S, Orr Z, Alpert EA, Davidovitch N, Shoham-Vardi I. Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem. Int J Equity Health 2022; 21:156. [DOI: 10.1186/s12939-022-01698-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/02/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance.
Methods
A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days.
Results
There were differences between Jewish and Arab patients’ social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty.
Conclusion
The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.
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Rothman RE, Niforatos JD, Youbi M, Polydefkis N, Hergenroeder A, Ako MC, Lobner K, Shaw-Saliba K, Hsieh YH. A cross-sectional study of participant recruitment rates in published phase III influenza therapeutic randomized controlled trials conducted in the clinical setting. Am J Emerg Med 2022; 61:184-191. [PMID: 36174486 DOI: 10.1016/j.ajem.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/20/2022] [Accepted: 09/03/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE A recent academic-government partnership demonstrated the feasibility of utilizing Emergency Departments (ED) as a primary site for subject enrollment in clinical trials and achieved high rates of recruitment in two U.S. EDs. Given the ongoing need to test new therapeutics for influenza and other emerging infections, we sought to describe the historical rates of participant recruitment into influenza Phase III therapeutic RCTs in various clinical venues, including EDs. STUDY DESIGN A cross-sectional study was performed of influenza therapeutic Phase III RCTs published in PubMed, Embase, Scopus, and Clinicaltrials.gov from January 2000 to June 2019. MAIN OUTCOME To estimate the weighted-average number of influenza-positive participants enrolled per site per season in influenza therapeutic RCT conducted in clinical settings, and to describe basic trial site characteristics. RESULTS 47 (0.7%) of 7008 articles were included for review of which 43 of 47 (91%) included information regarding enrollment sites; of these, 2 (5%) recruited exclusively from EDs with the remainder recruiting from mixed clinical settings (inpatient, outpatient, and ED). The median enrollment per study was 326 (IQR: 110, 502.5) with a median of 11 sites per study (IQR: 2, 59.5). Included studies reported a median of 201 (IQR: 74, 344.5) confirmed influenza-positive participants per study. The pooled number of participants enrolled per site per season was 11 (95% CI: 10, 12). The pooled enrollment numbers per clinical site after excluding the two 'ED only recruitment' studies were less [10.7 (95% CI: 9.9, 11.6)] than the pooled enrollment numbers per clinical site for the two 'ED only recruitment' studies [89.5 (95% CI 89.2-89.27)]. CONCLUSION AND RELEVANCE Published RCTs evaluating influenza therapeutics in clinical settings recruit participants from multiple sites but enroll relatively few participants, per site, per season. The few ED-based studies reported recruited more subjects per site per season. Untapped opportunities likely exist for EDs to participate and/or lead therapeutic RCTs for influenza or other emerging respiratory pathogens.
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Affiliation(s)
- Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Joshua D Niforatos
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mehdi Youbi
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nicholas Polydefkis
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Alaina Hergenroeder
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Michele-Corinne Ako
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Kathryn Shaw-Saliba
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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Lorvick J, Hemberg JL, Browne EN, Comfort ML. Routine and preventive health care use in the community among women sentenced to probation. HEALTH & JUSTICE 2022; 10:5. [PMID: 35122518 PMCID: PMC8817638 DOI: 10.1186/s40352-022-00167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/03/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND Women involved in the criminal legal (CL) system in the United States have much higher levels of chronic and infectious illness than women in the general population. Over 80% of women in the CL system are on community supervision, which means they receive health care in community settings. While the use of Emergency Department care among CL involved populations has been examined fairly extensively, less is known about engagement in routine and preventive medical care among people on community supervision. METHODS We conducted a longitudinal study of health care utilization among women with Medicaid who were currently or previously sentenced to probation in Alameda County, CA (N = 328). At baseline, 6- and 12-months, we interviewed participants about every medical care visit in the six months prior, and about potential influences on health care utilization based on the Behavioral Model for Vulnerable Populations (BMVP). Associations between BMVP factors and utilization of routine or preventive care were estimated using Poisson regression models with robust standard errors. Generalized estimating equations (GEE) were used account for repeated measures over time. RESULTS A diagnosis of one or more chronic illnesses was reported by 82% of participants. Two-thirds (62%) of women engaged in routine or preventive care in the six months prior to interview. A quarter of women engaging in routine or preventive care did not have a primary care provider (PCP). Having a PCP doubled the likelihood of using routine or preventive care (adjusted Relative Risk [adjRR] 2.27, p < 0.001). Subsistence difficulty (adjRR 0.74, p = 0.01) and unmet mental health care need (adjRR 0.83, p = 0.001) were associated with a lower likelihood of using routine or preventive care. CONCLUSION Findings underscore the importance of meeting the basic needs of women on community supervision and of connecting them with primary health care providers.
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Affiliation(s)
- Jennifer Lorvick
- Community Health and Implementation Research Program, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
| | - Jordana L. Hemberg
- Community Health and Implementation Research Program, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
| | - Erica N. Browne
- Women’s Global Health Imperative, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
| | - Megan L. Comfort
- Applied Justice Research Program, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
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The Checkpoint Program: Collaborative Care to Reduce the Reliance of Frequent Presenters on ED. Int J Integr Care 2021; 21:29. [PMID: 34220393 PMCID: PMC8231479 DOI: 10.5334/ijic.5532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: Growing pressures upon Emergency Departments [ED] call for new ways of working with frequent presenters who, although small in number, place extensive demands on services, to say nothing of the costs and consequences for the patients themselves. EDs are often poorly equipped to address the multi-dimensional nature of patient need and the complex circumstances surrounding repeated presentation. Employing a model of intensive short-term community-based case management, the Checkpoint program sought to improve care coordination for this patient group, thereby reducing their reliance on ED. Method: This study employed a single group interrupted time series design, evaluating patient engagement with the program and year-on-year individual differences in the number of ED visits pre and post enrolment. Associated savings were also estimated. Results: Prior to intervention, there were two dominant modes in the ED presentation trends of patients. One group had a steady pattern with ≥7 presentations in each of the last four years. The other group had an increasing trend in presentations, peaking in the 12 months immediately preceding enrolment. Following the intervention, both groups demonstrated two consecutive year-on-year reductions. By the second year, and from an overall peak of 22.5 presentations per patient per annum, there was a 53% reduction in presentations. This yielded approximate savings of $7100 per patient. Discussion: Efforts to improve care coordination, when combined with proactive case management in the community, can impact positively on ED re-presentation rates, provided they are concerted, sufficiently intensive and embed the principles of integration. Conclusion: The Checkpoint program demonstrated sufficient promise to warrant further exploration of its sustainability. However, health services have yet to determine the ideal organisational structures and funding arrangements to support such initiatives.
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Shashar S, Ellen M, Codish S, Davidson E, Novack V. Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years. Ann Fam Med 2021; 19:30-37. [PMID: 33431388 PMCID: PMC7800753 DOI: 10.1370/afm.2627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/14/2020] [Accepted: 07/24/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, Ben Gurion University of the Negev, Be'er-Sheva, Israel.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
| | - Shlomi Codish
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel-Aviv, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
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12
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Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending. J Gen Intern Med 2020; 35:3534-3541. [PMID: 32720238 PMCID: PMC7728931 DOI: 10.1007/s11606-020-06068-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Improving care for high-cost patients is increasingly important for improving the value of healthcare. Most prior research has focused on identifying patients with high costs, but the extent to which these costs are potentially preventable remains unclear. OBJECTIVE To identify patients with persistent preventable utilization and compare their characteristics with high-cost patients. DESIGN Descriptive analysis using Medicare claims data from 2013 to 2014. PARTICIPANTS Medicare fee-for-service and dual-eligible beneficiaries (N = 515,689) from the New York metropolitan area who were continuously enrolled in Medicare Parts A and B in 2013 and 2014. MAIN MEASURES The primary analysis focuses on patients with persistent preventable utilization (at least one preventable emergency department visit, hospitalization, or 30-day readmission in both 2013 and 2014) and high-cost patients in 2014 (top 10% of total annual spending). We compared demographic, medical, behavioral, and social characteristics and total and preventable healthcare utilization between these two groups. KEY RESULTS Patients with persistent preventable utilization accounted for 4.8% of the overall patient population, 13.4% of overall costs, but 46.2% of preventable costs among all Medicare patients. Compared with high-cost patients, patients with persistent preventable utilization had lower median healthcare costs ($33,383 vs. $56,552), but their median potentially preventable costs were seven times higher ($7151 vs. $928). We also found that 1.9% of patients could be categorized in both the persistent preventable utilization group and the high-cost group. This subset of patients had the highest median Medicare costs and preventable costs and represented over 30% of total preventable spending and 9.4% of overall costs among all Medicare patients. CONCLUSION Designing and targeting interventions for patients with persistent preventable utilization may offer an important opportunity to reduce unnecessary utilization and promote high-value care.
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Tsai ST, Tseng CH, Lin MC, Liao HY, Teoh BK, San S, Tsai CH, Huang HY, Lin YW. Acupuncture reduced the medical expenditure in migraine patients: Real-world data of a 10-year national cohort study. Medicine (Baltimore) 2020; 99:e21345. [PMID: 32769867 PMCID: PMC7593014 DOI: 10.1097/md.0000000000021345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES According to the data of Organisation for Economic Cooperation and Development, almost all the countries got increased medical expenditures in these years. Among the diseases, migraine is a condition that affects predominantly young and middle-aged people. It results in great economic losses. So we perform this research to investigate the acupuncture effect of reducing medical expenditure and medical resources use. PERSPECTIVE Acupuncture is a non-pharmacologic treatment and it became popular in recent years. In Taiwan, about 13% migraine patients visited acupuncture doctor. We hypothesized that the acupuncture had the additional effect than the medical treatment. SETTING We analysed the economic cost and medical visits in the real word. METHODS We used national cohort data from Taiwan, retrospectively gathered between 2000 and 2010. We selected newly diagnosed migraine patients who were diagnosed by registered neurologists formally licensed by the Taiwan Neurological Society. We divided these patients into two groups: with and without acupuncture treatment. The main outcome was medical expenditures and visits within 1 year after acupuncture. RESULTS In migraine patients who received acupuncture treatment, medical expenditures on emergency care and hospitalization were significantly lower than the group without acupuncture treatment. CONCLUSION According to our real-world data, acupuncture can reduce the medical expenditure in migraine patients within 1 year after diagnosis. For the health policy maker, it is cost effective to encourage combining acupuncture and western medicine to treat migraine patients. For the doctors in routine clinical practice, who may consider to consult acupuncture doctors to deal with the migraine patients together.
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Affiliation(s)
- Sheng-Ta Tsai
- Department of Neurology, China Medical University Hospital
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University
| | - Chun-Hung Tseng
- Department of Neurology, China Medical University Hospital
- School of Medicine, College of Medicine, China Medical University
| | - Mei-Chen Lin
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University
- Management Office for Health Data (DryLab), Clinical Trial Research Center (CTC)
| | - Hsien-Yin Liao
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University
- Department of Acupuncture, China Medical University Hospital
| | - Boon-Khai Teoh
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University
| | - Shao San
- Department of Anesthesiology, China Medical University Hospital
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital
- School of Medicine, College of Medicine, China Medical University
| | - Hung-Yu Huang
- Department of Neurology, China Medical University Hospital
| | - Yi-Wen Lin
- Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University
- Chinese Medicine Research Center, China Medical University, Taichung, Taiwan
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14
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Oslislo S, Heintze C, Möckel M, Schenk L, Holzinger F. What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany. BMC FAMILY PRACTICE 2020; 21:154. [PMID: 32731862 PMCID: PMC7393893 DOI: 10.1186/s12875-020-01222-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit. METHODS Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research). RESULTS Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED. CONCLUSIONS With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.
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Affiliation(s)
- Sarah Oslislo
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Christoph Heintze
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Möckel
- Division of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Medical and Veterinary Sciences, James Cook University, The College of Public Health, 1 James Cook Dr, Townsville, Douglas, QLD, 4814, Australia
| | - Liane Schenk
- Institute of Medical Sociology and Rehabilitation Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Holzinger
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
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15
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Association Between Residential Neighborhood Social Conditions and Health Care Utilization and Costs. Med Care 2020; 58:586-593. [DOI: 10.1097/mlr.0000000000001337] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Maeng D, Richman JH, Lee HB, Hasselberg MJ. Impact of integrating psychiatric assessment officers via telepsychiatry on rural hospitals' emergency revisit rates. J Psychosom Res 2020; 133:109997. [PMID: 32220648 DOI: 10.1016/j.jpsychores.2020.109997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the impact of integrating Psychiatric Assessment Officers (PAO) and telepsychiatry in rural hospitals on their all-cause emergency department (ED) revisit rates. As a pilot project, a full-time PAO was embedded in each of three rural hospitals in New York State and was augmented by telepsychiatry. METHOD A retrospective data analysis using ED census data obtained from the hospitals. The intervention group, defined as those patients treated by PAOs, was compared via a difference-in-difference method against a contemporaneous comparison group defined as those who visited the same EDs and had PAO-qualifying behavioral health diagnoses but were not seen by PAOs. RESULTS The intervention group was associated with an approximately 36% lower all-cause ED revisit rate during the first 90-day period (i.e. 1-90 days) following the initial PAO treatment (p = .003). A reduction of the similar magnitude (44%) persisted into the subsequent 90-day period (i.e., 91-180 days since the initial PAO treatment; p < .001). CONCLUSION The PAO telepsychiatry pilot program suggests a potential way to provide relief for overburdened EDs in rural communities that lack resources to treat patients with severe behavioral health symptoms.
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Affiliation(s)
- Daniel Maeng
- University of Rochester Medical Center, 300 Crittenden Boulevard Box PSYCH, Rochester, NY 14642, United States of America.
| | - Jennifer H Richman
- University of Rochester Medical Center, 300 Crittenden Boulevard Box PSYCH, Rochester, NY 14642, United States of America.
| | - H Benjamin Lee
- University of Rochester Medical Center, 300 Crittenden Boulevard Box PSYCH, Rochester, NY 14642, United States of America.
| | - Michael J Hasselberg
- University of Rochester Medical Center, 300 Crittenden Boulevard Box PSYCH, Rochester, NY 14642, United States of America.
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17
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Hinderaker K, Weinmann A. Association of Patients' Perception of Primary Care Provider Listening With Emergency Department Use. PRIMER : PEER-REVIEW REPORTS IN MEDICAL EDUCATION RESEARCH 2020; 4:7. [PMID: 32537607 DOI: 10.22454/primer.2020.951748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction This study examined whether patients' perceptions of their primary care providers' (PCP) listening frequency were associated with emergency department (ED) utilization, including a comparison to patients without PCPs. Methods Data were obtained from the 2015 California Health Interview Survey. Respondents were asked if they had a PCP and how often their PCPs listened, resulting in five groups: patients without a PCP (n=4,407), and patients with a PCP who perceived the PCP's listening frequency to be never (n=254), sometimes (n=1,282), usually (n=3,440), or always (n=11,651). Multiple linear regression was performed to determine if patient-perceived listening frequency of the PCP was associated with the patient's number of ED visits in the prior year, adjusting for various demographic, social, and health factors. Results Compared to patients without a PCP, patients with a PCP had on average 0.15 more ED visits in a year, highest among those whose PCPs were perceived as listening the least: never=0.55 more visits per year (95% CI: 0.09-1.02, P=.02), sometimes=0.26 (0.01-0.51, P=.04), usually=0.03 (-0.17-0.24, P=.73), and always=0.16 (-0.05-0.36, P=.13). Other significant increases in ED visits were associated with public insurance, African-American race, English proficiency, younger age, self-rated fair-to-poor health, asthma, and hypertension. Conclusions Patients who perceived their PCP as listening less frequently had more ED visits than patients whose PCPs were perceived as listening more frequently, and compared to patients without a PCP.
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Affiliation(s)
- Katie Hinderaker
- University of Minnesota Department of Family Medicine and Community Health, Minneapolis, MN
| | - Amanda Weinmann
- University of Minnesota Department of Family Medicine and Community Health, Minneapolis, MN
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18
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Shergill Y, Rice D, Smyth C, Tremblay S, Nelli J, Small R, Hebert G, Singer L, Rash JA, Poulin PA. Characteristics of frequent users of the emergency department with chronic pain. CAN J EMERG MED 2020; 22:350-358. [PMID: 32213214 DOI: 10.1017/cem.2019.464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain. METHODS We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details - number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either "chronic pain" or "not chronic pain" related. RESULTS We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain. CONCLUSIONS Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.
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Affiliation(s)
- Yaadwinder Shergill
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
- One Elephant Integrative Health Team Inc., Oakville, ON
| | - Danielle Rice
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Psychology, McGill University, Montreal, QC
| | - Catherine Smyth
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON
| | - Steve Tremblay
- Department of Psychology, McGill University, Montreal, QC
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - Jennifer Nelli
- Department of Anesthesiology, Hamilton Health Sciences, Hamilton, ON
| | - Rebecca Small
- Faculty of Medicine, Memorial University, St. John's, NL
| | - Guy Hebert
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON
| | - Lesley Singer
- Canadian Pain Network Patient Representative
- Patient Representative, Chronic Pain Network, Montreal, QC
| | - Joshua A Rash
- Department of Psychology, Memorial University, St. John's, NL
| | - Patricia A Poulin
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
- Department of Psychology, The Ottawa Hospital, Ottawa, ON
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Sheff A, Flaster A, Chaguturu S, Weil E. Putting the puzzle pieces together: Adapting a population health infrastructure to Medicaid risk. Healthcare (Basel) 2020; 8:100407. [DOI: 10.1016/j.hjdsi.2019.100407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/02/2019] [Accepted: 12/27/2019] [Indexed: 10/25/2022] Open
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20
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She Z, Gaglioti AH, Baltrus P, Li C, Moore MA, Immergluck LC, Rao A, Ayer T. Primary Care Comprehensiveness and Care Coordination in Robust Specialist Networks Results in Lower Emergency Department Utilization: A Network Analysis of Medicaid Physician Networks. J Prim Care Community Health 2020; 11:2150132720924432. [PMID: 32507022 PMCID: PMC7278335 DOI: 10.1177/2150132720924432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Care coordination is an essential and difficult to measure function of primary care. Objective: Our objective was to assess the impact of network characteristics in primary/specialty physician networks on emergency department (ED) visits for patients with chronic ambulatory care sensitive conditions (ACSCs). Subjects and Measures: This cross-sectional social network analysis of primary care and specialty physicians caring for adult Medicaid beneficiaries with ACSCs was conducted using 2009 Texas Medicaid Analytic eXtract (MAX) files. Network characteristic measures were the main exposure variables. A negative binomial regression model analyzed the impact of network characteristics on the ED visits per patient in the panel. Results: There were 42 493 ACSC patients assigned to 5687 primary care physicians (PCPs) connected to 11 660 specialist physicians. PCPs whose continuity patients did not visit a specialist had 86% fewer ED visits per patient in their panel, compared with PCPs whose patients saw specialists. Among PCPs connected to specialists in the network, those with a higher number of specialist collaborators and those with a high degree of centrality had lower patient panel ED rates. Conclusions: PCPs providing comprehensive care (ie, without specialist consultation) for their patients with chronic ACSCs had lower ED utilization rates than those coordinating care with specialists. PCPs with robust specialty networks and a high degree of centrality in the network also had lower ED utilization. The right fit between comprehensiveness of primary care, care coordination, and adequate capacity of specialty availability in physician networks is needed to drive outcomes.
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Affiliation(s)
- Zhaowei She
- Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | - Chaohua Li
- Morehouse School of Medicine, Atlanta, GA, USA
| | | | | | - Arthi Rao
- Georgia Institute of Technology, Atlanta, GA, USA
| | - Turgay Ayer
- Georgia Institute of Technology, Atlanta, GA, USA
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21
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Hodwitz K, Thakkar N, Schultz SE, Jaakkimainen L, Faulkner D, Yen W. Primary care performance of alternatively licenced physicians in Ontario, Canada: a cross-sectional study using administrative data. BMJ Open 2019; 9:e026296. [PMID: 31189675 PMCID: PMC6575712 DOI: 10.1136/bmjopen-2018-026296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Medical Regulatory Authorities (MRAs) provide licences to physicians and monitor those physicians once in practice to support their continued competence. In response to physician shortages, many Canadian MRAs developed alternative licensure routes to allow physicians who do not meet traditional licensure criteria to obtain licences to practice. Many physicians have gained licensure through alternative routes, but the performance of these physicians in practice has not been previously examined. This study compared the performance of traditionally and alternatively licenced physicians in Ontario using quality indicators of primary care. The purpose of this study was to examine the practice performance of alternatively licenced physicians and provide evaluative evidence for alternative licensure policies. DESIGN A cross-sectional retrospective examination of Ontario health administrative data was conducted using Poisson regression analyses to compare the performance of traditionally and alternatively licenced physicians. SETTING Primary care in Ontario, Canada. PARTICIPANTS All family physicians who were licenced in Ontario between 2000 and 2012 and who had complete medical billing data in 2014 were included (n=11 419). OUTCOME MEASURES Primary care quality indicators were calculated for chronic disease management, preventive paediatric care, cancer screening and hospital readmission rates using Ontario health administrative data. RESULTS Alternatively licenced physicians performed similarly to traditionally licenced physicians in many primary care performance measures. Minimal differences were seen across groups in indicators of diabetic care, congestive heart failure care, asthma care and cancer screening rates. Larger differences were found in preventive care for children less than 2 years of age, particularly for alternatively licenced physicians who entered Ontario from another Canadian province. CONCLUSIONS Our findings demonstrate that alternatively licenced physicians perform similarly to traditionally licenced physicians across many indicators of primary care. Our study also demonstrates the utility of administrative data for examining physician performance and evaluating medical regulatory policies and programmes.
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Affiliation(s)
- Kathryn Hodwitz
- College of Physicians and Surgeons of Ontario, Toronto, Ontario, Canada
| | - Niels Thakkar
- College of Physicians and Surgeons of Ontario, Toronto, Ontario, Canada
| | - Susan E Schultz
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Liisa Jaakkimainen
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family and Community Medicine, The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Faulkner
- College of Physicians and Surgeons of Ontario, Toronto, Ontario, Canada
| | - Wendy Yen
- College of Physicians and Surgeons of Ontario, Toronto, Ontario, Canada
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