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Gupta A, Chant ED, Mohile S, Vogel RI, Parsons HM, Blaes AH, Booth CM, Rocque GB, Dusetzina SB, Ganguli I. Health Care Contact Days Among Older Cancer Survivors. JCO Oncol Pract 2024:OP2300590. [PMID: 38452315 DOI: 10.1200/op.23.00590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/10/2023] [Accepted: 12/13/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care. METHODS We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days. RESULTS We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad." CONCLUSION Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.
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Affiliation(s)
| | - Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - Supriya Mohile
- Department of Medicine, University of Rochester, Rochester, NY
| | | | | | | | | | | | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
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Abstract
BACKGROUND Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized. OBJECTIVE To assess composition of, variation and patterns in, and factors associated with contact days among older adults. DESIGN Cross-sectional study. SETTING Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims. PARTICIPANTS Community-dwelling adults aged 65 years and older in traditional Medicare. MEASUREMENTS Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days. RESULTS In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad"). LIMITATION Study population limited to those in traditional Medicare. CONCLUSION On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (E.D.C.)
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Ateev Mehrotra
- Harvard University, Boston; and Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.M.)
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston; and Harvard University, Boston, Massachusetts (C.S.R.)
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Chant ED, Ritchie CS, Orav EJ, Ganguli I. Healthcare contact days among older adults living with dementia. J Am Geriatr Soc 2024. [PMID: 38263877 DOI: 10.1111/jgs.18744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/03/2023] [Accepted: 12/10/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population. METHODS We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days. RESULTS In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days. CONCLUSIONS Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.
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Affiliation(s)
- Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christine S Ritchie
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Ganguli I, Mulligan KL, Chant ED, Lipsitz S, Simmons L, Sepucha K, Rudin RS. Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2342464. [PMID: 37943557 PMCID: PMC10636635 DOI: 10.1001/jamanetworkopen.2023.42464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/28/2023] [Indexed: 11/10/2023] Open
Abstract
Importance Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations. Objective To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits. Design, Setting, and Participants Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023. Interventions In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips. Main outcomes and measures The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted. Results There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials. Conclusions and Relevance In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships. Trial Registration ClinicalTrials.gov Identifier: NCT04902664.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kathleen L. Mulligan
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Emma D. Chant
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Stuart Lipsitz
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Leigh Simmons
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Sepucha
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert S. Rudin
- Health Care Division, RAND Corporation, Boston, Massachusetts
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Chant ED, Crawford M, Yang CWW, Fisher ES, Morden NE, Ganguli I. Sources of Low-Value Care Received by Medicare Beneficiaries and Associated Spending Within US Health Systems. JAMA Netw Open 2023; 6:e2333505. [PMID: 37728931 PMCID: PMC10512103 DOI: 10.1001/jamanetworkopen.2023.33505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/04/2023] [Indexed: 09/22/2023] Open
Abstract
This cross-sectional study examines referrals for low-value health care services and associated spending by ordering clinician among Medicare beneficiaries.
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Affiliation(s)
- Emma D. Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Elliott S. Fisher
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nancy E. Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Abstract
A CuH-catalyzed enantioselective hydroamidation reaction of vinylarenes has been developed using readily accessible 1,4,2-dioxazol-5-ones as electrophilic amidating reagents. This method provides a straightforward and efficient approach to synthesize chiral amides in good yields with high levels of enantiopurity under mild conditions. Moreover, this transformation tolerates substrates bearing a broad range of functional groups.
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Affiliation(s)
- Yujing Zhou
- Department of Chemistry, Room 18-490, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Oliver D Engl
- Department of Chemistry, Room 18-490, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Jeffrey S Bandar
- Department of Chemistry, Room 18-490, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Emma D Chant
- Department of Chemistry, Room 18-490, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Stephen L Buchwald
- Department of Chemistry, Room 18-490, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
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Affiliation(s)
- Yujing Zhou
- Department of Chemistry, Room 18–490Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Oliver D. Engl
- Department of Chemistry, Room 18–490Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Jeffrey S. Bandar
- Department of Chemistry, Room 18–490Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Emma D. Chant
- Department of Chemistry, Room 18–490Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Stephen L. Buchwald
- Department of Chemistry, Room 18–490Massachusetts Institute of Technology Cambridge MA 02139 USA
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