Ambulatory Care Fragmentation and Subsequent Hospitalization: Evidence From the REGARDS Study.

Abstract

Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders. The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables. Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year. We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period. The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24). Highly fragmented ambulatory care is an independent risk factor for hospitalization.