Ambulatory Care Sensitive Admissions Research Articles

Trends in inequalities in avoidable hospitalisations across the COVID-19 pandemic: a cohort study of 23.5 million people in England

ObjectiveTo determine whether periods of disruption were associated with increased ‘avoidable’ hospital admissions and wider social inequalities in England.DesignObservational repeated cross-sectional study.SettingEngland (January 2019 to March 2022).ParticipantsWith the approval of...

Integrated Memory Care: Primary Care for Persons Living with Dementia

AbstractThe Integrated Memory Care (IMC) program is a nurse practitioner led, physician‐supported primary care model which serves individuals living with Alzheimer’s disease and related dementias (ADRD) and their care partners living in the community. Individualized care plans align with patients’ goals, and patients benefit from care coordination provided by an expert team that includes nurses, social workers, occupational therapists, and dementia care assistants, all working directly with primary care providers. The IMC adds a palliative care perspective as well, emphasizing aggressive symptom management and advance care planning, thereby providing holistic care for individuals living with ADRD.Over 2000 patients and family care partners have received care at IMC since 2015. The average age of the patient population is 78.6 years; 65% of patients are female; 42% of patients are non‐white. The practice has developed and tested dementia‐specific workflows that can be implemented in a fee‐for‐service primary care environment. Successful completion of dementia quality measures, such as documentation of dementia type and stage, as well as assessment of cognitive, functional, and behavioral symptoms, is >90%. The ambulatory care sensitive admission rate of patients enrolled in the program is 0.5‐0.9%, well below published rates of 13% to 15%. In a case‐matched control group of patients, the IMC relative risk of hospitalization was one‐half those managed in usual primary care.The IMC represents a novel model of care for individuals living with ADRD and their care partners, achieving superior patient outcomes and representing a financially sustainable model for this growing population. Its primary care systems and processes provide an integrated pathway to quality care, thereby facilitating the identification of patients in the primary care setting who are living with ADRD.

Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes

The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide. To examine whether primary care physicians' MIPS scores are associated with performance on process and outcome measures. Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. MIPS score. The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, -7.1 percentage points [95% CI, -8.0 to -6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, -4.8 percentage points [95% CI, -5.4 to -4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, -12.2 percentage points [95% CI, -13.1 to -11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, -8.9 [95% CI, -13.7 to -4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care-sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

Analysis of Affordable Health Care.

Lack of affordable health care affects the uninsured, commercially insured, and Medicare beneficiaries. Yet, the wide variation in providers' prices and practice styles suggests that more affordable care already may be available and data on low value and wasteful care suggest that lower cost care need not come at the expense of better quality. Although price variation has received the most attention in the literature and legislation, total cost of care is a function of both unit prices (fees) and the quantity of services. To partition provider-specific variation in total annual risk-adjusted per capita expenditures on health care services into variation in unit prices (fees) versus quantities of services, and to explore the relationship between low value, avoidable, discretionary, and recommended care to total health expenditures. The analysis is important because both prices and quantities of services can affect affordability and reductions in prices versus quantities have very different effects on providers' profits. 2018 data from the Minnesota State Employees Group Insurance Program (SEGIP) that offers a tiered cost-sharing health insurance benefit design to 130,000 State employees and their dependents (SEGIP "members"). Each year during open enrollment, SEGIP members choose a primary care clinic (PCC). The PCC can make decisions regarding both unit prices and prescribed services. PCCs are placed in one of four cost-sharing tiers based on the total annual risk-adjusted per capita health expenditures for the SEGIP members who choose their clinic. Members choosing higher cost PCCs face higher deductibles, copayments, and maximum out-of-pocket spending limits. Overall prices and use of inpatient, outpatient hospital, professional, and pharmaceutical services, total and avoidable use of emergency department visits and inpatient admissions, low value care, testing for patients with pneumonia, and recommended preventive care. Differences in total risk-adjusted annual per capita health expenditures across the care systems were substantial. Higher cost providers had both higher unit prices and higher use of services. Variation in the quantity of health care services explained more of the variance in total spending than variation in prices. Prices for professional services and use of inpatient, outpatient hospital, and pharmaceutical services, and ambulatory care sensitive admissions, contributed significantly to high total expenditures. Lower cost PCCs in the lowest cost-sharing tier had higher rates of low value care and lower emergency department visits per capita. Neither the number of investigations for patients with pneumonia nor the receipt of recommended mammography screening varied systematically by tier. Efforts to identify and expand sources of affordable care, including improved information and incentives for consumers, need to account for variation in both prices and quantities of services. Efforts to encourage more efficient use of health care services by providers need to consider the effect of those efforts on the provider's internal costs and thus their profits.

Relationship Between Physician Burnout And The Quality And Cost Of Care For Medicare Beneficiaries Is Complex.

Despite reports of a physician burnout epidemic, there is little research on the relationship between burnout and objective measures of care outcomes and no research on the relationship between burnout and costs of care. Linking survey data from 1,064 family physicians to Medicare claims, we found no consistent statistically significant relationship between seven categories of self-reported burnout and measures of ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs. The coefficients for ambulatory care-sensitive admissions and readmissions for all burnout levels, compared with never being burned out, were consistently negative (fewer ambulatory care-sensitive admissions and readmissions), suggesting that, counterintuitively, physicians who report burnout may nevertheless be able to create better outcomes for their patients. Even if true, this hypothesis should not indicate that physician burnout is beneficial or that efforts to reduce physician burnout are unimportant. Our findings suggest that the relationship between burnout and outcomes is complex and requires further investigation.

Association of Primary Care Engagement in Value-Based Reform Programs With Health Services Outcomes

Policy makers envision synergistic benefits from primary care reform programs that advance infrastructure and processes in the context of a supportive payment environment. However, these programs have been operationalized and implemented separately, raising the question of whether synergies are achieved. To evaluate associations between primary care engagement in voluntary delivery system and/or payment reform programs and health services outcomes. This was an observational longitudinal analysis of US ambulatory primary care organizations (PCOs) with attributed Medicare fee-for-service beneficiaries (1.6-1.9 million unique beneficiaries annually) using data for 2009, 2010, and 2015 to 2017; PCOs included multispecialty practices that delivered primary care. Data analyses were performed from January 2020 to December 2021. Annual PCO participation in or recognition by (1) the Centers for Medicare & Medicaid's meaningful use (MU) program, (2) the National Committee for Quality Assurance's Patient-Centered Medical Home (PCMH) program, and/or (3) the Medicare Shared Savings Program (MSSP), an Accountable Care Organizations program. Independent and joint associations between an additional year of participation by a PCO in each of the 3 reform programs, and 3 types of outcomes: (1) hospital utilization (all-cause admissions, ambulatory care sensitive admissions, all-cause readmissions, all-cause emergency department visits); (2) evidence-based diabetes guideline adherence (≥1 annual glycated hemoglobin test, low-density lipoprotein cholesterol test, nephropathy screening, and eye examination); and (3) Medicare spending (total, acute inpatient, and skilled nursing facility). The study sample comprised 47 880 unique PCOs (size ≤10 beneficiaries, 50%; ≤1-2 clinicians, 65%) and approximately 5.61 million unique Medicare beneficiaries (mean [SD] age, 71.4 [12.7] years; 3 207 568 [57.14%] women; 4 474 541 [79.71%] non-Hispanic White individuals) across the study years (2009, 2010, 2015-2017). Of the hospital utilization measures, only ambulatory care sensitive admission was associated with improved performance, showing a statistically significant marginal effect size for joint participation in MU and MSSP (-0.0002; 95% CI, -0.0005 to 0.0000) and MSSP alone (-0.0003; 95% CI, -0.0005 to -0.0001). For diabetes adherence, joint participation in PCMH and MU was associated with 0.06 more measures met (95% CI, 0.03 to 0.10) while participation in all 3 programs was associated with 0.05 more measures met (95% CI, 0.02 to 0.09). Stand-alone PCMH and stand-alone MU participation were also associated with improved performance. Joint participation in MU and MSSP was associated with $33.89 lower spending (95% CI, -$65.79 to -$1.99) as was stand-alone MSSP participation (-$37.04; 95% CI, -$65.73 to -$8.35). This longitudinal observational study found that participation by PCOs in single or multiple reform programs was associated with better performance for only a subset of health services outcomes. More consistent and larger synergies may be realized with improved alignment of program requirements and goals.

Integrated memory care clinic: Primary care for people living with dementia

AbstractBackgroundThe Integrated Memory Clinic (IMCC) serves individuals with a dementia diagnosis, such as Alzheimer’s disease or a related disorder, and their care partners who reside in a community setting. The IMCC is America’s first and only comprehensive primary and dementia care practice. The IMCC addresses a primary concern for nearly 6 million Americans living with dementia: How to identify a primary care practice that is knowledgeable about, and sensitive to, the complex medical and social issues associated with a dementia diagnosis and also that can manage the co‐morbidities common in aging. The model takes a primary palliative care perspective, emphasizing aggressive symptom management, advance care planning, and holistic care that focuses on improving the quality of life for the person living with dementia and their care partner. The IMCC’s patient‐centered approach allows patients to receive a broad array of health care services in a single visit from an interdisciplinary team. The IMCC team supports families living with dementia by focusing on the care recipient and care partner well‐being and quality of life, by processes designed to avoid inappropriate acute and emergency care utilization, and through stage‐based support and psychoeducational programs. The IMCC launched a Patient Family Advisory Council simultaneously with enrolling its first patient. The Council meets monthly to review and advise health care providers about clinic operations, communications, billing practices, and sustainability. Currently, four nurse practitioners deliver care to approximately 550 patients. The average age of the patient population is 78 years; 65% of patients are female; 42% of patients are non‐white. The ambulatory care sensitive admission rate ranges from 1.56% to 2.87% for the past 12 months. Performance in hypertension and diabetes management outperforms health system benchmark goals for primary care practices. The IMCC nurse practitioners’ overall patient experience scores are at 97th percentile, representing a meaningful and positive caregiver experience. The IMCC has earned national recognition as a patient‐centered medical home from the National Commission on Quality Assurance. The IMCC represents a novel model of care for people living with dementia and their caregivers and may be a more sustainable model for this growing vulnerable population.

Primary care quality and cost for privately insured patients in and out of US Health Systems: Evidence from four states.

To characterize physician health system membership in four states between 2012 and 2016 and to compare primary care quality and cost between in-system providers and non-system providers for the commercially insured population. Physician membership in health systems was obtained from a unique longitudinal database on health systems and matched at the provider level to 2014 all-payer claims data from Colorado, Massachusetts, Oregon, and Utah. Using an observational study design, we compared physicians in health systems to non-system physicians located in the same state and geography on average cost of care (risk-adjusted using the Johns Hopkins' Adjusted Clinical Grouper), five HEDIS quality measures, one measure of developmental screening, and two Prevention Quality Indicator Measures. Patients in commercial health plans were attributed to a primary care physician accounting for the plurality of office visits. A cohort for each quality measure was constructed based on appropriate measure specifications. The share of physicians in health systems increased steadily from 2012 to 2016 and ranged from 48% in Colorado to 63% in Utah in 2016. Compared to physicians not in a system, system physicians performed similarly on most HEDIS quality metrics compared to non-system physicians. Patients attributed to in-system physicians had about 40% higher rates (P<.05) of Ambulatory Care Sensitive Admissions (measured in admissions per 100000:921.33 in-system vs 674.61 not-in-system for acute composite; 2540.91 in-system vs 1972.17 for chronic composite In-system providers were associated with $29 (P<.05) higher average per member per month costs (453.37 vs 432.93). Overall, differences in performance by system membership were relatively small compared to differences across states and geography. A growing share of physicians is part of a health system from 2012 to 2016. Providers in health systems are not delivering primary care more efficiently than non-system providers for the commercially insured.

Association of Medicaid-Focused or Commercial Medicaid Managed Care Plan Type With Outpatient and Acute Care

Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown. To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan. This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020. Assignment to a Medicaid-focused insurance plan or a commercial managed care plan. Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations. A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching. Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Pediatric ambulatory care sensitive admission and deprivation index, ten years retrospective analysis

Abstract Background Ambulatory Care Sensitive Conditions (ACSCs) are conditions where effective community care and case management can help prevent the need for hospital admission. Even if the ACSC episode itself is managed well, an emergency admission for an ACSC is often symptom of overall poor quality of primary and community care. Lower socioeconomic status individuals show higher rates of hospitalization due to ACSCs. The purposes of this study is to examine the association between socioeconomic status and the risk of hospitalization due to an ACSC in pediatric population through a retrospective analysis of administrative data of the Abruzzo region. Methods We identified hospital discharge records from 2008 to 2018 of subjects under 18 years of age to take into consideration for the study. Hospitalizations due to ACSCs were selected by ICD9-CM coding developed by Billings et al. and implemented by Lu et al. For establishing the socioeconomic status, we used the Italian Deprivation Index (IDI) developed by Caranci et al. as a categorical variable expressed in quintiles. A multilevel logistic regression model was implemented using ACSC vs non ACSC hospitalization as dependent variables. Results In the study period, a total of 317,586 hospital discharge records were selected, 18059 (5.69%) of which related to ambulatory care sensitive hospitalization. After correcting for age, gender, and citizenship, ACSCs hospitalization was associated with lower IDI (aOR1.21;CI95%1.09-1.34) and a slight gradient as the deprivation increased. Moreover, it was also associated with emergency department admission (aOR6.53;CI95%6.19-6.89). Conclusions Avoidable hospitalization in pediatric settings is associated with lower socioeconomic status computed by IDI. This study confirms inequity in primary care or community care after adjusting for age, gender and citizenship. Italian deprivation index represents a useful tool to identify population and areas where improving prevention is necessary. Key messages The Italian deprivation index could be used to implement primary and community care strategies in pediatric settings. Socio-economic factors are associated with the performance of the health services.

Additional reimbursement for outpatient physicians treating nursing home residents reduces avoidable hospital admissions: Results of a reimbursement change in Germany

Potentially avoidable hospitalizations of nursing home residents are costly and may even be harmful for the residents concerned. This study analyzes whether the introduction, in Germany in 2016, of an additional reimbursement for outpatient care physicians treating nursing home residents has led to a reduction in hospital admissions. This analysis exploits the introduction of the additional reimbursement in a difference-in-difference approach, using recipients of professional home care as a control. The analysis is based on claims data from the largest German sickness fund, which provide complete information on health care and long-term care utilization for each insured person. Our analysis highlights a 5-percent reduction in overall hospital stays and an 8-percent reduction in ambulatory care-sensitive admissions as a result of the additional reimbursements. However, we found no effect for short-term hospital admissions or for admissions at night or at the weekend. We conclude that the overall health care utilization for nursing home patients seems to have improved due to an increased presence of physicians in nursing homes during daytime working hours. Thus, an additional reimbursement for outpatient care physicians seems to be an effective tool to reduce potentially avoidable hospital admissions in the nursing home sector. However, it does not appear to improve emergency care utilization, especially out-of-hour.

Machine learning application to the reduction of ambulatory care sensitive admissions (ACSA)

Abstract Background Reducing Ambulatory Care Sensitive Admissions (ACSA) not only enhances patients’ quality of life but could also save substantial costs. ACSA are avoidable admissions for chronic conditions that are associated with socio-economic status, health status, utilization and readiness of primary care service as well as environmental factors. Undoubtedly, health authorities are highly interested in enhancing the health care services in order to reduce the number of ACSA. The objective is to identify the geographic areas where the primary care workforce should be increased in order to maximize the decrease in ACSA. Methods Using ambulatory care and inpatient claims data as well as contextual variables, we apply support vector machine regression (SVR) to select the geographic areas (fr. Bassins de vie - BVs) and the number of to-be-added primary care nurses that maximize the ACSA reduction. We also take into account the constraints related to budget and the equality of health care access. Particularly, there are three possible constraints: (1) the total number of nurses can be added in the whole region; (2) the maximum number of the nurses can be added at each area; (3) the maximum density of nurses (numbers of the nurses per 10,000 habitants) can be reached at each area. The results are visualized using spatial maps. Preliminary results In 2014, 27,000 ACSA occurred in the Occitanie, France region. For a specific set of constraints values, the model identified 16 BVs (out of 201) where the addition of 30 nurses could lead to the maximum ACSA reduction in number which is 17. Conclusions In the French Occitanie region, our SVR model was able to target a small number of geographic areas to maximize the impact of increased primary care workforce on ACSA. Our approach is applied to a single region, and it can be applied to other regions or extended at the national level as well as to other countries. Key messages A decision support tool to help health authorities in locating primary health care resources for the maximum reduction of ambulatory care sensitive admissions. An application of machine learning in primary care services.

Ambulatory Care Sensitive Admissions in Individuals With Autism Spectrum Disorder, Intellectual Disability, and Population Controls.

Ambulatory care sensitive (ACS) admissions are those for which effective primary care can prevent the need for emergency department (ED) visits and inpatient hospitalizations, and are an indicator of primary care access. Individuals with autism spectrum disorder (ASD) and/or intellectual disability (ID) may be at higher risk for ACS admissions than individuals in the general population due to difficulty accessing primary care. The objective of this study was to compare the incidence of ACS admissions among four cohorts of individuals aged 2-24 years: ASD without co-occurring ID (ASD-only), ASD with co-occurring ID (ASD + ID), ID without ASD (ID-only), and population controls (PC). Data from ED visits and inpatient hospitalizations occurring between January 1, 2000 and December 31, 2015 were examined to identify ACS admissions. Generalized linear models were used to examine differences between cohorts on the number of ACS ED visits and inpatient hospitalizations. Results revealed the ASD + ID and ID-only cohorts had significantly higher rates of ACS inpatient hospitalizations than the PC cohort. Additionally, the ID-only cohort had higher rates of ACS ED visits than the PC cohort. The ASD-only and PC cohorts did not differ on incidence of ACS admissions. These findings suggest that presence of an ID with or without co-occurring ASD increased the risk for ACS inpatient hospitalizations, and presence of ID-only increased the risk for ACS ED visits. Future work should examine trajectories of ACS admissions over time and consider inclusion of additional characteristics that may elucidate reasons for differences in ACS admissions among these groups. Autism Res 2019, 12: 295-302 © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Preventable hospitalizations are a common indicator of problems with access to quality primary healthcare. Findings of this study suggest that individuals with intellectual disability, with or without autism spectrum disorder, have higher rates of preventable hospitalizations than the general population. Further research is needed to understand how to improve access to primary care and reduce preventable hospitalizations for this vulnerable population.

Are Changes in Medical Group Practice Characteristics Over Time Associated With Medicare Spending and Quality of Care?

Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.

Medical Group Characteristics and the Cost and Quality of Care for Medicare Beneficiaries.

To estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes. We linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries. Cross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care. Practices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care. Large practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.

Health care in a multi-payer system: Spillovers of health care service demand among adults under 65 on utilization and outcomes in medicare

This paper examines, theoretically and empirically, how changes in the demand for health insurance and medical services in the non-Medicare population − coverage eligibility changes for parents and the firm size composition of employment − spill over and affect health insurance coverage and how these factors affect per beneficiary Medicare spending. We find that factors that increase coverage and hence demand for medical services in the non-Medicare population generate contemporaneous decreases in per beneficiary Medicare spending and utilization, particularly for high variation services. Moreover, these increases in the demand for medical services in the non-Medicare population are not associated with increases in the total quantity of physician services supplied. Finally, we find that the higher Medicare spending associated with lower insurance coverage rates in the non-Medicare population does not generate improvements in measures of Medicare patients’ well-being, such as patient experience of care, ambulatory-care sensitive admissions, and mortality.

Quantile regression for overdispersed count data: a hierarchical method

Generalized Poisson regression is commonly applied to overdispersed count data, and focused on modelling the conditional mean of the response. However, conditional mean regression models may be sensitive to response outliers and provide no information on other conditional distribution features of the response. We consider instead a hierarchical approach to quantile regression of overdispersed count data. This approach has the benefits of effective outlier detection and robust estimation in the presence of outliers, and in health applications, that quantile estimates can reflect risk factors. The technique is first illustrated with simulated overdispersed counts subject to contamination, such that estimates from conditional mean regression are adversely affected. A real application involves ambulatory care sensitive emergency admissions across 7518 English patient general practitioner (GP) practices. Predictors are GP practice deprivation, patient satisfaction with care and opening hours, and region. Impacts of deprivation are particularly important in policy terms as indicating effectiveness of efforts to reduce inequalities in care sensitive admissions. Hierarchical quantile count regression is used to develop profiles of central and extreme quantiles according to specified predictor combinations.

GP Training practices in England: a description of their unique features based on national data

Postgraduate general practitioner (GP) training structures have been reorganised with the formation of Health Education England (HEE). We aimed to broaden the findings of previous studies and identify key features of GP training practices. In particular, we wanted to extend previous findings regarding QOF achievement and patient experience derived from the General Practice Patient Survey (GPPS), with recent data on the use of urgent cancer referral pathways (‘Two Week Wait’, or ‘2WW,’ referrals) and secondary care utilisation by GP training Practices. We compared training and non-training practices, adjusting for differences in practice size and demographic features. Compared with non-training practices, we found reported patient satisfaction with ‘access’ was 2.0% higher (p < 0.001), ‘communication’ 0.75% higher (p < 0.001), ‘overall experience’ 2.8% higher (p < 0.001), ‘continuity of care’ 2.2% lower (p < 0.001). Mean QOF scores were 11 points higher in training practices (p < 0.001). There were few differences between the two types of practice in terms of Emergency hospital admissions, Ambulatory Care Sensitive (ACSC) admissions, Accident and Emergency attendances and Out-Patient attendances. Training practices used the 2WW referral pathway more frequently than non-training practices resulting in a 1.1% higher ‘cancer detection rate’ (p = 0.007).

How do population, general practice and hospital factors influence ambulatory care sensitive admissions: a cross sectional study

BackgroundReducing unplanned hospital admissions is a key priority within the UK and other healthcare systems, however it remains uncertain how this can be achieved. This paper explores the relationship between unplanned ambulatory care sensitive condition (ACSC) admission rates and population, general practice and hospital characteristics. Additionally, we investigated if these factors had a differential impact across 28 conditions.MethodsWe used the English Hospital Episode Statistics to calculate the number of unplanned ACSC hospital admissions for 28 conditions at 8,029 general practices during 2011/12. We used multilevel negative binomial regression to estimate the influence of population (deprivation), general practice (size, access, continuity, quality, A&E proximity) and hospital (bed availability, % day cases) characteristics on unplanned admission rates after adjusting for age, sex and chronic disease prevalence.ResultsPractices in deprived areas (at the 90th centile) had 16% (95% confidence interval: 14 to 18) higher admission rates than those in affluent areas (10th centile). Practices with poorer care continuity (9%; 8 to 11), located closest to A&E (8%; 6 to 9), situated in areas with high inpatient bed availability (14%; 10 to 18) or in areas with a larger proportion of day case admissions (17%; 12 to 21) had more admissions. There were smaller associations for primary care access, clinical quality, and practice size. The strength of associations varied by ACSC. For example, deprivation was most strongly associated with alcohol related diseases and COPD admission rates, while continuity of primary care was most strongly associated with admission rates for chronic diseases such as hypertension and iron-deficiency anaemia.ConclusionsThe drivers of unplanned ACSC admission rates are complex and include population, practice and hospital factors. The importance of these varies markedly across conditions suggesting that multifaceted interventions are required to avoid hospital admissions and reduce costs. Several of the most important drivers of admissions are largely beyond the control of GPs. However, strategies to improve primary care continuity and avoid unnecessary short-stay admissions could lead to improved efficiency.

Inappropriate Utilization in Fee-for-Service Medicare and Medicare Advantage Plans.

This study uses a national multi-payer claims database to test for differences in potentially inappropriate emergency department (ED) visits and ambulatory care sensitive (ACS) admissions in fee-for-service (FFS) Medicare and Medicare Advantage (MA) plans. Rates of ACS admissions for MA enrollees were approximately one third those of FFS beneficiaries, controlling for covariates, which included the beneficiary's health status as represented by their risk score. This study then compared FFS and MA beneficiaries when they moved from one type of health plan to another. Again, controlling for covariates, potentially inappropriate ED visits and ACS admissions remained at their low baseline values for FFS beneficiaries who switched from FFS Medicare to MA plans, but rose for MA enrollees switching to FFS Medicare.