Increase In Primary Care Visits Research Articles

Home-Based Primary Care for Older Adults: Matched Case-Control Evaluation of Program’s Impact on Healthcare Utilization

Home-based Primary Care (HBPC) is an alternative model for homebound older adults. Healthcare utilization in HBPC was evaluated with a matched case-control design. Medical providers and social workers provided in-home visits. Enrolled patients were matched to controls on age, prior hospitalizations, and frailty risk. Difference-in-differences in utilization of primary care, specialty, and hospital services between 1-year pre- and 1-year post-enrollment were evaluated with hierarchical linear models. Analyses included 117 HBPC cases and 328 controls. HBPC cases had a significant increase in primary care visits compared to controls (7.8 ± 0.6; p < .0001) but significantly decreased utilization of in-clinic primary care visits (−3.2 ± 0.6; p < .0001). In-clinic specialty visits and hospital services did not differ between cases and controls (all p’s ≥ .75). Homebound patients accessed high-touch primary and social care, which is typically unachievable in clinic settings; however, additional work is needed to optimize services and target in-home care to impact healthcare utilization.

Healthcare use in 700 000 children and adolescents for six months after covid-19: before and after register based cohort study

ObjectivesTo explore whether and for how long use of healthcare services is increased among children and adolescents after covid-19.DesignBefore and after register based study.SettingGeneral population of Norway.ParticipantsNorwegians aged 1-19 years...

Effect of Medicaid Expansion on Visit Composition in a Louisiana Health Care System.

Background: In 2016, Louisiana expanded Medicaid to low-income adults under the Patient Protection and Affordable Care Act. By 2020, the uninsured rate of adults in Louisiana had dropped from 22.7% to 8.9%; however, few reports describe the effect Medicaid expansion has had on access and utilization of health care services in Louisiana.Methods: For this study, we collected all-payer emergency department and clinic visits from one health care system in Louisiana from 2015 to 2019. We used a time series analysis to compare trends before and after Medicaid expansion in health insurance coverage and emergency department visit type.Results: The changes in payer mix in the urgent care and primary care clinics and emergency departments after Medicaid expansion was driven by the uptake of Medicaid coverage in the previously uninsured. Medicaid expansion had a limited impact on the number of urgent care and emergent and nonemergent emergency department visits, but an increase in primary care visits was observed.Conclusion: Medicaid expansion reduced uncompensated care in our patient population and expanded the access to primary care clinics. Ongoing research is needed to understand the effect of nonfinancial barriers to care on access to and utilization of services in Louisiana.

Assessing the Long-Term Effectiveness of a Behavioral Health Home for Adults With Bipolar and Psychotic Disorders.

This study aimed to examine the impact of a behavioral health home (BHH) to better understand its potential to improve health for individuals with serious mental illness. Propensity score-weighted interrupted time series analysis was used to estimate service utilization and chronic disease management through 3.5 years after BHH implementation and to compre BHH enrollees (N=413) with other patients with serious mental illness in the same health system (N=1,929). Relative to control group members, BHH patients had an immediate increase in primary care visits (+0.18 visits/month), which remained higher throughout follow-up, and an immediate decrease in emergency department visits (-0.031 visits/month). Behavioral health outpatient visits, which were increasing for BHH participants before implementation, began decreasing postimplementation; this decrease (-0.016 visits/month) was significantly larger than for the control group. Inpatient and outpatient visits for general medical health were decreasing over time for both groups before implementation but decreased more slowly for BHH patients postimplementation. Although behavioral health inpatient visits decreased for both groups around the start of the BHH program and remained lower, this initial drop was larger for the non-BHH group. BHH participation was associated with decreases in hemoglobin A1c values but no shift in low-density lipoprotein cholesterol values. The results reflect the challenges of improving health for patients with serious mental illness, even as access to primary care is increased. Further study is needed about which complex interventions inside and outside of the health care system can help offset the 20- to 30-year mortality gap faced by this population.

The Impact of Increased Access to Telemedicine

We estimate the impact of increased access to telemedicine that followed widespread adoption during the March-April 2020 lockdown period in Israel (due to COVID-19). We focus on the post-lockdown period, which in Israel was characterized by a temporary return to normalcy. Prior to the lockdown, telemedicine accounted for about 5% of all primary care visits. It peaked at around 40% during the lockdown, and remained high, at around 20%, during the post-lockdown period. Using a difference-in-differences framework, we compare primary care episodes before and after the lockdown between patients with high and low access to telemedicine, with access defined based on their main primary care physician’s propensity to adopt telemedicine during the lockdown. Increased access to telemedicine results in a 3.5% increase in primary care visits, but a 5% lower per-episode cost, so overall resource utilization is slightly lower. We find that remote visits involve slightly fewer prescriptions and more follow-ups, mainly with the same physician, which is consistent with a prolonged diagnostic path in the absence of physical examination. However, analyzing specific conditions, we find no evidence of missed diagnoses or adverse outcomes. Taken together, our findings suggest that the increased convenience of telemedicine does not compromise care quality or raise costs. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Community-based outreach associated with increased health utilization among Navajo individuals living with diabetes: a matched cohort study

BackgroundNavajo community members face high rates of diabetes mellitus and other chronic diseases. The Navajo Community Health Representative Outreach Program collaborated with healthcare providers and academic partners to implement structured and coordinated outreach to patients living with diabetes. The intervention, called Community Outreach and Patient Empowerment or COPE, provides home-based health coaching and community-clinic linkages to promote self-management and engagement in healthcare services among patients living with diabetes. The purpose of this study was to evaluate how outreach by Navajo Community Health Representatives (“COPE Program”) affected utilization of health care services among patients living with diabetes.MethodsDe-identified data from 2010 to 2014 were abstracted from electronic health records at participating health facilities. In this observational cohort study, 173 cases were matched to 2880 controls. Healthcare utilization was measured as the number of times per quarter services were accessed by the patient. Changes in utilization over 4 years were modeled using a difference-in-differences approach, comparing the trajectory of COPE patients’ utilization before versus after enrollment with that of the control group. The model was estimated using generalized linear mixed models for count outcomes, controlling for clustering at the patient level and the service unit level.ResultsCOPE enrollees showed a 2.5% per patient per quarter (pppq) greater increase in total utilization (p = 0.001) of healthcare services than non-COPE enrollees; a 3.2% greater increase in primary care visits (p = 0.024); a 6.3% greater increase in utilization of counseling and behavioral health services (p = 0.013); and a 9.0% greater increase in pharmacy visits (p < 0.001). We found no statistically significant differences in utilization trends of inpatient, emergency room, specialty outpatient, dental, laboratory, radiology, or community encounter services among COPE participants versus control.ConclusionsA structured intervention consisting of Community Health Representative outreach and coordination with clinic-based providers was associated with a modest increase in health care utilization, including primary care and counseling services, among Navajo patients living with diabetes. Community health workers may provide an important linkage to enable patients to access and engage in clinic-based health care.Trial registrationNCT03326206, registered 10/31/2017, retrospectively registered.

Effect of Age on Healthcare Utilization in Patients with Sickle Cell

Background: The median life expectancy of patients with sickle cell disease surpassed 40 years of age in the last two decades. While sickle cell patients overall are known to have high utilization of health services due to vaso-occlusive pain crises (VOC), few studies have focused on the impact of age on utilization pattern. Due to this, our understanding of the patient population is frequently skewed based on data on younger patients. This study examines the utilization of healthcare in patients in two groups: below 40 years of age, and 40 years and over. We also examined the impact on these two cohorts of a home-based primary care program. Methods: All patients were enrolled in a home-based primary care program in which their primary care doctor visited their home every 4-6 weeks. Health utilization data were collected retrospectively, through chart review for one year prior to joining the home-based primary care program, and prospectively for one year after joining the program. Primary care appointments, reported crises, Sickle Cell Day Hospital visits, ED visits, admissions, 30-day readmissions, and total admission days were recorded. Results: A total of 30 patients was enrolled in the study, and 58 years of data were collected. There were 16 patients between 18 and 39, and 14 patients aged 40 and over. 50% of the 40 and over age group was SS genotype and 50% SC compared to only one patient in the below 40 population had genotype SC. The groups were not significantly different regarding gender distribution (57% female in the 40 and over population vs 50% female in the below 40 population). The 40 and over population had on average more comorbidities per patient. The 40 and over population had significantly more primary care visits every year both before and after the start of the home visits compared to the below 40 population,. The 40 and over population, also had significantly lower overall rates of acute care utilization than the patients under 40: number of crises, ED visits, admissions, 30-day readmissions, and total hospital admission days. When comparing pre and post home visiting within the 40 and older population, there was an increase in primary care visits and a decrease in in reported crises, ED visits, admissions and readmissions. There was no change in these parameters in the 18-39 year old patient group. Discussion: As sickle cell patients age, they are more likely to have cumulative co-morbidities due to their sickle cell disease. Despite their more advanced age and their increase in co-morbid conditions, patients 40 and above were shown in our study to have fewer ED visits and admissions than younger patients, and to further reduce ED visits and admissions when provided with home-based primary care. The younger group had higher utilization at baseline, and did not show improvement when receiving home-based primary care. The reduced acute care utilization in the older group could be due to increased use of primary care, which was further enhanced by enrollment in the home-based primary care program; better adherence to medical treatment; more skill and experience in disease self-management; better social support; or fewer vaso-occlusive crises despite a higher number of co-morbid conditions. The higher prevalence of SC disease in the older cohort is a possible confounder. Those patients with higher utilization at a younger age may be higher risk of mortality, thereby leading to a survivor effect in the older population. Research in the general medical population has shown that home-based primary care reduces acute care utilization in high-utilizing patients with multiple chronic conditions, but more research is needed on the impact in sickle cell patients. Conclusion: This is the first study, to our knowledge, of the impact of home-based primary care on adults with sickle cell disease. In this study, sickle cell patients aged 40 and under showed overall more acute care utilization than those over age 40. The older population had an increase in primary care visits, and overall a significant decrease in healthcare utilization after enrollment in the home visiting program. We did not see a significant decrease in utilization in the younger population with home visits. Disclosures Desai: Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Ironwood: Other: Adjudication Board; University of Pittsburgh: Research Funding; Novartis: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Potomac: Speakers Bureau.

Changes in Health Care Use Associated With the Introduction of Hospital Global Budgets in Maryland

In 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program included reducing unnecessary hospital utilization and encouraging greater use of primary care. To compare changes in hospital and primary care use through the first 2 years of Maryland's hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas. We matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption). Hospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay). We matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean [SD] age, 71.7 [12.5] years). Assuming parallel trends, we estimated a differential change in Maryland of -0.47 annual hospital stays per 100 beneficiaries (95% CI, -1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of -1.24 stays per 100 beneficiaries (95% CI, -2.46 to -0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (-0.8 visits/100 beneficiaries; 95% CI, -10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland's program. We did not find consistent evidence that Maryland's hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.

Do Patients Who Access Clinical Information on Patient Internet Portals Have More Primary Care Visits?

As health care costs alarm the nation and the debate increases about the impact of health information technologies, patients are reviewing their medical records increasingly through secure Internet portals. Important questions remain about the impact of portal use on office visits. To evaluate whether use of patient Internet portals to access records is associated with increased primary care utilization. A prospective cohort study. Primary care patients registered on patient Internet portals, within an integrated health system serving rural Pennsylvania and an academic medical center in Boston. Frequency of "clinical portal use" (days/2 mo intervals over 2 y) included secure messaging about clinical issues and viewing laboratory and radiology findings. In year 2, a subset of patients also gained access to their primary care doctor's visit notes. The main outcome was number of primary care office visits. In the first 2 months of the 2-year period, 14% of 44,951 primary care patients engaged in clinical portal use 2 or more days per month, 31% did so 1 day per month, and the remainder had no clinical portal use. Overall, adjusted for age, sex, and chronic conditions, clinical portal use was not associated with subsequent office visits. Fewer than 0.1% of patients engaged in high levels of clinical portal use (31 or more login days in 2 mo) that were associated with 1 or more additional visits in the subsequent 2 months (months 3 and 4). However, the reverse was true: office visits led to subsequent clinical portal use. Similar trends were observed among patients with or without access to visit notes. Patients turn to their portals following visits, but clinical portal use does not contribute to an increase in primary care visits.

Sexually transmitted disease clinics in the era of the affordable care act: is it time to tear down the walls?

Sexually transmitted disease clinics in the era of the affordable care act: is it time to tear down the walls?

Rehabilitation of elderly patients in the community following surgery for hip fracture – utilization of personal and health care services

Purpose: To assess the change in utilization of personal and health care services following surgery for hip fracture in elderly patients rehabilitated in the community. Methods: A descriptive study of patients hospitalized in the orthopedic surgery ward for traumatic hip fracture. The first interview took place after surgery and included functional and medical data, and details on utilization of personal and health care services in the month prior to surgery. The second interview took place at home three months after discharge from the hospital and documented corresponding data for the last month. Results: The study included 91 elderly patients. The mean number of contacts with health care providers increased from 4.6/month before HF to 6.4/month during rehabilitation; in particular an increase in home visits by primary care nurses and physicians from 0.4 to 1.0 visit/month (p < 0.001). Personal care showed a greater increase from 32.5 to 95.0 weekly hours (p < 0.001). Multivariate analyses showed that the increase in primary care visits was associated with chronic co-morbidity and being single, while the increase in personal care was associated with medium dependence level and an ambulatory rehabilitation setting. Conclusions: During the rehabilitation period in the community there was an increase in non-rehabilitative services-medical and personal. Morbidity and functional data could predict the increase in use at time of discharge from hospital.Implications for RehabilitationFracture of hip is a common event in the elderly that necessitates surgical repair.Rehabilitation treatment after surgery for hip fracture aimed to return the patients to pre-event functional status and prevent the further development of disability. Rehabilitation treatment can be provided either in the hospital or in the community.During rehabilitation period there is an increase in use of primary care and personal services. Part of the increase can be predicted at time of hospitalization.