Office-based Physician Visits Research Articles

2260. Differences in the Prevalence of Inappropriate Antibiotic Prescribing by Payer Type

Abstract Background Understanding the relationship between inappropriate prescribing and patient insurance type could inform the targeting of antibiotic stewardship initiatives. However, few national data on this topic exist. Methods We analyzed the National Ambulatory Medical Care Survey, a nationally representative survey of office-based physician visits. We included all years from 2016 to 2019 except 2017, a year during which the survey was not fielded. We identified visits resulting in an oral antibiotic prescription among children and non-elderly adults who were privately insured, publicly insured, or uninsured. The exposure was safety-net status (publicly insured/uninsured versus privately insured). The outcome was inappropriate antibiotic prescribing, defined as an antibiotic prescription in a visit for which none of the diagnosis codes justified antibiotic use (following the approach of Chua et al, BMJ 2019). We assessed the association between safety-net status and inappropriate antibiotic prescribing using linear regression, controlling for patient characteristics, calendar quarter, and specialty. Models accounted for the complex design of the survey and employed designed-based variance estimators. Results Of 413,830,032 weighted visits for children, 16.9% resulted in an antibiotic prescription. Among these visits, the unadjusted prevalence of inappropriate antibiotic prescriptions was 29.1% overall, 23.4% for safety-net patients, and 32.4% for privately insured patients (adjusted difference, safety-net minus private: -11.9%, 95% CI: -20.6%, -3.2%). Of 1,240,610,825 weighted visits for non-elderly adults, 11.0% resulted in an antibiotic prescription. Among these visits, the unadjusted prevalence of inappropriate antibiotic prescriptions was 50.1% overall, 60.7% for safety-net patients, and 47.9% for privately insured patients (adjusted difference, safety-net minus private: 11.3%, 95% CI: 2.4%, 20.3%). Conclusion Safety-net status was associated with a lower rate of inappropriate antibiotic prescribing among children but a higher rate among non-elderly adults. Antibiotic stewardship initiatives targeting clinicians who care for privately insured children and adults with safety-net insurance may be warranted. Disclosures Jeffrey A. Linder, MD, MPH, FACP, Amgen, Biogen, Eli Lily: Stocks/Bonds

Physician Office Visits That Included Complementary Health Approaches in U.S. Adults: 2005-2015.

Introduction: The Institute of Medicine has described the need for comparing models of care delivery involving complementary health approaches and conventional medical practitioners. As a step toward addressing this need, we used a nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided. Methods: NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. We examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for health visit. We ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide development of logistic regression models. Results: Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem. Conclusion: We present an overview of the first study of office-based physician visits where complementary health approaches were recommended or ordered to their patients. These data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

Emergency Department Utilization, Hospital Admissions, and Office-Based Physician Visits Among Under-Resourced African American and Latino Older Adults

ObjectivesThis study uses a theoretical model to explore (a) emergency department (ED) utilization, (b) hospital admissions, and (c) office-based physician visits among sample of under-resourced African American and Latino older adults.MethodsNine hundred five African American and Latino older adults from an under-resourced urban community of South Los Angeles participated in this study. Data was collected using face-to-face interviews. Poisson and logistic regression analysis were used to estimate the parameters specified in the Andersen behavioral model. Predictors included predisposing factors, defined as demographic and other personal characteristics that influence the likelihood of obtaining care, and enabling factors defined as personal, family, and community resources that support or encourage efforts to access health services.ResultsAfrican American older adults have a greater frequency of hospital admissions, ED, and physician visits than their Latino counterparts. About 25%, 45%, and 59% of the variance of the hospital admissions, ED utilization, and physician visits could be explained by predisposing and enabling characteristics. Lower health-related quality of life was associated with a higher number of hospital admissions, ED, and physician visits. Financial strain and difficulty accessing medical care were associated with a higher number of hospital admissions. Being covered by Medicare and particularly Medi-Cal were positively associated with higher hospital admissions, ED, and physician visits.DiscussionCompared to African American older adults, Latino older adults show higher utilization of (a) emergency department (ED) utilization, (b) hospital admissions, and (c) office-based physician visits. A wide range of predisposing and enabling factors such as insurance and financial difficulties correlate with some but not other types of health care use. Multi-disciplinary, culturally sensitive, clinic- and community-based interventions are needed to address enabling and predisposing factors that influence ED utilization and hospital admission among African American and Latino older adults in under-resourced communities.

Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA.

After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). Cancer screening procedures were coded as low value using USPSTF age thresholds. Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.

A Reduction in Health Care Expenditures Linked to Mental Health Service Use Among Adults With Chronic Physical Conditions.

The aim was to examine the impact of receipt of mental health services on health care expenditures for U.S. adults with major chronic physical conditions. Medical Expenditure Panel Survey data for 2004-2014 were analyzed for adults ages ≥18 with at least one of six chronic physical conditions (cardiovascular diseases, cancer, diabetes, emphysema, asthma, and arthritis) who were followed up for 2 years (N=33,419). Outcomes included overall health care spending and expenditure by service type (inpatient services, outpatient services, emergency department visits, office-based physician visits, and prescribed medication). A difference-in-differences model compared a change in health care costs in the subsequent year for those who did and did not receive mental health services in the preceding year. On average, the increase in overall health care expenditure in the subsequent year among adults receiving mental health services in the preceding year was smaller by 12.6 percentage points (p<0.05) than for those who did not receive such services. The difference was equivalent to $1,146 in 2014 constant U.S. dollars (p=0.05). Medication treatment alone did not have a meaningful effect on overall costs. The combination of psychotherapy and medication was associated with a per-capita reduction in overall health care expenditure of 21.7 percentage points, or $2,690 (p<0.01). The combination was also associated with reduced costs for office-based visits (p<0.05) and medication (p<0.05). Receipt of mental health services was associated with a reduction in overall health care costs, particularly for office-based visits and prescribed medication, among adults with chronic physical conditions.

Direct Medical Expenditure and Healthcare Utilization with Mental Disorders among Hispanic Population using Medical Expenditure Panel Survey 2013-2017

This study sought to assess how mental disorders’ incidence affects healthcare cost and utilization amongst the U.S. Hispanic population from 2013-2017. Using 2013-2017 Medical Expenditure Panel Survey (MEPS) data, a retrospective database analysis was conducted for the Hispanic population with mental disorders. Study outcomes were mental disorder incidence, healthcare utilization, and healthcare cost among the Hispanic population. All-cause direct medical utilization and expenditures were calculated for the following categories of health care services: inpatient hospitalizations, hospital outpatient visits, emergency room visits, office-based physician visits, home health care visits, and prescription medications. From the MEPS data, 4,122 respondents with a mental disorder (weighted sample size: 4,789,634) and 30,312 without a mental disorder (weighted sample size: 33,893,665) were identified. A significant trend appeared through the Generalized Linear Model (GLM) with gamma distribution and log-link function. The mental disorder group had markedly higher adjusted expenditures on emergency room visits, hospital outpatients, physician visits, home healthcare, and prescriptions compared to non-mental disorder patients (p

Duration of Outpatient Antibiotic Therapy in Common Outpatient Infections, 2017

Background: Community-acquired pneumonia (CAP), urinary tract infection (UTI), pharyngitis, acute otitis media (AOM), and skin and soft-tissue infection (SSTI) are among the most common outpatient conditions for which antibiotics are prescribed. The objective of this study was to describe the observed duration of outpatient antibiotic therapy compared with guideline recommendations for these common conditions in 2017 in the United States to identify antibiotic stewardship targets. Methods: We estimated therapy duration for oral and parenteral antibiotic prescriptions associated with CAP, AOM, pharyngitis, acute cystitis, pyelonephritis, SSTI, and sinusitis diagnoses from the IQVIA National Disease and Therapeutic Index 2017 dataset, a two-stage stratified cluster sample of office-based physician visits. We excluded azithromycin due to its unique pharmacokinetics, and we limited our study to prescriptions from emergency medicine, family practice, general practice, geriatrics, internal medicine, osteopathic medicine, and pediatrics physicians. We excluded observations with antibiotic prescriptions for multiple conditions. We used NDTI projection weights and complex sample methods to estimate antibiotic prescription numbers and durations by condition and age group. Results: Table 1 shows antibiotic prescriptions by condition and population. The median antibiotic therapy duration for all conditions except acute cystitis was 10 days. The median duration for acute cystitis was 7 days. Conclusions:Clinicians prescribed 10-day antibiotic courses for the most common outpatient conditions, regardless of guideline-recommended duration. Antibiotic stewardship efforts targeting excessive durations of antibiotic therapy for common outpatient conditions, particularly sinusitis in adults, CAP, SSTI, and acute cystitis, are needed.Funding: This work was supported by the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.Disclosures: Laura M. King is a contractor employed by Northrop Grumman Corporation to fulfill research needs at the Centers for Disease Control and Prevention as part of a contract covering many positions and tasks. All other authors declare no conflicts.

Real-world trends in biologic, oral systemic, and phototherapy in US patients with psoriasis or psoriatic arthritis

To the Editor: Biologics have transformed the treatment landscape for psoriasis and psoriatic arthritis (PsA) over the past 2 decades. Little is known about recent trends and predictors of biologic use in these disorders. We examined trends in real-world use of biologic, systemic, and phototherapies. We analyzed the 2001-2015 National Ambulatory Medical Care Survey, a cross-sectional, representative sample of US office-based physician visits. Psoriasis and PsA were identified by International Classification of Diseases, Ninth Revision, codes 696.1 and 696.0. Weighted frequencies/proportions of treatments were estimated, including systemic corticosteroids (SCSs), biologics, oral immunosuppressants, acitretin, and phototherapy. Treatment utilization trends were examined over 5-year intervals with logistic regression by using Stata, version 14.2 (StataCorp, College Station, TX). P values were corrected using the Benjamini-Hochberg approach. A weighted total (95% confidence interval) of 33,600,000 (29,400,000-37,800,000) psoriasis visits occurred from 2001 through 2015; 95.7% (94.3%-96.9%) were in adults, 49.6% (46.1-53.2%) in female patients, 78.4% (74.6%-1.7%) in white non-Hispanic patients, and 89.7% (85.6%-92.6%) in metropolitan areas. Systemic therapy was used in 20.9% (18.1%-24.0%) of visits, most commonly with biologics (8.0% [6.2%-10.3%]), followed by oral immunosuppressants (5.0% [3.8%-6.6%]), SCSs (3.5% [2.4%-5.2%]), and phototherapy (3.3% [2.2%-4.9%]). Visits with biologic use increased from 2001-2005 period to the 2011-2015 period (from 3.8% [1.5%-9.6%] to 13.1% [10.0%-16.9%] of visits; P = .01), particularly among dermatologists (from 4.1% [1.6%-10.3%] to 12.0% [9.0%-15.8%]; P < .001), privately insured patients (from 4.8% [1.6%-13.4%] to 17.3% [12.8%-23.0%]; P = .017), those residing in metropolitan areas (from 4.1% [1.6%-10.3%] to 12.0% [9.0%-15.8%]; P = .028), and those with PsA (from 19.1% [6.3%-45.4%] to 27.6% [15.9%-43.3%]; P = .01). Adalimumab (from 0.0% to 5.7% [3.8%-8.5%]) and ustekinumab (from 0.0% to 3.7% [2.0%-6.5%]) in particular increased over time. Oral retinoid use decreased over time (from 4.5% [1.9%-7.0%] to 1.7% [0.3%-3.0%]; P = .05); oral immunosuppressants (P ≥ .24) and phototherapy (P ≥ .06) did not. Psoriasis/PsA treatment has changed dramatically over the past 2 decades (Fig 1 and Supplemental Table I; available via Mendeley at https://data.mendeley.com/datasets/publish-confirmation/hsvnkcc8w8/2). Biologics were used at substantially higher rates (more than double) than oral systemic or phototherapy combined. Biologic use likely increased owing to better identification of moderate to severe disease, approval of multiple biologics, publication of long-term efficacy and safety data, improved payer coverage, patient-assistance programs, and direct-to-consumer advertising. Increasing biologic use over time was not offset by major decreases of other modalities, indicating that biologics expanded the moderate to severe psoriasis market and did not merely replace previous therapies. Surprisingly, SCS use persisted in metropolitan areas from 2001-2005 to 2011-2015 (from 1.7% [0-3.6%] to 5.6% [2.5%-8.7%], P = .15); 49.2% and 81.1% of SCS prescriptions for patients with psoriasis or PsA were in chronic follow-up visits. SCSs are not included in US or European psoriasis treatment guidelines, nor are they recommended for chronic management of PsA, owing to adverse events with long-term use, rebound flares, erythroderma, and generalized pustular psoriasis with short-term use.1Menter A. Korman N.J. Elmets C.A. et al.Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents.J Am Acad Dermatol. 2009; 61: 451-485Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar Increasing use of SCSs over time and in the chronic management of psoriasis and PsA are important practice gaps warranting intervention. Study strengths include examination of a nationally representative cohort of outpatient visits for psoriasis. Limitations include lack of data on psoriasis severity and individual longitudinal treatment course. In summary, biologic use in psoriasis substantially increased over time in multiple patient subsets, whereas oral systemic and phototherapy use plateaued. SCS use remained prevalent over time, suggesting an important practice gap.

Buprenorphine prescribing for opioid use disorder in medical practices: can office-based out-patient care address the opiate crisis in the United States?

Opioid use disorder (OUD) remains a serious public health issue, and treating adults with OUD is a major priority in the United States. Little is known about trends in the diagnosis of OUD and in buprenorphine prescribing by physicians in office-based medical practices. We sought to characterize OUD diagnoses and buprenorphine prescribing among adults with OUD in the United States between 2006 and 2015. We used a repeated cross-sectional design, based on data from the 2006-15 National Ambulatory Medical Care Surveys that surveyed nationally representative samples of office-based out-patient physician visits. Adult patients aged 18years or older with a diagnosis of OUD (n=1034 unweighted) were included. Buprenorphine prescribing was defined by whether visits involved buprenorphine or buprenorphine-naloxone, or not. We also examined other covariates (e.g. age, gender, race and psychiatric comorbidities). We observed an almost tripling of the diagnosis of OUD from 0.14% in 2006-10 to 0.38% in 2011-15 in office-based medical practices (P<0.001). Among adults diagnosed with OUD, buprenorphine prescribing increased from 56.1% in 2006-10 to 73.6% in 2011-15 (P=0.126). Adults with OUD were less likely to receive buprenorphine prescriptions if they were Hispanic [adjusted odds ratio (aOR)=0.26; 95% confidence interval (CI)=0.11, 0.60], had Medicaid insurance (aOR=0.27; 95% CI=0.10, 0.74) or were diagnosed with other psychiatric disorders (aOR=0.45; 95% CI=0.25, 0.83) or substance use disorders (aOR=0.19; 95% CI=0.09, 0.41). In office-based medical practices in the United States, diagnoses for opioid use disorder and buprenorphine prescriptions for adults with opioid use disorder increased from 0.14 and 56.1%, respectively, in 2006-10 to 0.38 and 73.6% in 2011-15.

High-risk opioid prescribing trends in the outpatient setting prior to issuance of federal guidance.

Co-prescription of opioid and benzodiazepine products increases the risk of overdose-related mortality four-fold due to respiratory depression. Accordingly, prevention of high-risk opioid prescribing (HROP) has become a focus over the past two decades and was the subject of a black-box warning (BBW) issued by the U.S. Food and Drug Administration (FDA) on August 31, 2016. Because older patients are at increased risk for these outcomes, we compared rates of HROP for older (aged ≥65 years) and younger (aged 18–64 years) adults using a repeated cross-sectional cohort design. Data from the National Ambulatory Medical Care Survey of U.S. office-based physician visits were accessed for 2006–2016 August. From 2006 to 2016, the opioid-prescribing rate increased by 40% among those aged 18–64 years and by 54% among those aged ≥65 years. From 2012–2013 to 2014–2016, the HROP rate, expressed as a proportion of all opioid-prescribing visits, increased to 26.6% among those aged 18–64 years but declined to 21.0% among those aged ≥65 years, primarily because of changes for patients aged ≥75 years. Prior to the FDA-issued BBW, the HROP prescribing rate trended upward for all adults, except in 2014–2016 when it began to decline among older adults.

Concomitant use of opioid medications with triptans or serotonergic antidepressants in US office-based physician visits.

BackgroundOpioids are not recommended for routine treatment of migraine because their benefits are outweighed by risks of medication overuse headache and abuse/dependence. A March 2016 US Food and Drug Administration (FDA) safety communication warned of the risk of serotonin syndrome from using opioids concomitantly with 5-hydroxytryptamine receptor agonists (triptans) or serotonergic antidepressants: selective serotonin reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors (SNRIs). Epidemiological information about co-prescribing of these medications is limited. The objective of this study was to estimate the nationwide prevalence of co-prescribing of an opioid with a serotonergic antidepressant and/or triptan in US office-based physician visits made by 1) all patients and 2) patients diagnosed with migraine.MethodsNational Ambulatory Medical Care Survey (NAMCS) data were obtained for 2013 and 2014. Physician office visits that included the new or continued prescribing of ≥1 opioid medication with a triptan or an SSRI/SNRI were identified. Co-prescribed opioids were stratified by agent to determine the proportion of co-prescriptions with opioids posing a higher risk of serotonergic agonism (meperidine, tapentadol, and tramadol).ResultsOf an annualized mean 903.6 million office-based physician visits in 2013–2014, 17.7 million (2.0% of all US visits) resulted in the prescribing of ≥1 opioid medication with a triptan or an SSRI/SNRI. Opioid–SSRI/SNRI was co-prescribed in 16,044,721 visits, while opioid–triptan was co-prescribed in 1,622,827 visits. One-fifth of opioid co-prescribing was attributable to higher-risk opioids, predominantly tramadol (18.6% of opioid–SSRI/SNRI, 21.8% of opioid–triptan). Of 7,672,193 visits for patients diagnosed with migraine, 16.3% included opioid prescribing and 2.0% included co-prescribed opioid–triptan.ConclusionDuring a period approximately 2 years prior to an FDA warning about the risk of serotonin syndrome from opioid–SSRI/SNRI or opioid–triptan co-prescribing, use of these combinations was common in the USA. Studies on prescribing patterns following the March 2016 warning, and on the risk of serotonin syndrome associated with these co-prescriptions, are needed.

Mental health status and healthcare utilization among community dwelling older adults

Background: Shifts in mental health utilization patterns are necessary to allow for meaningful access to care for vulnerable populations. There have been long standing issues in how mental health is provided, which has caused problems in that care being efficacious for those seeking it.Aims: To assess the relationship between mental health status and healthcare utilization among adults ≥65 years.Methods: A negative binomial regression model was used to assess the relationship between mental health status and healthcare utilization related to office-based physician visits, while a two-part model, consisting of logistic regression and negative binomial regression, was used to separately model emergency visits and inpatient services.Results: The receipt of care in office-based settings were marginally higher for subjects with mental health difficulties. Both probabilities and counts of inpatient hospitalizations were similar across mental health categories. The count of ER visits was similar across mental health categories; however, the probability of having an emergency department visit was marginally higher for older adults who reported mental health difficulties in 2012.Conclusion: These findings are encouraging and lend promise to the recent initiatives on addressing gaps in mental healthcare services.

Prevalence of depression and receipt of antidepressant pharmacotherapy among patients with Parkinson&amp;rsquo;s disease: a national assessment of US office-based physician visits

Prevalence of depression and receipt of antidepressant pharmacotherapy among patients with Parkinson&amp;rsquo;s disease: a national assessment of US office-based physician visits

Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits.

An estimated 27.8% of the United States (US) population aged≥20years has hyperlipidemia, defined as total serum cholesterol of≥240mg/dL. A previous study of US physician office visits for hyperlipidemia in 2005 found both suboptimal compliance and racial/ethnic disparities in screening and treatment. The aim was to estimate current rates of laboratory testing, lifestyle education, and pharmacotherapy for hyperlipidemia. Data were derived from the US National Ambulatory Medical Care Survey (NAMCS), a nationally representative study of office-based physician visits, for 2013-2014. Patients aged≥20years with a primary or secondary diagnosis of hyperlipidemia were sampled. Study outcomes included receipt or ordering of total cholesterol testing, diet/nutrition counseling, exercise counseling, and pharmacotherapy prescription including statins, ezetimibe, omega-3 fatty acids, niacin, or combination therapies. Compared with previously reported results for 2005, rates of pharmacotherapy have remained static (52.2 vs. 54.6% for 2005 and 2013-2014, respectively), while rates of lifestyle education have markedly declined for diet/nutrition (from 39.7 to 22.4%) and exercise (from 32.1 to 16.0%). Lifestyle education did not vary appreciably by race/ethnicity in 2013-2014. However, rates of lipid testing were much higher for whites (41.6%) than for blacks (29.9%) or Hispanics (34.2%). Tobacco education was ordered/provided in only 4.0% of office visits. Compliance with guidelines for the screening and treatment of hyperlipidemia remains suboptimal, and rates of lifestyle education have declined since 2005. There exists an urgent need for enhanced levels of provider intervention to reduce the morbidity and mortality associated with hyperlipidemia.

Health Insurance Coverage and Health Care Utilization: Evidence from the Affordable Care Act's Dependent Coverage Mandate

This paper investigates the impact of the Affordable Care Act’s (ACA’s) dependent coverage mandate on health insurance coverage rates and health care utilization among young adults. Using data from the Medical Panel Expenditure Survey, I exploit the discontinuity in health insurance coverage rates at age 26, the new dependent coverage age cutoff enforced by the ACA. Under alternative regression discontinuity design models, I find that 2.5% to 5.3% of young adults lose their health insurance coverage once they turn 26. This effect is mainly driven by those who lose their private health insurance plan coverage and those who lose their health insurance plan coverage, whose main holder resides outside of the household. I also find that the discrete change in health insurance coverage rates at age 26 is associated with significant changes in office-based physician and dental visits, but does not have a significant impact on the utilization of outpatient or emergency department services. Furthermore, the effects of the ACA’s dependent coverage mandate on health care spending and out-of-pocket costs are insignificant. These results are robust under alternative model specifications.

Injury prevention counselling during well-child visits in the USA: rates and determinants

BackgroundPediatric and adolescent injury prevention counselling (IPC) is recommended by USA medical organisations. Current rates and determinants of IPC in US child preventive care (‘well-child’) visits are unknown.Aims/Objectives/PurposeWe examined rates...

Residential Segregation and Disparities in Health Care Services Utilization

Using data from the 2006 Medical Expenditure Panel Survey and the 2000 Census, the authors explored whether race/ethnic disparities in health care use were associated with residential segregation. They used five measures of health care use: office-based physician visits, outpatient department physician visits, visits to nurses and physician's assistants, visits to other health professionals, and having a usual source of care. For each individual, the authors controlled for age, gender, marital status, insurance status, income, educational attainment, employment status, region, and health status. The authors used the racial-ethnic composition of the zip code to control for residential segregation. The findings suggest that disparities in health care utilization are related to both individuals' racial and ethnic identity and the racial and ethnic composition of their communities. Therefore, efforts to improve access to health care services and to eliminate health care disparities for African Americans and Hispanics should not only focus on individual-level factors but also include community-level factors.

The Socio-Geography of Heart Failure

Morbidity and mortality rates from heart failure are staggering and continue to pose daunting challenges to patients, providers, researchers, and the health care system. As populations age, the increasing burden of cardiovascular disease portends a humbling future, particularly for heart failure. Despite advances in medical care, heart failure prevalence, hospitalizations, and mortality rates have not declined; in 2007, more than 250 000 Americans died of heart failure, and the number of heart failure hospitalizations has tripled from about 1.3 million in 1979 to nearly 4 million in 2004.1,2 The burden of heart failure admissions and frequent readmissions are also costly to the health care system. Corresponding to the projected increase in heart failure prevalence, real medical costs for heart failure are projected to increase by ≈200% over the next 20 years.3 Articles see p 308 and 317 Reports from the Agency for HealthCare Research and Quality (AHRQ) recognize geographic variation in heart failure hospitalizations.4 Regional variations have been associated with number of primary care physicians per population, regional income level, and the proportion of Medicare payment.5 The mere presence of this variation implies that some, maybe even most, heart failure rehospitalizations are avoidable. Potential contributors to admission may include barriers at the system or individual level such as difficulties accessing primary or outpatient medical care services, poor quality of this care when accessed, or lack of patient adherence.5 However, optimal outpatient care may reduce avoidable hospitalizations and medical expenditures and improve quality of life, suggesting a potential opportunity.5 ### Geography Matters In this issue of Circulation: Heart Failure , two reports highlight associations of geography with heart failure service utilization and outcomes, …

Long-Term Effect of the Women's Health Initiative Study on Antiosteoporosis Medication Prescribing

To describe long-term prescribing patterns of osteoporosis therapy before and after the Women's Health Initiative (WHI) publication. We conducted a time-series analysis from 1997 to 2005 using nationally representative data based on office-based physician and hospital ambulatory clinic visits. Bivariate and multivariable analyses were conducted using chi-square tests and logistic regression, respectively, and trends in the prevalence of osteoporosis therapies were evaluated per 6-month (semiannual) intervals. Linear regression and graphic techniques were used to determine statistical differences in the prevalence trends between the two periods. Overall prevalence of therapeutic or preventive osteoporosis therapy was similar between the WHI periods. However, a significant decrease in estrogen therapy and increases in bisphosphonates, calcium/vitamin D were observed in the period after the WHI publication (p < 0.05). Multiple logistic regression analysis showed older age and white race were associated with a higher likelihood of antiosteoporosis medication (AOM) prescription, and Medicaid insurance type was associated with a lower likelihood of an AOM prescription. Excluding calcium/vitamin D, nonestrogen therapy was more likely to be prescribed in the after-WHI period (office-based physician clinic: [adjusted OR, aOR] 2.49 [2.04-4.04]; hospital-based clinic: aOR 2.42 [1.67-7.50]) Nonestrogen therapy was more prevalent in visits made by older women, women of white race, women with contraindicated conditions for estrogen therapy, and women from the Northeast region. After the WHI publication, the overall prevalence of osteoporosis therapy did not change; however, a shift from estrogen to nonestrogen therapy was observed after the WHI publication. Black women were less likely to receive nonestrogen antiosteoporosis therapy in hospital-based clinics.

The impact of obesity on time spent with the provider and number of medications managed during office-based physician visits using a cross-sectional, national health survey

BackgroundObesity is associated with morbidity, mortality, and increased health care costs. Few studies have examined the impact of obesity on outpatient office visits. The purpose of this study was to determine if outpatient visits by obese persons required more time with the provider and more prescription medication management compared to visits made by non-obese persons.MethodsObesity status was determined for 9,280 patient visits made by persons aged 18 years or older in the 2006 National Ambulatory Medical Care Survey. Multivariate analyses compared obese and non-obese visits, stratified by sex, for duration of the visit and the number of medications mentioned at the visit.ResultsAverage duration of visit was higher among visits with patients determined to be obese. However, these differences were not considered significant after statistical testing. Visits made by obese female patients were significantly more likely to involve more than two prescription medications (OR 1.26, 95% CI 1.05 - 1.51) and visits made by obese male patients were significantly more likely to involve more than two prescription medications (OR 1.46, 95% CI 1.16 - 1.83) as compared to visits made by non-obese patients.ConclusionTime spent with the provider was found to be greater among visits with obese patients, but not significantly different from visits with non-obese patients. The number of medications for each visit was found to be significantly greater for visits where the patient was considered to be obese. Increased time for the visit and increased numbers of medication for each visit translate into increased costs. These findings document the impact of obesity on our health care system and have great implications on medical care cost and planning.