Network Of Physicians Research Articles

COVID-19 in Patients (pts) with Chronic Myeloid Leukemia (CML): Results from the International CML Foundation (iCMLf) CML and COVID-19 (CANDID) Study

COVID-19 in Patients (pts) with Chronic Myeloid Leukemia (CML): Results from the International CML Foundation (iCMLf) CML and COVID-19 (CANDID) Study

The Role of Public–Private Partnerships to Increase Access to Contraception in an Emergency Response Setting: The Zika Contraception Access Network Program

The Zika Contraception Access Network (Z-CAN) program was a short-term emergency response intervention that used contraception to prevent unintended pregnancies to reduce Zika-related adverse birth outcomes during the 2016-2017 Zika virus outbreak in Puerto Rico. The Centers for Disease Control and Prevention (CDC) reported that a collaborative and coordinated response was needed from governments and private-sector partners to improve access to contraception during the Zika outbreak in Puerto Rico. In response, the National Foundation for the CDC, with technical assistance from CDC, established the Z-CAN program, a network of 153-trained physicians, that provided client-centered contraceptive counseling and same-day access to the full range of the Food and Drug Administration-approved reversible contraceptive methods at no cost for women who chose to prevent pregnancy. From May 2016 to September 2017, 29,221 women received Z-CAN services. Through Z-CAN, public-private partnerships provided a broad range of opportunities for partners to come together to leverage technical expertise, experience, and resources to remove barriers to access contraception that neither the public nor the private sector could address alone. Public-private partnerships focused on three areas: (1) the coordination of efforts among federal and territorial agencies to align strategies, leverage resources, and address sustainability; (2) the mobilization of private partnerships to secure resources from private corporations, domestic philanthropic organizations, and nonprofit organizations for contraceptive methods, physician reimbursement, training and proctoring resources, infrastructure costs, and a health communications campaign; and (3) the engagement of key stakeholders to understand context and need, and to identify strategies to reach the target population. Public-private partnerships provided expertise, support, and awareness, and could be used to help guide programs to other settings for which access to contraception could improve health outcomes.

Identification and management of Lynch syndrome in the Middle East and North African countries: outcome of a survey in 12 countries

BackgroundLynch syndrome (LS), the most common inherited form of colorectal cancer (CRC), is responsible for 3% of all cases of CRC. LS is caused by a mismatch repair gene defect and is characterized by a high risk for CRC, endometrial cancer and several other cancers. Identification of LS is of utmost importance because colonoscopic surveillance substantially improves a patient’s prognosis. Recently, a network of physicians in Middle Eastern and North African (ME/NA) countries was established to improve the identification and management of LS families. The aim of the present survey was to evaluate current healthcare for families with LS in this region.MethodsA questionnaire was developed that addressed the following issues: availability of clinical management guidelines for LS; attention paid to family history of cancer; availability of genetic services for identification and diagnosis of LS; and assessment of knowledge of LS surveillance. Members of the network and authors of recent papers on LS from ME/NA and neighbouring countries were invited to participate in the survey and complete the online questionnaire.ResultsA total of 55 individuals were invited and 19 respondents from twelve countries including Algeria, Azerbaijan, Cyprus, Egypt, Iran, Jordan, Kuwait, Lebanon, Morocco, Palestine, Tunisia, and Turkey completed the questionnaire. The results showed that family history of CRC is considered in less than half of the surveyed countries. Guidelines for the management of LS are available in three out of twelve countries. The identification and selection of families for genetic testing were based on clinical criteria (Amsterdam criteria II or Revised Bethesda criteria) in most countries, and only one country performed universal screening. In most of the surveyed countries genetic services were available in few hospitals or only in a research setting. However, surveillance of LS families was offered in the majority of countries and most frequently consisted of regular colonoscopy.ConclusionThe identification and management of LS in ME/NA countries are suboptimal and as a result most LS families in the region remain undetected. Future efforts should focus on increasing awareness of LS amongst both the general population and doctors, and on the improvement of the infrastructure in these countries.

The impact of sampling patients on measuring physician patient-sharing networks using Medicare data.

To investigate the impact of sampling patients on descriptive characteristics of physician patient-sharing networks. Medicare claims data from 10 hospital referral regions (HRRs) in the United States in 2010. We form a sampling frame consisting of the full cohort of patients (Medicare enrollees) with claims in the 2010 calendar year from the selected HRRs. For each sampling fraction, we form samples of patients from which a physician ("patient-sharing") network is constructed in which an edge between two physicians depicts that at least one patient in the sample encountered both of those physicians. The network is summarized using 18 network measures. For each network measure and sampling fraction, we compare the values determined from the sample and the full cohort of patients. Finally, we assess the sampling fraction that is needed to measure each network measure to specified levels of accuracy. We utilized administrative claims from the traditional (fee-for-service) Medicare. We found that measures of physician degree (the number of ties to other physicians) in the network and physician centrality (importance or prominence in the network) are learned quickly in the sense that a small sampling fraction suffices to accurately compute the measure. At the network level, network density (the proportion of possible edges that are present) was learned quickly while measures based on more complex configurations (subnetworks involving multiple actors) are learned relatively slowly with relative rates of learning depending on network size (the number of nodes). The sampling fraction applied to Medicare patients has a highly heterogeneous effect across different network measures on the extent to which sample-based network measures resemble those evaluated using the full cohort. Even random sampling of patients may yield physician networks that distort descriptive features of the network based on the full cohort, potentially resulting in biased results.

"Even though I am alone, I feel that we are many"- An appreciative inquiry study of asynchronous, provider-to-provider teleconsultations in Turkana, Kenya.

Non-physician clinicians (NPCs) in low and middle-income countries (LMICs) often have little physical proximity to the resources-equipment, supplies or skills-needed to deliver effective care, forcing them to refer patients to distant sites. Unlike equipment or supplies, which require dedicated supply chains, physician/specialist skills needed to support NPCs can be sourced and delivered through telecommunication technologies. In LMICs however, these skills are scarce and sparsely distributed, making it difficult to implement commonly used real-time (synchronous), hub-and-spoke telemedicine paradigms. An asynchronous teleconsultations service was implemented in Turkana County, Kenya, connecting NPCs with a volunteer network of remote physicians and specialists. In 2017-18, the service supported over 100 teleconsultations and referrals across 20 primary healthcare clinics and two hospitals. This qualitative study aimed to explore the impact of the telemedicine intervention on health system stakeholders, and perceived health-related benefits to patients. Data were collected using Appreciative Inquiry, a strengths-based, positive approach to assessing interventions and informing systems change. We highlight the impact of provider-to-provider asynchronous teleconsultations on multiple stakeholders and healthcare processes. Provider benefits include improved communication and team work, increased confidence and capacity to deliver services in remote sites, and professional satisfaction for both NPCs and remote physicians. Health system benefits include efficiency improvements through improved care coordination and avoiding unnecessary referrals, and increased equity and access to physician/specialist care by reducing geographical, financial and social barriers. Providers and health system managers recognised several non-health benefits to patients including increased trust and care seeking from NPCs, and social benefits of avoiding unnecessary referrals (reduced social disruption, displacement and costs). The findings reveal the wider impact that modern teleconsultation services enabled by mobile technologies and algorithms can have on LMIC communities and health systems. The study highlights the importance of viewing provider-to-provider teleconsultations as complex health service delivery interventions with multiple pathways and processes that can ultimately improve health outcomes.

Abstract A12: Evaluating physician network-based measures of care coordination through the lens of the patient experience

Abstract There is significant promise in analyzing physician patient-sharing networks to construct indirect measures of care coordination by defining relationships between physicians based on shared patients. This approach has the potential to uncover how otherwise latent organizational aspects of health care systems impact patient outcomes. A key challenge to this approach is how the various measures used to describe these networks infer the complex realities of health care delivery. The extent of patient-sharing relationships within physician networks has been associated with care utilization, cost of care, and some measures of care quality. While this approach has been validated to signal true professional relationships between physicians from the physicians’ perspective, it is unknown whether these measures reflect patients’ perceptions of their own care coordination. The objective of this study is to evaluate the associations between network-based measures of care coordination and patient-reported experience measures. We linked three publicly available data sources released by Centers for Medicare and Medicaid Services (CMS) that include national data on physician patient sharing in 2015, physician participation in a group practice, and patient-reported quality performance for group practices based on responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey in 2016. The outcomes of interest were patient-reported experience measures reflecting “Between visit communication,” “Clinicians working together for your care,” and “Getting timely care, appointments, and information” (CAHPS). The predictor variables of interests were physician group practice density (the number of physician pairs who share patients adjusting for total number of physician pairs) and clustering (the extent to which sets of three physicians all share patients). There were 476 groups that had patient-reported measures available. Patients’ perception of “Clinicians working together for your care” was significantly positively associated with both physician group practice density (p=0.02) and clustering (p=0.006). Physician group practice clustering was also significantly positively associated with “Getting timely care, appointments, and information” (p=0.005). This work suggests that network-based measures of care coordination are associated with some patient-reported experience measures. Evaluating and intervening on patient-sharing networks may provide novel strategies for initiatives aimed at improving quality of care and the patient experience. Citation Format: Erika L. Moen, Julie P. Bynum. Evaluating physician network-based measures of care coordination through the lens of the patient experience [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr A12.

Factors Associated with Mortality Among 4,227 Patients with COVID-19 in Massachusetts: A Retrospective Cohort Study

Background: Originating in Wuhan, China, SARS-Cov 2 (COVID-19) has since spread across the globe. Numerous patient characteristics and co-morbidities have been associated with COVID-19 severity and mortality, though most studies have occurred outside the United States and many have utilized relatively small sample sizes. The present study investigated factors related to mortality using a large and diverse sample of COVID-19 patients hospitalized in Massachusetts.Methods: Multi-site retrospective cohort study of 4,227 patients with laboratory-confirmed COVID-19 who were admitted to a hospital and either discharged or died by July 17, 2020. Hospitalization occurred within Mass General Brigham, a healthcare system which includes two academic medical centers, community and specialty hospitals, a large physician network, and other health care entities across the Commonwealth of Massachusetts. Demographic, clinical, and pharmacological data were extracted from electronic health records. Multivariable logistic regression analyses were utilized to investigate factors associated with COVID-19 mortality.Findings: 17,971 patients had tested positive for COVID-19 within the Mass General Brigham system. Of those, 4,227 (23·5%) patients had been admitted to hospital and either expired or discharged. Of the patients hospitalized, there were 3,674 (86%) who discharged and 553 (14%) who died. The mean age was 60·6 (SD = 19·1) and 53·1% were male. Of 2669 (63·1%) cases having at least one co-morbidity, 439 (16·5%) of those cases resulted in death. In multivariate logistic regression analysis, factors associated with mortality were age 75 years or older (odds ratio [OR] = 6·98, 95% CI: 4·13, 11·79), age 65-74 years old (OR = 3·22, 95% CI: 1·90, 5·45), male sex (OR = 1·58, 95% CI: 1·25, 2·00), blood cancer (OR = 2·00, 95% CI: 1·10, 3·63), chronic kidney disease (OR = 1·38, 95% CI: 1·05, 1·81), history of stroke (OR = 1·51, 95% CI: 1·09, 2·10), congestive heart failure (OR = 1·70, 95% CI: 1·26, 2·29), SSRI use (OR = 1·86, 95% CI: 1·15, 2·98), and BMI of 40+ (OR = 1·91, 95% CI: 1·19, 3·06). Subgroup analyses revealed COPD (OR = 1·62, 95% CI: 1·02, 2·57) as a unique risk factor for males and cardiovascular disease (OR = 2·57, 95% CI: 1·42, 4·63) and history of deep vein thrombosis or pulmonary embolism (OR = 2·83, 95% CI: 1·26, 6·36) for those under 65 years of age.Interpretation: Age and sex were the strongest demographic predictors of mortality. Many of the factors associated with mortality in the present study are also related to inflammation and hypercoagulability. The presence of these comorbidities and characteristics likely contribute to mortality risk, given that COVID-19 has been independently found to affect the hematologic system. It would be prudent to give special consideration to COVID-19 patients who have these characteristics or pre-existing conditions, when making decisions regarding treatment and level of care.Funding: None applicable.Declaration of Interests: None declared by all authors.Ethics Approval Statement: As the analyses were conducted for quality improvement and the report involves routinely collected and de-identified data, no ethical approval was required.

Provider networks and health plan premium variation

To examine how plan premiums are associated with physician network breadth, hospital network breadth, and hospital network quality on the Affordable Care Act's Health Insurance Marketplaces in all 50 states and the DC in 2016. Data on plan premiums and characteristics came from 2016 Robert Wood Johnson Foundation Health Insurance Exchange (HIX) Compare. Provider network information was obtained from Vericred. Hospital characteristics were obtained from CMS Hospital Compare and the American Hospital Association (AHA) survey. We analyzed how plan premiums were associated with variations in physician network breadth, hospital network breadth, and hospital network quality using ordinary least square regressions with state-rating area fixed effects and carrier fixed effects. Plan premiums were positively associated with physician network breadth and hospital network breadth. We find the following statistically significant results: a one standard deviation increase in physician network breadth was linked to a premium increase of 2.8 percent or $101 per year; a one standard deviation increase in hospital network breadth was linked to a premium increase of 2.4 percent or $86 per year. There was no significant association between premiums and hospital network quality, as measured by hospital star ratings and the inclusion of teaching hospitals or the top-20 hospitals nationwide. Physician network breadth and hospital network breadth contributed positively to plan premiums. The roles of the two types of provider network breadth are quantitatively similar. Premiums appear to be insensitive to hospital network quality.

Implementation of a protocol-driven pharmacy technician refill process at a large physician network

ObjectivesTo describe the implementation of a centrally located certified pharmacy technician (CPhT) team to streamline the process of approving medication refills for chronic disease state management within a multisite physician network. SettingPrimary care (PC) offices within a large physician network. Practice descriptionIncoming medication refill requests from patients and community pharmacies were typically received at each PC office and processed by medical assistants, nurses, or providers. Practice InnovationsA centralized team of CPhTs managed medication refill requests for 9 PC offices. Standardized protocols for 14 drug classes were built into the electronic medical record (EMR) system. Incoming medication refills were shifted from PC offices to the centrally located CPhT team. EvaluationThe implementation process was assessed through pharmacists’ random audits and feedback from providers, office staff, and patients. Refill reports from January 2020 through March 2020 were obtained. Refill requests’ characteristics were summarized and evaluated to determine the volume of refill requests, approved or denied requests, and requests requiring further PC staff analysis. ResultsChanges to the protocol process and EMR documentation included modifying or removing laboratory test value parameters, adjusting “grace period” refill quantity on the basis of the scheduled office visit date, and expanding the CPhT role to include communicating with patients and pharmacies regarding denied refills. Data showed that the CPhT team processed 81.7% of all refill requests. This averaged 215 requests per CPhT per day. Of the refill requests approved, 22.5% passed the protocol for the maximum quantity and refills permitted, and 17.3% were granted grace supplies until office visit protocol criteria were met. ConclusionA CPhT team processed 81% of the medication refill requests for 9 PC offices with institution-approved EMR protocols and ambulatory pharmacist supervision. There were many barriers identified and addressed, but through continuous evaluation the workflow and protocol continue to improve.

Risk Analysis of Latent Tuberculosis Infection among Health Workers Compared to Employees in Other Sectors.

Latent tuberculosis infection (LTBI) represents a work-related risk for health workers (HWs). Tuberculosis remains the second most common occupational infectious disease among HWs in Germany. Comparative figures on LTBI prevalence in the general population are missing because testing is only carried out in the context of an outbreak situation. The objective of this study is to investigate whether HWs are at greater risk of LTBI than workers in other sectors. This study is based on two samples. The first sample is a database of HWs who were examined by the German Occupational Physicians Network using an interferon-gamma release assay (IGRA). The second sample consists of general employees (non-health workers, non-HWs) from Hamburg who had no professional contact with the health care system. Propensity score matching (PS matching) was performed to ensure better comparability of the groups. The differences in the prevalence of positive test results from IGRAs were examined using univariate and multivariate analyses. After the PS matching of 1:10, 100 test subjects in the non-HW group and 1000 HWs remained to form the analysis collective. The HWs tended to exhibit higher IGRA values than non-HWs. The univariate analysis showed an odds ratio (OR) of 3.86 for the HWs (95% confidence interval (CI): 0.99 to 32.5; p = 0.056) with respect to a positive test result. The multivariate analysis produced an OR of 4.92, (95% CI: 1.3 to 43.7; p = 0.013) for HWs born in Germany. Despite the declining tuberculosis incidence rates in Germany, a comparison with non-exposed professional groups showed that HWs are at greater risk of LTBI. Preventive medical check-ups still seem to be indicated.

The association between patient sharing network structure and healthcare costs.

Study questionWhile physician relationships (measured through shared patients) are associated with clinical and utilization outcomes, the extent to which this is driven by local or global network characteristics is not well established. The objective of this research is to examine the association between local and global network statistics with total medical spending and utilization.Data sourceData used are the 2011 Massachusetts All Payer Claims Database.Study designThe association between network statistics and total medical spending and utilization (using standardized prices) is estimated using multivariate regression analysis controlling for patient demographics and health status.Data collectionWe limit the sample to continuously enrolled commercially insured patients in Massachusetts in 2011.Principal findingsMean patient age was 45 years, and 56.3% of patients were female. 73.4% were covered by a health maintenance organization. Average number of visits was 5.43, with average total medical spending of $4,911 and total medical utilization of $4,252. Spending was lower for patients treated by physicians with higher degree (p<0.001), eigenvector centrality (p<0.001), clustering coefficient (p<0.001), and measures reflecting the normalized degree (p<0.001) and eigenvector centrality (p<0.001) of specialists connected to a patient’s PCP. Spending was higher for patients treated by physicians with higher normalized degree, which accounts for physician specialty and patient panel size (p<0.001). Results were similar for utilization outcomes, although magnitudes differed indicating patients may see different priced physicians.ConclusionsGenerally, higher values of network statistics reflecting local connectivity adjusted for physician characteristics are associated with increased costs and utilization, while higher values of network statistics reflecting global connectivity are associated with decreased costs and utilization. As changes in the financing and delivery system advance through policy changes and healthcare consolidation, future research should examine mechanisms through which this structure impacts outcomes and potential policy responses to determine ways to reduce costs while maintaining quality and coordination of care.What this study addsIt is unknown whether local and global measures of physician network connectivity associated with spending and utilization for commercially insured patients?In this social network analysis, we found generally higher values of network statistics reflecting local connectivity are associated with increased costs and utilization, while higher values of network statistics reflecting global connectivity are associated with decreased costs and utilization.Understanding how to influence local and global physician network characteristics may be important for reducing costs while maintaining quality.

Data on multiple sclerosis in Germany and their representation in the ambulatory registry NeuroTransData (NTD) network

Description of basic data, common symptoms and their medical, non-drug and combined symptomatic treatment in a large sample of MS patients undergoing outpatient treatment of the German NeuroTransData (NTD) physician network. Currently there are 21,407 patients in the registry. Average age is 49.0 ± 13.0 years, 72,3 % of them female, average disease duration is 14.3 ± 8,9 years. Relapsing-remitting MS (RRMS) was present in 77 %, secondary-progressive MS (SPMS) 15 %, PPMS 5 %. The mean EDSS score of the total sample was 2.8 (range 0,5-8). Fatigue was the most common symptom in all subtypes (96 %), followed by spasticity (all 31 %, SPMS: 47 %; PPMS 36 %). Regarding symptomatic drug treatment, non-drug treatment and combined treatment, there was a wide range of variation. While spasticity was treated in 81 %, only 21 % of patients with fatigue receiving any form of therapy, Also, fecal and urine incontinence often remained untreated in 69 % resp. 56 % of cases. Setup, development and maintenance of a registry for a complex and chronic disease like MS represents an instrument to assess and improve patient care in the outpatient setting. Our results are hard to compare with the DMSG-registry, another German, more hospital-based data collection. However, both registries identify fatigue as the most common symptom in MS.

AORN Position Statement on Environmental Responsibility

<scp>AORN</scp> Position Statement on Environmental Responsibility

Early physician spillover responses to the oncology care model.

e19393 Background: As Medicare increasingly seeks to transform beneficiary care through provider reimbursement incentives, there is a possibility that non-beneficiary care will change too. There is limited information on how the Oncology Care Model (OCM) has affected care in this way. This study seeks to analyze the early utilization and cost effects of the OCM on the non-Medicare population. Methods: This was a retrospective analysis of a large physician network comprised of OCM participants and non-participants alike. The data spanned July 1st, 2015 to June 30th, 2017 – one year before and after the launch of the OCM. Several states are represented, and this population includes about 20% of the non-hospital-based community oncology footprint. A difference-in-differences approach was used to compare primary first-year effects on the Medicare population with first-year spillover effects on the Medicare Advantage (MA), private, and Medicaid populations. The utilization and costs of care under management of the practices were evaluated. Effects of the OCM for breast, lung, colon, and prostate cancer among Medicare, MA, private, and Medicaid populations at the physician-by-month level are estimated. Results: The OCM appears to have reduced office visits for Medicare breast cancer and colon cancer. These effects look to have spilled over to the Medicaid breast cancer population, but not elsewhere. The OCM also modestly decreased overall costs for each sub-type but these reductions were not observed in the non-Medicare populations. Conclusions: This research was not randomized, so un-observable differences between groups unrelated to the OCM could drive these results. It is also limited to practice-based care and does not include hospital or pharmacy care. Finally, these are first year effects and the literature suggests that effects can develop for a few years after program launch. That said, this paper suggests that care patterns appear to have changed under the OCM for both Medicare and non-Medicare lives, but not uniformly.

Impact of Changes in Clinical Microbiology Laboratory Location and Ownership on the Practice of Infectious Diseases.

The number of onsite clinical microbiology laboratories in hospitals is decreasing, likely related to the business model for laboratory consolidation and labor shortages, and this impacts a variety of clinical practices, including that of banking isolates for clinical or epidemiologic purposes. To determine the impact of these trends, infectious disease (ID) physicians were surveyed regarding their perceptions of offsite services. Clinical microbiology practices for retention of clinical isolates for future use were also determined. Surveys were sent to members of the Infectious Diseases Society of America's (IDSA) Emerging Infections Network (EIN). The EIN is a sentinel network of ID physicians who care for adult and/or pediatric patients in North America and who are members of IDSA. The response rate was 763 (45%) of 1,680 potential respondents. Five hundred forty (81%) respondents reported interacting with the clinical microbiology laboratory. Eighty-six percent of respondents thought an onsite laboratory very important for timely diagnostic reporting and ongoing communication with the clinical microbiologist. Thirty-five percent practiced in institutions where the core microbiology laboratory has been moved offsite, and an additional 7% (n = 38) reported that movement of core laboratory functions offsite was being considered. The respondents reported that only 24% of laboratories banked all isolates, with the majority saving isolates for less than 30 days. Based on these results, the trend toward centralized core laboratories negatively impacts the practice of ID physicians, potentially delays effective implementation of prompt and targeted care for patients with serious infections, and similarly adversely impacts infection control epidemiologic investigations.

Comparison of Office-Based Physician Participation in Medicaid Managed Care and Health Insurance Exchange Plans in the Same US Geographic Markets

Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans. To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets. This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019. Physician participation in a Medicaid managed care or health insurance exchange plan network. The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least 1 Medicaid managed care plan or, separately, at least 1 health insurance exchange plan. Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a median (interquartile range) of 63.4% (48.0%-81.3%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (31.0%-70.5%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer. In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States.

Primary care physician support for harmonizing HPV vaccination recommendations across genders — United States, 2018

In the United States, human papillomavirus (HPV) catch-up vaccination has been nationally recommended for women and men of different ages. We surveyed national networks of primary care physicians specializing in family medicine, pediatrics, and internal medicine to assess attitudes about HPV vaccination. Of 785 physicians, 730 (93.0%), were in favor of a change to harmonize the recommended catch-up vaccination age across genders; the most commonly cited reason was to simplify the immunization schedule (97.9%). After considering these and other data, the Advisory Committee on Immunization Practices updated national policy to recommend catch-up vaccination for all persons through age 26 years.

Physician networks and potentially inappropriate opioid prescriptions

Background: Opioid overdose is a national health priority and curbing inappropriate prescribing is critical. In 2016, the Centers for Disease Control and Prevention (CDC) issued appropriate prescribing guidelines.Objectives: Examine associations between care networks defined by shared patients and problematic opioid prescribing.Methods: Analysis was at the provider-year level. Social network analysis (SNA) applied to the Medicaid MarketScan® Research Database for the years 2010–2015 identified care communities, each community’s level of integration (centralization), and each provider’s integration (centrality). Nested multivariable logistic regressions controlling for patient mix and provider specialty simultaneously examined the risk of any (incident) and repeated (prevalent) inappropriate prescribing.Outcomes: Four behaviors defined by the CDC guidelines were examined: (1) more than 90 days continuous supply of high-dose opioid analgesics for chronic pain, (2) overlapping opioid supplies, (3) overlapping opioid and benzodiazepine prescriptions, and (4) prescribing an extended release opioid for an acute pain diagnosis.Results: Provider centrality was associated with reduced incidence of outcome (2) (OR: 0.95) and decreased prevalence of outcomes (1), (2), and (3). However, higher incidence (OR: 1.32) and prevalence (OR: 1.027) of outcome (4) were observed. Conversely, centralization associated with decreased incidence of (1) and (2) and lower prevalence of (1), (2), and (3).Conclusions: Greater provider integration is associated with a lower risk of a provider’s patients repeatedly having potentially inappropriate prescription fills; however, the association with a provider having any potentially problematic prescription is more ambiguous.

Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study.

BackgroundVariation in health care, when not based on patient preference, may result in poorer care. We determined whether variation in health services utilization, gastroenterologist care and outcomes existed among patients with elderly-onset inflammatory bowel disease (IBD).MethodsPatients with IBD (diagnosed ≥65 years) were identified from population-based health administrative data from Ontario, Canada (1999 to 2014). We assessed variation across multispecialty physician networks in gastroenterologist care and outcomes using multilevel logistic regression. Median odds ratios (MOR) described variation. We evaluated the association between gastroenterologist supply, specialist care and outcomes.ResultsIn 4806 patients, there was significant variation in having ever seen a gastroenterologist (MOR 3.35, P < 0.0001), having a gastroenterologist as the primary IBD care provider (MOR 4.16, P < 0.0001), 5-year colectomy risk in ulcerative colitis (MOR 1.38, P = 0.01), immunomodulator use (MOR 1.47, P = 0.001), and corticosteroid use (MOR 1.26, P = 0.006). No variation in emergency department visits, hospitalizations or intestinal resection (Crohn’s) was noted. Patients in networks with fewer gastroenterologists were less likely to see a gastroenterologist (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.56), have a gastroenterologist as their primary care provider (OR 0.27, 95% CI 0.12 to 0.59), be hospitalized within 5 years (OR 0.82, 95% CI 0.69 to 0.98), and be prescribed biologics within 1 year (OR 0.50, 95% CI 0.28 to 0.89).ConclusionsUtilization of gastroenterology care in patients with elderly-onset IBD varies greatly. Patients treated by gastroenterologists and in networks with more gastroenterologists have better outcomes. There is a need to ensure all individuals with IBD have equal access to and utilization of specialist care to ensure the best possible outcomes.

Physician Networks and the Complex Contagion of Clinical Treatment

Physician Networks and the Complex Contagion of Clinical Treatment