Primary Care Physician Visits Research Articles

Impact of early primary care physician follow-up on hospital readmission following gastrointestinal cancer surgery.

We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery. Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission. Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001). PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.

Clinical cohort of nonalcoholic fatty liver disease in a primary care setting.

Nonalcoholic fatty liver disease (NAFLD) is increasingly common, and primary care physicians (PCPs) are often the first to diagnose NAFLD. While guidelines on NAFLD management in primary care exist, there are limited data on clinical practice patterns. We gathered data from over 370,000 patients with at least one PCP visit between July 2016 and September 2023. Using ICD-10 codes to identify patients with a diagnosis of NAFLD or Nonalcoholic Steatohepatitis (NASH), we extracted demographics, comorbidities, laboratory results, prescriptions, imaging orders, and referrals to describe their care. We identified 10,334 patients with a diagnosis code of NAFLD (93.1%) and/or NASH (16.7%) during a PCP visit. Just over half (54.8%) were female, mean age was 52.8 years, and mean BMI was 33.2 kg/m2 with 90% having overweight or obese. More than 50% had hypertension and hyperlipidemia, and 38% had diabetes. At the diagnosis visit, 2.7% had ultrasound elastography ordered, 2.7% liver biopsy, and less than 1% magnetic resonance elastography. During follow-up ranging from 0 to 7 years, patients had a mean of 15 encounters, during which 4% were diagnosed with fibrosis or cirrhosis. Only 24.2% of patients were referred to a nutritionist and 18% had an appointment, and only 0.7% were referred to hepatology and 3.8% saw a hepatologist. PCPs have not widely implemented clinical practice guidelines for NAFLD, resulting in suboptimal care including for the substantial minority with fibrosis or cirrhosis. Patients might benefit from targeted NAFLD education for PCPs and improved decision and management support.

LDCT lung cancer screening implementation in a Veterans Affairs hospital: A quality initiative.

e23238 Background: Lung cancer is the number one cause of cancer related deaths worldwide. United States Preventive Services Task Force (USPSTF) recommends annual Lung Cancer Screening (LCS) with Low Dose Computerized Tomography (LDCT) for adults who are current smokers aged 50 to 80 years with at least 20 pack year smoking history or have quit smoking within the past 15 years. Although LCS is a national initiative for Veteran Affairs (VA) Hospitals, there are several barriers in practice. Methods: The LCS program was established with a dedicated coordinator to provide better access to high-quality in-house screening, while reducing the dependance on expensive community care services and referrals. Smoking history in Tobacco Pack Years (TPY) is updated during a Primary Care Physician (PCP) visit, which triggers a clinical reminder in the electronic medical record for LCS. The LCS coordinator would then receive a consult. After shared decision-making with the patient, physician and coordinator, the patients are scheduled for LDCT. If the results are Lung-RADS 1 (negative), 2 or 3 (benign appearing nodules) the patients are notified of the findings and provided with subsequent follow ups. All Lung RADS 4 (suspicious findings) are discussed in the lung tumor board, which includes radiologist, oncologist, pulmonologist, pathologist, cardio-thoracic surgeon, and fellows in training. The committee determines the follow-up scan interval and/or additional investigations. Results: The performance of our LCS Program from June 2022 to January 2024 was reviewed. 5941 patients were assessed for TPY, of those 1127 patients were eligible for LCS scans and 1032 (93.3%) were enrolled into the LCS Program. 951 LDCT scans have been conducted thus far, this includes 598 annual initial screenings, the remaining are follow ups. 57 patients (6.81%) had Lung-RADS 3 findings and are undergoing nodule tracking. 16 patients (1.91%) required diagnostic work-up which includes a PET scan or biopsy. 14 patients (1.67%) have been diagnosed with cancer. Conclusions: Our LDCT Program showed a high acceptance rate of 93.3%, much of which can be attributed to the multiple layers of screening and shared decision-making processes. Patients received three phone calls and a letter as a reminder of their LDCT appointments. Our radiology department has four dedicated slots for LDCT screening each day which allows for further compliance. TPY documentation was identified as a limiting factor in this process. The LCS coordinator verified the TPY history with the patients which helped overcome this shortcoming. Overall a multidisciplinary team approach contributed to the success of our program.

A randomized controlled trial evaluating the effects of nurse-led triage of 911 calls.

To better connect non-emergent 911 callers to appropriate care, Washington, DC, routed low-acuity callers to nurses. Nurses could provide non-emergent transportation to a health centre, recommend self-care or return callers to the traditional 911 system. Over about one year, 6,053 callers were randomized (1:1) to receive a business-as-usual response (ncontrol = 3,023) or further triage (ntreatment = 3,030). We report on seven of nine outcomes, which were pre-registered ( https://osf.io/xderw ). The proportion of calls resulting in an ambulance dispatch dropped from 97% to 56% (β = -1.216 (-1.324, -1.108), P < 0.001), and those resulting in an ambulance transport dropped from 73% to 45% (β = -3.376 (-3.615, -3.137), P < 0.001). Among those callers who were Medicaid beneficiaries, within 24 hours, the proportion of calls resulting in an emergency department visit for issues classified as non-emergent or primary care physician (PCP) treatable dropped from 29.5% to 25.1% (β = -0.230 (-0.391, -0.069), P < 0.001), and the proportion resulting in the caller visiting a PCP rose from 2.5% to 8.2% (β = 1.252 (0.889, 1.615), P < 0.001). Over the longer time span of six months, we failed to detect evidence of impacts on emergency department visits, PCP visits or Medicaid expenditures. From a safety perspective, 13 callers randomized to treatment were eventually diagnosed with a time-sensitive illness, all of whom were quickly triaged to an ambulance response. These short-term effects suggest that nurse-led triage of non-emergent calls can safely connect callers to more appropriate, timely care.

Disparities in Patient Portal Engagement Among Patients With Hypertension Treated in Primary Care

Patient portals are increasingly used for patient-clinician communication and to introduce interventions aimed at improving blood pressure control. To characterize patient portal use among patients with hypertension managed in primary care. This retrospective cohort study used electronic health records linked with patient portal log file data from a large, diverse Midwestern health care system. Patients with hypertension who had a primary care visit from January 1, 2021, to December 31, 2021, were included. The first visit in 2021 was considered the baseline visit; patient portal engagement was evaluated during the following year. Multivariate logistic regressions, presented as odds ratios (ORs) and 95% CIs, were used to evaluate associations between patient characteristics and patient portal engagement, adjusting for potential confounders. Primary exposures included 4 sociodemographic factors routinely collected in the electronic health record: race and ethnicity, insurance, preferred language, and smoking status. Indicators of patient engagement with the patient portal included accessing the patient portal at least once, accessing the portal within 7 days of at least 50.0% of primary care physician (PCP) visits, frequent logins (<28 vs ≥28), messaging (<2 vs ≥2), and sharing home blood pressure readings. Among 366 871 patients (mean [SD], 63.5 [12.6] years), 52.8% were female, 3.4% were Asian, 7.8% were Hispanic, 19.7% were non-Hispanic Black, 66.9% were non-Hispanic White, and 2.3% were of other race or ethnicity. During the 1-year study period starting in 2021, 70.5% accessed the patient portal at least once, 60.2% accessed around the time of their PCP visits, 35.7% accessed the portal frequently, 28.9% engaged in messaging, and 8.7% shared home blood pressure readings. Compared with White patients, non-Hispanic Black and Hispanic patients had lower odds of any access (Black: OR, 0.53; 95% CI, 0.52-0.54; Hispanic: OR, 0.66; 95% CI, 0.64-0.68), access around PCP visit time (Black: OR, 0.49; 95% CI, 0.48-0.50; Hispanic: OR, 0.62; 95% CI, 0.60-0.64), frequent access (Black: OR, 0.56; 95% CI, 0.55-0.57; Hispanic: OR, 0.71; 95% CI, 0.69-0.73), and messaging (Black: OR, 0.63; 95% CI, 0.61-0.64); Hispanic: OR, 0.71; 95% CI, 0.69-0.73). This cohort study of patients with hypertension found clear sociodemographic disparities in patient portal engagement among those treated in primary care. Without special efforts to engage patients with portals, interventions that use patient portals to target hypertension may exacerbate disparities.

Factors affecting hospitalization and mortality in a retrospective study of elderly patients with heart failure

BackgroundHeart failure (HF) has a high prevalence in an elderly population and leads to a substantial hospitalization and mortality. The objective of this study was to investigate factors that affect hospitalization and mortality in an elderly population.MethodsA retrospective observational study was conducted of HF patients aged 76–95 years residing in Region Halland, Sweden. Between 2013 and 2019, a total of 3134 patients received a novel diagnosis of HF and were subsequently monitored for one year using data from a healthcare database. The patients were categorized into HF-phenotypes according to ejection fraction (EF) and those with HF diagnose solely based on clinical criteria with no defined EF. Cox regression analysis for hospital admissions and mortality was evaluated adjusted for pharmacotherapies, healthcare utilization and clinical characteristics.ResultsEchocardiogram was performed in 56% of the patients and 51% were treated with recommended HF pharmacotherapy with betablockers combined with renin-angiotensin-aldosterone-system inhibition. The average number of inpatient days was 10.7 while the average number of visits to primary care physician was 5.4 and 8.7 to primary care nurse respectively. A Cox regression analysis for hospital admissions and mortality revealed that an eGFR < 30 ml/min was associated with a hazard ratio (HR) of 1.88 (confidence interval [CI] 1.56–2.28), elevated NT-proBNP with an HR of 2.09 (CI 1.59–2.76), diabetes with an HR of 1.31 (CI 1.13–1.52), and chronic obstructive pulmonary disease with an HR of 1.51 (CI 1.29–1.77). Having a primary care physician visit was associated to an HR of 0.16 (CI 0.14–0.19), and the use of recommended heart failure pharmacotherapy was associated with an HR of 0.52 (CI 0.44–0.61).ConclusionsIn a Swedish elderly population with HF, factors such as advancing age, kidney dysfunction, elevated NT-proBNP levels, diabetes, and COPD were associated with an increased risk of both mortality and hospitalization. Conversely, patients who received recommended heart failure treatment and made regular visits to their primary care physician were associated with a decreased risk. This indicates that elderly patients with HF benefit from recommended HF treatment and highlights that follow-ups in primary care could be advantageous.

Preventive Primary Care in the Postpartum Year: The Role of Medicaid Delivery System Reform

Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year. The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024. Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation. Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse.

Patients in pain

Communication research on medical interaction has made inroads into how patients shape treatment outcomes as well as how physician presentation of treatment can shape patient acceptance or resistance. Pain is the number one reason patients visit primary care physicians. The overprescription of opioids for chronic pain remains a major public health problem in the US and constitutes a risk factor for opioid addiction. In this study, we investigated how primary care physicians communicate recommendations for alternatives to opioid treatments for patients with self-reported moderate to serious chronic musculoskeletal pain and examined the relationship between communication strategies and patient resistance to non-opioid treatment recommendations. We relied on a convenience sample of 35 video recorded visits in which musculo-skeletal pain was reported as moderate to severe (or over 5 on the pain scale). Using a combined approach of abductive analysis, conversation analysis and descriptive statistics, we show that physicians are less likely to face patient resistance when they frame their non-opioid pain treatment recommendation as novel and present the treatment as concrete and tailored to the patient’s problem.

What a pain in the … back: a review of current treatment options with a focus on naproxen sodium.

Non-specific low back pain (LBP) represents a challenging and prevalent condition that is one of the most common symptoms leading to primary care physician visits. While established guidelines recommend prioritizing non-pharmacological approaches as the primary course of action, pharmacological treatments are advised when non-pharmacological approaches are ineffective or based on patient preference. These guidelines recommend non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxers (SMRs) as the first-line pharmacological options for acute or subacute LBP, while NSAIDs are the exclusive first-line pharmacological option for chronic LBP. Although SMRs are generally effective for acute LBP, the available evidence does not support the view that they improve functional recovery, and their comparative efficacy to NSAIDs and other analgesics remains unknown, while studies have shown them to introduce adverse events without significantly reducing LBP. Moreover, opioids continue to be widely prescribed for LBP, despite limited evidence for effectiveness and known risks of addiction and overdose. Broader use of non-opioid pharmacotherapy, including the appropriate use of OTC options, is critical to addressing the opioid crisis. The balance of evidence indicates that NSAIDs have a favorable benefit-risk profile when compared to other available pharmacological treatment options for non-specific LBP, a condition that is primarily acute in nature and well-suited for self-treatment with OTC analgesics. While clinical guidelines do not differentiate between NSAIDs, evidence indicates that OTC naproxen sodium effectively relieves pain across multiple types of pain models, and furthermore, the 14-h half-life of naproxen sodium allows sustained, all day pain relief with reduced patient pill burden as compared to shorter acting options. Choosing the most appropriate approach for managing LBP, including non-pharmacological options, should be based on the patient's condition, severity of pain, potential risks, and individual patient preference and needs.

Association of a Heart Failure Management Incentive in Primary Care With Clinical Outcomes: A Retrospective Cohort Study.

We aim to examine the association between primary care physicians' billing of Q050A, a pay-for-performance heart failure (HF) management incentive fee code, and the composite outcome of mortality, hospitalization, and emergency department visits. This population-based cohort study linked administrative health databases in Ontario, Canada, for patients with HF aged >66 years between January 1, 2008, and March 31, 2020. Cases were patients with HF who had a Q050A fee code billed. Cases and controls were matched 1:1 on age, sex, patient status on being rostered to a primary care physician, cardiologist, or internist visit in the 6 months before study enrollment, Johns Hopkins Adjusted Clinical Group resource use bands, days between HF diagnosis and study enrollment (±2 years), and the logit of the propensity score. A Cox proportional hazards model assessed the association of Q050A with the outcome. A total of 59 664 cases had a Q050A billed, whereas 244 883 patients did not. Before matching, patients who had a Q050A billed were more likely to be men (52% versus 49%), were rostered to a primary care physician (100% versus 96%), had a higher Charlson Comorbidity Index, and had higher health care costs. The mean follow-up was 481 days for cases and 530 days for controls. The composite outcome (hazard ratio, 1.11 [95% CI, 1.09-1.12]) was significantly higher for cases than controls. The Q050A incentive improved financial compensation for primary care physicians managing patients with HF but was not associated with improvements in the outcome. Research on promoting evidence-based HF management is warranted.

Association of primary care visit length with outpatient utilization, continuity, and care processes.

Little is known about how variation in the scheduled length of primary care visits can impact patients' patterns of health care utilization. To evaluate how the scheduled length of in-person visits with primary care physicians (PCPs) was associated with PCP and patient characteristics, outpatient utilization, and preventive care receipt. This retrospective cohort study examined data from a large American academic health system. PCP visit length template was defined as either 15- and 30-min scheduled appointments (i.e. 15/30), or 20- and 40-min scheduled appointments (i.e. 20/40). Of 222 included PCPs, 85 (38.3%) used the 15/30 template and 137 (61.7%) used the 20/40 template. The 15/30 group had higher proportions of male (49.4%, vs. 35.8% in the 20/40 group) and family medicine (37.6% vs. 21.2%) physicians. In adjusted patient-level analysis (N = 238,806), having a 15/30 PCP was associated with 9% more primary care visits (incidence rate ratio [IRR], 1.09; 95% confidence interval [CI], 1.03-1.14), and 8% fewer specialty care visits (IRR, 0.92; 95% CI, 0.86-0.98). PCP visit length template was not associated with significant differences in obstetrics/gynaecology visits, continuity of care, or preventive care receipt. In interaction analyses, having a 15/30 PCP was associated with additional primary care visits among non-Hispanic White patients (IRR, 1.10; 95% CI, 1.04-1.16) but not among non-Hispanic Black patients. PCPs' choices about the scheduled length of in-person visits may impact their patients' specialty care use, and have varying impacts across different racial/ethnic groups.

Exploring the Relationship Between Medication Adherence and Diabetes Disparities among Hispanic Patients in a Large Health System

BackgroundSub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level.ObjectiveTo examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health).DesignThis study used clinical, administrative, and prescription dispensing data (January–December 2021) derived from the electronic health records of 5 Academic Medical Centers in UC Health, and linear regression models (LRMs) to conduct a cross-sectional analysis of the association between medication adherence, race/ethnicity, and HbA1c level. Adjusted LRMs were run with and without the measure of medication adherence to assess this relationship.ParticipantsPatients with a UC Health primary care physician (PCP), with ≥ 1 PCP visit within the last 3 years, ages 18–75, reporting Asian, Hispanic, or White race/ethnicity, and who had ≥ 2 encounters with an ICD diagnosis of diabetes or had a prescription for a diabetes medication within the last 2 years, as of 12/31/21 (N = 27, 542; Asian = 6253, Hispanic = 7216, White = 14,073).Main MeasuresOur measure of medication adherence was the proportion of days covered (PDC) for diabetes medications in 2021. Our outcome was the most recent HbA1c value.Key ResultsIn the LRM excluding the PDC, Hispanic ethnicity was positively associated with HbA1c level (β = 0.31, p = < 0.001). In the LRM model including PDC, PDC was negatively associated with HbA1c level (β = − 0.18, p = < 0.001). However, the positive relationship between Hispanic ethnicity and HbA1c level did not change (β = 0.31, p = < 0.001).ConclusionsThe findings of this study suggest that the relationship between Hispanic ethnicity, HbA1c level, and factors outside of medication adherence should be explored among primary care patients receiving care in Academic Medical Centers.

Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness

Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. ClinicalTrials.gov Identifier: NCT03224858.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition. To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition. This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023. Follow-up with a PCP within 30 days after hospital discharge for the index admission. The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission. The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups. In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

Patient Travel Distance to Neurologist Visits.

The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care. We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Unique patterns of healthcare utilization following the opening of the Samson Assuta Ashdod University Hospital

Our aim was to examine the influence of the market entry of Samson Assuta Ashdod University Hospital on community and hospital-based healthcare utilization (HCU). A retrospective study was conducted among Maccabi Health Services enrollees in the regions of Ashdod (n = 94,575) and Netanya (control group, n = 80,200) before and after this market entry. Based on difference-in-differences framework, we examined the change in HCU of Ashdod region’s enrollees compared to the control group and following the market entry using multivariable generalized estimating equations models. Our results revealed that, as hypothesized, after the market entry and compared to the control group, there was a 4% increase in specialists visits not requiring referral (RR = 1.04, 95% CI 1.03–1.06, p < 0.001), a 4% increase in MRI and CT scans (RR = 1.04, 95% CI 1.01–1.08, p = 0.022), and a 33% increase in emergency room visits (RR = 1.33, 95% CI 1.29–1.38, p < 0.001). Unexpectedly, no changes were observed in the number of hospital admissions (RR = 1.05, 95% CI 0.97–1.14, p = 0.250), and hospitalization days (RR = 0.99, 95% CI 0.94–1.04, p = 0.668). Moreover, and unexpectedly, there was a 1% decrease in primary care physician visits (RR = 0.99, 95% CI 0.98–1.00, p = 0.002), a 11% decrease in specialists visits requiring a referral (RR = 0.89, 95% CI 0.86–0.91, p < 0.001), and a 42% decrease in elective surgeries (RR = 0.58, 95% CI 0.55–0.60, p < 0.001). We conclude that this market entry was not translated to an increase in utilization of all services. The unique model of maintaining the continuity of care that was adopted by the hospital and patients’ loyalty may led to the unique inter-relationship between the hospital and community care.

Rates and predictors of visits to primary care physicians during and after treatment of childhood acute lymphoblastic leukemia: A population-based cohort study.

Patient re-engagement with primary care physicians (PCPs) after cancer treatment is essential to facilitate survivorship care and to meet non-oncology primary care needs. We identified rates and predictors of PCP visits both during and after treatment among a population-based cohort of children with acute lymphoblastic leukemia (ALL). Children of age less than 18years at ALL diagnosis in Ontario between 2002 and 2012 were linked to administrative data and matched to controls without cancer. PCPs at diagnosis were identified and PCP visit rates during treatment compared between patients and controls. Post-treatment PCP visit rates were also calculated. Predictors included demographic-, disease-, and PCP-related variables. A total of 743/793 (94%) patients and 3112/3947 (79%) controls had a PCP at diagnosis. Almost half of patients (361/743, 45%) did not visit their PCP during treatment. Visit rate during treatment was 0.64 per person per year (PPPY) versus 1.4 PPPY among controls (adjusted rate ratio [aRR] 0.47, 95th confidence interval [95CI]: 0.40-0.54; p<.0001). No disease- or PCP-related factors were associated with visit rates. Total 711 patients completed frontline therapy; 287 (40.4%) did not have a PCP visit after treatment. Nonetheless, survivors overall visited PCPs post treatment more often than controls (aRR 1.4, 95CI: 1.2-1.6; p<.0001). Survivors who saw their PCP during treatment had post-treatment visit rates twice that of other survivors (aRR 2.0, 95CI: 1.6-2.5; p<.0001). Only a portion of children with ALL see their PCPs during treatment and return to PCP care following treatment completion. Post-treatment engagement with PCPs may be improved by PCP involvement during ALL treatment.

Chronic Psychotic Disorders and Correctional Involvement: A Population-Based Matched Case-Control Study in Ontario, Canada.

Individuals with chronic psychotic disorders are overrepresented in correctional facilities, but little is known about factors that increase the risk of correctional involvement. The objective of this study was to compare individuals with chronic psychotic disorders who were released from correctional facilities in Ontario to individuals with chronic psychotic disorders but no correctional involvement on sociodemographic, clinical, and prior mental health-related health service utilization characteristics. All individuals with chronic psychotic disorders who were released from a provincial correctional facility in Ontario in 2010 were matched (1:2) by age and sex to Ontario residents with chronic psychotic disorders and no correctional involvement. Covariates included sociodemographic (rural residence, marginalization such as residential instability quintile, material deprivation quintile, dependency quintile, and ethnic concentration quintile) and clinical (duration of chronic psychotic disorder and comorbidities) characteristics, and mental health-related health service utilization characteristics (primary care physician, psychiatrist and emergency department visits, and hospitalizations) 1 and 3 years prior to correctional involvement. The association between correctional involvement and prior health service utilization was measured by estimating incidence rate ratios using Poisson and negative-binomial regressions. Individuals with correctional involvement (N = 3,197) lived in neighbourhoods with higher material deprivation and residential instability, and had a shorter duration of illness, and more psychosocial comorbidities (e.g., behavioural issues and depression) than individuals without correctional involvement (N = 6,393). Adjusting for sociodemographic and clinical variables, individuals with correctional involvement had a higher rate of mental health-related primary care physician visits, emergency department visits, and hospitalizations but a lower rate of psychiatrist visits prior to correctional involvement, compared to individuals without correctional involvement. Despite higher mental health-related comorbidities and higher rates of accessing acute mental health services among individuals with chronic psychotic disorders and correctional involvement, visits to psychiatrists prior to involvement were low.

Association of Participation in a Value-Based Insurance Design Program With Health Care Spending and Utilization

Value-based insurance design (VBID) has mostly been used in improving medication use and adherence for certain conditions or patients, but its outcomes remain uncertain when applied to other services and to all health plan enrollees. To determine the association of participation in a California Public Employees' Retirement System (CalPERS) VBID program with its enrollees' health care spending and utilization. A retrospective cohort study with difference-in-differences propensity-weighted 2-part regression models was performed in 2021 to 2022. A VBID cohort was compared with a non-VBID cohort both before and after VBID implementation in California in 2019 with 2 years' follow-up. The study sample included CalPERS preferred provider organization continuous enrollees from 2017 through 2020. Data were analyzed from September 2021 to August 2022. The key VBID interventions include (1) if selecting and using a primary care physician (PCP) for routine care, PCP office visit copayment is $10 (otherwise, PCP office visit copayment is $35 as for specialist visit); and (2) annual deductibles reduced by a half through completion of the following 5 activities: annual biometric screening, influenza vaccine, nonsmoking certification, second opinion for elective surgical procedures, and disease management participation. The primary outcome measures included annual per member total approved payments for multiple inpatient and outpatient services. The 2 compared cohorts of 94 127 participants (48 770 were female [52%]; 47 390 were younger than 45 years old [50%]) had insignificant baseline differences after propensity-weighting adjustment. The VBID cohort had significantly lower probabilities of inpatient admissions (adjusted relative odds ratio [OR], 0.82; 95% CI, 0.71-0.95), and higher probabilities of receiving immunizations (adjusted relative OR, 1.07; 95% CI, 1.01-1.21) in 2019. Among those with positive payments, VBID was associated with higher mean total allowed amounts for PCP visits in 2019 and 2020 (adjusted relative payments ratio, 1.05; 95% CI, 1.02-1.08). There were no significant differences for inpatient and outpatient combined totals in 2019 and 2020. The CalPERS VBID program achieved desired goals for some interventions with no added total costs in its first 2 years of operation. VBID may be used to promote valued services while containing costs for all enrollees.

Predictors of combat training attrition in Israel Defense Forces soldiers.

Attrition from combat service carries significant organizational and personal ramifications, but predicting factors associated with attrition remains challenging. To evaluate medical and psychosocial factors associated with attrition from basic combat training (BCT) in the Israel Defense Forces (IDF). In addition, we identify subsets of the recruit population which exhibit certain trends in terms of medical corresponding with a high risk of attrition. A cross-sectional study of IDF combat trainees undergoing infantry BCT between 2012 and 2017. Data were collected from the soldiers' electronic medical and administrative records. We used multivariable logistic regression and the SAS® decision-tree tool to analyse key predictive factors for attrition. A total of 46 472 soldiers enlisted to BCT during the research period. The mean body mass index (BMI) was 21.8 (SD 3.54). The overall attrition rate was 10%. The following factors were associated with attrition from BCT: ethnicity (P < 0.01), BMI (P < 0.01), pre-enlisting motivation score (P < 0.01) and the number of mental health officer visits (P < 0.01). Using a decision-tree model, we found a high attrition rate among soldiers who had >5.2 to primary care physician visits (11% attrition rate versus 3%) or more than 11 sick leave days (59% versus 19%). This study sheds light on unique measures relating to attrition. Attrition is associated with several demographic and psychosocial factors. Early prediction of motivation and monitoring of healthcare utilization may enable early identification and focused interventions targeting soldiers at high risk for attrition. These findings need to be further translated into actionable directives and further investigations.