Primary Care Provider Visits Research Articles

Primary care use after cancer treatment: an analysis of linked administrative data.

Primary care-led follow-up is a safe and acceptable alternative to oncologist-led follow-up. We sought to investigate patterns of primary care use during cancer follow-up care. We identified all persons in Nova Scotia, diagnosed with an invasive breast, prostate, colorectal, or gynecologic cancer between January 2006 and December 2013. We linked this dataset to cancer centre, hospital discharge abstracts, physicians' billing, and census data. We identified a survivor cohort (n = 12,201), then descriptively examined primary care use during follow-up care. Multivariate Poisson and negative binomial regression, respectively, were used to examine primary care use for two outcomes: total number of primary care provider (pcp) visits (all reasons) and total number of cancer-specific pcp visits. The mean numbers of pcp visits (all reasons) and cancer-specific pcp visits per year for survivors who did not receive cancer centre follow-up (cc-fup) were 8.12 and 0.43 visits, respectively, and for survivors who continued to receive cc-fup were 8.75 and 0.63 visits, respectively. Age, cancer type, stage at diagnosis, comorbidity scores, year of diagnosis, and receipt of cc-fup were associated with both outcomes. Compared with prostate cancer survivors, breast, colorectal, and gynecologic cancer survivors had, respectively, 56%, 69%, and 56% fewer expected cancer-specific PCP visits. Receipt of cc-fup increased the expected number of pcp visits (all reasons) by 12% and cancer-specific pcp visits by 50%. Primary care use was higher in survivors who continued to visit their oncology teams for follow-up. This suggests that survivors who remain with their oncology teams after treatment continue to have high needs not met by these teams alone.

Advanced Health Information Technologies to Engage Parents, Clinicians, and Community Nutritionists in Coordinating Responsive Parenting Care: Descriptive Case Series of the Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care Randomized Controlled Trial.

BackgroundSocioeconomically disadvantaged newborns receive care from primary care providers (PCPs) and Women, Infants, and Children (WIC) nutritionists. However, care is not coordinated between these settings, which can result in conflicting messages. Stakeholders support an integrated approach that coordinates services between settings with care tailored to patient-centered needs.ObjectiveThis analysis describes the usability of advanced health information technologies aiming to engage parents in self-reporting parenting practices, integrate data into electronic health records to inform and facilitate documentation of provided responsive parenting (RP) care, and share data between settings to create opportunities to coordinate care between PCPs and WIC nutritionists.MethodsParents and newborns (dyads) who were eligible for WIC care and received pediatric care in a single health system were recruited and randomized to a RP intervention or control group. For the 6-month intervention, electronic systems were created to facilitate documentation, data sharing, and coordination of provided RP care. Prior to PCP visits, parents were prompted to respond to the Early Healthy Lifestyles (EHL) self-assessment tool to capture current RP practices. Responses were integrated into the electronic health record and shared with WIC. Documentation of RP care and an 80-character, free-text comment were shared between WIC and PCPs. A care coordination opportunity existed when the dyad attended a WIC visit and these data were available from the PCP, and vice versa. Care coordination was demonstrated when WIC or PCPs interacted with data and documented RP care provided at the visit.ResultsDyads (N=131) attended 459 PCP (3.5, SD 1.0 per dyad) and 296 WIC (2.3, SD 1.0 per dyad) visits. Parents completed the EHL tool prior to 53.2% (244/459) of PCP visits (1.9, SD 1.2 per dyad), PCPs documented provided RP care at 35.3% (162/459) of visits, and data were shared with WIC following 100% (459/459) of PCP visits. A WIC visit followed a PCP visit 50.3% (231/459) of the time; thus, there were 1.8 (SD 0.8 per dyad) PCP to WIC care coordination opportunities. WIC coordinated care by documenting RP care at 66.7% (154/231) of opportunities (1.2, SD 0.9 per dyad). WIC visits were followed by a PCP visit 58.9% (116/197) of the time; thus, there were 0.9 (SD 0.8 per dyad) WIC to PCP care coordination opportunities. PCPs coordinated care by documenting RP care at 44.0% (51/116) of opportunities (0.4, SD 0.6 per dyad).ConclusionsResults support the usability of advanced health information technology strategies to collect patient-reported data and share these data between multiple providers. Although PCPs and WIC shared data, WIC nutritionists were more likely to use data and document RP care to coordinate care than PCPs. Variability in timing, sequence, and frequency of visits underscores the need for flexibility in pragmatic studies.Trial RegistrationClinicalTrials.gov NCT03482908; https://clinicaltrials.gov/ct2/show/NCT03482908International Registered Report Identifier (IRRID)RR2-10.1186/s12887-018-1263-z

Frequent User System Engagement: A Quality Improvement Project to Examine Outcomes of a Partnership to Improve the Health of Emergency Department Frequent Users.

Patterns of frequent emergency department (ED) use correlate with a variety of care needs. Health care systems should address these needs in collaboration with community health partners. Approximately 600 patients frequent a local ED for nonemergent needs. Approximately 15% of those patients are homeless. A program consistent with the Corporation for Supportive Housing's Frequent User System Engagement (FUSE) model was developed and implemented in a community setting. Eleven participants were enrolled in this pilot program. Eligible candidates enrolled in the program received coordinated multidisciplinary care and stable housing. ED visits, primary care provider visits, and number of diagnostic tests and costs changed significantly over time. The FUSE program is equipped to address the needs of the whole person, resulting in a meaningful impact on overall health while decreasing frequency of ED visits.

Predictors of enrollment in opioid agonist therapy after opioid overdose or diagnosis with opioid use disorder: A cohort study

BackgroundMedicaid recipients have a high burden of opioid overdose and opioid use disorder (OUD). Opioid agonist therapies are an effective treatment for OUD, but there is a wide and persisting gap between those who are indicated and those who receive treatment. The objective of this study was to identify the predictors of enrollment in opioid agonist therapy within 6 months of an opioid overdose or OUD diagnosis in a cohort of Medicaid recipients. MethodsUsing multiple linked, state-level databases, we conducted a retrospective cohort study of 17,449 Medicaid recipients in Rhode Island who had an opioid overdose or an OUD diagnosis between July 2013 and June 2018. ResultsThe majority (58 %) of Medicaid recipients did not enroll in opioid agonist therapy within 6 months. In adjusted models, having one or more prior overdose (adjusted risk ratio [ARR] = 0.33, 95 % CI: 0.28, 0.38), alcohol use disorder (ARR = 0.56, 95 % CI: 0.52, 0.60), or back problems (ARR = 0.58, 95 % CI: 0.55, 0.61) were strong predictors of non-enrollment. Conversely, emergency department (ARR = 1.31, 95 % CI: 1.28–1.34) and primary care provider (ARR = 1.03, 95 % CI: 1.01–1.34) visit frequency above the 75th percentile were associated with timely enrollment in opioid agonist therapy. ConclusionsOur findings underscore the need to enhance pathways to treatment for OUD through varied nodes of engagement with healthcare systems. Interventions to improve screening for OUD and referrals to opioid agonist therapies should include high-impact settings, such as treatment programs for alcohol and substance use disorders, pain clinics, and outpatient behavioral care settings.

Improving Chronic Obstructive Pulmonary Disease (COPD) Symptoms Using a Team-Based Approach.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients' self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149). Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms. An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.

Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care

ObjectivesOur study examined the proportion of skilled nursing facility (SNF) post-acute care residents who did not receive timely primary care provider (PCP) services following discharge, factors associated with lack of timely PCP services, and factors associated with perfect 30-day home time among those who did not receive timely PCP services. DesignLongitudinal cohort study; data sources included Medicare claims and other administrative databases. Setting and Participants25,357 fee-for-service New York State Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care in 2014 and then discharged to the community. MethodsOur outcomes were a timely PCP visit (within 7 days of SNF discharge) and perfect 30-day home time, and we examined their association with patient, SNF, and county factors. ResultsAmong SNF discharges, 60.6% had a timely PCP visit. In multivariate regression analyses, female sex, nonwhite race, Medicare only status, less functional impairment and medical comorbidity, a surgical hospitalization, fewer hospital days, more SNF days, absence of home health services, for-profit SNF status, higher SNF star rating, lower ratio of registered nurse/total nursing hours, and rural counties were associated with lower odds of a timely PCP visit following SNF discharge. Among those without a timely PCP visit, female sex, less cognitive and functional impairment, less medical comorbidity, a surgical hospitalization, fewer hospital days, receipt of home health services, and higher SNF star rating were associated with increased odds of perfect 30-day home time following SNF discharge. Conclusions and ImplicationsThat 4 in 10 post-acute care SNF patients did not have a timely PCP visit post-SNF discharge, with racial minority and rural county status associated with decreased odds of a timely PCP visit, is concerning. Examination of whether the timing and type of outpatient visit may have varying effects on different post-acute care subpopulations would build on this work.

The Influence of an Opioid Use Disorder on Initiating Physical Therapy for Low Back Pain: A Retrospective Cohort.

Low back pain (LBP) is common among patients with an opioid use disorder (OUD). The extent to which patients with an OUD initiate physical therapy for LBP is unknown. The aim of this study was to examine the association between a history of an OUD and initiation of physical therapy for LBP within 60 days of a primary care provider (PCP) visit for this condition. Claims from a single state-wide all payer claims database from June 30, 2013 and August 31, 2015 were used to establish a retrospective cohort of patients who consulted a PCP for a new episode of LBP. The outcome measure was patients who had at least 1 physical therapy claim within 60-days after the PCP visit. After propensity score matching on covariates, logistic regression was used to compare the outcome of patients with a history of an OUD to patients without an OUD. Propensity score matching resulted in 1360 matched pairs of participants. The mean age was 47.2 years (15.9) and 55.9% were female. Compared to patients without an OUD, patients with an OUD were less likely to initiate physical therapy for LBP (adjusted odds ratio = 0.65, 95% confidence intervals:0.49-0.85). After a visit to a PCP for a new episode of care for LBP, patients with a history of an OUD are less likely to initiate physical therapy.

Healthcare resource utilization following ECG sensor patch screening for atrial fibrillation.

BackgroundScreening for asymptomatic, undiagnosed atrial fibrillation (AF) has the potential to allow earlier treatment, possibly resulting in prevention of strokes, but also to increase medical resource utilization.ObjectiveTo compare healthcare utilization rates during the year following initiation of screening among participants screened for AF by electrocardiogram (ECG) sensor patch compared with a matched observational control group.MethodsA total of 1718 participants recruited from a health care plan based on age and comorbidities who were screened with an ECG patch (actively monitored group) as part of a prospective, pragmatic research trial were matched by age, sex, and CHA2DS2-VASc score with 3371 members from the same health plan (observational control group). Healthcare utilization, including visits, prescriptions, procedures, and diagnoses, during the 1 year following screening was compared between the groups using health plan claims data.ResultsOverall, the actively monitored group had significantly higher rates of cardiology visits (adjusted incidence rate ratio [aIRR] [95% confidence interval (CI)]: 1.43 [1.27, 1.60]), no difference in primary care provider visits (aIRR [95% CI]: 1.0 [0.95, 1.05]), but lower rates of emergency department (ED) visits and hospitalizations (aIRR [95% CI]: 0.80 [0.69, 0.92]) compared with controls. Among those with newly diagnosed AF, the reduction in ED visits and hospitalizations was even greater (aIRR [95% CI]: 0.27 [0.17, 0.43]).ConclusionAF screening in an asymptomatic, moderate-risk population with an ECG patch was associated with an increase in cardiology outpatient visits but also significantly lower rates of ED visits and hospitalizations over the 1 year following screening.

S1060 Rates of Vaccine Administration After Liver Transplantation at a Large Tertiary Care Center

INTRODUCTION: There is clear evidence that vaccination prevents morbidity and mortality in high risk populations. We evaluated the quality of vaccination in liver transplant recipients at our institution and to what extent there is adherence to current guidelines. METHODS: A retrospective review of patients transplanted between 1/2015 and 1/2018 at our institution was performed. Data collected included patient demographics, travel distance to transplant center, insurance provider and primary care provider (PCP) visits. Vaccination status and eligibility for Influenza (IV), Pneumococcus (PV), Hepatitis-A (HAV) and B (HBV), Tdap and Td (TdV) were obtained through our EMR and the Michigan Care Improvement Registry. Statistics were calculated using analysis of variance (ANOVA), chi-square, Fisher’s exact test and Wilcoxon Rank Sum Test. RESULTS: 406 patients were evaluated with 336 (83.0%) Caucasians, 44 (10.8%) African-Americans, 15 (3.7%) Hispanics with ages ranging from 21-77 years old. 173 (42.6%) patients received the influenza vaccine in the year prior to transplant whereas only 97 (23.9%) were vaccinated in the year following transplant. 92 (33%) vaccine eligible patients were vaccinated for HAV pre-transplant with 66 (23.7%) patients vaccinated post-transplant, 121 (29.8%) of patients remained unvaccinated. 116 (31.4%) were vaccinated for HBV pre-transplant and 20 (5.4%) post-transplant, leaving 233 (57%) unvaccinated. PV rates increased from 185 (45.6%) to 267 (66%) post-transplant, TdaP 168 (41.4%) to 208 (51.2%) and Td 34 (8.4%) to 40 (10.0%) post-transplant respectively. Post-transplant vaccination was consistently associated with pre-transplant primary care visits (PV: 33.8% vs 57.3% P < 0.001, IV: 54.6% vs 45.6% P = 0.121, HAV: 63.6% vs 45.1% P = 0.008, HBV 50% vs 47.9%, Tdap: 50.0% vs 36.9% P = 0.121). Shorter distance to the transplant center, private insurance, female gender and pre-transplant influenza vaccine administration were also associated with a trend towards higher vaccine rates post-transplant (Table 2). CONCLUSION: Our data reveals vaccination rates in liver transplant recipients decline significantly in the post-transplant period. Additionally, a significant number of at-risk individuals remain unvaccinated. Pre-transplant habits such as regular PCP visits, IV administration and locating close to the transplant center could help improve uptake. As a result of this data, ensuring regular PCP visitation upon transplant listing will be implemented as a quality improvement initiative.Table 1.: Demonstrating Vaccination rates pre- and post-liver transplantTable 2.: Demonstrating factors influencing vaccine uptake. (F) = Fisher Exact Test, (W) = Wilcoxon Rank Sum Test, (C) = Chi Square Analysis. Distance in Miles

The relationship between integrated pediatric psychology and primary care visit length, revenue, content over 24 months.

Introduction: Integrating behavioral health providers into pediatric primary care to provide behavioral health (BH) services is both effective and efficient; however, the impact of pediatric integrated services on the operational and financial outcomes of primary care provider (PCP) visits has not been thoroughly investigated. The present study examined whether length of practice integration predicts the relationship between BH content addressed in a PCP visit, visit length, and revenue generation. Method: A total of 1,209 pediatric encounters with 25 PCPs across 7 primary care offices in a predominantly rural health system were abstracted for the presence or absence of BH content, visit length, duration of integration, and revenue. χ2 analyses and the generalized linear model framework were used to address the study objectives. Results: Integration was associated with more PCP visits with a BH topic discussed at 6-11 months of integration but not at 14-24 months. Visits with a BH topic were longer than medical-only visits and shorter when a practice was integrated for 6-11 months but not at 14-24 months of integration. Public insurance and integration were associated with lower revenue generation per minute. Visit content was not associated with PCP revenue. Discussion: Results suggest a relationship between integration and the operational and financial outcomes of PCP visits. This study shows that initial efficiencies or improvements (e.g., time, cost, content) associated with integrating BH may be lost over time. Future studies should evaluate sustainability in relation to program impact. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Electronic Decision Support for Management of CKD in Primary Care: A Pragmatic Randomized Trial

Most adults with chronic kidney disease (CKD) in the United States are cared for by primary care providers (PCPs). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record with or without pharmacist follow-up to improve the management of CKD in primary care. Pragmatic cluster-randomized trial. 524 adults with confirmed creatinine-based estimated glomerular filtration rates of 30 to 59mL/min/1.73m2 cared for by 80 PCPs at the University of California San Francisco. Electronic health record data were used for patient identification, intervention deployment, and outcomes ascertainment. Each PCP's eligible patients were randomly assigned as a group into 1 of 3 treatment arms: (1) usual care; (2) eCDSS: testing of creatinine, cystatin C, and urinary albumin-creatinine ratio with individually tailored guidance for PCPs on blood pressure, potassium, and proteinuria management, cardiovascular risk reduction, and patient education; or (3) eCDSS plus pharmacist counseling (eCDSS-PLUS). The primary clinical outcome was change in blood pressure over 12 months. Secondary outcomes were PCP awareness of CKD and use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and statin therapy. All 80 eligible PCPs participated. Meanpatient age was 70 years, 47% were nonwhite, and mean estimated glomerular filtration rate was 56±0.6mL/min/1.73m2. Among patients receiving eCDSS with or without pharmacist counseling (n=336), 178 (53%) completed laboratory measurements and 138 (41%) had laboratory measurements followed by a PCP visit with eCDSS deployment. eCDSS was opened by the PCP for 102 (74%) patients, with at least 1 suggested order signed for 83 of these 102 (81%). Changes in systolic blood pressure were-2.1±1.5mm Hg with usual care,-2.8±1.8mm Hg with eCDSS, and-1.1±1.1 with eCDSS-PLUS (P=0.7). PCP awareness of CKD was 16% with usual care, 26% with eCDSS, and 32% for eCDSS-PLUS (P=0.09). In as-treated analyses, PCP awareness of CKD was significantly greater with eCDSS and eCDSS-PLUS (73% and 69%) versus usual care (47%; P=0.002). Recruitment of smaller than intended sample size and limited uptake of the testing component of the intervention. Although we were unable to demonstrate the effectiveness of eCDSS to lower blood pressure and uptake of the eCDSS was limited by low testing rates, eCDSS use was high when laboratory measurements were available and was associated with higher PCP awareness of CKD. Grants from government (National Institutes of Health) and not-for-profit (American Heart Association) entities. Registered at ClinicalTrials.gov with study number NCT02925962.

Assessment of clinical inertia in people with diabetes within primary care.

Clinical inertia, defined as a delay in treatment intensification, is prevalent in people with diabetes. Treatment intensification rates are as low as 37.1% in people with haemoglobin A1c (HbA1c) values >7%. Intensification by addition of medication therapy may take 1.6 to more than 7 years. Clinical inertia increases the risk of cardiovascular events. The primary objective was to evaluate rates of clinical inertia in people whose diabetes is managed by both pharmacists and primary care providers (PCPs). Secondary objectives included characterizing types of treatment intensification, HbA1c reduction, and time between treatment intensifications. Retrospective chart review of persons with diabetes managed by pharmacists at an academic, safety-net institution. Eligible subjects were referred to a pharmacist-managed cardiovascular risk reduction clinic while continuing to see their PCP between October 1, 2016 and June 30, 2018. All progress notes were evaluated for treatment intensification, HbA1c value, and type of medication intensification. Three hundred sixty-three eligible patients were identified; baseline HbA1c 9.6% (7.9, 11.6) (median interquartile range [IQR]). One thousand one hundred ninety-two pharmacist and 1739 PCP visits were included in data analysis. Therapy was intensified at 60.5% (n = 721) pharmacist visits and 39.3% (n = 684) PCP visits (P < .001). The median (IQR) time between interventions was 49 (28, 92) days for pharmacists and 105 (38, 182) days for PCPs (P < .001). Pharmacists more frequently intensified treatment with glucagon-like peptide-1 agonists and sodium glucose cotransporter-2 inhibitors. Pharmacist involvement in diabetes management may reduce the clinical inertia patients may otherwise experience in the primary care setting.

Low Colorectal Cancer Screening Uptake and Persistent Disparities in an Underserved Urban Population.

Colorectal cancer screening has increased substantially in New York City in recent years. However, screening uptake measured by telephone surveys may not fully capture rates among underserved populations. We measured screening completion within 1 year of a primary care visit among previously unscreened patients in a large urban safety-net hospital and identified sociodemographic and health-related predictors of screening.We identified 21,256 patients ages 50 to 75 who were seen by primary care providers (PCP) in 2014, of whom 14,425 (67.9%) were not up-to-date with screening. Because PCPs facilitate the majority of screening, we compared patients who received screening within 1 year of an initial PCP visit to those who remained unscreened using multivariable logistic regression.Among patients not up-to-date with screening at study outset, 11.5% (1,658 patients) completed screening within 1 year of a PCP visit. Asian race, more PCP visits, and higher area-level income were associated with higher screening completion. Factors associated with remaining unscreened included morbid obesity, ever smoking, Elixhauser comorbidity index of 0, and having Medicaid/Medicare insurance. Age, sex, language, and travel time to the hospital were not associated with screening status. Overall, 39.9% of patients were up-to-date with screening by 2015.In an underserved urban population, colorectal cancer screening disparities remain, and overall screening uptake was low. Because more PCP visits were associated with modestly higher screening completion at 1 year, additional community-level education and outreach may be crucial to increase colorectal cancer screening in underserved populations.

Implementing a pharmacist-run Lyme disease postexposure prophylaxis clinic augmented by academic detailing within the Veterans Health Administration

ObjectiveTo describe the implementation of a pharmacist-run Lyme disease postexposure prophylaxis (PEP) clinic augmented by academic detailing within a health care system. SettingButler Veterans Affairs Health Care System. Practice descriptionA pharmacist-run clinic, referred to as a PharmLD clinic, was established. A patient presenting to the health care system with a chief complaint of a tick bite would be scheduled to the PharmLD clinic for the evaluation of appropriateness of Lyme disease PEP. The pharmacist prescribed a single dose of doxycycline 200 mg and provided education on Lyme disease, provided education only, or referred the patient to their primary care provider (PCP). Academic detailing with PCPs, nurses, and pharmacists was used to improve outcomes in those not seen in the clinic. Practice innovationTo our knowledge, the evaluation of a pharmacist-run Lyme disease PEP clinic in a health care system alone or in combination with academic detailing has not been previously described in the literature. EvaluationDoxycycline PEP prescriptions from April through September 2016 (preimplementation) were compared with prescriptions from April through September 2018 (postimplementation). A retrospective chart review was performed to evaluate prescribing appropriateness on the basis of Infectious Diseases Society of America guidelines. ResultsThe postimplementation group saw a 55.9% improvement in doxycycline prescribing appropriateness. The improvement in appropriateness stemmed largely from the dose and duration prescribed. Eighteen of the 39 prescriptions (46%) came from the PharmLD clinic. During the postimplementation period, 40 patients were seen in the PharmLD clinic. Of these patients, 18 were prescribed doxycycline PEP (45%), 12 received education only (30%), and 10 were referred to their PCP for further evaluation (25%). These PharmLD clinic encounters resulted in the mitigation of 30 PCP visits. ConclusionA pharmacist-run Lyme disease PEP clinic, coupled with academic detailing, has increased access to care and improved the quality of care received.

Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016.

Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline. To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends. National, population-based. Adult health plan members aged 18 to 64 years. PCP visit rates per 100 member-years. In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%). Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions. Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care. None.

Antipsychotic Medication Adherence and Healthcare Services Utilization in Two Cohorts of Patients with Serious Mental Illness.

ObjectiveTo evaluate differences in patient characteristics and real-world outcomes in two distinct high-risk cohorts of patients with serious mental illness (SMI).MethodsRetrospective cross-sectional analysis using a national multi-payer claims database. Two SMI cohorts identified by a technical expert panel—patients recently discharged (RD) from an SMI-related hospitalization and early episode (EE) patients—were evaluated for antipsychotic medication adherence, healthcare utilization, and spending patterns.ResultsThe analysis included 51,705 patients with bipolar disorder, major depressive disorder, and schizophrenia. More than half were over age 46 and >60% were female. Adherence to psychiatric medications was low (52.5% RD and 16.1% EE). More than half of RD and 100% of EE patients switched medications at least once annually, but 19% of RD patients switched ≥2 times compared to 14% of EE. The RD cohort (generally older and sicker) had higher psychiatric related utilization and higher annual costs (US$21,171 versus US$15,398). In both cohorts, women were more likely to have an emergency department (ED) and primary care provider (PCP) visit, but less likely to be hospitalized. Patients age <46 were less likely to have a PCP visit and more likely to have an ED visit, but younger patients age 18–24 were less likely to be hospitalized.ConclusionEfforts to manage SMI are confounded by heterogeneity and low adherence to treatment. By better understanding which patients are at higher risk for specific adverse outcomes, clinicians can target interventions more appropriately to reduce the significant burden of SMI.

Clinical trajectories, healthcare resource use, and costs of long-term hematopoietic stem cell transplantation survivors: a latent class analysis.

To identify patterns of healthcare utilization in allogeneic and autologous hematopoietic stem cell transplantation (HSCT) recipients and evaluate factors associated with high-need and high-cost post-transplantation care. Latent class analysis of a retrospective cohort of long-term allogeneic (n = 436) and autologous (n = 888) HSCT survivors within the Truven MarketScan database (2009-2014). We assessed factors associated with the latent classes by comparing post-transplantation healthcare utilization including inpatient admissions and length of stay, emergency room visits, specialist visits, and primary care provider visits. Four utilization classes were identified in allogeneic and autologous HSCT recipients: (i) outpatient specialist care dominant (51.8% and 57.3%), (ii) outpatient primary care dominant (10.3% and 25.7%), (iii) outpatient/inpatient balanced (20.6% and 13.5%), and (iv) inpatient dominant (17.2% and 3.5%). Mean monthly healthcare expenditures in the inpatient dominant utilization class were $41,097 and $25,556 for allogeneic and autologous survivors, respectively, which were two to five times higher compared with other classes during the 2-year post-transplantation period. Factors associated with the high utilization class were transfusion (OR = 1.87, 95% CI 1.06-3.30) and 100-day post-transplant graft-versus-host-disease (OR = 1.76, 95% CI 1.05-2.94) in allogeneic HSCT; higher baseline Charlson comorbidity index (OR = 1.45, 95% CI 1.19-1.76) in autologous HSCT. Based on distinct patterns of healthcare utilization following HSCT, we identified factors associated with higher resource utilization and greater healthcare related expenditures. Earlier identification of high-cost and high-need HSCT long-term survivors could pave the way for clinicians to offer more continuous engagement in survivorship care delivery.

The association of chronic diseases and mammography among Medicare beneficiaries living in Appalachia.

Objective:This study assessed the relationship between presence and number of chronic disease and reception of mammogram in women 65 years and older, and how this relationship is influenced by primary care provider visits.Methods:A total of 3306 women diagnosed with breast cancer from 2006 to 2008 from cancer registries in four Appalachian states were analyzed.Results:Having a mammogram within the past 2 years was associated with having at least one chronic disease. The presence of a chronic disease was associated with an increased likelihood of breast cancer screening adherence but was not a strong predictor when demographic variables were added.Conclusion:This study supports the findings that women with more primary care provider visits were more likely to adhere to breast cancer screening guidelines but having several chronic diseases presents a barrier to achieving guideline-concordant mammography screening, highlighting the importance of preventive screening for patients managing chronic diseases.

Acute Healthcare Utilization of a Multidisciplinary Neurocognitive Dementia Patient Cohort.

Background and PurposeUpon referral from the primary care provider (PCP), dementia is diagnosed either by a neuropsychological evaluation (NPE) or at a multidisciplinary neurocognitive clinic (MNC). Following the NPE, patients continue receiving care from their PCP. In contrast, patients at the MNC are followed by a multidisciplinary care team that provides expertise across specialties in dementia care and education for the patient, family members, and care providers. The purpose of the study was to determine the utilization of acute healthcare services during the 2 years following a diagnosis of dementia in patients from the MNC and NPE.MethodsA retrospective review was performed of 581 electronic medical records from January 2010 through December 2014 for 2 cohorts of patients diagnosed with dementia 1) by a neuropsychologist or 2) in a MNC. Acute-care hospital admissions, emergency room (ER) visits, and nonroutine PCP visits were identified. Categorical demographics and utilization variables were summarized by frequency. Chi-square analysis was used to analyze demographic characteristics and overall utilization between MNCs and NPE. Utilization in comparison with various demographic characteristics was analyzed using Spearman correlation coefficients and negative binomial regressions.ResultsPatients evaluated in the MNC were older, more severely impaired, and lived alone more often compared with NPE patients, but there was no increase in hospital admissions and ER visits. Patients who underwent NPE were 1.58 times more likely to have a nonroutine PCP office visit than patients evaluated in the MNC (p=0.0093).ConclusionsPerforming follow-up in multidisciplinary clinics provides patients with more education and may help to reduce the utilization of healthcare services.

Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: Findings from the Veterans Affairs system

Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed if the frequency of visits with primary care providers (PCPs) is associated with higher use of evidence-based statin prescriptions and adherence among patients with ASCVD. We identified patients with ASCVD aged ≥18 years receiving care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into frequent PCP visitors (annual PCP visits ≥ median number of PCP visits for the entire cohort) and infrequent PCP visitors (annual PCP visits < median number of patient visits). We assessed any- and high-intensity statin prescription as well as statin adherence which was defined by proportion of days covered (PDC). We included 1,249,061 patients with ASCVD (mean age was 71.9 years; 98.0% male). Median number of annual PCP visits was 3. Approximately 80.1% patients were on statins with 23.8% on high-intensity statins. Mean PDC was 0.715 ± 0.336 with 58.3% patients with PDC ≥0.8. Frequent PCP visitors had higher frequency of statin use (82.2% vs 77.4%), high-intensity statin use (26.4% vs 20.3%), and statin adherence (mean PDC 0.73 vs 0.68; P < .01) compared to infrequent PCP visitors. After adjusting for covariates, frequent PCP visits was associated with greater odds of being on any statin, high intensity statin, and higher statin adherence. Frequent visits with PCPs is associated with a higher likelihood of any statin use, high intensity statin use, and statin adherence. Further research endeavors are needed to understand the reasons behind these associations.