Receipt Of Specialty Care Research Articles

Associations between specialty care and improved outcomes among patients with diabetic foot ulcers.

Specialty care may improve diabetic foot ulcer outcomes. Medically underserved populations receive less specialty care. We aimed to determine the association between specialty care and ulcer progression, major amputation, or death. If a beneficial association is found, increasing access to specialty care might help advance health equity. We retrospectively analyzed a cohort of Wisconsin and Illinois Medicare patients with diabetic foot ulcers (n = 55,409), stratified by ulcer severity (i.e., early stage, osteomyelitis, or gangrene). Within each stratum, we constructed Kaplan-Meier curves for event-free survival, defining events as: ulcer progression, major amputation, or death. Patients were grouped based on whether they received specialty care from at least one of six disciplines: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, and vascular surgery. Multivariate Cox proportional hazard models estimated the association between specialty care and event-free survival, adjusting for sociodemographic factors and comorbidities, and stratifying on ulcer severity. Patients who received specialty care had longer event-free survival compared to those who did not (log-rank p<0.001 for all ulcer severity strata). After adjusting, receipt of specialty care, compared to never, remained associated with improved outcomes for all ulcer severities (early stage adjusted hazard ratio 0.34, 95% CI 0.33-0.35, p<0.001; osteomyelitis aHR 0.22, 95% CI 0.20-0.23, p<0.001; gangrene aHR 0.22, 95% CI 0.20-0.24, p<0.001). Specialty care was associated with longer event-free survivals for patients with diabetic foot ulcers. Increased, equitable access to specialty care might improve diabetic foot ulcer outcomes and disparities.

Substance Use and Mental Health Comorbidities and Receipt of Specialty Care Among Patients Enrolled in a Low-Barrier HIV Clinic.

Low-barrier care is one model of a differentiated service delivery approach for people with HIV (PWH) who are not engaged in conventionally-organized HIV care. Although psychiatric and substance use disorders are common among patients in low-barrier clinics, approaches to behavioral health service delivery within this context have not been well-described. We conducted a descriptive analysis using retrospective review of medical records to evaluate substance use and psychiatric comorbidities and receipt of behavioral health services among patients in the Max Clinic in Seattle, Washington. Among 227 patients enrolled from 2015 to mid-2020, most had a history of hazardous substance use (85%), a psychiatric diagnosis (69%) or unstable housing (69%) documented in the medical record. Less than half of patients referred for depression treatment (33%) or for opioid use disorder treatment (40%) completed even one specialty care visit. More effective approaches are needed to engage patients in behavioral health services within the context of low-barrier HIV care.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

IntroductionRural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities....

1659. Association of Rurality and Identifying as Black with Receipt of Specialty Care among Patients Hospitalized with Diabetic Foot Ulcers: a Medicare cohort study

Abstract Background Among those with diabetic foot ulcers, rural patients identifying as Black face at least 10% greater risk of major amputation or death compared to the US as a whole. As specialty care is associated with lower risk of major amputation, this difference could be driven by specialty care access. We hypothesize that rural patients and, particularly, rural patients identifying as Black, receive less inpatient specialty care compared to the overall cohort. Methods We built a cohort of all Medicare patients hospitalized with diabetic foot ulcers (2013–2014). Rurality was measured using Rural Urban Commuting Area codes. Race was categorized using the Research Triangle Institute algorithm. Specialty care was defined as receiving inpatient care from at least 1 of 6 relevant specialties to address diabetes, infection, biomechanics or vascular disease, per National Provider Taxonomy codes: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, and vascular surgery. We reported observed differences in specialty care, overall and stratified by rurality, identifying as Black, and ulcer severity. Pearson X2 tests were performed on observed frequencies. Results Overall, 32.2% of the cohort received inpatient specialty care. This proportion decreased to 29.6% for rural patients (X2 = 36.2, p ≤ 0.001) and 26.2% for rural patients identifying as Black (X2 = 19.5, p ≤ 0.001). Among those with osteomyelitis, 54.3% of the cohort received specialty care, while only 49.5% of rural patients, 50.8% of patients identifying as Black, and 37.6% of rural patients identifying as Black received specialty care; the disparity for rural patients identifying as Black was greater than the sum of rural and racial disparities (4.8% for rural + 3.5% for Blacks = 8.3% versus a 16.7% observed difference for rural Blacks; Figure 1). Notably, only 2.7% of patients presenting with osteomyelitis were seen by an infectious disease specialist. This proportion decreased to 2.5% for rural patients. Observed Proportions of Patients Receiving Specialty Care Stratified by Rurality, Identifying as Black, and Ulcer Severity Conclusion A smaller proportion of rural patients received specialty care, and rural patients identifying as Black were half as likely to receive specialty care than the overall cohort. Improving specialty access for these high-risk patients may reduce disparities in major amputations. Disclosures All Authors: No reported disclosures.

Geographic differences in receipt of addictions treatment in a national sample of patients with alcohol use disorders from the U.S. Veterans Health Administration

Background: In the United States, alcohol use disorder (AUD) is common and costly but substantially undertreated. Rurality is an important determinant of health that may influence receipt of evidence-based alcohol-related care. In a large, national sample of Veterans Health Administration (VA) patients with AUD with documented and non-Hispanic Black, Hispanic, or non-Hispanic White race/ethnicity, we examine whether meeting national Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for specialty addictions care and receiving evidence-based medications for AUD differs across patients living in urban, large rural, and small rural areas. Methods: VA electronic health record data were used to identify all patients with AUD documented in Fiscal Year 2012. Rurality was measured using a three-category rural and urban commuting area (RUCA) classification linked to patient zip code. Logistic regression models with clustered standard errors—iteratively adjusted for hypothesized confounders—were used to estimate the likelihood and marginal probabilities of receiving care for patients living in small and large rural areas, relative to urban areas. Primary outcomes included HEDIS initiation (any visit within 14 days of initial AUD visit after a 60-day period of no treatment), HEDIS engagement (2 or more AUD visits within 30 days of HEDIS initiation visit) and having any filled prescription for AUD medications (naltrexone, disulfiram, acamprosate, or topiramate). Results: For all outcomes, patients living in large and small rural areas had a lower likelihood of receiving evidence-based AUD treatment than patients living in urban areas (all p-values < 0.05); differences in marginal probabilities across groups were relatively small. Conclusions: In this national sample of VA patients with AUD, those living in more rural areas were less likely to receive evidence-based treatment for AUD than those living in urban areas. Further research is needed to investigate strategies to increase receipt of specialty care and pharmacotherapy in more rural areas.

Are inner-city children with asthma receiving specialty care as recommended in national asthma guidelines?

ABSTRACTObjective: To examine whether children with asthma in an urban health care network are receiving asthma specialty care, and which factors, if any, are associated with the receipt of this care, including child's racial/ethnic group, age, socio-economic status (SES), insurance, and/or acute care utilization. Methods: This study is a retrospective cohort study of children aged 7–17 years who received primary care at an urban medical center in 2012 and had a primary or secondary ICD9 code for asthma. Data on asthma-related health care utilization from 1997 to 2012 were accessed using a software application linked to the electronic medical record. Analyses included descriptive statistics (means and percentages) as well as bivariate and multivariable logistic regressions. Results: The participants were 4959 children (59% Hispanic and 37% Black, Non-Hispanic) with a mean age = 11.1 years ± 3.05, with 56.8% males. Only 19% of the children had outpatient asthma specialist care: pulmonary (16%) and/or allergy (7%). Only 42% with an asthma-related hospitalization had an outpatient asthma specialist visit. The receipt of specialty care did not vary by race/ethnicity, SES or private vs. public insurance, but was more likely with hospitalization for asthma (OR 3.4) or ≥2 lifetime ED visits (OR 2.6) and less likely for those who were uninsured (OR 0.7). Conclusions: In contrast to guideline recommendations, few inner-city children with high asthma morbidity in this sample had seen asthma specialists. Efforts are needed to ensure that inner-city children with asthma are receiving guideline-recommended asthma specialty care.

Factors associated with high short-acting β2-agonist use in urban children with asthma

BackgroundOne goal of guideline-based asthma therapy is minimal use of short-acting β2 agonist (SABA) medications. Inner-city children with asthma are known to have high SABA use. ObjectiveTo examine factors associated with high SABA use in inner-city children with asthma. MethodsOne hundred inner-city children with persistent asthma were enrolled into a randomized controlled trial of an emergency department (ED) and home intervention. All children underwent serologic allergen specific IgE and salivary cotinine testing at the ED enrollment visit. Pharmacy records for the past 12 months were obtained. Number of SABA fills during the past 12 months was categorized into low- to moderate- vs high-use groups. SABA groups were compared by the number of symptom days and nights, allergen sensitization, and exposures. Regression models were used to predict high SABA use. ResultsMean number of SABA fills over 12 months was 3.12. Unadjusted bivariate analysis showed that high SABA users were more than 5 times more likely to have an asthma hospitalization, almost 3 times more likely to have an asthma intensive care unit admission, and more than 3 times more likely to have prior specialty asthma care or positive cockroach sensitization than low to moderate SABA users. In the final regression model, for every additional inhaled corticosteroid fill, a child was 1.4 times more likely and a child with positive cockroach sensitization was almost 7 times more likely to have high SABA use when controlling for prior intensive care unit admission, receipt of specialty care, child age, and income. ConclusionProviders should closely monitor SABA and controller medication use, allergen sensitization, and exposures in children with persistent asthma. Trial registrationClinicalTrials.gov, identifier NCT01981564.

Two faces of patient safety and care quality: a Franco-American comparison

Patient safety, and more broadly the quality of care, is typically discussed with reference to the reduction of preventable adverse events within hospitals and adherence to practice guidelines on care processes. We call it the 'care-centered approach' and recognize that the United States is a leader in the field. Another face of patient safety and care quality may be defined as the 'system-centered approach'. It focuses on access to a timely and effective continuum of health-care services--clinical prevention, primary care and appropriate referral to and receipt of specialty care. Although France's efforts to pursue a care-centered approach to patient safety are limited, its system-centered approach yields some benefits. Based on the evidence we have reviewed for access to primary care (hospital discharges for avoidable hospital conditions), mortality amenable to medical intervention and consumer satisfaction, in the United States and France, there appear to be good grounds for bolstering the system-centered approach in the United States.