Specialty Care Visits Research Articles

Which veterans enroll in a VA health information exchange program?

To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions. Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients' sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records. Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50-64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment. Enrollment in HIE is complex, with several factors involved in a patient's decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation.

Demographic, Clinical, and Service Utilization Factors Associated with Suicide-Related Visits among Alaska Native and American Indian Adults.

Alaska Native and American Indian people (AN/AIs) are disproportionately affected by suicide. Within a large AN/AI health service organization, demographic, clinical, and service utilization factors were compared between those with a suicide-related health visit and those without. Cases had higher odds of a behavioral health diagnosis, treatment for an injury, behavioral health specialty care visits, and opioid medication dispensation in the year prior to a suicide-related visit compared to gender-, age-, and residence- (urban versus rural) matched controls. Odds of a suicide-related visit were lower among those with private insurance and those with non-primary care ambulatory clinic visits.

Characterizing the severe asthma population in the United States: claims-based analysis of three treatment cohorts in the year prior to treatment escalation

Objectives: Little is known about the disposition of severe patients prior to treatment escalation. To classify patients by treatment step using pharmacy data and describe their economic and healthcare utilization, insurance status, and sociodemographic characteristics in the year prior to escalation to Global Initiative for Asthma (GINA) steps 4 and 5. Methods: This was a retrospective claims cohort study of asthma patients (age 12–75 years) newly initiated on “stable therapy” (three consecutive months of therapy) with omalizumab, high intensity corticosteroids (HICS; ≥1000 µg/d inhaled fluticasone equivalent or oral prednisone), or high-dose inhaled corticosteroid (HDICS; ≥500–<1000 µg/d fluticasone equivalent) from 2002 to 2011. Other asthma treatments were compared as a reference. Results: Of 25 297 patients, 856 initiated omalizumab, 6926 initiated HICS, and 11 445 initiated HDICS. In the year prior to treatment escalation to omalizumab, HICS, and HDICS, respectively, individuals had high annual mean medical expenditures ($14 071, $12 030, and $7570), utilization (27 outpatient and 10 specialty care visits; 19 outpatient and three specialty; 15 outpatient and two specialty), asthma-related prescription drugs (11.74, 7.8, and 5.17) and chronic comorbidities (2.68, 2.67, and 2.19). Prior to omalizumab treatment, patients were more likely to be salaried, full-time employees with commercial PPO/POS insurance. Conclusions: Prior to escalating treatment to GINA steps 4 and 5, individuals experienced significant annual medical expenditures, healthcare resource utilization and polypharmacy burden, which may reflect poorly controlled asthma and the need to escalate treatment. Medical claims data and utilization-based measures may be helpful in classifying individuals by GINA treatment step.

Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system.

Lower continuity of care has been associated with higher rates of adverse outcomes for persons with multiple chronic medical conditions. It is unclear, however, whether this relationship also exists within integrated systems that offer high levels of informational continuity through shared electronic health records. We conducted a retrospective cohort study of 12,200 seniors with 3 or more chronic conditions within an integrated delivery system. Continuity of care was calculated using the Continuity of Care Index, which reflects visit concentration with individual clinicians. Using Cox proportional hazards regression permitting continuity to vary monthly until the outcome or censoring event, we separately assessed inpatient admissions and emergency department visits as a function of primary care continuity and specialty care continuity. After adjusting for covariates (demographics; baseline, primary, and specialty care visits; baseline outcomes; and morbidity burden), greater primary care continuity and greater specialty care continuity were each associated with a lower risk of inpatient admission (respective hazard ratios (95% CIs) = 0.97 (0.96, 0.99) and 0.95 (0.93, 0.98)) and a lower risk of emergency department visits (respective hazard ratios = 0.97 (0.96, 0.98) and 0.98 (0.96, 1.00)). For the subgroup with 3 or more primary care and 3 or more specialty care visits, specialty care continuity (but not primary care continuity) was independently associated with a decreased risk of inpatient admissions (hazard ratio = 0.94 (0.92, 0.97)), and primary care continuity (but not specialty care continuity) was associated with a decreased risk of emergency department visits (hazard ratio = 0.98 (0.96, 1.00)). In an integrated delivery system with high informational continuity, greater continuity of care is independently associated with lower hospital utilization for seniors with multiple chronic medical conditions. Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs.

Capsule commentary on Zuchowski et al., challenges in referral communication between VHA primary care and specialty care.

Potential improvements in clinical outcomes and reduced costs resulting from high quality coordination between primary care (PCP) and specialty care providers (SCP) will remain unrealized without substantive attention to the technological and interprofessional factors affecting continuity and co-management.1 Zuchowski and colleagues conducted this mixed method study to identify and understand PCPs’ perceived barriers to communicating with SCPs in the nationally integrated VA health care system setting.2 Survey data collected from PCPs were used to evaluate variation in perceived ease of communication with SCPs by provider type. Qualitative interviews conducted with primary care medical home team members from the same region were analyzed to provide an explanatory framework for the quantitative findings. Survey data indicate that population-focused SCPs were generally considered the easiest to communicate with, while those from surgical specialties were viewed by PCPs as the most difficult. Interview data identified two communication challenges: SCP rejection of PCP referral requests and PCP inability to communicate patient-specific scheduling needs effectively.2 Together, the overlapping samples illustrate general trends in communication barriers that persist despite VA’s infrastructural and fiscal advantages over the private sector. While the study design did not collect corresponding data from SCPs, validate SCP referral rejection rate, or examine SCP factors in delayed scheduling, extant literature indicates that these challenges are endemic and persistent.3–5 Data from PCPs in this study contribute evidence that electronic consults (i.e., e-consults) may ameliorate some of these challenges. E-consults can guide treatment decisions, identify information required for an effective specialty care visit, and perhaps most important, e-consults can foster interprofessional relationships between PCPs and the SCPs they may never meet in person, but on whose expertise they rely. As Taylor et al. suggest, partnered with attention to “…referral rate for primary care physicians, the number of referrals avoided through pre-consult exchanges, and the number of referrals that are completed and not completed,”3 e-consults have the potential to reveal specific practice patterns associated with unsatisfactory referrals, thus moving us closer to identifying trigger points for enacting co-management in medical home settings.

Health Care Contacts in the Year Before Suicide Death

Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples. To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed. Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states. In all, 5,894 individuals who died by suicide, and were health plan members in the year before death. Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site. Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means. This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Health Care Utilization and Barriers Experienced by Individuals With Spinal Cord Injury

ObjectivesTo identify from whom individuals with spinal cord injury (SCI) seek health care, the percentage who receive preventative care screenings, and the frequency and types of barriers they encounter when accessing primary and specialty care services; and to examine how sociodemographic factors affect access to care and receipt of preventative screenings. DesignCross-sectional, observational study using an Internet-based survey. SettingInternet based. ParticipantsAdults (N=108) with SCI who use a wheelchair as their primary means of mobility in the community. InterventionsNot applicable. Main Outcome MeasuresHealth care utilization during the past year, barriers encountered when accessing health care facilities, and receipt of routine care and preventative screenings. ResultsAll but 1 participant had visited a primary care provider within the past 12 months, and 85% had had ≥1 visit to specialty care providers. Accessibility barriers were encountered during both primary care (91.1%) and specialty care (80.2%) visits; most barriers were clustered in the examination room. The most prevalent barriers were inaccessible examination tables (primary care=76.9%; specialty care=51.4%) and lack of transfer aids (primary care=69.4%; specialty care=60.8%). Most participants had not been weighed during their visit (89%) and had remained seated in their wheelchair during their examinations (85.2%). Over one third of individuals aged ≥50 years had not received a screening colonoscopy, 60% of women aged ≥50 years had not had a mammogram within the past year, 39.58% of women had not received a Papanicolaou smear within the previous 3 years, and only 45.37% of respondents had ever received bone density testing. ConclusionsIndividuals with SCI face remediable obstacles to care and receive fewer preventative care screenings than their nondisabled counterparts. We recommend that clinics conduct Americans with Disabilities Act self-assessments, ensure that their clinical staff are properly trained in assisting individuals with mobility disabilities, and take a proactive approach in discussing preventative care screenings with their patients who have SCI.

Specialty use among patients with treated hypertension in a patient-centered medical home.

Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use. To describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation. One-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods. Adults aged 18-85 years with treated hypertension. System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009. Resource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties. Compared to baseline, the study population averaged 7% fewer adjusted specialty visits during implementation (P < 0.001) and 4% fewer adjusted specialty visits in the first post-implementation year (P = 0.02). Patients were 12% less likely to have any cardiology visits during implementation and 13% less likely during the first post-implementation year (P < 0.001). In interaction analysis, patients with low morbidity had at least 27% fewer specialty visits during each of 3 years following baseline (P < 0.001); medium morbidity patients had 9% fewer specialty visits during implementation (P < 0.001) and 5% fewer specialty visits during the first post-implementation year (P = 0.007); high morbidity patients had 3% (P = 0.05) and 5% (P = 0.009) higher specialty use during the first and second post-implementation years, respectively. Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients.

Access to Multiple Sclerosis Specialty Care

Health care providers recommend an annual visit to a multiple sclerosis specialty care provider. To examine potential barriers to the implementation of this recommendation in the Veterans Health Administration. Observational cohort study. Veterans Health Administration. Participants were drawn from the Veterans Affairs Multiple Sclerosis National Data Repository and were included if they had an outpatient visit in 2007 and were alive in 2008 (N = 14,723). Specialty care visit, receipt of medical services. A total of 9643 (65.5%) participants had a specialty care visit in 2007. Veterans who were service connected, had greater medical comorbidity, and who lived in urban settings were more likely to have received a specialty care visit. Veterans who were older and had to travel greater distances to a center were less likely to have a specialty care visit. Access to care in rural areas and areas at a greater distance from a major medical center represent notable barriers to rehabilitation and other multiple sclerosis-related care.

When Comorbidity, Aging, and Complexity of Primary Care Meet: Development and Validation of the Geriatric CompleXity of Care Index

To develop and validate the Geriatric CompleXity of Care Index (GXI), a comorbidity index of medical, geriatric, and psychosocial conditions that addresses disease severity and intensity of ambulatory care for older adults with chronic conditions. DEVELOPMENT phase: variable selection and rating by clinician panel. VALIDATION phase: medical record review and secondary data analysis. Assessing the Care of Vulnerable Elders-2 study. Six hundred forty-four older (≥75) individuals receiving ambulatory care. 32 conditions categorized according to severity, resulting in 117 GXI variables. A panel of clinicians rated each GXI variable with respect to the added difficulty of providing primary care for an individual with that condition. Modified versions of previously validated comorbidity measures (simple count, Charlson, Medicare Hierarchical Condition Category), longitudinal clinical outcomes (functional decline, survival), intensity of ambulatory care (primary, specialty care visits, polypharmacy, number of eligible quality indicators (NQI)) over 1year of care. The most-morbid individuals (according to quintiles of GXI) had more visits (7.0 vs 3.7 primary care, 6.2 vs 2.4 specialist), polypharmacy (14.3% vs 0% had ≥14 medications), and greater NQI (33 vs 25) than the least-morbid individuals. Of the four comorbidity measures, the GXI was the strongest predictor of primary care visits, polypharmacy, and NQI (P<.001, controlling for age, sex, function-based vulnerability). Older adults with complex care needs, as measured by the GXI, have healthcare needs above what previously employed comorbidity measures captured. Healthcare systems could use the GXI to identify the most complex elderly adults and appropriately reimburse primary providers caring for older adults with the most complex care needs for providing additional visits and coordination of care.

Comparing common reasons for inpatient and outpatient visits between commercially-insured duloxetine or pregabalin initiators with fibromyalgia

BackgroundThe purpose of this study was to examine the main reasons for inpatient or outpatient visits after initiating duloxetine or pregabalin.MethodsCommercially insured patients with fibromyalgia and aged 18–64 years who initiated duloxetine or pregabalin in 2006 with 12-month continuous enrollment before and after initiation were identified. Duloxetine and pregabalin cohorts with similar demographics, pre-index clinical and economic characteristics, and pre-index treatment patterns were constructed via propensity scoring stratification. Reasons for inpatient admissions, physician office visits, outpatient hospital visits, emergency room visits, and primary or specialty care visits over the 12 months post-index period were examined and compared. Logistic regression was used to assess the contribution of duloxetine versus pregabalin initiation to the most common reasons for visits, controlling for cross-cohort differences.ResultsPer the study design, the duloxetine (n = 3711) and pregabalin (n = 4111) cohorts had similar demographics (mean age 51 years, 83% female) and health care costs over the 12-month pre-index period. Total health care costs during the 12-month post-index period were significantly lower for duloxetine patients than for pregabalin patients ($19,378 versus $27,045, P < 0.05). Eight of the 10 most common reasons for inpatient admissions and outpatient hospital (physician office, emergency room, primary or specialty care) visits were the same for both groups. Controlling for cross-cohort differences, duloxetine patients were less likely to be hospitalized due to an intervertebral disc disorder or major depressive disorder, to have a physician office visit due to nonspecific backache/other back/neck pain (NB/OB/NP) disorder, or to go to specialty care due to a soft tissue, NB/OP/NP, or intervertebral disc disorder. However, duloxetine patients were more likely to have a primary care visit due to a soft tissue disorder, essential hypertension, or other general symptoms.ConclusionAmong similar commercially insured patients with fibromyalgia who initiated duloxetine or pregabalin, duloxetine patients had significantly lower health care costs over the 12-month post-index period. The leading reasons for inpatient or outpatient visits were also somewhat different.

Improving Access to Care for Uninsured Patients at an Academic Medical Center: The Access Partnership

Uninsured individuals face great challenges in accessing both primary and specialty care. The Access Partnership (TAP) is a novel collaboration between primary and specialty care providers at an urban academic medical center to provide care coordination and facilitate access to specialty services for uninsured patients. We reviewed administrative data and performed phone surveys of the 213 patients who entered the program over a one-year period. Specialty care visit attendance was analyzed from administrative data for these patients. We then surveyed patients by phone (60% response rate). Patient-reported access to care and satisfaction with care were significantly higher after TAP (33% vs. 87%, p&lt;0.001 and 41% vs. 91%, p&lt;0.001, respectively). 89% of referrals were completed within 90 days among TAP patients, a rate similar to studies involving insured patients. TAP enrollment was associated with significantly decreased patient-reported barriers to specialty care as well as improved access to and satisfaction with care.

Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients

BackgroundMore than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time.ObjectivesTo examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare.MethodsA retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations.ResultsAmong Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics.ConclusionsGreater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.

Opioid Use and Dependence Among Persons With Migraine: Results of the AMPP Study

To assess the frequency of opioid use for acute migraine treatment and characterize use groups by sociodemographics, health-care resource utilization (HRU), comorbidities and probable dependence within a large, US population-based sample of persons with migraine. Opioids are used in the acute treatment of migraine. However, their use is controversial. Data from the 2009 American Migraine Prevalence and Prevention (AMPP) study were used to categorize persons with migraine into 4 groups based on reported opioid use: nonusers (between 2005 and 2009), previous users (history of use between 2005 and 2008 but no-use in 2009), and current opioid users (those reporting use of opioids in the 3 months preceding the 2009 American Migraine Prevalence and Prevention survey). Current opioid users were divided into nondependent and probable dependence users according to criteria for dependence adapted for inclusion in the survey from the Diagnostic and Statistical Manual of Mental Disorders-4th edition. All opioid-use groups were contrasted by sociodemographics, headache characteristics, medical and psychiatric comorbidities (depression [measured by the Patient Health Questionnaire-9], anxiety [measured by the Primary Care Evaluation of Mental Health Disorders, PRIME-MD], and cardiovascular events and risk factors), and headache-related HRU. In a sample of 5796 migraineurs, 4076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users. Among current opioid users, 153 (16.6%) met criteria for probable dependence and 769 (83.4%) did not. Headache-related disability (Migraine Disability Assessment sum scores) increased across groups as follows: nonusers: 7.8, previous users: 13.3, current nondependent users: 19.1, and current probable dependence users: 44.4, as did monthly headache frequency: nonusers: 3.2 days/month, previous users: 4.3 days/month, current nondependent users: 5.6 days/month, and current probable dependence users: 8.6 days/month. The prevalence of depression and anxiety was highest among current users with probable dependence. Rates of headache-related HRU were higher for all opioid-use groups for emergency department/urgent care, primary care, and specialty care visits compared to nonusers. Opioid use for migraine is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), and greater HRU for headache. Longitudinal studies are needed to further assess the directionality and causality between opioid use and the outcomes we examined.

Mayo Clinic Employees Responded To New Requirements For Cost Sharing By Reducing Possibly Unneeded Health Services Use

Some health plans have experimented with increasing consumer cost sharing, on the theory that consumers will use less unnecessary health care if they are expected to bear some of the financial responsibility for it. However, it is unclear whether the resulting decrease in use is sustained beyond one or two years. In 2004 Mayo Clinic's self-funded health plan increased cost sharing for its employees and their dependents for specialty care visits (adding a $25 copayment to the high-premium option) and other services such as imaging, testing, and outpatient procedures (adding 10 or 20percent coinsurance, depending on the option). The plan also removed all cost sharing for visits to primary care providers and for preventive services such as colorectal screening and mammography. The result was large decreases in the use of diagnostic testing and outpatient procedures that were sustained for four years, and an immediate decrease in the use of imaging that later rebounded (possibly to levels below the expected trend). Beneficiaries decreased visits to specialists but did not make greater use of primary care services. These results suggest that implementing relatively low levels of cost sharing can lead to a long-term decrease in utilization.

Reliance on Veterans Affairs Outpatient Care by Medicare-eligible Veterans

To examine longitudinal changes in Medicare-eligible veterans' reliance on the Department of Veterans Affairs (VA) healthcare system for primary and specialty care over 4 years. We merged VA administrative and Medicare claims data to examine outpatient use during fiscal years (FY) 2001 to 2004 by 15,520 Medicare-eligible veterans who used VA primary care in FY2000. Reliance on VA outpatient care was defined as the proportion of total (VA/Medicare) visits received in VA for primary or specialty care. Of 869,000 primary and specialty care visits in the study period, 39% occurred within VA and 77% were specialty care. Reliance on VA primary care was substantially higher than specialty care (66% vs. 50% in FY2001; P<0.001). Reliance on VA primary and specialty care decreased over time (57% vs. 31% in FY2004; P<0.001). Significant shifts occurred at both extremes of VA reliance. From FY2001 to FY2004, the proportion of patients in the top decile of reliance on VA primary care decreased from 39% to 31%, whereas the proportion in the bottom decile doubled from 8% to 18%. Similarly, the proportion of patients in the top decile of reliance on VA specialty care decreased from 24% to 13%, whereas the proportion in the bottom decile doubled from 22% to 47%. Reliance on VA primary and specialty care among VA primary care patients decreased substantially over time, particularly for specialty care. Increasing use of non-VA services may complicate VA's implementation of patient-centered medical home models and performance measurement.

Patient-reported care coordination: associations with primary care continuity and specialty care use.

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

The Socio-Geography of Heart Failure

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

Cost-Effectiveness of Implementing the Chronic Care Model for Diabetes Care in a Military Population

Applying the chronic care model (CCM) for diabetes management helps improve health outcomes and patient care. The CCM was implemented at U.S. Air Force Wilford Hall Medical Center through the Diabetes Outreach Clinic (DOC) in 2006, but its cost-effectiveness in this setting is unknown. We constructed a Markov decision model to estimate DOC cost-effectiveness compared with usual care (UC) over a 20-year period. Based on empirical, post-intervention demographic and clinical data, we applied United Kingdom Prospective Diabetes Study risk equations to predict long-term probabilities of developing microvascular or macrovascular complications. Health care system and societal perspectives were considered, discounting costs and benefits at 3% annually. Intervention costs and outcomes were obtained from military data, while other costs, disease progression data, and utilities were drawn from published literature. From a health care system perspective, the DOC cost $45,495 per quality-adjusted life-year (QALY) compared with UC; from a societal perspective, the DOC compared with UC cost $42,051/QALY (when the model started with the uncomplicated diabetes cohort), $61,243/QALY (when starting with the DOC cohort), or $61,813/QALY (when starting with the UC cohort). In one-way sensitivity analyses, results were most sensitive to yearly costs for specialty care visits. In probabilistic sensitivity analysis, the DOC was favored in 51% of model iterations using an acceptability threshold of $50,000/QALY and in 72% at a threshold of $100,000/QALY. The DOC strategy for diabetes care, performed with the CCM methodology in a military population, appears to be economically reasonable compared with UC.

Patterns and Predictors of Health Service Utilization in Adolescents With Pain: Comparison Between a Community and a Clinical Pain Sample

There is limited research describing the patterns of healthcare utilization in adolescents with chronic pain. This study describes healthcare utilization in a clinical chronic pain sample, and compares the patterns of service use of this group to a community sample with intermittent pain complaints. We also investigated demographic and clinical factors that predicted healthcare visits and medication use in the clinical sample. Data on 117 adolescents (aged 12–18; n = 59 clinical pain sample, n = 58 community) were collected. Caregivers and adolescents reported on sociodemographics, medical visits, current medications, pain, activity limitations, and depression. As hypothesized, the clinical pain sample had higher rates of healthcare consultation on all types of medical visits (general, specialty care, complementary medicine, mental health, OT/PT), and higher medication use compared to the community sample. Regression analyses revealed that higher annual income, greater pain frequency, and higher levels of caregiver-reported activity limitations were associated with a greater number of healthcare visits for the total sample. Within the clinical pain sample, higher pain frequency and greater activity limitations (caregiver report) predicted more specialty care visits. Additionally, higher income and greater levels of depressive symptoms predicted a higher number of prescribed medications. Perspective This study contributes to the limited available data on health service and medication use in a clinical chronic pain sample versus a community sample of adolescents. We also identify clinical factors (pain frequency, parent-reported activity limitations, depressive symptoms) and demographic factors (gender, income) associated with healthcare utilization.