Access to Primary, Mental Health, and Specialty Care: a Comparison of Medicaid and Commercially Insured Populations in Oregon

Reported Strategies by Medicaid Managed Care Organizations to Improve Access to Behavioral Health Services

Policy Points Despite the growing role of managed care organizations (MCOs) in financing and delivering behavioral health services in Medicaid, little is known about MCO strategies to overcome critical access barriers and the factors influencing these strategies. Through semistructured interviews of 27 administrators and executives across 19 local, regional, and national Medicaid MCOs, we describe a number of reported approaches to enhance behavioral health access: 1) contracting with core groups of Medicaid-focused behavioral health providers to provide a substantial share of care, and 2) targeted strategies to enhance the existing workforce through outreach, training, and workforce support programs; rate enhancements; telehealth and mobile unit care models; and high-touch case management. Findings highlight MCO perspectives on barriers and facilitators of access to behavioral health care, as well potential strategies that hold promise for other MCOs. Future research should evaluate the outcomes associated with these strategies and identify best practices that can be adapted across MCOs.

CONTEXT

Behavioral health access gaps are well documented in Medicaid, in which managed care now covers most enrollees, and for which there are typically fewer options for going out-of-network for care. Despite the growing role of managed care organizations (MCOs) in financing and delivering behavioral health services, little is known about MCO levers that can improve access to care.

METHODS

We interviewed 27 administrators and executives across 19 Medicaid MCO carriers with local, regional, or national operating presence to understand strategies to address behavioral health access barriers and the factors influencing these strategies. To achieve maximum heterogeneity, we employed iterative purposive sampling using a sampling matrix of plan and state characteristics. One-hour interviews were recorded, professionally transcribed, and analyzed using a coding scheme that was developed iteratively. Codes were bundled into major themes after iterative discussions, with analysis conducted at the MCO level.

FINDINGS

MCOs perceived acute access challenges for children and adolescents, rural geographies, and crisis and transitional services. To address these challenges, MCOs reported contracting with core groups of Medicaid-focused behavioral health providers, supplemented with targeted strategies to enhance the existing workforce. These strategies focused on enhancing provider retention and capacity through outreach, training, and workforce support programs; rate enhancements; telehealth and mobile unit care models; and high-touch case management to align members to appropriate providers or service levels. Strategies were influenced by state policy contexts, including by regional financing and organization of behavioral health services, rate setting procedures, and administrative and regulatory requirements.

CONCLUSIONS

As state Medicaid programs increasingly grapple with behavioral health access gaps, understanding MCO approaches and common challenges may help policymakers better align resources, incentives, and regulations centered on improving existing gaps in accessing behavioral health care. Future research should evaluate the outcomes associated with MCO perceptions and accompanying strategies and identify best practices that can be adapted across MCOs.

Preventive Care Needs of the North Carolina Medicaid Expansion Population

Introduction

Effective December 2023, North Carolina expanded Medicaid eligibility to cover individuals up to 138% of the Federal Poverty Level. The authors sought to understand the preventive care needs of the newly Medicaid-eligible population.

Methods

The authors conducted a repeat cross-sectional analysis using the 2016, 2018, 2020, and 2022 North Carolina Behavioral Risk Factor Surveillance Survey. The authors defined the Medicaid expansion population as those aged 18-64 years with household incomes below 138% Federal Poverty Level and reporting no current source of insurance. The authors compared with those enrolled in traditional Medicaid and all nonelderly adult North Carolinians, evaluating up-to-date use of preventive care services. Survey weights were used to estimate total unmet need.

Results

The authors estimated 294,000 individuals in the Medicaid expansion population in 2022. Preventive care use was low for the expansion population in all years. In 2022, 36.7% (27.7%-46.8%) reported having a regular source of care, 40.2% (31.1%-50%) reported a past-year wellness visit, and 45.7% (36.6%-55.2%) reported delaying needed care owing to cost. Among eligible respondents, 28.6% (13.8%-50.2%) were up to date with colorectal cancer screening (vs 49.4% [30.5%-68.4%] for traditional Medicaid and 71% [67.3%-74.4%] for all North Carolina population). It was estimated that 176,000 in the expansion population needed a wellness visit; 186,000 needed a regular care provider; and 66,000 needed 1 or more cancer screening.

Conclusions

The North Carolina Medicaid expansion population has a high number of unmet preventive care needs. North Carolina should consider approaches to improve provider capacity for those in Medicaid and promote preventive care and risk reduction for the newly enrolled expansion population.

The Use of an Artificial Intelligence Platform OpenEvidence to Augment Clinical Decision-Making for Primary Care Physicians

BACKGROUND

Artificial intelligence (AI) platforms can potentially enhance clinical decision-making (CDM) in primary care settings. OpenEvidence (OE), an AI tool, draws from trusted sources to generate evidence-based medicine (EBM) recommendations to address clinical questions. However, its effectiveness in real-world primary care cases remains unknown.

OBJECTIVE

To evaluate the performance of OE in providing EBM recommendations for five common chronic conditions in primary care: hypertension, hyperlipidemia, diabetes mellitus type 2, depression, and obesity.

METHODS

Five patient cases were retrospectively analyzed. Physicians posed specific clinical questions, and OE responses were evaluated on clarity, relevance, evidence support, impact on CDM, and overall satisfaction. Four independent physicians provided ratings using a 0 to 4 scale.

RESULTS

OE provided accurate, evidence-based recommendations in all cases, aligning with physician plans. OE was scored on a scale of zero to four, where zero was very unclear, and four was very clear. Mean scores across cases were clarity (3.55 ± 0.60), relevance (3.75 ± 0.44), support (3.35 ± 0.49), and satisfaction (3.60 ± 0.60). However, the impact on CDM was limited (1.95 ± 1.05), as OE primarily reinforced rather than modified plans.

CONCLUSION

OE was rated high in clarity, relevance, and evidence-based support, reinforcing physician decisions in common chronic conditions. While the impact on CDM was minimal due to the study's retrospective nature, OE shows promise in augmenting the primary care physician. Prospective trials are needed to evaluate its utility in complex cases and multidisciplinary settings.

Relationship between social determinants of health and hospitalizations and costs among patients with bipolar disorder 1

BACKGROUND

Bipolar disorder type 1 (BD-1) is a serious episodic mental illness whose severity can be impacted by social determinants of health (SDOH). To date the relationship of social and economic factors with health care utilization has not been formally analyzed using real-world data.

OBJECTIVE

To describe patient characteristics and assess the influence of SDOH on hospitalizations and costs in patients with BD-1 insured with commercial and managed Medicaid health plans.

METHODS

This retrospective observational study used data from the Medical Outcomes Research for Effectiveness and Economics (MORE2) Registry to identify patients aged 18 years and older with evidence of BD-1 between July 1, 2016, and December 31, 2018. SDOH were linked to patients at the "near neighborhood" level (based on ZIP9 area). Multivariable models assessed the relationship between patient characteristics and hospitalizations (incidence rate ratios [95% CI]) and costs (cost ratios [95% CI]).

RESULTS

Of 243,286 patients with BD-1, 62,148 were covered by commercial insurance and 181,138 by Medicaid. Mean ages [±SD] were similar (commercial 39.8 [±14.8]; Medicaid 40.1 [±13.6]), with more female patients in both cohorts (commercial 59.8%; Medicaid 65.4%). All-cause hospitalization rates were 21.6% for commercial and 35.1% for Medicaid patients; emergency department visits were 39.7% and 64.3%, respectively. All-cause costs were $15,379 [±$27,929] for commercial and $21,474 [±$37,600] for Medicaid. Older age was a significant predictor of fewer hospitalizations compared with those aged younger than 30 years, particularly ages 40-49 for both commercial (0.60 [0.57-0.64]) and Medicaid (0.82 [0.80-0.85]). Increasing age was associated with significantly higher costs, especially age 65 and older (commercial 1.37 [1.31-1.44]); (Medicaid 1.43 [1.38-1.49]). Initial treatment with antipsychotics plus antianxiety medications was a significant predictor of higher hospitalizations (commercial 2.12 [1.98-2.27]; Medicaid 1.62 [1.57-1.68]) and higher costs (commercial 1.86 [1.80-1.92]); Medicaid 1.80 [1.76-1.84]). Household income was inversely associated with hospitalizations for Medicaid (<$30,000 [1.16 (1.12-1.19)]; $30,000-$39,999 [1.11 (1.07-1.15)]; $40,000-$49,999 [1.08 (1.05-1.12)]; $50,000-$74,999 [1.06 (1.02-1.09)]). Not speaking English well or at all was associated with 90% higher hospitalizations for commercial patients (1.93 [1.36-2.76]) but 40% fewer hospitalizations for Medicaid patients (0.59 [0.53-0.67]). Low English language proficiency was associated with significantly higher costs for commercial patients (2.22 [1.86-2.64]) but lower costs for Medicaid patients (0.57 [0.53-0.61]).

CONCLUSIONS

Medicaid patients with BD-1 had high SDOH burden, hospitalizations, and costs. The association of lower English proficiency with fewer hospitalizations and lower costs in Medicaid patients suggests a potential disparity in access to care. These findings highlight the importance of addressing social risk factors to advance health equity in treatment of mental illness.

Rural/urban differences in health care utilization and costs by perinatal depression status among commercial enrollees

PURPOSE

To understand differences in health care utilization and medical expenditures by perinatal depression (PND) status during pregnancy and 1-year postpartum overall and by rural/urban status.

METHODS

We estimated differences in health care utilization and medical expenditures by PND status for individuals with an inpatient live-birth delivery in 2017, continuously enrolled in commercial insurance from 3 months before pregnancy through 1-year postpartum (study period), using MarketScan Commercial Claims data. Multivariable regression was used to examine differences by rurality.

FINDINGS

Ten percent of commercially insured individuals had claims with PND. A smaller proportion of rural (8.7%) versus urban residents (10.0%) had a depression diagnosis (p < 0.0001). Of those with PND, a smaller proportion of rural (5.5%) versus urban residents (9.6%) had a depression claim 3 months before pregnancy (p < 0.0001). Compared with urban residents, rural residents had greater differences by PND status in total inpatient days (rural: 0.7, 95% confidence interval [CI]: 0.6-0.9 vs. urban: 0.5, 95% CI: 0.5-0.6) and emergency department (ED) visits (rural: 0.7, 95% CI: 0.6-0.9 vs. urban: 0.5, 95% CI: 0.4-0.5), but a smaller difference by PND status in the number of outpatient visits (rural: 9.2, 95% CI: 8.2-10.2 vs. urban: 13.1, 95% CI: 12.7-13.5). Differences in expenditures for inpatient services by PND status differed by rural/urban status (rural: $2654; 95% CI: $1823-$3485 vs. urban: $1786; 95% CI: $1445-$2127).

CONCLUSIONS

Commercially insured rural residents had more utilization for inpatient and ED services and less utilization for outpatient services. Rural locations can present barriers to evidence-based care to address PND.

High-risk Prescribing Following Surgery Among Payer Types for Patients on Chronic Opioids

OBJECTIVE

Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance.

BACKGROUND

Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance.

METHODS

In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber.

RESULTS

Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402).

CONCLUSIONS

Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality.

Prevalence of type 2 diabetes diagnoses in the perioperative and survivorship periods following surgical management of endometrial cancer: An opportunity for screening and intervention?

OBJECTIVE

To determine the prevalence of Type 2 diabetes mellitus (T2DM) diagnoses during the peri-operative and survivorship periods in patients following surgical management of endometrial cancer (EC).

METHODS

An IRB-approved, retrospective single-institution cohort study was performed in patients who underwent surgical management of EC from 2014 to 2020. The perioperative period was defined as the 30 days before and after surgery. T2DM diagnoses occurring during survivorship were recorded. T2DM diagnoses were defined by a HgbA1c ≥6.5% or a random blood glucose ≥200 mg/dL. Sequelae of peri-operative T2DM and predictors of future T2DM were examined utilizing univariate analysis.

RESULTS

Of 519 patients meeting inclusion criteria, 37 (7.1%) were diagnosed with T2DM in the perioperative period. Patients diagnosed with T2DM in the perioperative period had significantly higher BMI (p = 0.006) compared to no T2DM, but there were no significant differences in age (p = 0.20), ethnicity/race (p > 0.05) or ECOG score (p = 0.19). The rates of intraoperative complications between groups did not significantly differ, except for vascular complications (p = 0.005), and the incidence of any postoperative complication was higher in the perioperative T2DM group (p = 0.01). With a median follow-up of 29 months [range 11.6-49.0 months], an additional 18.3% (n = 88) of the cohort met diagnostic criteria for T2DM. BMI (p < 0.001), perioperative glucose (p < 0.001), and HgbA1c (p = 0.002) demonstrate risk for a T2DM diagnosis during survivorship.

CONCLUSION(S)

In this retrospective cohort of EC patients, 25.4% were diagnosed with T2DM, with the majority diagnosed in the survivorship period. Surgical management and subsequent surveillance of EC presents an opportunity to diagnose at-risk patients with T2DM.

Medicaid Value-Based Payments and Health Care Use for Patients With Mental Illness

Importance

Medicaid patients with mental illness comprise one of the most high-need and complex patient populations. Value-based reforms aim to improve care, but their efficacy in the Medicaid program is unclear.

Objective

To investigate if New York state's Medicaid value-based payment reform was associated with improved utilization patterns for patients with mental illness.

Design, Setting, and Participants

This retrospective cohort study used a difference-in-differences analysis to compare changes in utilization between Medicaid beneficiaries whose outpatient practices participated in value-based payment reform and beneficiaries whose practices did not participate from before (July 1, 2013-June 30, 2015) to after reform (July 1, 2015-June 30, 2019). Participants were Medicaid beneficiaries in New York state aged 18 to 64 years with major depression disorder, bipolar disorder, and/or schizophrenia. Data analysis was performed from April 2021 to July 2023.

Exposure

Beneficiaries were exposed to value-based payment reforms if their attributed outpatient practice participated in value-based payment reform at baseline (July 1, 2015).

Main Outcomes and Measures

Primary outcomes were the number of outpatient primary care visits and the number of behavioral health visits per year. Secondary outcomes were the number of mental health emergency department visits and hospitalizations per year.

Results

The analytic population comprised 306 290 individuals with depression (67.4% female; mean [SD] age, 38.6 [11.9] years), 85 105 patients with bipolar disorder (59.6% female; mean [SD] age, 38.0 [11.6] years), and 71 299 patients with schizophrenia (45.1% female; mean [SD] age, 40.3 [12.2] years). After adjustment, analyses estimated a statistically significant, positive association between value-based payments and behavioral health visits for patients with depression (0.91 visits; 95% CI, 0.51-1.30) and bipolar disorder (1.01 visits; 95% CI, 0.22-1.79). There was no statistically significant changes to primary care visits for patients with depression and bipolar disorder, but value-based payments were associated with reductions in primary care visits for patients with schizophrenia (-1.31 visits; 95% CI, -2.51 to -0.12). In every diagnostic population, value-based payment was associated with significant reductions in mental health emergency department visits (population with depression: -0.01 visits [95% CI, -0.02 to -0.002]; population with bipolar disorder: -0.02 visits [95% CI, -0.05 to -0.001]; population with schizophrenia: -0.04 visits [95% CI, -0.07 to -0.01]).

Conclusions and Relevance

In this cohort study, Medicaid value-based payment reform was statistically significantly associated with an increase in behavioral health visits and a reduction in mental health emergency department visits for patients with mental illness. Medicaid value-based payment may be effective at altering health care utilization in patients with mental illness.

Real-world analysis of patients with haemophilia A and haemophilia A carriers in the United States: Demographics, clinical characteristics and costs

INTRODUCTION

Females with haemophilia A (HA [FHAs]) and HA carriers (HACs) have an increased risk of bleeding and complications compared to the general population.

AIM

To examine the characteristics, billed annualised bleed rates (ABRb ), costs and healthcare resource utilisation for males with HA (MHAs), FHAs and HACs in the United States.

METHODS

Data were extracted from the IBM® MarketScan® Research Databases (Commercial and Medicaid) for claims during the index period (July 2016 to September 2018) and analysed across MHAs, FHAs and HACs.

RESULTS

Dual diagnosis females (DDFs; both HA and HAC claims) were grouped as a separate cohort. MHAs were generally younger than females (all cohorts) by up to 19 years (Commercial) and 23 years (Medicaid). ABRb  >0 was more frequent in females. Factor VIII claims were higher for MHAs versus female cohorts. Joint-related health issues were reported for 24.4 and 25.6% (Commercial) and 29.3 and 26.6% (Medicaid) of MHAs and FHAs, respectively; lower rates were reported in the other two cohorts. Heavy menstrual bleeding claims occurred for approximately a fifth (Commercial) to a quarter (Medicaid) of female cohorts. All-cause emergency department and inpatient visits in FHAs and DDFs were similar to, or more frequent than, those in MHAs; bleed-related inpatient visits were infrequent. In MHAs (Commercial), mean all-cause total costs ($214,083) were higher than in FHAs ($40,388), HACs ($15,647) and DDFs ($28,320) with similar trends for Medicaid patients.

CONCLUSIONS

FHAs and HACs may be undermanaged and undertreated. Further research is needed to fully understand these cohorts' bleeding rates, long-term complications and costs.

Characteristics of Specialty Mental Health Provider Networks in Oregon Medicaid

OBJECTIVE

Provider networks for mental health are narrower than for other medical specialties. Providers' influence on access to care is potentially greater in Medicaid because enrollees are generally limited to contracted providers, without out-of-network options for nonemergency mental health care. The authors used claims-based metrics to examine variation in specialty mental health provider networks.

METHODS

In a cross-sectional analysis of 2018 Oregon Medicaid claims data, claims from adults ages 18-64 years (N=100,515) with a psychiatric diagnosis were identified. In-network providers were identified as those associated with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a health plan (coordinated care organization [CCO]) during the study period. Specialty mental health providers were categorized as prescribers (psychiatrists and mental health nurse practitioners) and nonprescribers (therapists, counselors, clinical nurse specialists, psychologists, and social workers). Measures of network composition, provider-to-population ratio, continuity, and concentration of care were calculated at the CCO level; the correlation between these measures was estimated to describe the degree to which they capture unique dimensions of provider networks.

RESULTS

Across 15 CCOs, the number of prescribing providers per 1,000 patients was relatively stable. CCOs that expanded their networks did so by increasing the number of nonprescribing providers. Moderately negative correlations were found between the nonprescriber provider-to-population ratio and proportions of visits with prescribers as well as with usual provider continuity.

CONCLUSIONS

This analysis advances future research and policy applications by offering a more nuanced view of provider network measurement and describing empirical variation across networks.

Interest in and Barriers to Telehealth Uptake in an Obstetric and Pediatric Medicaid Population

Telehealth has been shown to be generally well accepted by patients and physicians with an increasing desire and utilization of this practice since the COVID-19 pandemic. However, studies looking specifically at the United States’ low socioeconomic populations’ interest in and barriers to accessing Telehealth care are limited. In this study, we performed a survey to determine the interest of pediatric and obstetric patients on and the reasons they may or may not choose Telehealth visits in a practice that serves solely California Medicaid (Medi-Cal) patients. A total of 636 patients completed the questionnaire, 383 (60%) from an obstetric practice and 253 (40%) from a pediatric practice. The majority expressed that they were not interested in Telehealth (N=407, 64%), and 228 (36%) stated interest. Interest in Telehealth was related to domains of cost, access, and attitude (P<0.005 for each) for the entire sample. The highest scores (preference toward Telehealth) were noted in the domain of enjoyment; this suggests that both pediatric and obstetric patients may decline Telehealth in favor of in-person meetings simply because they like meeting with their provider. Despite readily available technology/access for Telehealth visits in low socioeconomic patients, in-person healthcare may be preferred by this patient population. In the world of changing healthcare delivery and epidemics, in-person visits are an important option for disadvantaged patients.

Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid

Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2 percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4 percent of mental health prescribers, 59.0 percent of mental health nonprescribers, and 54.0 percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion

Background

Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use.

Methods

Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression.

Results

Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001).

Conclusions

More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Emergency Department Visits Within 90 Days of Anterior Cruciate Ligament Reconstruction

Background:

Emergency department (ED) visits after orthopaedic surgery such as anterior cruciate ligament reconstruction (ACLR) affect patients and health care systems and should be better understood.

Purpose:

To determine the incidence, predictors, and reasons for ED visits within 90 days after ACLR.

Study Design:

Descriptive epidemiologic study.

Methods:

Patients who had undergone ACLR between 2010 and 2020 were identified in a national database, and 90-day ED visits, readmissions, risk factors, and primary diagnoses for visits were determined. One-year postoperative data were used to establish baseline weekly ED visits for the cohort. Patient age, sex, Elixhauser comorbidity index, region of the country (Northeast, Midwest, West, South), and insurance coverage (Medicare, Medicaid, and commercial) were extracted, and these variables were compared using univariate analysis and multivariate logistic regression.

Results:

Out of 81,179 patients, ED visits were identified for 6764 (8.3%), and readmissions were identified for 592 (0.7%). Overall, 5300 patients had 1 ED visit, 1020 patients had 2 visits, 275 patients had 3 visits, and 169 patients had ≥4 or more visits; visits occurred within 2 weeks of surgery 38% of the time. Notably, weekly visits returned to baseline at week 3. Independent predictors of ED utilization from multivariate analysis were insurance type (relative to commercial insurance: Medicaid [odds ratio [OR], 2.41; 95% CI, 2.23-2.60] and Medicare [OR, 1.38; 95% CI, 1.19-1.60]), higher Elixhauser comorbidity index (per 2-point increase: OR, 2.24; 95% CI, 2.18-2.29), younger age (per 10-year decrease: OR, 1.23; 95% CI, 1.21-1.24), female sex (OR, 1.05; 95% CI, 1.02-1.08), and region of the country (relative to the West: Midwest [OR, 1.33; 95% CI, 1.26-1.39], Northeast [OR, 1.24; 95% CI, 1.18-1.30], and South [OR, 1.17; 95% CI, 1.12-1.23]). In the first 2 weeks, 67.5% of ED visits were for issues involving the surgical site, most commonly surgical-site pain (29% of all visits). In the total 90-day period, 39.4% of visits involved the surgical site.

Conclusion:

Within 90 days of ACLR, >8% of patients visited the ED, while 0.7% were readmitted. ED visits increased in the first 2 postoperative weeks and returned to baseline rates around week 3. Within the first 2 weeks, two-thirds of visits involved the surgical site. Younger patients, patients with greater comorbidity burden, those in certain regions of the country, and those with Medicaid had greater odds of ED utilization.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting

OBJECTIVE

To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake.

STUDY DESIGN

Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits.

RESULTS

Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups.

CONCLUSIONS

Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.