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Trivedi RB, Rossi FS, Javier SJ, Greene L, Singer SJ, Vanneman ME, Goldstein M, Zulman DM. Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. J Gen Intern Med 2022; 37:4071-4079. [PMID: 35869316 PMCID: PMC9708986 DOI: 10.1007/s11606-022-07705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.
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Affiliation(s)
- Ranak B Trivedi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA.
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Fernanda S Rossi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara J Singer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Goldstein
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, DC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Orme WH, Fowler JC, Bradshaw MR, Carlson M, Hadden J, Daniel J, Flack JN, Freeland D, Head J, Marder K, Weinstein BL, Madan A. Functional Rehabilitation: An Integrated Treatment Model for Patients With Complex Physical and Psychiatric Conditions. J Psychiatr Pract 2022; 28:193-202. [PMID: 35511095 DOI: 10.1097/pra.0000000000000623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The health care delivery system in the United States, structured to provide single-disease care, presents unique challenges for patients with complex physical and psychiatric comorbidities. Patients in these populations are often referred to multiple specialty clinics, encounter little continuity of care or collaboration among their providers, incur high health care costs, and experience poor treatment outcomes. Given these barriers, questions remain about the extent to which siloed and fragmented care, as opposed to the complex nature of the illnesses themselves, contribute to poor outcomes. If given the opportunity to receive well-integrated, consistent, and personalized care, can patients with historically difficult-to-treat comorbid medical and mental illnesses make progress? This article describes an innovative model of care called functional rehabilitation that is designed to address existing barriers in treatment. The functional rehabilitation program seeks to disrupt the escalating effects of interacting comorbidities by offering highly collaborative treatment from a small team of clinicians, personalized interventions using a shared decision-making framework, multipronged treatment options, colocation in a large hospital system, and significant 1:1 time with patients. The article includes a case example with longitudinal outcome data that illustrates how progress can be made with appropriate programmatic supports. Future research should examine the cost-effectiveness of this model of care.
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Messinger JC, Kesselheim AS, Vine SM, Fischer MA, Barenie RE. Associations Between Copays, Coverage Limits for Naloxone, and Prescribing in Medicaid. Subst Abuse 2022; 16:11782218221126972. [PMID: 36199698 PMCID: PMC9528040 DOI: 10.1177/11782218221126972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/28/2022] [Indexed: 11/25/2022]
Abstract
Aims: To describe naloxone dispensing in Medicaid fee-for-service (FFS) and examine relationships between copays and coverage limits for naloxone and its dispensing rates. Methods: Cross-sectional study using Medicaid FFS State Drug Utilization Data to quantify the use of naloxone in 2018. The primary outcomes of this study were the proportion of naloxone prescriptions relative to all prescriptions and all opioid prescriptions dispensed in each state. We obtained drug benefit design information from the Medicaid Behavioral Health Services Database. The primary analysis examined the influence of copays (yes/no), copay amounts, and coverage limits on medication dispensing using simple linear regression, excluding states with no measurable use or less than 5% Medicaid FFS. Results: We found substantial variability across 50 states and DC in the proportion of prescriptions dispensed for Narcan and generic naloxone. We found a positive relationship between copay and copay amount and dispensing of generic naloxone. However, a sensitivity analysis including the broadest possible cohort of states failed to confirm this relationship. We found no other relationships between copays or coverage limits and dispensing of any naloxone formulation. Conclusions: Substantial variation exists between the rates of naloxone dispensing across the US for Medicaid patients, but we did not find a meaningful relationship between plan design and dispensing. Whether drug benefit designs in Medicaid influence naloxone use requires further evaluation to avoid limiting access to this life-saving medication.
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Affiliation(s)
- John C Messinger
- Harvard Medical School, Boston, MA, USA
- Program on Regulation, Therapeutics, and Law (PORTAL), Boston, MA, USA
| | - Aaron S Kesselheim
- Harvard Medical School, Boston, MA, USA
- Program on Regulation, Therapeutics, and Law (PORTAL), Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Seanna M Vine
- Program on Regulation, Therapeutics, and Law (PORTAL), Boston, MA, USA
| | - Michael A Fischer
- Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Rachel E Barenie
- Program on Regulation, Therapeutics, and Law (PORTAL), Boston, MA, USA
- The University of Tennessee Health Science Center, Memphis, TN, USA
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Ganguli I, McGlave C, Rosenthal MB. National Trends and Outcomes Associated With Presence and Type of Usual Clinician Among Older Adults With Multimorbidity. JAMA Netw Open 2021; 4:e2134798. [PMID: 34846529 PMCID: PMC8634053 DOI: 10.1001/jamanetworkopen.2021.34798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults. OBJECTIVE To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending. DESIGN, SETTING, AND PARTICIPANTS This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021. MAIN OUTCOMES AND MEASURES Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics. RESULTS A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1). CONCLUSIONS AND RELEVANCE In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire McGlave
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Pinheiro LC, Reshetnyak E, Safford MM, Nanus D, Kern LM. Differences in ambulatory care fragmentation between cancer survivors and noncancer controls. Cancer 2020; 126:3094-3101. [PMID: 32286692 PMCID: PMC7275891 DOI: 10.1002/cncr.32869] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with chronic conditions are treated by many providers, which can increase the risk of communication gaps across providers and potential harm to patients. However, to the authors' knowledge, the extent of fragmented care among this population is unknown. In the current study, the authors sought to determine whether cancer survivors have more fragmented care than noncancer controls and to quantify the extent of fragmentation. METHODS Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study linked to Medicare claims were used. The authors included beneficiaries with continuous Part A and B coverage for 12 months at the time of their baseline REGARDS survey. The primary outcome of the current study was claims-based fragmentation over 12 months, which was calculated using the reversed Bice-Boxerman Index so a higher score reflected greater fragmentation. Unadjusted differences in fragmentation were compared between cancer survivors and controls. Beta regression models were used to estimate associations between cancer status and fragmentation, adjusting for potential confounders. RESULTS The authors included 4922 participants aged ≥65 years at baseline. Of these patients, approximately 21% were cancer survivors. Survivors had a median of 11 visits (interquartile range, 7-15 visits) with 5 providers compared with controls, who had a median of 9 visits (interquartile range, 6-14 visits) with 4 providers (P < .0001). Cancer survivors had significantly more fragmented care compared with controls (median reversed Bice-Boxerman Index, 0.80 vs 0.76; P < .0001). After adjusting for confounders, cancer survivors had an increased odds of having fragmented care (odds ratio, 1.08; 95% CI, 1.02-1.14). CONCLUSIONS Care fragmentation is more prevalent among cancer survivors compared with those without a history of cancer. Future studies should examine whether fragmentation puts survivors at risk of worse outcomes.
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Affiliation(s)
- Laura C Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Evgeniya Reshetnyak
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David Nanus
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lisa M Kern
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
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