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Philpot LM, Ramar P, Sanchez W, Ebbert JO, Loftus CG. Effect of Integrated Gastroenterology Specialists in a Primary Care Setting: a Retrospective Cohort Study. J Gen Intern Med 2021; 36:1279-1284. [PMID: 33219446 PMCID: PMC8131457 DOI: 10.1007/s11606-020-06346-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gastrointestinal (GI) complaints are common in primary care practices. The patient-centered medical home (PCMH) may improve coordination and collaboration by facilitating coordination across healthcare settings and within the community, enhancing communication between providers, and focusing on quality of care delivery. OBJECTIVE To investigate the effect of integrated community gastroenterology specialists (ICS-GI) model within a large primary care practice. DESIGN Retrospective cohort with propensity-matched historic controls. PATIENTS We identified 265 patients who had a visit with one of our ICS-GI specialists and matched them (1:2) to 530 similar patients seen prior to the implementation of the ICS-GI model. MAIN MEASURES Frequency of diagnostic testing for GI indications, visits to our outpatient GI referral practice, emergency department and hospital utilization, and time to access of specialty care for the whole population and by GI condition group. KEY RESULTS Patients seen in our ICS-GI model had similar outpatient care utilization (OR = 1.0, 95% CI 0.7-1.4, p = 0.90), were more likely to have visits in primary care (OR OR=1.5, 95% CI 1.1-2.2, p = 0.02), and were less likely to have visits to our GI outpatient referral practice (OR = 0.3, 95% CI 0.2-0.7, p < 0.0001). Condition-specific analyses show that all GI conditions experienced decreased visits to the outpatient GI referral practice outside of patients with GI neoplasm. Populations did not differ in emergency department, hospital, or diagnostic utilization. CONCLUSIONS We observed that an embedded specialist in primary care model is associated with improved care coordination without compromising patient safety. The PCMH could be extended to include subspecialty care.
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Affiliation(s)
- Lindsey M Philpot
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Rochester, MN, USA.
| | - Priya Ramar
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Rochester, MN, USA
| | - William Sanchez
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic , Rochester, MN, USA
| | - Jon O Ebbert
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Rochester, MN, USA.,Community Internal Medicine, Department of Medicine, Mayo Clinic , Rochester, MN, USA
| | - Conor G Loftus
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic , Rochester, MN, USA
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Soh JGS, Wong WP, Mukhopadhyay A, Quek SC, Tai BC. Predictors of 30-day unplanned hospital readmission among adult patients with diabetes mellitus: a systematic review with meta-analysis. BMJ Open Diabetes Res Care 2020; 8:8/1/e001227. [PMID: 32784248 PMCID: PMC7418689 DOI: 10.1136/bmjdrc-2020-001227] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023] Open
Abstract
Adult patients with diabetes mellitus (DM) represent one-fifth of all 30-day unplanned hospital readmissions but some may be preventable through continuity of care with better DM self-management. We aim to synthesize evidence concerning the association between 30-day unplanned hospital readmission and patient-related factors, insurance status, treatment and comorbidities in adult patients with DM. We searched full-text English language articles in three electronic databases (MEDLINE, Embase and CINAHL) without confining to a particular publication period or geographical area. Prospective and retrospective cohort and case-control studies which identified significant risk factors of 30-day unplanned hospital readmission were included, while interventional studies were excluded. The study participants were aged ≥18 years with either type 1 or 2 DM. The random effects model was used to quantify the overall effect of each factor. Twenty-three studies published between 1998 and 2018 met the selection criteria and 18 provided information for the meta-analysis. The data were collected within a period ranging from 1 to 15 years. Although patient-related factors such as age, gender and race were identified, comorbidities such as heart failure (OR=1.81, 95% CI 1.67 to 1.96) and renal disease (OR=1.69, 95% CI 1.34 to 2.12), as well as insulin therapy (OR=1.45, 95% CI 1.24 to 1.71) and insurance status (OR=1.41, 95% CI 1.22 to 1.63) were stronger predictors of 30-day unplanned hospital readmission. The findings may be used to target DM self-management education at vulnerable groups based on comorbidities, insurance type, and insulin therapy.
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Affiliation(s)
- Jade Gek Sang Soh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Health and Social Sciences, Singapore Institute of Technology, Singapore
| | - Wai Pong Wong
- Health and Social Sciences, Singapore Institute of Technology, Singapore
| | - Amartya Mukhopadhyay
- Respiratory and Critical Care Medicine, National University Hospital, Singapore
- National University Singapore, Yong Loo Lin School of Medicine, Singapore
| | - Swee Chye Quek
- Department of Paediatrics, National University Hospital, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Dilger BT, Gill MC, Lenhart JG, Garrison GM. Visit Entropy Associated with Diabetic Control Outcomes. J Am Board Fam Med 2019; 32:739-745. [PMID: 31506370 PMCID: PMC10725661 DOI: 10.3122/jabfm.2019.05.190026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/07/2019] [Accepted: 04/16/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Chronic diseases such as type 2 diabetes place a large burden on the health care system and are associated with increased morbidity and mortality. A team-based multidisciplinary approach that organizes care to improve chronic disease management may actually decrease traditional continuity of care metrics. Visit entropy (VE) provides a novel measure of care organization produced by team-based approaches. Higher VE, reflecting more disorganized care, has been associated with more hospital readmissions. We hypothesized that higher VE was also associated with reduced adherence to the D5 quality criteria. METHODS A retrospective study of 6590 adult diabetic patients in 5 established medical home practices was conducted. Multivariate logistic regression was used to determine if VE was associated with the dependent variable of D5 control. Separate models for usual provider continuity, continuity of care index, and sequence continuity were also constructed. RESULTS Less organized care with a higher VE was associated with decreased odds of D5 control (odds ratio = 0.88; 95% confidence interval, 0.80 to 0.97). The other continuity measures were not significant. Age, education level, and initial HgA1c were significant covariates, but sex, race, endocrine consults, and Charlson comorbidity were not significant. The Number Needed to be Exposed to more organized care to produce 1 more controlled diabetic was 32.5. CONCLUSIONS More organized care reflected by a lower VE is associated with improved odds of D5 diabetic control. VE represents a better measure of care organization in team-based medical home environments than traditional continuity of care metrics.
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Affiliation(s)
- Benjamin T Dilger
- From Department of Family Medicine, Mayo Clinic, Rochester, MN 55905 (BTD, MCG, GMG); Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 55703 (JGL)
| | - Margaret C Gill
- From Department of Family Medicine, Mayo Clinic, Rochester, MN 55905 (BTD, MCG, GMG); Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 55703 (JGL)
| | - Jill G Lenhart
- From Department of Family Medicine, Mayo Clinic, Rochester, MN 55905 (BTD, MCG, GMG); Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 55703 (JGL)
| | - Gregory M Garrison
- From Department of Family Medicine, Mayo Clinic, Rochester, MN 55905 (BTD, MCG, GMG); Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI 55703 (JGL).
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Styles E, Kidney RSM, Carlin C, Peterson K. Diabetes Treatment, Control, and Hospitalization Among Adults Aged 18 to 44 in Minnesota, 2013-2015. Prev Chronic Dis 2018; 15:E142. [PMID: 30468422 PMCID: PMC6266539 DOI: 10.5888/pcd15.180255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Of more than 300,000 adult Minnesotans who have received a diagnosis of diabetes, 16% are younger than 45 years; however, state diabetes surveillance data primarily describe older adults. National reports suggest adults younger than 45 years are less likely than older adults with diabetes to meet blood glucose (hemoglobin A1c [HbA1c]) goals. For this study on age-specific differences, we examined Minnesota data sets to determine if younger adults (ie, aged 18–44 y) are less likely to meet HbA1c goals and if hospitalization patterns differ from older adults (ie, aged 45–74 y) with diabetes. Methods We used Behavioral Risk Factor Surveillance System data to describe demographic characteristics and health behaviors of people with diabetes, clinical quality data to assess HbA1c levels, and hospital discharge data to assess reasons for hospitalization. Results Compared with older adults with diabetes, adults aged 18 to 44 were more likely to use tobacco and to have had depression; these younger adults were less likely to report having HbA1c levels checked in the last year. According to age-specific cutoffs, 40.5% of 18- to 44-year-olds met HbA1c goals versus 74.7% of people aged 45 to 64 and 84.4% of people aged 65 to 74. Hospitalization rates for diabetes as a primary cause were highest among 18- to 44-year-olds at 47 per 1,000 adults with diabetes, much higher than older ages. Hospitalization rates for mental health problems were higher among younger adults. Conclusion Our analysis confirmed that 18- to 44-year-olds with diabetes have poorer HbA1c control than older adults with diabetes. These results underscore the importance of age-based public health surveillance of diabetes. Age-stratified surveillance can inform efforts to monitor clinical care quality and to design clinical/public health interventions.
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Affiliation(s)
- Emily Styles
- Minnesota Department of Health, Division of Health Promotion and Chronic Disease, St. Paul, Minnesota
| | - Renée S M Kidney
- Minnesota Department of Health, Division of Health Promotion and Chronic Disease, St. Paul, Minnesota.,Minnesota Department of Health, Diabetes Unit, Division of Health Promotion and Chronic Disease, 85 E Seventh Pl, PO Box 64882, St. Paul, MN 55164.
| | - Caroline Carlin
- University of Minnesota, Medical School, Department of Family Medicine and Community Health, St. Paul, Minnesota
| | - Kevin Peterson
- University of Minnesota, Medical School, Department of Family Medicine and Community Health, St. Paul, Minnesota
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Moradi S, Sahebi Z, Ebrahim Valojerdi A, Rohani F, Ebrahimi H. The association between the number of office visits and the control of cardiovascular risk factors in Iranian patients with type2 diabetes. PLoS One 2017; 12:e0179190. [PMID: 28666031 PMCID: PMC5493291 DOI: 10.1371/journal.pone.0179190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 05/25/2017] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Patients with diabetes type2 should receive regular medical care. We aimed at investigating the association between the number of office visits and improvement of their cardiovascular-risk factors. METHODS Four hundred and ninety patients with type 2 diabetes mellitus who were followed in a tertiary center were enrolled in this longitudinal study. The minimum follow up period was 3 years. Patient data were extracted from manual or electronic records. RESULTS Sixty- four percent of cases were females, the mean age was 61 ± 12.45 years, and the mean disease duration was 6.5 ±7.9 years. The mean number of office visits was 2.69 ± 0.91 per year. Comparing the means of each of the cardio-vascular risk factors showed a significant decrease in all cardiovascular risk factors, while there was a significant weight gain over the same period. The association between changes in these parameters and the number of patients' office visits per year were not statistically significant. In patients with disease duration less than 5 years, each additional office visits by one visit per year was associated with a decrease in serum total cholesterol by 6.94 mg/dl. The mean number of office visits per year in patients older than 60 years old was more than younger patient (p = 0.001). CONCLUSION The decrease in the mean values of the investigated parameters was statistically significant between the first year of follow up and the following years. Yet, these changes were not related to the mean number of patients' office visits per year, which may reflect the poor compliance of patients to treatment regardless of the number of their office visits.
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Affiliation(s)
- Sedighe Moradi
- Endocrine research center, Institute of endocrinology and metabolism, Iran University of Medical Sciences, Tehran, Iran
- * E-mail:
| | - Zeinab Sahebi
- Endocrine research center, Institute of endocrinology and metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Ameneh Ebrahim Valojerdi
- Endocrine research center, Institute of endocrinology and metabolism, Division of biostatistics, Iran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Rohani
- Endocrine research center, Institute of endocrinology and metabolism, Research Center for Growth & development in Childhood and adolescence, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Ebrahimi
- Students’ scientific research center, Tehran University of Medical Sciences, Tehran, Iran
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Elrashidi MY, Philpot LM, Young NP, Ramar P, Swanson KM, McKie PM, Crane SJ, Ebbert JO. Effect of integrated community neurology on utilization, diagnostic testing, and access. Neurol Clin Pract 2017; 7:306-315. [PMID: 28840913 PMCID: PMC5566794 DOI: 10.1212/cpj.0000000000000378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: The primary care medical home (PCMH) aims to promote delivery of high-value health care. However, growing demand for specialists due to increasingly older adults with complicated and chronic disease necessitates development of novel care models that efficiently incorporate specialty expertise while maintaining coordination and continuity with the PCMH. We describe the effect of a model of integrated community neurology (ICN) on health care utilization, diagnostic testing, and access. Methods: This is a retrospective, matched case-control comparison of patients referred to ICN for a face-to-face consultation over a 12-month period. The control group consisted of propensity score–matched patients referred to a non-colocated neurology practice during the study period. Administrative data were used to assess for diagnostic testing, visit utilization, and patient time to appointment. Results: From October 1, 2014, to September 30, 2015, we identified 459 patients evaluated by ICN for a face-to-face visit and 459 matched controls evaluated by the non-colocated neurology practice. The majority of patients were Caucasian and female. ICN patients had lower odds of EMGs ordered (adjusted odds ratio [OR] 0.64; 95% confidence interval [CI] 0.46–0.89; p = 0.009), MRI brain (adjusted OR 0.60; 95% CI 0.45–0.79; p = 0.0004), or subsequent referral to outpatient neurology (adjusted OR 0.62; 95% CI 0.47–0.83; p = 0.001). ICN was not associated with an increase in emergency department visits, hospitalizations, or appointment wait time. Conclusions: The ICN model in a PCMH has the potential to reduce diagnostic testing and utilization.
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Affiliation(s)
- Muhamad Y Elrashidi
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Lindsey M Philpot
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Nathan P Young
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Priya Ramar
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Kristi M Swanson
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Paul M McKie
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Sarah J Crane
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
| | - Jon O Ebbert
- Division of Primary Care Internal Medicine, Department of Medicine (MYE, SJC, JOE), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (LMP, PR, KMS, JOE), Department of Neurology (NPY), and Department of Cardiovascular Diseases (PMM), Mayo Clinic, Rochester, MN
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