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Chien AT, Spence SJ, Okumura MJ, Lu S, Chan CH, Houtrow AJ, Kuo DZ, Van Cleave JM, Shanske SA, Schuster MA, Kuhlthau KA, Toomey SL. Impairment Types and Combinations Among Adolescents and Young Adults with Disabilities: Colorado 2014-2018. Acad Pediatr 2024; 24:587-595. [PMID: 37925071 PMCID: PMC11056312 DOI: 10.1016/j.acap.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Understanding the types of functional challenges faced by adolescents and young adults with disabilities (AYA-WD) can help payers, clinicians, community-based service providers, and policymakers recognize and meet needs. This paper describes state-level prevalence rates for 1) AYA-WD overall and for 2) impairment types singly and in combinations; and 3) examines how rates may differ between those insured by Medicaid versus commercial insurance. METHODS This descriptive study uses Colorado's All Payer Claims Dataset 2014-2018 to identify insured 10- to 26-year-olds (Medicaid only: 333,931; commercially only: 392,444). It then applies the previously validated Children with Disabilities Algorithm (CWDA) and its companion, the Diagnosis-to-Impairment-Type Algorithm (DITA), to compare state-level prevalence rates by insurance source for disability overall and for each of five impairment types singly and in combination. RESULTS Disability prevalence was greater among the Medicaid-insured AYA-WD by +7.6% points (pp)-Medicaid: 11.9% (47,654/333,931), commercial: 4.3% (16,907/392,444). Most AYA-WD had a single impairment, but the prevalence of AYA-WD with two or more impairments was greater among the Medicaid-insured than the commercially insured (+9.9 pp; Medicaid: 33.5% [15,963/47,654], commercial: 23.7% [3992/16, 907]), as was the prevalence of impairment types that were physical (+6.7 pp; Medicaid: 54.7% [26,054/47,654], commercial: 48.0% [8121/16,907]); developmental (+4.1 pp; Medicaid: 35.4% [16,874/47,654], commercial: 31.3% [5290/16,907]); psychiatric (+6.7 pp; Medicaid 21.3% [10,175/47,654], commercial: 14.6% [2470/16,907]), and intellectual (+9.3 pp; Medicaid: 26.2% [12,501/47,654], commercial: 16.9% [2858/16,907]). CONCLUSIONS CWDA and DITA can be used to understand the rates at which impairment types and combinations occur in a population with childhood-onset disabilities.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics (AT Chien and SL Toomey), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (AT Chien and SL Toomey), Harvard Medical School, Boston, Mass.
| | - Sarah J Spence
- Department of Neurology (SJ Spence), Boston Children's Hospital, Boston, Mass
| | - Megumi J Okumura
- Division of General Pediatrics (MJ Okumura), University of California San Francisco Benioff Children's Hospital
| | - Sifan Lu
- College of Medicine, State University of New York-Downstate (S Lu), Brooklyn, NY
| | - Christina H Chan
- Biostatistics and Research Design Center (CH Chan), Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Mass
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation (AJ Houtrow), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Dennis Z Kuo
- Department of Pediatrics (DZ Kuo), University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jeanne M Van Cleave
- Department of Pediatrics (JM Van Cleave), Anschutz School of Medicine, University of Colorado, Aurora, CO
| | - Susan A Shanske
- Department of Social Work (SA Shanske), Boston Children's Hospital, Boston, Mass
| | - Mark A Schuster
- Kaiser Permanent Bernard J. Tyson School of Medicine (MA Schuster), Pasadena, Calif
| | - Karen A Kuhlthau
- Center for Child and Adolescent Health Research and Policy (KA Kuhlthau), Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics (AT Chien and SL Toomey), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (AT Chien and SL Toomey), Harvard Medical School, Boston, Mass
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Wisk LE, Garvey KC, Fu C, Landrum MB, Beaulieu ND, Chien AT. Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes. Acad Pediatr 2024; 24:59-67. [PMID: 37148967 DOI: 10.1016/j.acap.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types. METHODS Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes. RESULTS Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors). CONCLUSIONS Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.
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Affiliation(s)
- Lauren E Wisk
- Division of General Internal Medicine and Health Services Research (LE Wisk), David Geffen School of Medicine at the University of California, Los Angeles (UCLA); Department of Health Policy and Management (LE Wisk), Fielding School of Public Health at UCLA, Los Angeles, Calif.
| | | | - Christina Fu
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Mary Beth Landrum
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Nancy D Beaulieu
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Alyna T Chien
- Department of Pediatrics (AT Chien), Harvard Medical School, Boston, Mass; Division of General Pediatrics (AT Chien), Boston Children's Hospital, Mass
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Chien AT, Wisk LE, Beaulieu N, Houtrow AJ, Van Cleave J, Fu C, Cutler D, Landrum MB. Specialist use among privately insured children with disabilities. Health Serv Res 2023. [PMID: 37461185 DOI: 10.1111/1475-6773.14199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities. DATA SOURCES AND STUDY SETTING A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study. STUDY DESIGN This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns. DATA COLLECTION/EXTRACTION METHODS This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm. PRINCIPAL FINDINGS Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001. CONCLUSIONS Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren E Wisk
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nancy Beaulieu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeanne Van Cleave
- Department of Pediatrics, University of Colorado School of Medicine, Anshutz Medical Campus, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - David Cutler
- Department of Economics, Harvard University, National Bureau of Economic Research, Cambridge, Massachusetts, USA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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Liu L, Chien AT, Singer SJ. Enabling System Functionalities of Primary Care Practices for Team Dynamics in Transformation to Team-Based Care: A Qualitative Comparative Analysis (QCA). Healthcare (Basel) 2023; 11:2018. [PMID: 37510459 PMCID: PMC10379116 DOI: 10.3390/healthcare11142018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Team-based primary care has been shown to be an important initiative for transforming primary care to achieve whole-person care, enhance health equity, and reduce provider burnout. Organizational approaches have been explored to better implement team-based care but a thorough understanding of the role of system functions is lacking. We aimed to identify the combinations of system functionalities in primary care practices that most enable effective teamwork. We used a novel method, qualitative comparative analysis (QCA), to identify cross-case patterns in 19 primary care practices in the Harvard Academic Innovations Collaborative (AIC), an initiative for transforming primary care practices by establishing teams and implementing team-based care. QCA findings identified that primary care practices with strong team dynamics exhibited strengths in three operational care process functionalities, including management of abnormal test results, cancer screening and medication management for high-priority patients, care transitions, and in health information technology (HIT) functionality. HIT functionality alone was not sufficient to achieve the desired outcomes. System functionalities in a primary care practice that support physicians and their teams in identifying patients with urgent and complex acute illnesses requiring immediate response and care and overcoming barriers to collaboration within and across institutional settings, may be essential for sustaining strong team-based primary care.
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Affiliation(s)
- Lingrui Liu
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, Rockville, MD 20857, USA
| | - Alyna T. Chien
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA;
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Sara J. Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
- Stanford Graduate School of Business, Stanford, CA 94305, USA
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Pandey A, Eastman D, Hsu H, Kerrissey MJ, Rosenthal MB, Chien AT. Value-Based Purchasing Design And Effect: A Systematic Review And Analysis. Health Aff (Millwood) 2023; 42:813-821. [PMID: 37276480 PMCID: PMC11026120 DOI: 10.1377/hlthaff.2022.01455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.
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Affiliation(s)
| | | | - Heather Hsu
- Heather Hsu, Boston University, Boston, Massachusetts
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Smith AJB, Zhou RA, Sites E, Hallvik SE, Cutler DM, Chien AT. Childbirths at home and in birthing centers rose during COVID-19: Oregon 2020 vs prior years. Am J Obstet Gynecol 2022; 227:108-111. [PMID: 35305962 PMCID: PMC8925081 DOI: 10.1016/j.ajog.2022.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Anna Jo Bodurtha Smith
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania Health Systems, 600 N. Wolfe St., Philadelphia, PA 21287-1281.
| | | | | | | | - David M Cutler
- Department of Economics, Harvard University, Cambridge, MA
| | - Alyna T Chien
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Shields MC, Beaulieu ND, Lu S, Busch AB, Cutler DM, Chien AT. Increases in Inpatient Psychiatry Beds Operated by Systems, For-Profits, and Chains, 2010-2016. Psychiatr Serv 2022; 73:561-564. [PMID: 34433287 DOI: 10.1176/appi.ps.202100182] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study explored trends in the quantity of inpatient psychiatry beds and in facility characteristics. METHODS Using the National Bureau of Economic Research's Health Systems and Provider Database, the authors examined changes in the number of psychiatric facilities and beds, focusing on system ownership, profit status, facility type (general acute care versus freestanding), and affiliation with psychiatric hospital chains from 2010 to 2016. RESULTS The number of psychiatric beds was relatively unchanged from 2010 (N=112,182 beds) to 2016 (N=111,184). However, the number of beds operated by systems increased by 39.8% (N=15,803); for-profits, by 56.9% (N=8,572); and chains, by 16.7% (N=6,256). Net increases in beds were primarily concentrated in for-profit freestanding psychiatric hospitals. In 2016, most for-profit beds were part of chains (70.2%) and systems (61.3%). CONCLUSIONS Inpatient psychiatry has shifted toward increased ownership by systems, for-profits, and chains. Payers and policy makers should safeguard against profiteering, and future research should investigate the implications of these trends on quality of care.
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Affiliation(s)
- Morgan C Shields
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Nancy D Beaulieu
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Sifan Lu
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Alisa B Busch
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - David M Cutler
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
| | - Alyna T Chien
- Center for Mental Health, Department of Psychiatry, University of Pennsylvania, Philadelphia (Shields); Department of Health Care Policy (Beaulieu, Busch) and Department of Pediatrics (Lu, Chien), Harvard Medical School, Boston; Division of General Pediatrics, Boston Children's Hospital, Boston (Lu, Chien); McLean Hospital, Belmont, Massachusetts (Busch); National Bureau of Economic Research, Cambridge, Massachusetts (Cutler); Department of Economics, Harvard University, Cambridge Massachusetts (Cutler)
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Chien AT, Leyenaar J, Tomaino M, Woloshin S, Leininger L, Barnett ER, McLaren JL, Meara E. Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices. Ann Fam Med 2022; 20:42-50. [PMID: 35074767 PMCID: PMC8786429 DOI: 10.1370/afm.2759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/21/2021] [Accepted: 06/21/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - JoAnna Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Marisa Tomaino
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Steven Woloshin
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,The Lisa Schwartz Foundation for Truth in Medicine, Norwich, Vermont
| | - Lindsey Leininger
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire
| | - Erin R Barnett
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jennifer L McLaren
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ellen Meara
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire.,National Bureau of Economic Research, Cambridge, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Conroy K, Samnaliev M, Cheek S, Chien AT. Pediatric Primary Care-Based Social Needs Services and Health Care Utilization. Acad Pediatr 2021; 21:1331-1337. [PMID: 33516898 DOI: 10.1016/j.acap.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the relationship between use of primary care-based social needs services and subsequent utilization of ambulatory, emergency, and inpatient services. METHODS This retrospective 2012 to 2015 cohort study uses electronic medical record data from an academic pediatric primary care practice that screens universally for social needs and delivers services via in-house social work staff. Logistic regression (N = 7300) examines how patient characteristics relate to practice-based social service use. Negative binomial models with inverse probability of treatment weights (N = 4893) estimate adjusted incidence rate ratios for ambulatory, emergency, and inpatient service use among those who used social services compared to those who did not. RESULTS Forty-five percent of patients used primary care-based social needs services. This use was significantly greater among those with disabling or complex medical conditions than those without (adjusted odds ratio and 95% confidence interval (CI) of 9.81 [7.39-13.01] and 2.76 [2.44-3.13], respectively); those from low-income versus high-income backgrounds (1.40 [1.21-1.61]); and Blacks and Latinos than Whites (1.33 [1.09-1.62] and 1.29 [1.05-1.59], respectively). Patients who used social services subsequently utilized ambulatory, emergency, and inpatient services at significantly higher rates than those who did not (adjusted incidence rate ratios and 95% CI of 1.54 [1.45-1.63], 1.50 [1.36-1.65], and 3.23 [2.31-4.51], respectively). CONCLUSIONS Primary care-based social needs service use was associated with increased utilization of ambulatory services without reductions in emergency or inpatient admissions. This pattern suggests increased health care needs or access and could have payment model-dependent financial implications for practices.
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Affiliation(s)
- Kathleen Conroy
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass; Harvard Medical School (K Conroy, M Samnaliev, and AT Chien), Boston, Mass.
| | - Mihail Samnaliev
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass; Harvard Medical School (K Conroy, M Samnaliev, and AT Chien), Boston, Mass
| | - Sara Cheek
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass
| | - Alyna T Chien
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass; Harvard Medical School (K Conroy, M Samnaliev, and AT Chien), Boston, Mass
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Gourevitch RA, Chien AT, Bambury EA, Shah NT, Riedl C, Rosenthal MB, Sinaiko AD. Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance. JAMA Netw Open 2021; 4:e2121410. [PMID: 34406401 PMCID: PMC8374613 DOI: 10.1001/jamanetworkopen.2021.21410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending. OBJECTIVE To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending. DESIGN, SETTING, AND PARTICIPANTS This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606). EXPOSURES Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries. MAIN OUTCOMES AND MEASURES The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use. RESULTS The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers. CONCLUSIONS AND RELEVANCE The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.
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Affiliation(s)
| | - Alyna T. Chien
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A. Bambury
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Neel T. Shah
- Ariadne Labs, Boston, Massachusetts
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Anna D. Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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11
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Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of Pediatric Inpatient Services in the United States. Pediatrics 2021; 148:peds.2020-041723. [PMID: 34127553 PMCID: PMC8642812 DOI: 10.1542/peds.2020-041723] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States. METHODS We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model. RESULTS Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing. CONCLUSIONS Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.
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Affiliation(s)
- Anna M. Cushing
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Emily M. Bucholz
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Alyna T. Chien
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Daniel A. Rauch
- Division of Pediatric Hospital Medicine, Tufts Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts
| | - Kenneth A. Michelson
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
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12
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Chien AT, Pandey A, Lu S, Bucholz EM, Toomey SL, Cutler DM, Beaulieu ND. Pediatric Hospital Services Within a One-Hour Drive: A National Study. Pediatrics 2020; 146:peds.2020-1724. [PMID: 33127850 DOI: 10.1542/peds.2020-1724] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Departments of Pediatrics and .,Departments of Pediatrics and
| | - Abhinav Pandey
- Division of General Pediatrics, Departments of Pediatrics and.,Departments of Pediatrics and
| | - Sifan Lu
- Division of General Pediatrics, Departments of Pediatrics and.,Departments of Pediatrics and
| | - Emily M Bucholz
- Departments of Pediatrics and.,Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Sara L Toomey
- Division of General Pediatrics, Departments of Pediatrics and.,Departments of Pediatrics and
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts; and.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Nancy D Beaulieu
- Health Care Policy, Harvard Medical School, Boston, Massachusetts
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13
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Chien AT. Did the Rising Tide Float All Boats? J Pediatr 2020; 226:9-10. [PMID: 32615195 DOI: 10.1016/j.jpeds.2020.04.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Pediatrics Harvard Medical School, Boston, Massachusetts.
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14
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Nguyen KH, Chien AT, Meyers DJ, Li Z, Singer SJ, Rosenthal MB. Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates. Inquiry 2020; 57:46958020952911. [PMID: 32844691 PMCID: PMC7453437 DOI: 10.1177/0046958020952911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.
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Affiliation(s)
- Kevin H Nguyen
- Brown University School of Public Health, Providence, RI, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA.,Boston Children's Hospital, Boston, MA, USA
| | - David J Meyers
- Brown University School of Public Health, Providence, RI, USA
| | - Zhonghe Li
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sara J Singer
- Stanford University School of Medicine, Stanford, CA, USA.,Stanford Graduate School of Business, Stanford, CA, USA
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15
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Rodin D, Chien AT, Ellimoottil C, Nguyen PL, Kakani P, Mossanen M, Rosenthal M, Landrum MB, Sinaiko AD. Physician and facility drivers of spending variation in locoregional prostate cancer. Cancer 2020; 126:1622-1631. [PMID: 31977081 DOI: 10.1002/cncr.32719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/11/2019] [Accepted: 12/07/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown. METHODS In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee-for-service and were included in the Surveillance, Epidemiology, and End Results-Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient-level spending, and differences between those that were high-spending and low-spending were examined. RESULTS Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists. CONCLUSIONS Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alyna T Chien
- Department of Medicine, Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Pragya Kakani
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Matthew Mossanen
- Division of Urology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Meredith Rosenthal
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Anna D Sinaiko
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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16
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Bucholz EM, Toomey SL, Butala NM, Chien AT, Yeh RW, Schuster MA. Suitability of elderly adult hospital readmission rates for profiling readmissions in younger adult and pediatric populations. Health Serv Res 2020; 55:277-287. [PMID: 32037552 DOI: 10.1111/1475-6773.13269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To determine the correlation between hospital 30-day risk-standardized readmission rates (RSRRs) in elderly adults and those in nonelderly adults and children. DATA SOURCES/STUDY SETTING US hospitals (n = 1760 hospitals admitting adult patients and 235 hospitals admitting both adult and pediatric patients) in the 2013-2014 Nationwide Readmissions Database. STUDY DESIGN Cross-sectional analysis comparing 30-day RSRRs for elderly adult (≥65 years), middle-aged adult (40-64 years), young adult (18-39 years), and pediatric (1-17 years) patients. PRINCIPAL FINDINGS Hospital elderly adult RSRRs were strongly correlated with middle-aged adult RSRRs (Pearson R2 .69 [95% confidence interval (CI) 0.66-0.71]), moderately correlated with young adult RSRRs (Pearson R2 .44 [95% CI 0.40-0.47]), and weakly correlated with pediatric RSRRs (Pearson R2 .28 [95% CI 0.17-0.38]). Nearly identical findings were observed with measures of interquartile agreement and Kappa statistics. This stepwise relationship between age and strength of correlation was consistent across every hospital characteristic. CONCLUSIONS Hospital readmission rates in elderly adults, which are currently used for public reporting and hospital comparisons, may reflect broader hospital readmission performance in middle-aged and young adult populations; however, they are not reflective of hospital performance in pediatric populations.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara L Toomey
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Neel M Butala
- Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alyna T Chien
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Robert W Yeh
- Department of Cardiology, Beth Israel Deaconess Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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17
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Brooks JV, Chien AT, Singer SJ, Peters AS. Intentional or Not: Teamwork Learning at Primary Care Clinics. Med Sci Educ 2019; 29:969-975. [PMID: 34457573 PMCID: PMC8368961 DOI: 10.1007/s40670-019-00784-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents' learning has not been described. This study aimed to understand the role of teamwork in residents' learning during and after the establishment of teams. METHODS Interviews with 37 primary care residents addressed their experiences at outpatient clinic, including their perceptions about whether team-based care affected their educational experience. Using qualitative thematic analysis, transcripts were coded to identify themes about teamwork and learning, both positive and negative. RESULTS Residents described learning both about and through teamwork at continuity clinic, despite variation in the speed and extent of initial integration into teams. As residents learned how to work on a team, they realized the importance of face-to-face time together and trusting one another. Team members also taught residents about the clinical system and social aspects of patient care, as well as some procedural skills, which led them to understand how teamwork can improve patient care and efficiency. Finally, residents learned, through both optimal and suboptimal first-hand team experiences, to see team-based care as a model for future primary care practice. CONCLUSIONS While integrating residents into primary care teams, educators should consider the potential value of teamwork as an intentional learning method. Team members, beyond the preceptor, can offer valuable instruction, and team-based workplace learning prepares residents to use teamwork to optimize care for patients.
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Affiliation(s)
- Joanna Veazey Brooks
- Department of Population Health, University of Kansas School of Medicine, 3901 Rainbow Blvd, Mail Stop 3044, Kansas City, KS 66160 USA
| | - Alyna T. Chien
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, USA
| | - Sara J. Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
| | - Antoinette S. Peters
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, USA
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18
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Pace LE, Percac-Lima S, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:1146-1153. [PMID: 31011969 PMCID: PMC6614558 DOI: 10.1007/s11606-019-05003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 11/06/2018] [Accepted: 03/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions. OBJECTIVES To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion. DESIGN A retrospective cohort study using explicit chart abstraction methods. PARTICIPANTS Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016. MAIN MEASURES Rates and timing of test ordering and completion and patterns of visits and communications. KEY RESULTS At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists. LIMITATIONS The study relied on documented care, and findings may be most generalizable to academically affiliated institutions. CONCLUSIONS Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.
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Affiliation(s)
- Lydia E Pace
- Harvard Medical School, Boston, MA, USA.
- Division of Women's Health, Brigham and Women's Hospital, OBC 3-34, 75 Francis Street, Boston, MA, 02115-9950, USA.
| | - Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanford University School of Medicine and Graduate School of Business, Stanford, CA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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Abstract
BACKGROUND AND OBJECTIVES Youth with chronic physical conditions (CPCs) may be at greater risk for developing chronic mental health conditions (MHCs), and limitations in the ability to engage in developmentally appropriate activities may contribute to the risk of MHCs among youth with CPCs. We compared the risk of incident MHCs in youth with and without CPCs and explored whether activity limitations contribute to any such association. METHODS The 2003-2014 Medical Expenditure Panel Survey provided a nationally representative cohort of 48 572 US youth aged 6 to 25 years. We calculated the 2-year cumulative incidence of MHCs overall and by baseline CPC status. Cox proportional hazard models were used to estimate the association between CPCs and incident MHCs, adjusting for sociodemographic characteristics. Stepwise models and the Sobel test evaluated activity limitations as a mediator of this relationship. RESULTS The 2-year cumulative incidence of MHCs was 7.8% overall, 11.5% in youth with CPCs (14.7% of sample), and 7.1% in those without. The adjusted risk of incident MHCs was 51% greater (adjusted hazard ratio 1.51; 95% confidence interval 1.30-1.74) in youth with CPCs compared with those without. Activity limitations mediated 13.5% of this relationship (P < .001). CONCLUSIONS This nationally representative cohort study supports the hypotheses that youth with CPCs have increased risk for MHCs and that activity limitations may play a role in MHC development. Youth with CPCs may benefit from services to bolster their ability to participate in developmentally important activities and to detect and treat new onset MHCs.
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Affiliation(s)
- John S Adams
- Department of Pediatrics, Cambridge Health Alliance, Cambridge, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Alyna T Chien
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Lauren E Wisk
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
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20
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Chien AT, Toomey SL, Kuo DZ, Van Cleave J, Houtrow AJ, Okumura MJ, Westfall MY, Petty CR, Quinn JA, Kuhlthau KA, Schuster MA. Care Quality and Spending Among Commercially Insured Children With Disabilities. Acad Pediatr 2019; 19:291-299. [PMID: 29932986 DOI: 10.1016/j.acap.2018.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 04/16/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities; children with chronic conditions that are not complex; and children without disabling, complex, or chronic conditions. METHODS This cross-sectional study comprised 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1 to 19years old during 2008 to 2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD subgroups. We used 14 validated or National Quality Forum-endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components. RESULTS CWD constituted 4.5% of all enrollees. Care quality for CWD was between 11% and 59% for 8 of 14 quality measures and >80% for the 6 remaining measures and was generally comparable to that for non-CWD subgroups. Annual plan spending among CWD was a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean and median values were higher than for all other groups as well. CONCLUSIONS CWD were prevalent in our commercially insured population. CWD experienced suboptimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School.
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School
| | - Dennis Z Kuo
- Division of General Pediatrics, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY
| | - Jeanne Van Cleave
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Anschutz Medical Campus , Aurora, Colo
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine , Pittsburgh, Pa
| | - Megumi J Okumura
- Division of General Pediatrics, University of California San Francisco Benioff Children's Hospital; Division of General Pediatrics, Department of Pediatrics, University of California San Francisco School of Medicine , San Francisco
| | | | - Carter R Petty
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital
| | | | - Karen A Kuhlthau
- Department of Pediatrics, Harvard Medical School; Division of General Academic Pediatrics, Massachusetts General Hospital for Children , Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School; Kaiser Permanente School of Medicine , Pasadena, Calif
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21
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Meyers DJ, Chien AT, Nguyen KH, Li Z, Singer SJ, Rosenthal MB. Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients. JAMA Intern Med 2019; 179:54-61. [PMID: 30476951 PMCID: PMC6583420 DOI: 10.1001/jamainternmed.2018.5118] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions. OBJECTIVE To evaluate the association of establishing team-based primary care with patient health care use and costs. DESIGN, SETTING, AND PARTICIPANTS We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018. EXPOSURES Practices participated in a 4-year learning collaborative that created and supported team-based primary care. MAIN OUTCOMES AND MEASURES Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care. RESULTS Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02). CONCLUSIONS AND RELEVANCE While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.
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Affiliation(s)
- David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Alyna T Chien
- Department of Pediatrics, Harvard Medical School, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin H Nguyen
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Zhonghe Li
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Abstract
BACKGROUND There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care. OBJECTIVE To examine how team dynamics relate to perceptions of safety culture in primary care and whether care coordination plays an intermediating role. RESEARCH DESIGN This is a cross-sectional survey study with 63% response (n = 1082). SUBJECTS The study participants were attending clinicians, resident physicians and other staff who interacted with patients from 19 primary care practices affiliated with Harvard Medical School. MAIN MEASURES Three domains corresponding with our main measures: team dynamics, care coordination and safety culture. All items were measured on a 5-point Likert scale. We used linear regression clustered by practice site to assess the relationship between team dynamics and perceptions of safety culture. We also performed a mediation analysis to determine the extent to which care coordination explains the relationship between perceptions of team dynamics and of safety culture. RESULTS For every 1-point increase in overall team dynamics, there was a 0.76-point increase in perception of safety culture [95% confidence interval (CI) 0.70-0.82, P < 0.001]. Care coordination mediated the relationship between team dynamics and the perception of safety culture. CONCLUSION Our findings suggest there is a relationship between team dynamics, care coordination and perceptions of patient safety in a primary care setting. To make patients safer, we may need to pay more attention to how primary care providers work together to coordinate care.
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Affiliation(s)
- Karen J Blumenthal
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alyna T Chien
- Department of Pediatrics, Harvard Medical School, Boston MA, USA.,Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Department of Organizational Behavior, Stanford University Graduate School of Business, Stanford, CA, USA
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Sinaiko AD, Chien AT, Hassett MJ, Kakani P, Rodin D, Meyers DJ, Fraile B, Rosenthal MB, Landrum MB. What drives variation in spending for breast cancer patients within geographic regions? Health Serv Res 2018; 54:97-105. [PMID: 30318592 DOI: 10.1111/1475-6773.13068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 08/09/2018] [Accepted: 08/30/2018] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To estimate and describe factors driving variation in spending for breast cancer patients within geographic region. DATA SOURCE Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2009-2013. STUDY DESIGN The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient-level and physician-level variance in spending. Services associated with high spending physicians were estimated using linear regression. DATA EXTRACTION METHOD A total of 20 818 women with a breast cancer diagnosis in 2010-2011. PRINCIPAL FINDINGS We observed substantial between-patient and between-provider variation in spending following diagnosis and at the end-of-life. Immediately following diagnosis, 48% of between-patient and 31% of between-physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end-of-life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days. CONCLUSIONS Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient-doctor discussions.
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Affiliation(s)
- Anna D Sinaiko
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Alyna T Chien
- Harvard Medical School, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Michael J Hassett
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Belen Fraile
- Department of Finance, Value and Population Health Management, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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24
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Brooks JV, Singer SJ, Rosenthal M, Chien AT, Peters AS. Feeling inadequate: Residents' stress and learning at primary care clinics in the United States. Med Teach 2018; 40:920-927. [PMID: 29228837 DOI: 10.1080/0142159x.2017.1413236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Educators hope that residents' experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure. METHODS In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data. RESULTS 73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents' comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors. CONCLUSIONS Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents' attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.
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Affiliation(s)
- Joanna Veazey Brooks
- a Department of Health Policy & Management , University of Kansas School of Medicine , Kansas City , KS , USA
| | - Sara J Singer
- b Department of Health Policy & Management , Harvard Chan School of Public Health , Boston , MA , USA
| | - Meredith Rosenthal
- b Department of Health Policy & Management , Harvard Chan School of Public Health , Boston , MA , USA
| | - Alyna T Chien
- c Department of Medicine, Division of General Pediatrics , Boston Children's Hospital and Harvard Medical School , Boston , MA , USA
| | - Antoinette S Peters
- d Department of Population Medicine , Harvard Pilgrim Health Care Institute and Harvard Medical School , Boston , MA , USA
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25
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Correnti CM, Klein DJ, Elliott MN, Veledar E, Saraiya M, Chien AT, Schwebel DC, Mrug S, Tortolero SR, Cuccaro PM, Schuster MA, Chen SC. Racial disparities in fifth-grade sun protection: Evidence from the Healthy Passages study. Pediatr Dermatol 2018; 35:588-596. [PMID: 29962040 PMCID: PMC6168341 DOI: 10.1111/pde.13550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. METHODS Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. RESULTS Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P < .001), with the greatest association with flossing teeth (odds ratio = 2.41, 95% confidence interval = 1.86-3.13, P < .001). Factors for lower odds of sunscreen adherence included being male and non-Hispanic black or Hispanic and having lower socioeconomic status. School-based sun-safety education and involvement in team sports were not significant factors. CONCLUSION Our data confirm low use of sun protection among fifth-graders. Future research should explore how public health success in increasing prevalence of other preventive health behaviors may be applied to enhance sun protection messages. Identifying risk factors for poor adherence enables providers to target patients who need more education. Improving educational policies and content in schools may be an effective way to address sun safety.
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Affiliation(s)
- Christina M. Correnti
- Department of Dermatology, University of Maryland School of Medicine,
Baltimore, Maryland
- Department of Dermatology, Emory University School of Medicine, Atlanta,
Georgia
| | - David J. Klein
- Division of General Pediatrics, Boston Children’s Hospital, Boston,
Massachusetts
- RAND Corporation, Santa Monica, California
| | | | - Emir Veledar
- Department of Dermatology, Emory University School of Medicine, Atlanta,
Georgia
| | - Mona Saraiya
- Division of Cancer Prevention and Control’s Epidemiology and Applied
Research Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alyna T. Chien
- Division of General Pediatrics, Boston Children’s Hospital, Boston,
Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston,
Massachusetts
| | - David C. Schwebel
- Department of Psychology, University of Alabama at Birmingham, Alabama
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Alabama
| | - Susan R. Tortolero
- Center for Health Promotion and Prevention Research, University of Texas
Health Science Center School of Public Health, Houston, Texas
| | - Paula M. Cuccaro
- Center for Health Promotion and Prevention Research, University of Texas
Health Science Center School of Public Health, Houston, Texas
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston,
Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston,
Massachusetts
- Kaiser Permanente School of Medicine, Pasadena, California
| | - Suephy C. Chen
- Department of Dermatology, Emory University School of Medicine, Atlanta,
Georgia
- Division of Dermatology, Atlanta Veterans Affairs Medical Center, Atlanta,
Georgia
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26
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Krikorian ML, Growdon AS, Chien AT. Assessment of Hospitalist-Subspecialist Agreement About Who Should Be in Charge and Comparison With Actual Assignment Practices. Hosp Pediatr 2018; 8:479-485. [PMID: 30049683 DOI: 10.1542/hpeds.2017-0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND A key juncture in patient hospitalization is determining which type of physician should be primarily responsible for directing treatment. We (1) examine the frequency hospitalists and subspecialists agree on preferred assignments and (2) compare preferred assignment with actual assignment. METHODS Using a mixed methods approach, we first surveyed 66 physicians in 8 specialties about hospitalist assignments versus subspecialist assignments for 176 diagnoses at an academic children's hospital. Agreement was calculated by using the interrater reliability coefficient, Pi . We subsequently compared survey responses to actual hospitalization data from January 2009 to August 2015. RESULTS Specialty and physician response rates were 100% and 44%, respectively. For preferred assignment among hospitalists and specialists, some diagnoses (eg, gastroesophageal reflux, syncope) experienced high agreement (π = 0.714-1.000); other diagnoses (eg, Guillain-Barre, encephalopathy) had less agreement (π = 0.000-0.600). Hematologists and oncologists agreed among themselves most frequently (73%); endocrinologists agreed among themselves least frequently (9%). Perceptions of agreement were often higher than actual survey results. Of the 25 highest volume diagnoses, 7 were conditions with consensus (Pi ≥ 0.6) about assignment, and of those conditions, 6 were assigned to a subspecialist at least 50% of the time, although consensus indicated a hospitalist should have been assigned (1597 hospitalizations). CONCLUSIONS This is the first study used to analyze preferences of hospitalist-subspecialist assignment and show variation from actual practice. Although physicians assessed the same patient information, agreement on preferred assignment varied noticeably across diagnoses and subspecialties. With our results, we reveal potential challenges in integrating hospitalists with other specialists and provide evidence for standardizing certain aspects of physician roles.
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Affiliation(s)
- Mariam L Krikorian
- Department of Health Policy and Management, T.H. Chan School of Public Health Harvard University, Boston, Massachusetts; and
| | - Amanda S Growdon
- Department of General Pediatrics, Boston Children's Hospital, and Harvard University Medical School, Boston, Massachusetts
| | - Alyna T Chien
- Department of General Pediatrics, Boston Children's Hospital, and Harvard University Medical School, Boston, Massachusetts
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27
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Smith AJ, Turner EL, Kinra S, Bodurtha JN, Chien AT. A Cost Analysis of Universal versus Targeted Cholesterol Screening in Pediatrics. J Pediatr 2018; 196:201-207.e2. [PMID: 29703359 DOI: 10.1016/j.jpeds.2018.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/16/2017] [Accepted: 01/10/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To compare the number of children needed to screen to identify a case of childhood dyslipidemia and estimate costs under universal vs targeted screening approaches. STUDY DESIGN We constructed a decision-analytic model comparing the health system costs of universal vs targeted screening for hyperlipidemia in US children aged 10 years over a 1-year time horizon. Targeted screening was defined by family history: dyslipidemia in a parent and/or early cardiovascular disease in a first-degree relative. Prevalence of any hyperlipidemia (low-density lipoprotein [LDL] ≥130 mg/dL) and severe hyperlipidemia (LDL ≥190 mg/dL or LDL ≥160 mg/dL with family history) were obtained from published estimates. Costs were estimated from the 2016 Maryland Medicaid fee schedule. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost per case detected. RESULTS For universal screening, the number needed to screen to identify 1 case was 12 for any hyperlipidemia and 111 for severe hyperlipidemia. For targeted screening, the number needed to screen was 7 for any hyperlipidemia and 49 for severe hyperlipidemia. The incremental cost per case detected for universal compared with targeted screening was $1980 for any hyperlipidemia and $32 170 for severe hyperlipidemia. CONCLUSIONS Our model suggests that universal cholesterol screening detects hyperlipidemia at a low cost per case, but may not be the most cost-efficient way to identify children with severe hyperlipidemia who are most likely to benefit from treatment.
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Affiliation(s)
- Anna Jo Smith
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke Global Health Institute, Duke University, Durham, NC
| | - Sanjay Kinra
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Joann N Bodurtha
- McKusick-Nathans Institute of Genetic Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alyna T Chien
- Harvard Medical School, Boston, MA; Department of General Pediatrics, Boston Children's Hospital, Boston, MA
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Percac-Lima S, Pace LE, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding. J Gen Intern Med 2018; 33:415-422. [PMID: 29302885 PMCID: PMC5880768 DOI: 10.1007/s11606-017-4273-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations. DESIGN Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96). CONCLUSIONS Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.
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Affiliation(s)
- Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Lydia E Pace
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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29
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Chien AT, Newhouse JP, Iezzoni LI, Petty CR, Normand SLT, Schuster MA. Socioeconomic Background and Commercial Health Plan Spending. Pediatrics 2017; 140:peds.2017-1640. [PMID: 28974535 PMCID: PMC5654394 DOI: 10.1542/peds.2017-1640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees' socioeconomic background is controversial. METHODS We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008-2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees' socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds. RESULTS Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees. CONCLUSIONS Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.
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Affiliation(s)
- Alyna T. Chien
- Division of General Pediatrics, Department of Medicine and,Departments of Pediatrics
| | - Joseph P. Newhouse
- Health Care Policy, and,Departments of Health Policy and Management and,John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts;,National Bureau of Economic Research, Cambridge, Massachusetts; and
| | - Lisa I. Iezzoni
- Medicine, Harvard Medical School,,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Carter R. Petty
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine and,Departments of Pediatrics
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30
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Affiliation(s)
- Anna D Sinaiko
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Alyna T Chien
- Harvard Medical School, Boston, Massachusetts3Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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31
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Chien AT, Kuhlthau KA, Toomey SL, Quinn JA, Okumura MJ, Kuo DZ, Houtrow AJ, Van Cleave J, Landrum MB, Jang J, Janmey I, Furdyna MJ, Schuster MA. Quality of Primary Care for Children With Disabilities Enrolled in Medicaid. Acad Pediatr 2017; 17:443-449. [PMID: 28286057 DOI: 10.1016/j.acap.2016.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/28/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD. METHODS Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters. RESULTS CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (-3.4%) and no emergency department visits for asthma (-5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD. CONCLUSIONS One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Karen A Kuhlthau
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Megumi J Okumura
- Division of General Pediatrics, University of California San Francisco Beinoff Children's Hospital, San Francisco, Calif; Division of General Pediatrics, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif
| | - Dennis Z Kuo
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Ark
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Jeanne Van Cleave
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Jisun Jang
- The Clinical Research Center, Boston Children's Hospital, Boston, Mass
| | - Isabel Janmey
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michael J Furdyna
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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Chien AT, Ganeshan S, Schuster MA, Lehmann LS, Hatfield LA, Koplan KE, Petty CR, Sinaiko AD, Sequist TD, Rosenthal MB. The Effect of Price Information on the Ordering of Images and Procedures. Pediatrics 2017; 139:peds.2016-1507. [PMID: 28087684 DOI: 10.1542/peds.2016-1507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/external median prices, on how often pediatric-focused and adult-oriented clinicians (most frequently general pediatricians and adult specialists caring for pediatric-aged patients, respectively) order imaging studies and procedures for 0- to 21-year-olds. METHODS In January 2014, we randomized 227 pediatric-focused and 279 adult-oriented clinicians to 1 of 3 study arms: Control (no price display), Single Median Price, or Paired Internal/External Median Prices (both with price display in the ordering screen of electronic health record). We used 1-way analysis of variance and paired t tests to examine how frequently clinicians (1) placed orders and (2) designated tests to be completed internally within an accountable care organization. RESULTS For pediatric-focused clinicians, there was no significant difference in the rates at which orders were placed or designated to be completed internally across the study arms. For adult-oriented clinicians caring for children and adolescents, however, those in the Single Price and Paired Price arms placed orders at significantly higher rates than those in the Control group (Control 3.2 [SD 4.8], Single Price 6.2 [SD 6.8], P < .001 and Paired Prices 5.2 [SD 7.9], P = .04). The rate at which adult-oriented clinicians designated tests to be completed internally was not significantly different across arms. CONCLUSIONS The effect of price information on ordering rates appears to depend on whether the clinician is pediatric-focused or adult-oriented.
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Affiliation(s)
- Alyna T Chien
- Harvard Medical School, Boston, Massachusetts; .,Division of General Pediatrics, Department of Medicine, and
| | | | - Mark A Schuster
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Department of Medicine, and
| | - Lisa Soleymani Lehmann
- Harvard Medical School, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, District of Columbia
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Carter R Petty
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Anna D Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D Sequist
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Partners Healthcare System, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Chien AT, Schiavoni KH, Sprecher E, Landon BE, McNeil BJ, Chernew ME, Schuster MA. How Accountable Care Organizations Responded to Pediatric Incentives in the Alternative Quality Contract. Acad Pediatr 2016; 16:200-7. [PMID: 26523636 DOI: 10.1016/j.acap.2015.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/24/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE From 2009 to 2010, 12 accountable care organizations (ACOs) entered into the alternative quality contract (AQC), BlueCross BlueShield of Massachusetts's global payment arrangement. The AQC included 6 outpatient pediatric quality measures among 64 total measures tied to pay-for-performance bonuses and incorporated pediatric populations in their global budgets. We characterized the pediatric infrastructure of these adult-oriented ACOs and obtained leaders' perspectives on their ACOs' response to pediatric incentives. METHODS We used Massachusetts Health Quality Partners and American Hospital Association Survey data to characterize ACOs' pediatric infrastructure as extremely limited, basic, and substantial on the basis of the extent of pediatric primary care, outpatient specialist, and inpatient services. After ACOs had 16 to 43 months of experience with the AQC, we interviewed 22 leaders to gain insight into how organizations made changes to improve pediatric care quality, tried to reduce pediatric spending, and addressed care for children with special health care needs. RESULTS ACOs' pediatric infrastructure ranged from extremely limited (eg, no general pediatricians in their primary care workforce) to substantial (eg, 42% of workforce was general pediatricians). Most leaders reported intensifying their pediatric quality improvement efforts and witnessing changes in quality metrics; most also investigated pediatric spending patterns but struggled to change patients' utilization patterns. All reported that the AQC did little to incentivize care for children with special health care needs and that future incentive programs should include this population. CONCLUSIONS Although ACOs involved in the AQC were adult-oriented, most augmented their pediatric quality improvement and spending reduction efforts when faced with pediatric incentives.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Katherine H Schiavoni
- Harvard Medical School, Boston, Mass; Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Mass
| | - Eli Sprecher
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Barbara J McNeil
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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Chien AT, Kuhlthau KA, Toomey SL, Quinn JA, Houtrow AJ, Kuo DZ, Okumura MJ, Van Cleave JM, Johnson CK, Mahoney LL, Martin J, Landrum MB, Schuster MA. Development of the Children With Disabilities Algorithm. Pediatrics 2015; 136:e871-8. [PMID: 26416938 DOI: 10.1542/peds.2015-0228] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A major impediment to understanding quality of care for children with disabilities (CWD) is the lack of a method for identifying this group in claims databases. We developed the CWD algorithm (CWDA), which uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify CWD. METHODS We conducted a cross-sectional study that (1) ensured each of the 14,567 codes within the 2012 ICD-9-CM codebook was independently classified by 3 to 9 pediatricians based on the code's likelihood of indicating CWD and (2) triangulated the resulting CWDA against parent and physician assessment of children's disability status by using survey and chart abstraction, respectively. Eight fellowship-trained general pediatricians and 42 subspecialists from across the United States participated in the code classification. Parents of 128 children from a large, free-standing children's hospital participated in the parent survey; charts of 336 children from the same hospital were included in the abstraction study. RESULTS CWDA contains 669 ICD-9-CM codes classified as having a ≥75% likelihood of indicating CWD. Examples include 318.2 Profound intellectual disabilities and 780.72 Functional quadriplegia. CWDA sensitivity was 0.75 (95% confidence interval 0.63-0.84) compared with parent report and 0.98 (0.95-0.99) compared with physician assessment; its specificity was 0.86 (0.72-0.95) and 0.50 (0.41-0.59), respectively. CONCLUSIONS ICD-9-CM codes can be classified by their likelihood of indicating CWD. CWDA triangulates well with parent report and physician assessment of child disability status. CWDA is a new tool that can be used to assess care quality for CWD.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| | - Karen A Kuhlthau
- Departments of Pediatrics, and Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dennis Z Kuo
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas; and
| | - Megumi J Okumura
- Division of General Pediatrics, Beinoff Children's Hospital, and Department of Pediatrics, Division of General Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Jeanne M Van Cleave
- Departments of Pediatrics, and Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Chelsea K Johnson
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Lindsey L Mahoney
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Julia Martin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
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Berry JG, Zaslavsky AM, Toomey SL, Chien AT, Jang J, Bryant MC, Klein DJ, Kaplan WJ, Schuster MA. Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care. Pediatrics 2015; 136:251-62. [PMID: 26169435 PMCID: PMC4516938 DOI: 10.1542/peds.2014-3131] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hospital quality-of-care measures are publicly reported to inform consumer choice and stimulate quality improvement. The number of hospitals and states with enough pediatric hospital discharges to detect worse-than-average inpatient care remains unknown. METHODS This study was a retrospective analysis of hospital discharges for children aged 0 to 17 years from 3974 hospitals in 44 states in the 2009 Kids' Inpatient Database. For 11 measures of all-condition or condition-specific quality, we assessed the number of hospitals and states that met a "power standard" of 80% power for a 5% level significance test to detect when care is 20% worse than average over a 3-year period. For this assessment, we approximated volume as 3 times actual 2009 admission volumes. RESULTS For all-condition quality, 1380 hospitals (87% of all pediatric discharges) and all states met the power standard for the family experience-of-care measure; 1958 hospitals (95% of discharges) and all states met the standard for adverse drug events. For condition-specific quality measures of asthma, birth, and mental health, 203 to 482 hospitals (52%-90% of condition-specific discharges) met the power standard and 40 to 44 states met the standard. One hospital and 16 states met the standard for sickle cell disease. No hospital and ≤27 states met the standard for the remaining measures studied (appendectomy, cerebrospinal fluid shunt surgery, gastroenteritis, heart surgery, and seizure). CONCLUSIONS Most children are admitted to hospitals in which all-condition measures of quality have adequate power to show modest differences in performance from average, but most condition-specific measures do not. Policies regarding incentives for pediatric inpatient quality should take these findings into account.
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Affiliation(s)
- Jay G. Berry
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Sara L. Toomey
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Alyna T. Chien
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Jisun Jang
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts; and
| | | | | | | | - Mark A. Schuster
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
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Affiliation(s)
- Anna D Sinaiko
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Alyna T Chien
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
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Song H, Chien AT, Fisher J, Martin J, Peters AS, Hacker K, Rosenthal MB, Singer SJ. Development and validation of the primary care team dynamics survey. Health Serv Res 2014; 50:897-921. [PMID: 25423886 DOI: 10.1111/1475-6773.12257] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To develop and validate a survey instrument designed to measure team dynamics in primary care. DATA SOURCES/STUDY SETTING We studied 1,080 physician and nonphysician health care professionals working at 18 primary care practices participating in a learning collaborative aimed at improving team-based care. STUDY DESIGN We developed a conceptual model and administered a cross-sectional survey addressing team dynamics, and we assessed reliability and discriminant validity of survey factors and the overall survey's goodness-of-fit using structural equation modeling. DATA COLLECTION We administered the survey between September 2012 and March 2013. PRINCIPAL FINDINGS Overall response rate was 68 percent (732 respondents). Results support a seven-factor model of team dynamics, suggesting that conditions for team effectiveness, shared understanding, and three supportive processes are associated with acting and feeling like a team and, in turn, perceived team effectiveness. This model demonstrated adequate fit (goodness-of-fit index: 0.91), scale reliability (Cronbach's alphas: 0.71-0.91), and discriminant validity (average factor correlations: 0.49). CONCLUSIONS It is possible to measure primary care team dynamics reliably using a 29-item survey. This survey may be used in ambulatory settings to study teamwork and explore the effect of efforts to improve team-based care. Future studies should demonstrate the importance of team dynamics for markers of team effectiveness (e.g., work satisfaction, care quality, clinical outcomes).
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Affiliation(s)
- Hummy Song
- PhD Program in Health Policy (Management), Harvard University, Boston, MA
| | - Alyna T Chien
- Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Josephine Fisher
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
| | - Julia Martin
- Division of General Pediatrics, Boston Children's Hospital , Boston, MA
| | - Antoinette S Peters
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA
| | - Karen Hacker
- Allegheny County Health Department, Pittsburgh, PA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
| | - Sara J Singer
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA.,Department of Medicine, Harvard Medical School, 677 Huntington Avenue, Boston, MA, 02115
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Abstract
BACKGROUND AND OBJECTIVES Children with special health care needs (CSHCN) face unique challenges in accessing affordable health care. Massachusetts implemented major health reform in 2006; little is known about the impact of this state's health reform on uninsurance, access to care, and financial protection for privately and publicly insured CSHCN. METHODS We used a difference-in-differences (DD) approach to compare uninsurance, access to primary and specialty care, and financial protection in Massachusetts versus other states and Washington, DC before and after Massachusetts health reform. Parent-reported data were used from the 2005-2006 and 2009-2010 National Survey of Children with Special Health Care Needs and adjusted for age, gender, race/ethnicity, non-English language at home, and functional difficulties. RESULTS Postreform, living in Massachusetts was not associated with significant decreases in uninsurance or increases in access to primary care for CSHCN. For privately insured CSHCN, Massachusetts was associated with increased access to specialists (DD = 6.0%; P ≤ .001) postreform. For publicly insured CSHCN, however, there was a significant decrease in access to prescription medications (DD = -7.2%; P = .003) postreform. Living in Massachusetts postreform was not associated with significant changes in financial protection compared with privately or publicly insured CSHCN in other states. CONCLUSIONS Massachusetts health reform likely improved access to specialists for privately insured CSHCN but did not decrease instances of uninsurance, increase access to primary care, or improve financial protection for CSHCN in general. Comparable provisions within the Affordable Care Act may produce similarly modest outcomes for CSHCN.
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Affiliation(s)
| | - Alyna T Chien
- Harvard Medical School, Boston, Massachusetts; andDivision of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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Chien AT, Chin MH, Alexander GC, Tang H, Peek ME. Physician financial incentives and care for the underserved in the United States. Am J Manag Care 2014; 20:121-9. [PMID: 24738530 PMCID: PMC4110893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To estimate: (1) the percentage of physicians whose compensation is variable; (2) the frequency at which performance incentives for productivity, care quality, patient satisfaction, and resource use were used to determine compensation; and (3) how much incentives differ for physicians who serve greater percentages of patients who are Medicaid-insured, racial/ethnic minorities, or who face language barriers, versus those who do not. STUDY DESIGN Cross-sectional study of 3234 nationally representative physicians responding to the 2008 Center for Studying Health System Change's Health Tracking Physician Survey (HTPS). METHODS We examined the degree to which practices' percentage of Medicaid revenues and physicians' panel characteristics were associated with physicians' financial incentives using χ² statistics and multivariate logistic regression (adjusting for physician specialty, practice type, and capitation levels, and area-based factors). RESULTS Compensation was variable for 69% of respondents, was most frequently tied to productivity (68%), and less often to care quality (19%), patient satisfaction (21%), or resource use (14%). Physicians were significantly less likely to report variable compensation if the percentage Medicaid revenues was 50% or more (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI], 0.57-0.95) or if physician panels were at least 50% Hispanic (adjusted OR 0.74, 95% CI, 0.56-0.99). However, physicians were significantly more likely to report use of all 4 performance incentives if percentage of Medicaid revenues was 6% to 24%. CONCLUSIONS Physicians report different types of financial incentives designed to alter care quality and quantity; incentive types differ by the degree that practices derive revenues from Medicaid or serve Hispanic patients. Further investigation is needed to understand how to align financial incentives with disparity-reduction efforts.
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Chien AT, Song Z, Chernew ME, Landon BE, McNeil BJ, Safran DG, Schuster MA. Two-year impact of the alternative quality contract on pediatric health care quality and spending. Pediatrics 2014; 133:96-104. [PMID: 24366988 PMCID: PMC4079291 DOI: 10.1542/peds.2012-3440] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the 2-year effect of Blue Cross Blue Shield of Massachusetts' global budget arrangement, the Alternative Quality Contract (AQC), on pediatric quality and spending for children with special health care needs (CSHCN) and non-CSHCN. METHODS Using a difference-in-differences approach, we compared quality and spending trends for 126,975 unique 0- to 21-year-olds receiving care from AQC groups with 415,331 propensity-matched patients receiving care from non-AQC groups; 23% of enrollees were CSHCN. We compared quality and spending pre (2006-2008) and post (2009-2010) AQC implementation, adjusting analyses for age, gender, health risk score, and secular trends. Pediatric outcome measures included 4 preventive and 2 acute care measures tied to pay-for-performance (P4P), 3 asthma and 2 attention-deficit/hyperactivity disorder quality measures not tied to P4P, and average total annual medical spending. RESULTS During the first 2 years of the AQC, pediatric care quality tied to P4P increased by +1.8% for CSHCN (P < .001) and +1.2% for non-CSHCN (P < .001) for AQC versus non-AQC groups; quality measures not tied to P4P showed no significant changes. Average total annual medical spending was ~5 times greater for CSHCN than non-CSHCN; there was no significant impact of the AQC on spending trends for children. CONCLUSIONS During the first 2 years of the contract, the AQC had a small but significant positive effect on pediatric preventive care quality tied to P4P; this effect was greater for CSHCN than non-CSHCN. However, it did not significantly influence (positively or negatively) CSHCN measures not tied to P4P or affect per capita spending for either group.
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Affiliation(s)
- Alyna T. Chien
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Departments of Pediatrics and
| | - Zirui Song
- Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Bruce E. Landon
- Health Care Policy, Harvard Medical School, Boston, Massachusetts;,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Barbara J. McNeil
- Health Care Policy, Harvard Medical School, Boston, Massachusetts;,Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Dana G. Safran
- Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts; and,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Departments of Pediatrics and
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Affiliation(s)
- Alyna T Chien
- From the Division of General Pediatrics, Boston Children's Hospital (A.T.C.), Harvard Medical School (A.T.C.), and the Department of Health Policy and Management, Harvard School of Public Health (M.B.R.) - all in Boston
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Barry CL, Chien AT, Normand SLT, Busch AB, Azzone V, Goldman HH, Huskamp HA. Parity and out-of-pocket spending for children with high mental health or substance abuse expenditures. Pediatrics 2013; 131:e903-11. [PMID: 23420919 PMCID: PMC3581843 DOI: 10.1542/peds.2012-1491] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act required health plans to provide mental health and substance use disorder (MH/SUD) benefits on par with medical benefits beginning in 2010. Previous research found that parity significantly lowered average out-of-pocket (OOP) spending on MH/SUD treatment of children. No evidence is available on how parity affects OOP spending by families of children with the highest MH/SUD treatment expenditures. METHODS We used a difference-in-differences study design to examine whether parity reduced families' (1) share of total MH/SUD treatment expenditures paid OOP or (2) average OOP spending among children whose total MH/SUD expenditures met or exceeded the 90th percentile. By using claims data, we compared changes 2 years before (1999-2000) and 2 years after (2001-2002) the Federal Employees Health Benefits Program implemented parity to a contemporaneous group of health plans that did not implement parity over the same 4-year period. We examined those enrolled in the Federal Employees Health Benefits Program because their parity directive is similar to and served as a model for the new federal parity law. RESULTS Parity led to statistically significant annual declines in the share of total MH/SUD treatment expenditures paid OOP (-5%, 95% confidence interval: -6% to -4%) and average OOP spending on MH/SUD treatment (-$178, 95% confidence interval: -257 to -97). CONCLUSIONS This study provides the first empirical evidence that parity reduces the share and level of OOP spending by families of children with the highest MH/SUD treatment expenditures; however, these spending reductions were smaller than anticipated and unlikely to meaningfully improve families' financial protection.
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Affiliation(s)
- Colleen L. Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alyna T. Chien
- Division of General Pediatrics, Children’s Hospital Boston, Boston, Massachusetts; Departments of,General Pediatrics, and
| | - Sharon-Lise T. Normand
- Health Care Policy, Harvard Medical School, Boston, Massachusetts;,Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Alisa B. Busch
- Health Care Policy, Harvard Medical School, Boston, Massachusetts;,McLean Hospital, Bellmont, Massachusetts;,Health Services Research Division, Partners Psychiatry and Mental Health; and
| | - Vanessa Azzone
- Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Howard H. Goldman
- Department of Psychiatry, University of Maryland, Baltimore, Maryland
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Abstract
OBJECTIVE To determine (1) the proportion of parents who report a need for and receipt of effective care coordination for their child, (2) whether unmet care coordination needs differ by children with special health care needs (CSHCN) status and sociodemographic characteristics, and (3) whether having a personal provider or family-centered care mitigates disparities. METHODS This study was a cross-sectional analysis of the 2007 National Survey for Children's Health, a nationally representative survey of 91 642 parents. Outcome measures were parent report of need for and lack of effective care coordination. We also examined the effect of parent report of having a personal provider and family-centered care. We conducted weighted bivariate and multivariate analyses. RESULTS Forty-one percent of parents reported that their child needed care coordination. Among those who needed care coordination, 31% did not receive effective coordination. CSHCN (41%) were more likely than children without special health care needs (26%; P < .001) to have unmet care coordination needs. Latino (40%) and black (37%) children were more likely to have unmet needs than white (27%; P < .001) children. These patterns remained in multivariate analysis. Having a personal provider decreased the odds of having unmet need for care coordination but did not attenuate disparities. Receiving family-centered care mitigated disparities associated with race/ethnicity but not with health status or health insurance. CONCLUSIONS A considerable proportion of parents reported their child needed more care coordination than they received. This was especially true for parents of CSHCN and parents of black and Latino children. Interventions that enhance family-centered care might particularly contribute to reducing racial/ethnic disparities.
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Affiliation(s)
- Sara L Toomey
- MPhil, MSc, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
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Wallander JL, Fradkin C, Chien AT, Mrug S, Banspach SW, Davies S, Elliott MN, Franzini L, Schuster MA. Racial/ethnic disparities in health-related quality of life and health in children are largely mediated by family contextual differences. Acad Pediatr 2012; 12:532-8. [PMID: 22884796 DOI: 10.1016/j.acap.2012.04.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 04/10/2012] [Accepted: 04/14/2012] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To examine (1) racial/ethnic disparities in health-related quality of life (HRQOL), and overall health status among African-American, Hispanic, and white 5th graders in the general population and (2) the extent to which socioeconomic status (SES) and other family contextual variables mediate any disparities. METHODS A total of 4824 African-American, Hispanic, and white fifth-graders participating in a population-based, cross-sectional survey conducted in 3 U.S. metropolitan areas reported their own HRQOL by using the Pediatric Quality of Life Inventory Version 4.0 and supplemental personal and social well-being scales. Parents reported these children's overall health status. SES was indexed by parent education and household income. Other family contextual variables included family structure and degree to which English is spoken at home. RESULTS Marked racial/ethnic disparities were observed across all measures of HRQOL and health status, favoring white children and especially disfavoring Hispanic children. Most of these disparities were no longer significant after adjusting for SES and other family contextual differences that were observed among these racial/ethnic groups. Only disparities in parent-reported overall health status and self-reported global self-worth remained. CONCLUSIONS Racial/ethnic disparities in children's health status are substantial but may be mediated by corresponding disparities in SES and other family contextual variables. Race/ethnicity and family context are related to one another and should be considered jointly in efforts to reduce health disparities in children.
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Affiliation(s)
- Jan L Wallander
- Psychological Sciences, Center of Excellence on Health Disparities, University of California, Merced, USA.
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Schwebel DC, Roth DL, Elliott MN, Chien AT, Mrug S, Shipp E, Dittus P, Zlomke K, Schuster MA. Marital conflict and fifth-graders' risk for injury. Accid Anal Prev 2012; 47:30-35. [PMID: 22405236 DOI: 10.1016/j.aap.2012.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 07/12/2011] [Accepted: 01/05/2012] [Indexed: 05/31/2023]
Abstract
BACKGROUND Injuries are the leading cause of morbidity and mortality for American children. Marital conflict has been associated with a range of negative health outcomes, but little is known about how marital conflict may influence risk of injury among children. We hypothesized marital conflict would be related to increased youth injury risk after controlling for relevant demographic and parenting covariates. METHODS A community sample of 3218 fifth-graders recruited from three US locales was utilized. Ordinal logistic regression models were used to predict the frequency of unintentional injuries from marital conflict while adjusting for demographics, parenting factors (nurturance, communication, involvement with youth), and family cohesion. RESULTS Higher levels of marital conflict were associated with higher rates of injury that required professional medical attention (OR=1.20, 95% CI 1.06, 1.35 per standard deviation). The same association held after inclusion of all covariates in a multivariate ordinal logistic regression model. CONCLUSIONS Parental marital conflict is associated with higher rates of injuries requiring professional medical attention in preadolescent children.
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Affiliation(s)
- David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, USA.
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Chien AT, Wroblewski K, Damberg C, Williams TR, Yanagihara D, Yakunina Y, Casalino LP. Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures? J Gen Intern Med 2012; 27:548-54. [PMID: 22160817 PMCID: PMC3326117 DOI: 10.1007/s11606-011-1946-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 10/18/2011] [Accepted: 10/31/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs. OBJECTIVE To examine the association between PO location and P4P performance. DESIGN Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S. PARTICIPANTS 160 POs participating in 2009. MAIN MEASURES We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use. KEY RESULTS The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001). CONCLUSIONS Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Children's Hospital Boston, and Department of Pediatrics, Harvard Medical School, 21 Autumn Street-Room 223, Boston, MA 02215, USA.
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Lee HC, Chien AT, Bardach NS, Clay T, Gould JB, Dudley RA. The impact of statistical choices on neonatal intensive care unit quality ratings based on nosocomial infection rates. ACTA ACUST UNITED AC 2011; 165:429-34. [PMID: 21536958 DOI: 10.1001/archpediatrics.2011.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings. DESIGN Cross-sectional study based on risk-adjusted nosocomial infection rates. SETTING NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008. PARTICIPANTS One hundred twenty-six California NICUs and 10 487 VLBW infants. MAIN EXPOSURES Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years. MAIN OUTCOME MEASURES Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the κ statistic. RESULTS Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89. CONCLUSIONS The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.
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Affiliation(s)
- Henry C Lee
- Department of Pediatrics, Division of Neonatology, University of California at San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA.
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