Associations of Internal Medicine Residency Milestone Ratings and Certification Examination Scores With Patient Outcomes

Importance

Despite its importance to medical education and competency assessment for internal medicine trainees, evidence about the relationship between physicians' milestone residency ratings or the American Board of Internal Medicine's initial certification examination and their hospitalized patients' outcomes is sparse.

Objective

To examine the association between physicians' milestone ratings and certification examination scores and hospital outcomes for their patients.

Design, Setting, and Participants

Retrospective cohort analyses of 6898 hospitalists completing training in 2016 to 2018 and caring for Medicare fee-for-service beneficiaries during hospitalizations in 2017 to 2019 at US hospitals.

Main Outcomes and Measures

Primary outcome measures included 7-day mortality and readmission rates. Thirty-day mortality and readmission rates, length of stay, and subspecialist consultation frequency were also assessed. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year.

Exposures

Certification examination score quartile and milestone ratings, including an overall core competency rating measure equaling the mean of the end of residency milestone subcompetency ratings categorized as low, medium, or high, and a knowledge core competency measure categorized similarly.

Results

Among 455 120 hospitalizations, median patient age was 79 years (IQR, 73-86 years), 56.5% of patients were female, 1.9% were Asian, 9.8% were Black, 4.6% were Hispanic, and 81.9% were White. The 7-day mortality and readmission rates were 3.5% (95% CI, 3.4%-3.6%) and 5.6% (95% CI, 5.5%-5.6%), respectively, and were 8.8% (95% CI, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%) for mortality and readmission at 30 days. Mean length of stay and number of specialty consultations were 3.6 days (95% CI, 3.6-3.6 days) and 1.01 (95% CI, 1.00-1.03), respectively. A high vs low overall or knowledge milestone core competency rating was associated with none of the outcome measures assessed. For example, a high vs low overall core competency rating was associated with a nonsignificant 2.7% increase in 7-day mortality rates (95% CI, -5.2% to 10.6%; P = .51). In contrast, top vs bottom examination score quartile was associated with a significant 8.0% reduction in 7-day mortality rates (95% CI, -13.0% to -3.1%; P = .002) and a 9.3% reduction in 7-day readmission rates (95% CI, -13.0% to -5.7%; P < .001). For 30-day mortality, this association was -3.5% (95% CI, -6.7% to -0.4%; P = .03). Top vs bottom examination score quartile was associated with 2.4% more consultations (95% CI, 0.8%-3.9%; P < .003) but was not associated with length of stay or 30-day readmission rates.

Conclusions and Relevance

Among newly trained hospitalists, certification examination score, but not residency milestone ratings, was associated with improved outcomes among hospitalized Medicare beneficiaries.

Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up

Importance

In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community.

Objective

To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up.

Design, Setting, and Participants

This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023.

Exposure

Implementation of payments for TCM.

Main Outcomes and Measures

Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up.

Results

The study sample comprised 79 125 965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%).

Conclusions

These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.

Approaches to Comparing the Impact of Socioeconomic Disadvantage on Acute Myocardial Infarction Care Within and Across Countries: A Scoping Review

BACKGROUND

Understanding how cardiovascular disease treatment and outcomes differ for socioeconomically disadvantaged patients across countries may reveal insights into the impact of countries' policy initiatives on health equity. However, methods of undertaking these studies are poorly characterized.

METHODS

We performed a scoping review to identify studies describing between-country comparisons of socioeconomic inequalities in the care of acute myocardial infarction (AMI). We sought to determine the extent to which such comparisons have been conducted, the methodologies used, and outcomes assessed. We searched Medline from January 1, 2013 to September 30, 2023 for peer-reviewed English-language publications. Studies were included if they stratified patients by a measure of socioeconomic disadvantage (eg, race, ethnicity, income, education, occupation, immigrant status) and made comparisons between 2 or more countries.

RESULTS

Our search yielded 4861 articles focused on patients with AMI, of which 7 met our inclusion criteria. Common individual-level proxies for disadvantage were self-reported income or education. In contrast, we found no cross-country comparisons focused on other measures of disadvantage such as race and ethnicity. There was marked heterogeneity in methods and thresholds used to define socioeconomic disadvantage at the individual level. All included studies found that patients with higher income and higher educational attainment had improved AMI outcomes.

CONCLUSIONS

Between-country comparisons of socioeconomic disparities in AMI outcomes are scarce and heterogeneous, but all identified studies relied on metrics of disadvantage including income and education that could be uniformly measured across countries. We found no articles addressing other types of inequities, likely because of significant methodologic challenges.

Primary Care Physicians In Medicare Advantage Were Less Costly, Provided Similar Quality Versus Regional Average

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

Sex-Based Disparities in Acute Myocardial Infarction Treatment Patterns and Outcomes in Older Adults Hospitalized Across 6 High-Income Countries: An Analysis From the International Health Systems Research Collaborative

BACKGROUND

Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries.

METHODS

We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality.

RESULTS

Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI.

CONCLUSIONS

We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.

Clinician Risk Tolerance and Rates of Admission From the Emergency Department

Importance

Much remains unknown about the extent of and factors that influence clinician-level variation in rates of admission from the emergency department (ED). In particular, emergency clinician risk tolerance is a potentially important attribute, but it is not well defined in terms of its association with the decision to admit.

Objective

To further characterize this variation in rates of admission from the ED and to determine whether clinician risk attitudes are associated with the propensity to admit.

Design, Setting, and Participants

In this observational cohort study, data were analyzed from the Massachusetts All Payer Claims Database to identify all ED visits from October 2015 through December 2017 with any form of commercial insurance or Medicaid. ED visits were then linked to treating clinicians and their risk tolerance scores obtained in a separate statewide survey to examine the association between risk tolerance and the decision to admit. Statistical analysis was performed from 2022 to 2023.

Main Outcomes and Measures

The ratio between observed and projected admission rates was computed, controlling for hospital, and then plotted against the projected admission rates to find the extent of variation. Pearson correlation coefficients were then used to examine the association between the mean projected rate of admission and the difference between actual and projected rates of admission. The consistency of clinician admission practices across a range of the most common conditions resulting in admission were then assessed to understand whether admission decisions were consistent across different conditions. Finally, an assessment was made as to whether the extent of deviation from the expected admission rates at an individual level was associated with clinician risk tolerance.

Results

The study sample included 392 676 ED visits seen by 691 emergency clinicians. Among patients seen for ED visits, 221 077 (56.3%) were female, and 236 783 (60.3%) were 45 years of age or older; 178 890 visits (46.5%) were for patients insured by Medicaid, 96 947 (25.2%) were for those with commercial insurance, 71 171 (18.5%) were Medicare Part B or Medicare Advantage, and the remaining 37 702 (9.8%) were other insurance category. Of the 691 clinicians, 429 (62.6%) were male; mean (SD) age was 46.5 (9.8) years; and 72 (10.4%) were Asian, 13 (1.9%) were Black, 577 (83.5%) were White, and 29 (4.2%) were other race. Admission rates across the clinicians included ranged from 36.3% at the 25th percentile to 48.0% at the 75th percentile (median, 42.1%). Overall, there was substantial variation in admission rates across clinicians; physicians were just as likely to overadmit or underadmit across the range of projected rates of admission (Pearson correlation coefficient, 0.046 [P = .23]). There also was weak consistency in admission rates across the most common clinical conditions, with intraclass correlations ranging from 0.09 (95% CI, 0.02-0.17) for genitourinary/syncope to 0.48 (95% CI, 0.42-0.53) for cardiac/syncope. Greater clinician risk tolerance (as measured by the Risk Tolerance Scale) was associated with a statistically significant tendency to admit less than the projected admission rate (coefficient, -0.09 [P = .04]). The other scales studied revealed no significant associations.

Conclusions and Relevance

In this cohort study of ED visits from Massachusetts, there was statistically significant variation between ED clinicians in admission rates and little consistency in admission tendencies across different conditions. Admission tendencies were minimally associated with clinician innate risk tolerance as assessed by this study's measures; further research relying on a broad range of measures of risk tolerance is needed to better understand the role of clinician attitudes toward risk in explaining practice patterns and to identify additional factors that may be associated with variation at the clinician level.

Predictors of treatment intensification in uncontrolled hypertension

PURPOSE

Prior studies have shown that treatment intensification for patients presenting with uncontrolled hypertension (HTN) rarely occurs, even during visits to the patient's own primary care physicians (PCPs). In this article, we identified predictors of treatment intensification for uncontrolled HTN.

METHODS

We conducted a cross-sectional study using nationally representative survey data on visits by patients aged 18 or above with uncontrolled HTN, defined as a recorded SBP at least 140 and/or a DBP at least 90 using data from the National Ambulatory Medical Care Survey (NAMCS) 2008-2018. Our outcome is treatment intensification defined as the addition of a new blood pressure medication.

RESULTS

We analyzed 22 559 visits to PCPs where uncontrolled HTN was noted, representing 801 023 786 visits nationally. Among these encounters, 2138 (10.3%) of the visits resulted in treatment intensification. Visits with the patient's own PCP had higher rates of treatment intensification than visits to another PCP (10.8 vs. 5.9%, P  < 0.0001). Visits for patients previously on antihypertensive medications had lower rates of treatment intensification (11% for no medications, 10.4% for one medication, 6.6% for ≥2 medications, P  < 0.0001), but there were no statistically significant differences in rates of intensification for those with relevant comorbidities (9.4% for no chronic conditions, 10.8% for one to two chronic conditions, 8.9% for at least three chronic conditions, P  = 0.12). Multivariable adjusted results were similar to the unadjusted findings.

CONCLUSION

Visits for patients with uncontrolled HTN rarely result in treatment intensification. Substantial opportunity exists to improve management of HTN, particularly for patients on fewer medications or seen by a covering provider.

Differences in Primary Care Follow-up After Acute Care Discharge Within and Across Health Systems: a Retrospective Cohort Study

BACKGROUND

Timely primary care follow-up after acute care discharge may improve outcomes.

OBJECTIVE

To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system).

DESIGN

Retrospective cohort study.

PATIENTS

Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay.

MAIN MEASURES

Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics.

KEY RESULTS

The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges).

CONCLUSIONS

Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study

BACKGROUND

Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries.

METHODS

We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery.

RESULTS

The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada).

CONCLUSIONS

We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

Proportion Of Preventive Primary Care Visits Nearly Doubled, Especially Among Medicare Beneficiaries, 2001-19

There is debate about the value of preventive visits in primary care, and multiple policy trends during the past fifteen years may have influenced the likelihood of US adults undergoing preventive primary care visits. Using nationally representative, serial cross-sectional data on adult visits to primary care physicians from the 2001-19 National Ambulatory Medical Care Survey, we characterized temporal trends in the proportion of primary care visits with a preventive focus and the differential characteristics of these visits. Based on a sample of 139,783 unweighted (5,902,144,258 weighted) US primary care visits, we found that the proportion of primary care visits with a preventive focus increased between 2001 and 2019 (12.8 percent of visits in 2001-02 versus 24.6 percent in 2018-19; [Formula: see text]), with the greatest rate of increase seen for people with Medicare. Primary care visits with a preventive focus involved more time spent with the physician and addressed fewer reasons for the visit compared with problem-based visits. At least one of the following was significantly more likely to occur during a preventive visit than a problem-based visit: counseling provision, ordering of preventive labs, or ordering of a preventive image or procedure. Our findings demonstrate a relative increase in preventive versus problem-based visits in primary care and suggest the importance of enhanced insurance coverage in influencing preventive care delivery trends.

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Importance

Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.

Objective

To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.

Design, Setting, and Participants

In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.

Exposure

Incident dementia diagnosis.

Main Outcomes and Measures

The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.

Results

The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).

Conclusions and Relevance

In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

Opportunities for Savings in Risk Arrangements for Oncologic Care

Importance

As the US accelerates adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA), high spending for cancer care is a potential target for savings.

Objective

To quantify the extent to which ACOs and other risk-bearing organizations operating in a specific geographic area (hospital referral region [HRR]) could achieve savings by steering patients to efficient medical oncology practices.

Design, Setting, and Participants

This observational study included serial cross-sections of Medicare beneficiaries with cancer from 2010 to 2018. Data were analyzed from August 2021 to March 2023.

Main Outcomes and Measures

Total spending and spending by category in the 1-year period following an index visit for a patient with newly diagnosed (incident) or poor-prognosis cancer.

Results

The incident cohort included 1 309 825 patients with a mean age of 74.0 years; the most common cancer types were breast (21.4%), lung (16.7%), and colorectal cancer (10.0%). The poor prognosis cohort included 1 429 973 (mean age, 72.7 years); the most common cancer types were lung (26.6%), lymphoma (11.7%), and leukemia (7.3%). Options for steering varied across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57 314 in 2009 to 2010 to $66 028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% higher than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods ($20 390 and $19 718, respectively) followed by Part B (infused) chemotherapy ($8022 and $11 699). Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high (>0.90 in all categories with most >0.98), but these attenuated over time.

Conclusions and Relevance

These results suggest there may be opportunities for ACOs and other risk-bearing organizations to select or drive referrals to lower-spending oncology practices in many local markets.

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

Importance

The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases.

Objective

To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED.

Design, Setting, and Participants

This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023.

Main Outcomes and Measures

The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated.

Results

A total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5-percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission.

Conclusion and Relevance

Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.

Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care

Importance

Health-related social needs are increasingly being screened for in primary care practices, but it remains unclear how much additional financing is required to address those needs to improve health outcomes.

Objective

To estimate the cost of implementing evidence-based interventions to address social needs identified in primary care practices.

Design, Setting, and Participants

A decision analytical microsimulation of patients seen in primary care practices, using data on social needs from the National Center for Health Statistics from 2015 through 2018 (N = 19 225) was conducted. Primary care practices were categorized as federally qualified health centers (FQHCs), non-FQHC urban practices in high-poverty areas, non-FQHC rural practices in high-poverty areas, and practices in lower-poverty areas. Data analysis was performed from March 3 to December 16, 2022.

Intervention

Simulated evidence-based interventions of primary care-based screening and referral protocols, food assistance, housing programs, nonemergency medical transportation, and community-based care coordination.

Main Outcomes and Measures

The primary outcome was per-person per-month cost of interventions. Intervention costs that have existing federally funded financing mechanisms (eg, the Supplemental Nutrition Assistance Program) and costs without such an existing mechanism were tabulated.

Results

Of the population included in the analysis, the mean (SD) age was 34.4 (25.9) years, and 54.3% were female. Among people with food and housing needs, most were program eligible for federally funded programs, but had low enrollment (eg, due to inadequate program capacity), with 78.0% of people with housing needs being program eligible vs 24.0% enrolled, and 95.6% of people with food needs being program eligible vs 70.2% enrolled. Among those with transportation insecurity and care coordination needs, eligibility criteria limited enrollment (26.3% of those in need being program eligible for transportation programs, and 5.7% of those in need being program eligible for care coordination programs). The cost of providing evidence-based interventions for these 4 domains averaged $60 (95% CI, $55-$65) per member per month (including approximately $5 for screening and referral management in clinics), of which $27 (95% CI, $24-$31) (45.8%) was federally funded. While disproportionate funding was available to populations seen at FQHCs, populations seen at non-FQHC practices in high-poverty areas had larger funding gaps (intervention costs not borne by existing federal funding mechanisms).

Conclusions and Relevance

In this decision analytical microsimulation study, food and housing interventions were limited by low enrollment among eligible people, whereas transportation and care coordination interventions were more limited by narrow eligibility criteria. Screening and referral management in primary care was a small expenditure relative to the cost of interventions to address social needs, and just under half of the costs of interventions were covered by existing federal funding mechanisms. These findings suggest that many resources are necessary to address social needs that fall largely outside of existing federal financing mechanisms.

Estimated Annual Spending on Lecanemab and Its Ancillary Costs in the US Medicare Program

This cross-sectional cost analysis uses data from the 2018 Health and Retirement Study to estimate the potential future Medicare spending and beneficiary costs for lecanemab.

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

Importance

Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries.

Objective

To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries.

Design, Setting, and Participants

Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data.

Exposures

Being in the top and bottom quintile of income within and across countries.

Main Outcomes and Measures

Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates.

Results

We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients.

Conclusions and Relevance

High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

Differences In Use Of Services And Quality Of Care In Medicare Advantage And Traditional Medicare, 2010 And 2017

Medicare Advantage (MA) enrollment growth could make it difficult for MA plans to maintain their track record of limiting discretionary utilization while delivering higher-quality care than traditional Medicare. We compared quality and utilization measures in Medicare Advantage and traditional Medicare in 2010 and 2017. Clinical quality performance was higher in MA health maintenance organizations (HMOs) and preferred provider organizations (PPOs) than in traditional Medicare for almost all measures in both years. MA HMOs outperformed traditional Medicare on all measures in 2017. MA HMOs' performance on nearly all seven patient-reported quality measures improved, and MA HMOs outperformed traditional Medicare on five of those measures in 2017. MA PPOs performed the same as or better than traditional Medicare on all but one patient-reported quality measure in 2010 and 2017. The number of emergency department visits was 30 percent lower, the number of elective hip and knee replacements was approximately 10 percent lower, and the number of back surgeries was almost 30 percent lower in MA HMOs than in traditional Medicare in 2017. Utilization trends were similar in MA PPOs, but differences from traditional Medicare were narrower. Despite increased enrollment, overall utilization remains lower in Medicare Advantage than in traditional Medicare, whereas quality performance is the same or higher.

Adult Primary Care Physician Visits Increasingly Address Mental Health Concerns

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical Care Surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.7 percent of visits in 2006-07 to 15.9 percent by 2016 and 2018. Black patients were 40 percent less likely than White patients to have a mental health concern addressed during a primary care visit, and Hispanic patients were 40 percent less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. These findings emphasize the need for payment and billing approaches (that is, value-based care models and billing codes for integrated behavioral health) as well as organizational designs and supports (that is, colocated therapy or psychiatry providers, availability of e-consultation, and longer visits) that enable primary care physicians to adequately address mental health needs.

Primary Care Visits in the USA and Australia 2000-2016

BACKGROUND

There are major concerns about the sustainability of the US primary care (PC) system.

OBJECTIVE

We use similar data from the USA and Australia on adult visits to primary care physicians to examine how primary care service delivery and content in the countries have changed since the year 2001.

DESIGN/SETTING/PARTICIPANTS

Longitudinal analyses of nationally representative data collected in a similar manner on outpatient visits to PC in the USA (National Ambulatory Medical Care Survey, NAMCS) and Australia (Bettering the Evaluation and Care of Health, BEACH), 2001-2016.

MAIN MEASURES

For each visit, we ascertained the problems/diagnoses managed; the length of the visit in minutes; what medications were recorded; whether counseling, advice, or education was provided; the rate of imaging and diagnostics tests; the laboratory tests ordered; and whether the visit resulted in a referral to another physician.

KEY RESULTS

Between 2001 and 2016, there were 128,770 encounters with adult patients in NAMCS and 1,338,963 in BEACH. In the USA, the proportion of encounters with 3 or more problems managed increased from 28.7 to 54.8% whereas Australia started at a lower proportion (10.6%) and increased to just 14.1%. Visit times in the USA increased from 17.2 min in 2001 to 22.9 min in 2016 as compared to 14.4 min increasing to 15.2 in Australia. There were significantly more medications recorded over time in NAMCS than BEACH (2.02 in 2001 to 3.32 in 2016, USA, and 1.10 and 1.04, Australia), and US encounters resulted in imaging studies, lab tests, or referrals with relatively increasing frequency.

CONCLUSION

Relative to Australia, PC visits in the USA increasingly entail more complexity with visits that have grown comparatively longer over time, with more problems addressed, and with more content.

Alternative Payments and Physician Organizations

There are longstanding concerns about the sustainability of the US health care system. Payment reform has been seen over the last decade as a key strategy to reorienting the US health care system around value. Alternative payment models (APMs) that seek to accomplish this goal have become increasingly prevalent in the US, yet there is a perception that physicians are resistant to their use and that organizations have been slow to adopt such models. The reasons for the limited effectiveness of APM programs are multifactorial and include aspects related to the design and implementation of these programs and lack of alignment and coordination across different payers and health care sectors. Most importantly, however, is that the current organizational structures in US health care serve to dampen the direct impact of these incentives, often because health care delivery organizations face conflicting incentives themselves. Organizations filter and refine the incentives from multiple external payment contracts and develop internal incentive systems that best reflect the amalgamation of the incentives embedded across their contracts, and thus the fragmented nature of the US health care system serves to undermine efforts to transform care under value-based contracts. In addition to organizations having conflicting incentives, there also are fundamental problems with the design and implementation of APMs that hinder their acceptance among physicians and the organizations in which they work. Moreover, much remains to be learned about how organizations can best adapt to succeed under these models, and how organizational culture can be leveraged to transform care.

Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction

IMPORTANCE

Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown.

OBJECTIVE

To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019).

EXPOSURES

Enrollment in Medicare Advantage vs traditional Medicare.

MAIN OUTCOMES AND MEASURES

The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions).

RESULTS

The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]).

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

Patterns of specialist out-of-pocket costs for Australian Medicare services: implications for price transparency

Objective To explore out-of-pocket (OOP) costs within specialties and individual specialists, and use of Medicare Benefits Schedule (MBS) data for potential price transparency initiatives. Methods We conducted a cross-sectional descriptive study of claims for a 10% random sample of Medicare enrolees for out-of-hospital MBS-billed subsequent and initial consultations between 1 January 2014 and 31 December 2014, specific to cardiologist, oncologist and ophthalmologists (with at least 10 patient visits in 2014). Our main outcomes were the number of locations per provider, number of unique OOP consultation costs per provider and provider-location, and the proportion of bulk-billed visits for these visits. Results We studied 970 cardiologists, 913 ophthalmologists and 376 oncologists. At least 67% of specialists across each specialty had at least two practice locations: cardiologists had a median of three (interquartile range [IQR]: 2-4) and ophthalmologists and oncologists both had a median of two (IQR: 1-3). For subsequent consultations, cardiologists had a median of three unique costs per location (IQR: 2-3), whereas ophthalmologists had a median of four unique costs per location (IQR: 3-5). In contrast, oncologists had a median of one unique cost per location (IQR: 1-2) (57.6% of oncologists' provider-locations charged only the bulk-billing amount). Conclusions Specialists have distinct fee lists that can vary based on location. Summary statistics on price transparency websites based on a single amount (like a median or mean OOP charge) might mask substantial variation in costs and lead to bill shock for individual patients.

National Trends in Antihypertensive Treatment Among Older Adults by Race and Presence of Comorbidity, 2008 to 2017

BACKGROUND

In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy.

OBJECTIVE

To evaluate older adults' antihypertensive use following guideline changes.

DESIGN

Time series analysis.

PATIENTS

Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension.

INTERVENTION

Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations.

KEY RESULTS

The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients.

CONCLUSIONS

Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity.

Perspectives of Emergency Clinicians About Medical Errors Resulting in Patient Harm or Malpractice Litigation

This cross-sectional study analyzes responses to a survey about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians.

Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns?

The authors of this Viewpoint argue that the focus on hospital readmission rates as a measure of quality during the past decade, although undoubtedly leading to some improvements in care, has had minimal demonstrable benefit and has even distracted clinicians and health system leaders from other crucial quality concerns.

Turnover among new Medicare Advantage enrollees may be greater than perceived

OBJECTIVES

To characterize the proportion of Medicare Advantage (MA) enrollees who switched insurers or disenrolled to traditional Medicare (TM) in the years immediately after first choosing to join an MA health plan.

STUDY DESIGN

Retrospective analysis using 2012-2017 Medicare enrollment data.

METHODS

We studied enrollees who joined MA between 2012 and 2016 and identified all enrollees who changed insurers (switched insurance or disenrolled to TM) at least once between the start of enrollment and the end of the study period. We categorized each change as switching insurers or disenrollment to TM, and by whether the previous insurer had exited the market.

RESULTS

Among 6,520,169 new MA enrollees, 15.6% had changed insurance within 1 year after enrollment in MA and 49.2% had changed insurance by 5 years. More enrollees switched insurers rather than disenrolled, and most enrollees who changed insurers did not do so as a result of insurer exits.

CONCLUSIONS

New MA enrollees change insurers at a substantial rate when followed across multiple years. These changes may disincentivize insurers from investing in preventive care and chronic disease management and, as shown in several non-MA populations, may lead to discontinuities in care, increased expenditures, and inferior health outcomes.

The Underuse of Medicare's Prevention and Coordination Codes in Primary Care : A Cross-Sectional and Modeling Study

BACKGROUND

Efforts to better support primary care include the addition of primary care-focused billing codes to the Medicare Physician Fee Schedule (MPFS).

OBJECTIVE

To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS.

DESIGN

Cross-sectional and modeling study.

SETTING

Nationally representative claims and survey data.

PARTICIPANTS

Medicare patients.

MEASUREMENTS

Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill.

RESULTS

Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services.

LIMITATION

Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes.

CONCLUSION

Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Evolving Practice Choices by Newly Certified and More Senior General Internists : A Cross-Sectional and Panel Comparison

BACKGROUND

Hospital medicine has grown as a field. However, no study has examined trends in career choices by internists over the past decade.

OBJECTIVE

To measure changes in practice setting for general internists.

DESIGN

Using Medicare fee-for-service claims (2008 to 2018) and data from the American Board of Internal Medicine, practice setting types were measured annually for general internists initially certifying between 1990 and 2017.

SETTING

General internists (non-subspecializing) treating Medicare fee-for-service beneficiaries.

PATIENTS

Medicare fee-for-service beneficiaries aged 65 years and older with at least 20 evaluation and management (E&M) visits annually.

MEASUREMENTS

Practice setting types were defined as hospitalist (>95% inpatient E&M), outpatient only (100% outpatient E&M), or mixed.

RESULTS

67 902 general internists, comprising 80% of all general internists initially certified from 1990 to 2017 (n = 84 581), were studied. From 2008 to 2018, both hospitalists and outpatient-only physicians increased as percentages of general internists (25% to 40% and 23% to 38%, respectively). This was accompanied by a 56% decline in the percentage of mixed-practice physicians (52% to 23%) as these physicians largely migrated to outpatient-only practice. By 2018, 71% of newly certified general internists practiced as hospitalists compared with only 8% practicing as outpatient-only physicians. Most (86% of hospitalists in 2013) had the same practice type 5 years later. This retention rate was similar across early career and more senior physicians (86% and 85% for the 1999 and 2012 initial certification cohorts, respectively) and for the outpatient-only practice type (95%) but was only 57% for the mixed practice type.

LIMITATION

Practice setting measurement relied only on Medicare fee-for-service claims.

CONCLUSION

Newly certified general internists are largely choosing hospital medicine as their career choice whereas more senior physicians increasingly see patients only in the outpatient setting.

PRIMARY FUNDING SOURCE

This study did not receive direct funding.

Association of the Patient Protection and Affordable Care Act With Ambulatory Quality, Patient Experience, Utilization, and Cost, 2014-2016

IMPORTANCE

The Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility at the discretion of states to US individuals earning up to 138% of the federal poverty level (FPL) and made private insurance subsidies available to most individuals earning up to 400% of the FPL. Its national impact remains debated.

OBJECTIVE

To determine the association of the ACA with ambulatory quality, patient experience, utilization, and cost.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used difference-in-differences (DiD) analyses comparing outcomes before (2011-2013) and after (2014-2016) ACA implementation for US adults aged 18 to 64 years with income below and greater than or equal to 400% of the FPL. Participants were respondents to the Medical Expenditure Panel Survey, a nationally representative annual survey. Data analysis was performed from January 2021 to March 2022.

EXPOSURES

ACA implementation.

MAIN OUTCOMES AND MEASURES

For quality and experience, this study examined previously published composites based on individual measures, including high-value care composites (eg, preventive testing) and low-value care composites (eg, inappropriate imaging), an overall patient experience rating, a physician communication composite, and an access-to-care composite. For utilization, outpatient, emergency, and inpatient encounters and prescribed medicines were examined. Overall and out-of-pocket expenditures were analyzed for cost.

RESULTS

The total sample included 123 171 individuals (mean [SD] age, 39.9 [13.4] years; 65 034 women [52.8%]). After ACA implementation, adults with income less than 400% of the FPL received increased high-value care (diagnostic and preventive testing) compared with adults with income 400% or higher of the FPL (change from 70% to 72% vs change from 84% to 84%; adjusted DiD, 1.20%; 95% CI, 0.18% to 2.21%; P = .02) with no difference in any other quality composites. Individuals with income less than 400% of the FPL had larger improvements in experience, communication, and access composites compared with those with income greater than or equal to 400% of the FPL (global rating of health, change from 69% to 73% vs change from 79% to 81%; adjusted DiD, 2.12%; 95% CI, 0.18% to 4.05%; P = .03). There were no differences in utilization or cost, except that receipt of primary care increased for those with lower income vs those with higher income (change from 65% to 66% vs change from 80% to 77%; adjusted DiD, 2.97%; 95% CI, 1.18% to 4.77%; P = .001) and total out-of-pocket expenditures decreased for those with lower income vs those with higher income (change from $504 to $439 vs from $757 to $769; adjusted DiD, -$105.50; 95% CI, -$167.80 to -$43.20; P = .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional national study, the ACA was associated with improved patient experience, communication, and access and decreased out-of-pocket expenditures, but little or no change in quality, utilization, and total cost.

Surgical Outcomes in Canada and the United States: An Analysis of the ACS-NSQIP Clinical Registry

BACKGROUND

There has been longstanding uncertainty over whether lower healthcare spending in Canada might be associated with inferior outcomes for hospital-based care. We hypothesized that mortality and surgical complication rates would be higher for patients who underwent four common surgical procedures in Canada as compared to the US.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective cohort study of all adults who underwent hip fracture repair, colectomy, pancreatectomy, or spine surgery in 96 Canadian and 585 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) between January 1, 2015 and December 31, 2019. We compared patients with respect to demographic characteristics and comorbidity. We then compared unadjusted and adjusted outcomes within 30-days of surgery for patients in Canada and the US including: (1) Mortality; (2) A composite constituting 1-or-more of the following complications (cardiac arrest; myocardial infarction; pneumonia; renal failure/; return to operating room; surgical site infection; sepsis; unplanned intubation).

RESULTS

Our hip fracture cohort consisted of 21,166 patients in Canada (22.3%) and 73,817 in the US (77.7%), for colectomy 21,279 patients in Canada (8.9%) and 218,307 (91.1%), for pancreatectomy 873 (7.8%) in Canada and 12,078 (92.2%) in the US, and for spine surgery 14,088 (5.3%) and 252,029 (94.7%). Patient sociodemographics and comorbidity were clinically similar between jurisdictions. In adjusted analyses odds of death was significantly higher in Canada for two procedures (colectomy (OR 1.22; 95% CI 1.044-1.424; P = .012) and pancreatectomy (OR 2.11; 95% CI 1.26-3.56; P = .005)) and similar for hip fracture and spine surgery. Odds of the composite outcome were significantly higher in Canada for all 4 procedures, largely driven by higher risk of cardiac events and post-operative infections.

CONCLUSIONS

We found evidence of higher rates of mortality and surgical complications within 30-days of surgery for patients in Canada as compared to the US.

US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis

OBJECTIVES

Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.

DESIGN, SETTING AND PARTICIPANTS

Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.

EXPOSURES

NPs/PAs.

MAIN OUTCOME MEASURES

Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.

RESULTS

Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination.

CONCLUSIONS AND RELEVANCE

While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

Weak correlations in health services research: Weak relationships or common error?

OBJECTIVE

To examine whether the correlation between a provider's effect on one population of patients and the same provider's effect on another population is underestimated if the effects for each population are estimated separately as opposed to being jointly modeled as random effects, and to characterize how the impact of the estimation procedure varies with sample size.

DATA SOURCES

Medicare claims and enrollment data on emergency department (ED) visits, including patient characteristics, the patient's hospitalization status, and identification of the doctor responsible for the decision to hospitalize the patient.

STUDY DESIGN

We used a three-pronged investigation consisting of analytical derivation, simulation experiments, and analysis of administrative data to demonstrate the fallibility of stratified estimation. Under each investigation method, results are compared between the joint modeling approach to those based on stratified analyses.

DATA COLLECTION/EXTRACTION METHODS

We used data on ED visits from administrative claims from traditional (fee-for-service) Medicare from January 2012 through September 2015.

PRINCIPAL FINDINGS

The simulation analysis demonstrates that the joint modeling approach is generally close to unbiased, whereas the stratified approach can be severely biased in small samples, a consequence of joint modeling benefitting from bivariate shrinkage and the stratified approach being compromised by measurement error. In the administrative data analyses, the estimated correlation of doctor admission tendencies between female and male patients was estimated to be 0.98 under the joint model but only 0.38 using stratified estimation. The analogous correlations for White and non-White patients are 0.99 and 0.28 and for Medicaid dual-eligible and non-dual-eligible patients are 0.99 and 0.31, respectively. These results are consistent with the analytical derivations.

CONCLUSIONS

Joint modeling targets the parameter of primary interest. In the case of population correlations, it yields estimates that are substantially less biased and higher in magnitude than naive estimators that post-process the estimates obtained from stratified models.

Estimated Annual Spending on Aducanumab in the US Medicare Program

This cross-sectional study examines upper bound and lower bound annualized Medicare costs for administering aducanumab to beneficiaries with the approved indications of mild cognitive impairment or mild dementia.

Coding-Driven Changes In Measured Risk In Accountable Care Organizations

Claims data, which form the foundation of risk adjustment in payment for health care services, may reflect efforts to capture more-or more severe-clinical conditions rather than true changes in health status. This can distort payments. We quantify this in the context of Medicare's accountable care organization (ACO) program by comparing risk scores derived from two different measurement approaches. One approach uses diagnoses coded on claims based on Centers for Medicare and Medicaid Services Hierarchical Condition Categories (HCC), and the other uses self-reported, survey-based health data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS). During 2013-16 HCC-based risk scores grew faster than CAHPS-based risk scores (2.1 percent versus 0.3 percent annually), and the gap in HCC- and CAHPS-based risk score growth varied widely across ACOs. The average gap in risk score growth appears to be the result primarily of HCC coding practices rather than poor performance of the CAHPS model, suggesting that coding practices (not necessarily driven by ACO contracts) may account for most of the observed risk score growth for ACO beneficiaries.

Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019

BACKGROUND

Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care.

OBJECTIVE

To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination.

DESIGN

Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time.

SETTING

Traditional fee-for-service Medicare.

PATIENTS

20% sample of Medicare beneficiaries.

MEASUREMENTS

Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients.

RESULTS

The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019.

LIMITATION

Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel.

CONCLUSION

Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Representativeness of Participants Eligible to Be Enrolled in Clinical Trials of Aducanumab for Alzheimer Disease Compared With Medicare Beneficiaries With Alzheimer Disease and Mild Cognitive Impairment

This study evaluates whether patients enrolled in trials of aducanumab, EMERGE and ENGAGE, were representative of patients with dementia enrolled in Medicare by estimating the proportions of Medicare beneficiaries with Alzheimer disease (AD) or mild cognitive impairment (MCI) who would have been excluded from these trials.

Attitudes toward risk among emergency physicians and advanced practice clinicians in Massachusetts

OBJECTIVE

Risk aversion is a personality trait influential to decision making in medicine. Little is known about how emergency department (ED) clinicians differ in their attitudes toward risk taking.

METHODS

We conducted a cross-sectional survey of practicing ED clinicians (physicians and advanced practice clinicians [APCs]) in Massachusetts using the following 4 existing validated scales: the Risk-Taking Scale (RTS), Stress from Uncertainty Scale (SUS), the Fear of Malpractice Scale (FMS), and the Need for (Cognitive) Closure Scale (NCC). We used Cronbach's α to assess the reliability of each scale and performed multivariable linear regressions to analyze the association between the score for each scale and clinician characteristics.

RESULTS

Of 1458 ED clinicians recruited for participation, 1116 (76.5%) responded from 93% of acute care hospitals in Massachusetts. Each of the 4 scales demonstrated high internal consistency reliability with Cronbach's αs ranging from 0.76 to 0.92. The 4 scales also were moderately correlated with one another (0.08 to 0.54; all P < 0.05). The multivariable results demonstrated differences between physicians and APCs, with physicians showing a greater tolerance for risk or uncertainty (NCC difference, -3.58 [95% confidence interval, CI, -5.26 to -1.90]; SUS difference, -3.14 [95% CI: -4.99 to -1.29]) and a higher concern about malpractice (FMS difference, 1.14 [95% CI, 0.11-2.17]). Differences were also observed based on clinician age (a proxy for years of experience), with greater age associated with greater tolerance of risk or uncertainty (age older than 50 years compared with age 35 years and younger; NCC difference, -2.84 [95% CI, -4.69 to -1.00]; SUS difference, -4.71 [95% CI, -6,74 to -2.68]) and less concern about malpractice (FMS difference, -3.19 [95% CI, -4.31 to -2.06]). There were no appreciable differences based on sex, and there were no consistent associations between scale scores and the practice and payment characteristics assessed.

CONCLUSION

We found that risk attitudes of ED clinicians were associated with type of training (physician vs APC) and age (experience). These differences suggest one possible explanation for the observed differences in decision making.

National Trends In ED Visits, Hospital Admissions, And Mortality For Medicare Patients During The COVID-19 Pandemic

Concerns about avoidance or delays in seeking emergency care during the COVID-19 pandemic are widespread, but national data on emergency department (ED) visits and subsequent rates of hospitalization and outcomes are lacking. Using data on all traditional Medicare beneficiaries in the US from October 1, 2018, to September 30, 2020, we examined trends in ED visits and rates of hospitalization and thirty-day mortality conditional on an ED visit for non-COVID-19 conditions during several stages of the pandemic and for areas that were considered COVID-19 hot spots versus those that were not. We found reductions in ED visits that were largest by the first week of April 2020 (52 percent relative decrease), with volume recovering somewhat by mid-June (25 percent relative decrease). These reductions were of similar magnitude in counties that were and were not designated as COVID-19 hot spots. There was an early increase in hospitalizations and in the relative risk for thirty-day mortality, starting with the first surge of the pandemic, peaking at just over a 2-percentage-point increase. These results suggest that patients were presenting with more serious illness, perhaps related to delays in seeking care.

Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups

IMPORTANCE

Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups.

OBJECTIVE

To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities.

MAIN OUTCOMES AND MEASURES

Admission from the ED.

RESULTS

The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98).

CONCLUSIONS AND RELEVANCE

This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician's propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients.

Estimated Effect on Life Expectancy of Alleviating Primary Care Shortages in the United States

BACKGROUND

Prior studies have reported that greater numbers of primary care physicians (PCPs) per population are associated with reduced population mortality, but the effect of increasing PCP density in areas of low density is poorly understood.

OBJECTIVE

To estimate how alleviating PCP shortages might change life expectancy and mortality.

DESIGN

Generalized additive models, mixed-effects models, and generalized estimating equations.

SETTING

3104 U.S. counties from 2010 to 2017.

PARTICIPANTS

Children and adults.

MEASUREMENTS

Age-adjusted life expectancy; all-cause mortality; and mortality due to cardiovascular disease, cancer, infectious disease, respiratory disease, and substance use or injury.

RESULTS

Persons living in counties with less than 1 physician per 3500 persons in 2017 had a mean life expectancy that was 310.9 days shorter than for persons living in counties above that threshold. In the low-density counties (n = 1218), increasing the density of PCPs above the 1:3500 threshold would be expected to increase mean life expectancy by 22.4 days (median, 19.4 days [95% CI, 0.9 to 45.6 days]), and all such counties would require 17 651 more physicians, or about 14.5 more physicians per shortage county. If counties with less than 1 physician per 1500 persons (n = 2636) were to reach the 1:1500 threshold, life expectancy would be expected to increase by 56.3 days (median, 55.6 days [CI, 4.2 to 105.6 days]), and all such counties would require 95 754 more physicians, or about 36.3 more physicians per shortage county.

LIMITATION

Some projections are based on extrapolations of the actual data.

CONCLUSION

In counties with fewer PCPs per population, increases in PCP density would be expected to substantially improve life expectancy.

PRIMARY FUNDING SOURCE

None.

Using Consistently Low Performance to Identify Low-Quality Physician Groups

Importance

There has been a growth in the use of performance-based payment models in the past decade, but inherently noisy and stochastic quality measures complicate the assessment of the quality of physician groups. Examining consistently low performance across multiple measures or multiple years could potentially identify a subset of low-quality physician groups.

Objective

To identify low-performing physician groups based on consistently low performance after adjusting for patient characteristics across multiple measures or multiple years for 10 commonly used quality measures for diabetes and cardiovascular disease (CVD).

Design, Setting, and Participants

This cross-sectional study used medical and pharmacy claims and laboratory data for enrollees ages 18 to 65 years with diabetes or CVD in an Aetna health insurance plan between 2016 and 2019. Each physician group's risk-adjusted performance for a given year was estimated using mixed-effects linear probability regression models. Performance was correlated across measures and time, and the proportion of physician groups that performed in the bottom quartile was examined across multiple measures or multiple years. Data analysis was conducted between September 2020 and May 2021.

Exposures

Primary care physician groups.

Main Outcomes and Measures

Performance scores of 6 quality measures for diabetes and 4 for CVD, including hemoglobin A1c (HbA1c) testing, low-density lipoprotein testing, statin use, HbA1c control, low-density lipoprotein control, and hospital-based utilization.

Results

A total of 786 641 unique enrollees treated by 890 physician groups were included; 414 655 (52.7%) of the enrollees were men and the mean (SD) age was 53 (9.5) years. After adjusting for age, sex, and clinical and social risk variables, correlations among individual measures were weak (eg, performance-adjusted correlation between any statin use and LDL testing for patients with diabetes, r = -0.10) to moderate (correlation between LDL testing for diabetes and LDL testing for CVD, r = .43), but year-to-year correlations for all measures were moderate to strong. One percent or fewer of physician groups performed in the bottom quartile for all 6 diabetes measures or all 4 cardiovascular disease measures in any given year, while 14 (4.0%) to 39 groups (11.1%) were in the bottom quartile in all 4 years for any given measure other than hospital-based utilization for CVD (1.1%).

Conclusions and Relevance

A subset of physician groups that was consistently low performing could be identified by considering performance measures across multiple years. Considering the consistency of group performance could contribute a novel method to identify physician groups most likely to benefit from limited resources.

Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels

STUDY OBJECTIVE

Rates of admission from the emergency department (ED) vary widely across regions of the country, hospitals within regions, and physicians within hospitals. Our objective was to determine the extent to which variation in admission decisions was described by differences in admission rates at these 3 levels. This understanding will serve to better target interventions to modify rates of admission where appropriate.

METHODS

In this cross-sectional observational cohort study, we analyzed Medicare fee-for-service claims for ED visits from 2012 to 2015 in a 20% random sample of beneficiaries. We first estimated the total regional-, hospital-, and physician-level variations in rates of admission and their proportions of the total variation after adjusting for patient and each level's covariates. We then estimated the extent to which each level's characteristics accounted for variation at that respective level.

RESULTS

Our study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs across 306 hospital referral regions. The mean rate of admission was 38.9% and ranged from 21.4% to 53.0% for physicians at the 10^th and 90^th percentile of the distribution, respectively. The residual (unexplained) variations at the regional, hospital, and physician levels were 13.3% (95% confidence interval [CI], 11.2 to 15.5%), 60.1% (57.1 to 62.9%), and 26.7% (26.4 to 26.9%), respectively. Regional, hospital, and physician characteristics accounted for 9.1% (95% CI, -5.6 to 23.8%), 51.1% (48.8 to 53.5%), and 2.7% (1.3 to 4.1%), respectively, of the explained variation at their respective levels.

CONCLUSION

Within-area variation, both across hospitals within a region and across physicians within a hospital, is a more substantial component of observed variation in admission rates from the ED than regional level variation. These findings suggest that variation in admission rates is at least in part related to institutional norms and cultures as well as heterogeneity of physician decisionmaking within hospitals, both of which could be targets of interventions to modify rates of admission.

Medicare's Care Management Codes Might Not Support Primary Care As Expected

To enhance compensation for primary care activities that occur outside of face-to-face visits, the Centers for Medicare and Medicaid Services recently introduced new billing codes for transitional care management (TCM) and chronic care management (CCM) services. Overall, rates of adoption of these codes have been low. To understand the patterns of adoption, we compared characteristics of the practices that billed for these services to those of the practices that did not and determined the extent to which a practice other than the beneficiary's usual primary care practice billed for the services. Larger practices and those using other novel billing codes were more likely to adopt TCM or CCM. Over a fifth of all TCM claims and nearly a quarter of all CCM claims were billed by a practice that was not the beneficiary's assigned primary care practice. Our results raise concerns about whether these codes are supporting primary care as originally expected.

Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims

OBJECTIVE

Diagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.

SETTING/PARTICIPANTS

1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 'index' outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).

OUTCOME MEASURES

90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.

DESIGN

Using retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.

RESULTS

Rates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI -5.0 to -0.7, p=0.008), 4.1 fewer hospitalisations (95% CI -6.9 to -1.2, p=0.006) and 4.9 fewer ED visits (95% CI -8.1% to -1.6%, p=0.003) per 1000 visits.

CONCLUSION

Higher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

Use of diabetes medications in traditional Medicare and Medicare Advantage

OBJECTIVES

To compare use of diabetes medications between beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM).

STUDY DESIGN

Retrospective cohort analysis of Medicare enrollment and Part D event claims during 2015-2016.

METHODS

Data came from 1,027,884 TM and 838,420 MA beneficiaries who received at least 1 prescription for an oral or injectable diabetes medication. After matching MA and TM enrollees by demographic characteristics and geography, we analyzed use of medication overall, choices of first diabetes medication for those new to medication, and patterns of adding medications.

RESULTS

Overall and for patients on 1, 2, or 3 diabetes medications, use of metformin was higher in MA by about 3 percentage points, but use of newer medication classes was 5.1 percentage points higher in TM overall (21.3% vs 16.2%). Use of guideline-recommended first-line agents was higher in MA. For those who started metformin first, use of a sulfonylurea as a second medication was 7.8 percentage points higher in MA than TM (61.5% vs 53.7%), whereas use of medications from newer classes was 7.7 percentage points lower (22.0% vs 29.7%). Mean total spending was $149 higher in TM for those taking 1 medication and $298 higher for those taking 2 medications. Differences in spending among MA plans were of similar magnitude to the MA-TM differences.

CONCLUSIONS

MA enrollees are more likely to be treated with metformin and sulfonylureas and less likely to receive costly newer medications than those in TM, but there also is substantial variation within MA. A limitation of the study is that we could not assess glucose control using glycated hemoglobin levels.