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The American Journal of Managed Care September 2018
Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Hepatitis C Care Cascade Among Persons Born 1945-1965: 3 Medical Centers
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“Precision Health” for High-Need, High-Cost Patients
Dhruv Khullar, MD, MPP, and Rainu Kaushal, MD, MPH
From the Editorial Board: A. Mark Fendrick, MD
A. Mark Fendrick, MD
Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH
Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
Early Experiences With the Acute Community Care Program in Eastern Massachusetts
Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
Economic Evaluation of Patient-Centered Care Among Long-Term Cancer Survivors
JaeJin An, BPharm, PhD, and Adrian Lau, PharmD
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Fragmented Ambulatory Care and Subsequent Healthcare Utilization Among Medicare Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Adjusting Medicare Advantage Star Ratings for Socioeconomic Status and Disability
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; Cheryl L. Damberg, PhD; Ann Haas, MS, MPH; Mallika Kommareddi, MPH; Anagha Tolpadi, MS; Megan Mathews, MA; and Marc N. Elliott, PhD

Fragmented Ambulatory Care and Subsequent Healthcare Utilization Among Medicare Beneficiaries

Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Among Medicare beneficiaries, the relationship between fragmented ambulatory care and subsequent emergency department visits and hospital admissions varies with the number of chronic conditions.
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ABSTRACT

Objectives: We sought to determine the associations between fragmented ambulatory care and subsequent emergency department (ED) visits and hospital admissions, while considering possible interactions between fragmentation and number of chronic conditions.

Study Design: We conducted a cohort study over 3 years among 117,977 fee-for-service Medicare beneficiaries who were attributed to primary care physicians in a 7-county region of New York and had 4 or more ambulatory visits in the baseline year.

Methods: We calculated fragmentation scores using a modified Bice-Boxerman Index and, because scores were skewed, divided them into quintiles. We used Cox regression models to determine associations between fragmentation and ED visits and, separately, hospital admissions, stratifying by number of chronic conditions and adjusting for age, gender, number of ambulatory visits, and case mix.

Results: Among those with 1 to 2 or 3 to 4 chronic conditions, having the most (vs the least) fragmented care significantly increased the hazard of an ED visit and, separately, increased the hazard of an admission (adjusted P <.05 for each comparison). Among those with 5 or more chronic conditions, having the most fragmented care significantly increased the hazard of an ED visit but decreased the hazard of an admission (adjusted P <.05 for each comparison). Among those with 0 chronic conditions, having fragmented care was not associated with either outcome.

Conclusions: The relationship between fragmented ambulatory care and subsequent utilization varies with the number of chronic conditions. Beneficiaries with a moderate burden of chronic conditions (1-2 or 3-4) appear to be at highest risk of excess ED visits and admissions due to fragmented care.

Am J Manag Care. 2018;24(9):e278-e284
Takeaway Points

Among Medicare beneficiaries, the relationship between fragmented ambulatory care and subsequent healthcare utilization varies with the number of chronic conditions.
  • Among those with 1 to 2 or 3 to 4 chronic conditions, having the most (vs the least) fragmented care significantly increased the hazard of an emergency department (ED) visit and, separately, increased the hazard of a hospital admission (adjusted P <.05 for each comparison).
  • Among those with 5 or more chronic conditions, having the most fragmented care significantly increased the hazard of an ED visit but decreased the hazard of an admission (adjusted P <.05 for each comparison).
  • Among those with 0 chronic conditions, having fragmented care was not associated with either outcome.
Patients routinely receive care from multiple ambulatory providers, especially if they have chronic conditions.1 Receiving care from multiple providers may be appropriate, but it often leads to gaps in communication across providers,2 which can result in suboptimal care. Previous studies have found that more fragmented care (that is, care spread across many providers with no dominant provider) is associated with more testing, more overuse of procedures, and lower patient satisfaction compared with less fragmented care.3-5 Prior studies have also found associations between more fragmented care and higher rates of emergency department (ED) visits, higher rates of hospital admissions, and higher costs compared with less fragmented care.6-8

However, the association between fragmentation and these outcomes is not yet sufficiently described to enable the design of interventions to address it. For example, fragmentation has typically been measured as a continuous variable, which is appropriate but assumes that the relationship between fragmentation and outcomes is linear,6,8 which may not be the case; rather, a threshold effect may be present, in which a certain amount of fragmentation increases the risk of an outcome. Also, previous studies have adjusted for the number of chronic conditions or case mix, which is appropriate but may mask the possibility that fragmentation affects patients differently depending on how many chronic conditions they have.8

Thus, we sought to determine the associations between care fragmentation in the ambulatory setting and subsequent ED visits and hospital admissions, while considering whether those associations vary with number of chronic conditions.

METHODS

Overview

We conducted a cohort study (2010-2012) of fee-for-service (FFS) Medicare beneficiaries who received care from physicians in the Hudson Valley of New York to determine associations between fragmented ambulatory care and subsequent ED visits and hospital admissions. The Institutional Review Board of Weill Cornell Medicine approved the protocol.

Setting

The Hudson Valley consists of 7 counties immediately north of New York City (Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester). Approximately 85% of the people in this region live in urban or suburban areas.9,10 Approximately 85% of residents have health insurance, and approximately 10% live at or below the federal poverty level.9,11 At the time of the study, most healthcare in the region was delivered by physicians in small- and medium-size private practices, using FFS reimbursement from multiple payers.12

Data

We used Medicare FFS claims data for 2010-2012, extracting the following claim-level variables: patient study identifier (ID), patient date of birth, patient gender, date of service, rendering provider ID, Current Procedural Terminology (CPT) codes, and International Classification of Diseases, Ninth Revision (ICD-9) codes. We also extracted monthly patient-level enrollment data.

Study Sample

We first identified primary care physicians (general internists and family medicine physicians) in the claims who had billing zip codes in the Hudson Valley (Figure). We determined which Medicare beneficiaries 65 years and older could be attributed to those primary care physicians, based on 2010 claims, using previously defined logic.13 Of those, we identified beneficiaries who were continuously enrolled that year and had 1 or more ambulatory visits. Ambulatory visits were defined by CPT codes, using a modified version of the definition by the National Committee for Quality Assurance (NCQA).14 Modifications restricted the definition to evaluation-and-management visits for adults in an office setting, excluding management-only visits (eg, physical therapy) and non–office-based visits (eg, visits in nursing homes). This definition also excluded ED visits.

We excluded beneficiaries with outlier observations (>99.9th percentile) for number of ambulatory visits or unique providers, because those observations may have been erroneous. Next, we restricted the cohort to those with 4 or more ambulatory visits in the baseline year, because calculating fragmentation with 3 or fewer ambulatory visits can lead to statistically unstable estimates.8 We required that beneficiaries be continuously enrolled in Medicare for at least 1 more consecutive year, contributing data for 2 years (2010-2011) or 3 years (2010-2012). Finally, we excluded those who were in the hospital on January 1, 2011, because they were not at risk of an ED visit or hospital admission at the start of follow-up.


 
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