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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
Joanne E. Brady, PhD; Claudia Vellozzi, MD, MPH; Susan Hariri, PhD; Danielle L. Kruger, BA; David R. Nerenz, PhD; Kimberly Ann Brown, MD; Alex D. Federman, MD, MPH; Katherine Krauskopf, MD, MPH; Natalie Kil, MPH; Omar I. Massoud, MD; Jenni M. Wise, RN, MSN; Toni Ann Seay, MPH, MA; Bryce D. Smith, PhD; Anthony K. Yartel, MPH; and David B. Rein, PhD
“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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RESULTS

Study Sample

We identified 139,614 adults 65 years or older who were continuously enrolled in Medicare FFS in 2010, were attributed to a primary care physician in the Hudson Valley, and had 1 or more ambulatory visit that year (Figure). The average age of this group was 76.8 (SD = 7.5) years, which is fairly similar to that of Medicare beneficiaries 65 years or older nationally (average [SD] age, 75.1 [7.8] years).23

Our sample was composed of the 117,977 (85%) beneficiaries who did not have outlier observations, had 4 or more ambulatory visits, had continuous enrollment for at least 1 more consecutive year, and were not hospitalized on the first day of 2011 (Figure).

Sample Characteristics

Among the 117,977 beneficiaries in our sample, the mean age was 77.2 years (Table 1). More than half (60.8%) were women. The distribution of counts of chronic conditions was as follows: 1.4% had 0 chronic conditions, 18.6% had 1 to 2 chronic conditions, 39.1% had 3 to 4, and 41.0% had 5 or more. Most beneficiaries (93%) contributed data for all 3 years of the study, whereas the remainder (7%) contributed data for the first 2 years only.

The 13,439 beneficiaries (10% of the total) who were excluded because they had 3 or fewer ambulatory visits were younger and healthier than those who were included (eAppendix C). The 7978 beneficiaries (6% of the total) who were excluded because they were not continuously enrolled in 2011 (including due to death that year) or were hospitalized on January 1, 2011, were older, less likely to be female, and sicker than those who were included (eAppendix C).

Ambulatory Care at Baseline

Among those who were included, the typical (median) beneficiary had 12 ambulatory visits with 5 unique providers in the baseline year (Table 1). The typical beneficiary also had 40% of ambulatory visits with their most frequently seen provider. As the proportion of visits with the most frequently seen provider decreased, fragmentation increased (Table 2). Just 2.5% of the sample had 1 provider for all visits (resulting in a fragmentation score equal to 0.00).

Associations With ED Visits and Hospital Admissions

One-fourth of beneficiaries (25%) had 1 or more ED visits during follow-up. The median observation time until an ED visit or censoring (for the ED visit models) was 1.7 years. One-third of beneficiaries (33%) had 1 or more hospital admissions during follow-up. The median observation time until a hospital admission or censoring was 2.0 years. Schoenfeld residuals and zph tests showed that our models did not violate the underlying statistical assumptions.

Among those with 0 chronic conditions, having fragmented care did not increase the hazard of an ED visit (Table 3). Among those with 1 or more chronic conditions, having the most (vs the least) fragmented care significantly increased the hazard of an ED visit, by a magnitude of 13% for those with 1 to 2 chronic conditions (P <.01), 14% for those with 3 to 4 chronic conditions (P <.0001), and 10% for those with 5 or more chronic conditions (P = .001). Some but not all of the intermediate fragmentation categories were also associated with an increased hazard of an ED visit.

Among those with 0 chronic conditions, having fragmented care did not increase the hazard of a hospital admission (Table 4). 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 a hospital admission, by a magnitude of 14% for those with 1 or 2 chronic conditions (P <.01) and 6% for those with 3 or 4 chronic conditions (P <.05). Among those with 5 or more chronic conditions, having the most fragmented care decreased the adjusted hazard of a hospital admission by 5% (P = .03). Most intermediate fragmentation categories were not associated with a significant difference in the hazard of admission.

Sensitivity analyses using 2 alternative fragmentation indices (eAppendices D and E) showed results consistent with our base-case analyses, both for ED visits and hospital admissions.


 
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