Medical Care最新文献

Background: PRECIDENTD (PRevention of CardIovascular and DiabEtic KidNey Disease in Type 2 Diabetes) is a PCORnet® Study evaluating 2 classes of medications, SGLT2 inhibitors and GLP-1 receptor agonists, among people with type 2 diabetes. Participants obtain their assigned medication through their health insurance and complete semi-annual study assessments.

Objective: We engaged multiple partners to develop a centralized text message-based program to facilitate adherence and retention in PRECIDENTD and evaluated its performance from April 2024 to April 2025.

Methods: The PRECIDENTD study team applied best practices in digital health tool design and built the program with technology company MEMOTEXT. Patient partners identified program goals, co-wrote message content, and completed internal testing. We then deployed the program to PRECIDENTD participants and analyzed responses.

Measures: We assessed response rate to interactive text messages, proportion of messages flagging participants needing additional support, and the adherence problems identified.

Results: The text messaging program includes interactive messages querying if participants are taking the study medication, as well as one-way study timeline messages. During the first year, 450 PRECIDENTD participants across 20 sites received texts. Interactive message response rate was 80%, and 25% of responses identified problems (ie, trouble getting fills/refills and experiencing a health concern or side effect), prompting an outreach call.

Conclusions: We co-designed a digital tool that engaged participants and helped identify study participants needing assistance obtaining and adhering to study medications. Collaborative development of similar centralized tools may augment the capacity of national studies to answer important comparative effectiveness research questions.

Background: The Veterans Health Administration (VHA) greatly expanded the proportion of health care services it purchases from community providers over the last decade, which could impact the quality of care and create care fragmentation. Continuity of care between inpatient and outpatient care delivery systems is critical for high-quality mental health care.

Objective: To compare rates of outpatient follow-up visits between VHA-purchased and VHA-delivered psychiatric hospitalizations, overall and by VHA facility.

Methods: Using VHA electronic medical records and community care claims data, we compared 7-day and 30-day outpatient follow-up rates across VHA-purchased and VHA-delivered settings. We estimated follow-up rates and comparisons overall as well as separately for 4 diagnosis groups and separately across VHA facilities.

Results: Our sample included 64,784 hospitalizations; more than 30% were VHA-purchased as opposed to VHA-delivered. Compared with VHA-delivered hospitalizations, follow-up rates were 30.1 (95% CI: 27.8-32.5) percentage points lower at 7 days and 22.5 (95% CI: 20.8-24.1) percentage points lower at 30 days for VHA-purchased hospitalizations. Lower follow-up rates occurred for neurocognitive disorder discharges for both VHA-purchased and delivered care. Follow-up rates at 30 days were significantly lower for VHA-purchased hospitalizations at 121 out of 128 facilities and significantly higher at no facility.

Conclusions: VHA enrollees seeking mental health care and VHA program managers could benefit from data on psychiatric care quality differences between community providers and VHA providers. From a system perspective, VHA-purchased care quality reports and value-based purchasing contracts could include outpatient follow-up quality measures to incentivize higher quality care.

Background: There is a significant shortage of psychiatrists compared with the demand for their services. We studied Medicare Part D claims of psychiatrists and similar clinician prescribers to identify possible shifts in medication prescribing to address this gap.

Objective: This pharmacoepidemiology study aimed to identify prescribing patterns among psychiatrists, family physicians, internists, physician associates/assistants (PAs), and nurse practitioners (NPs), as well as trends.

Design: An observational, retrospective cohort study of Medicare Part D claims from 2013 to 2022 was conducted. Psychiatrists' prescription patterns were compared with those of non-psychiatrists, using the National Provider Identifier (NPI). Diagnosis information was not available in the dataset.

Participants: In 2022, more than 32,400 psychiatrists' prescriptions were submitted for more than 36.6 million Medicare Part D claims for various medications.

Main measures: Prescribers and medication claim counts were analyzed to determine the most commonly prescribed drugs by psychiatrists. Total psychiatrist prescription counts and trends were compared with those of primary care physicians, PAs, and NPs.

Key results: Family practice physicians wrote more than 55 million prescriptions in 2022, nearly twice the number written by psychiatrists. From 2013 to 2022, prescriptions written by PAs and NPs showed a strong upward trend. In 2020, prescription claims by NPs surpassed psychiatrists, and by 2022, they had exceeded those of internal medicine physicians.

Conclusions: Claims by NPs increased from 8.6% to 24.8%, whereas psychiatrists' claims decreased from 24.4% to 18.0%. As of 2023, NPs and PAs comprise a significant portion of the workforce that addresses gaps in mental health medication care for Medicare patients.

Objective: To examine changes in persistent emergency department (ED) use by adult frequent ED (FED) users over time comparing prepandemic versus peripandemic periods, and to identify distinct characteristics of individuals who remained FED users over time during the pandemic versus the prepandemic era.

Methods: We conducted a retrospective, secondary, longitudinal analysis in Texas, following 2 cohorts of ED users over 36 months (cohort 1: March 2017-February 2020; cohort 2: March 2019-February 2022). The main outcomes were whether a baseline FED (≥9 ED visits/12 mo) user remained a FED user persistently over the next 24 months and whether they were persistent FED users prepandemic or peripandemic. Multivariable regressions estimated changes in persistent FED use across cohorts and assessed differences between individuals who remained persistent FED users during the pandemic compared with the prepandemic period.

Setting: All-payer Texas Hospital ED Research Data File from 2016 to 2022.

Results: About 1 million individuals had at least one ED visit in the baseline years, totaling 4.6 million visits. Overall, FED users accounted for 8% of all ED users but over 40% of visits. Although more than half of FED users at baseline exhibited persistent FED use over the next 24 months, there was a 7% decline in the proportion of return FED users after the onset of COVID-19 which was statistically significant (AOR=0.82; 95% CI=0.80-0.84), and this effect was more pronounced when patients with any COVID-19-related ED visit during the study period were excluded (AOR=0.10; 95% CI=0.09-0.11). Individuals aged 45 years or older, those with congestive heart failure and diabetes with complications, and those with public insurance (when COVID-19-related visits were excluded) had higher odds of remaining persistent FED users during the pandemic.

Conclusions: Many FED users will seek ED care for multiple years, given their medical complexity. Future research should identify heterogeneous subgroups among persistent FED users to tailor interventions towards their needs.

Background: Medicare Advantage (MA) encounter data became available for research in 2019; data quality concerns remain.

Objectives: We evaluated the consistency of ICD-10-CM comorbidity coding between MA and Fee-For-Service (FFS) data.

Methods: We used round 7 (2017) of the National Health and Aging Trends Study (NHATS) linked to Medicare enrollment, MA encounter, and FFS claims (2016-2017). We included participants continuously enrolled in MA or FFS for 1 year before round 7. Comorbidities were identified using ICD-10-CM codes from the Gagne combined comorbidity index. Demographic, socioeconomic, and clinical covariates from NHATS for FFS beneficiaries were standardized to resemble those for MA beneficiaries. We estimated crude and standardized comorbidity prevalence differences (PDs) between MA and FFS beneficiaries.

Results: Among 5158 beneficiaries (MA: 40%, FFS: 60%), MA beneficiaries were more likely to be Black, Hispanic, and socioeconomically disadvantaged. After standardization, comorbidity prevalence was similar between groups. Peripheral vascular disorder (PD=7.2%, 95% CI: 3.8%-10.6%) and renal failure (PD=3.7%, 95% CI: 0.9%-6.5%) were more common in MA beneficiaries; fluid/electrolyte disorders (PD=-3.2%, 95% CI: -5.5 to -1.0%) and deficiency anemias (PD=-5.0%, 95% CI: -7.6 to -2.3%) were more common in FFS beneficiaries. Other PDs were less than 3 percentage points.

Conclusions: Discrepancies in comorbidity prevalence may reflect true differences or coding variations influenced by provider incentives, documentation standards, or diagnostic priorities. Comorbidity prevalence was largely consistent between MA encounters and FFS claims, supporting the reliability of MA encounter data for aging research. Additional validation studies should address remaining discrepancies.

Background: Understanding whether patients' preferences for physicians are influenced by racial or ethnic concordance is crucial for balancing patient care satisfaction and health care workforce diversity.

Objectives: To investigate whether patients' preferences for physicians are influenced by racial or ethnic concordance and whether these preferences are reflected in the availability of physicians by race.

Research design: A patient-focused randomized online experiment was conducted to evaluate preferences for physicians while a physician-focused randomized field experiment was conducted to evaluate physician availability by race. The patient-focused experiment involved respondents selecting primary care physicians, while the physician-focused field experiment was conducted on a random sample of primary care physicians in Texas, which reports physician race.

Results: White respondents preferred White physicians by 10 percentage points (ppts) (95% CI: 0.048-0.157, P<0.01). Hispanic respondents favored Hispanic physicians by 27 ppts (95% CI: 0.148-0.398, P<0.01) while Black respondents favored Black physicians by 15 ppts (95% CI: -0.013 to 0.395, P=0.07). Overall, White physicians were preferred by 4.8 ppts (95% CI: 0.004-0.092, P=0.030) at the expense of Asian physicians, who were less preferred by 9.2 ppts (95% CI: -0.187 to 0.003, P=0.06). These findings are consistent with the physician-focused field experiment where Asian physicians offered appointments 3 days sooner than White providers (95% CI: -6.1 to 0.1 days, P=0.05).

Conclusion: We find that concordance preferences for physicians varied by race. Some patients may be dissatisfied if these preferences are not met while some physicians may face unequal employment outcomes if they are met.

Background: Despite national attention to address disparities in health care, significant language-based health inequities exist in the United States.

Objectives: To evaluate whether readmissions for patients with limited English proficiency (LEP) are associated with the LEP volume of the hospital and to determine whether and to what extent the effect of hospital LEP volume on readmissions for LEP patients is conditional on the hospitals' nurse work environment.

Research design: Cross-sectional analysis using 3 data sources from 2016: New Jersey Discharge Data Collection System, RN4CAST-US survey, and American Hospital Association Annual Survey.

Subjects: A total of 424,745 patients, 9.2% of which were defined as having LEP (n=38,906), in 68 hospitals.

Measures: The RN4CAST survey utilized the Practice Environment Scale of the Nursing Work Index to measure nurses' ratings of their hospitals' nurse work environment. The outcome variable was 7-day readmissions, representing a potentially avoidable re-visit to the hospital. Hospital LEP volume was measured as the percentage of index admissions of LEP patients.

Results: In the fully adjusted stratified model, in hospitals with poor work environments, a 10-percentage point increase in LEP volume was significantly associated with 6% higher odds of a 7-day readmission for LEP patients [OR=1.06, 95% CI (1.04-1.08), P<0.001]. In hospitals with favorable environments, a 10-percentage point increase in LEP volume was associated with 2% higher odds of a 7-day readmission; however, this difference was not statistically significant [OR=1.02, 95% CI (0.99-1.06)].

Conclusion: Readmission disparities were greatest in hospitals serving higher proportions of patients with LEP; however, the disparities were rendered insignificant in hospitals with the favorable nurse work environments.

Background: To identify patients at the highest risk for acute care utilization, health care systems have developed "hot spotter" programs. Homelessness is a robust social determinant of acute care utilization.

Objectives: To describe the prevalence, patterns, and correlates of meeting criteria for a hot spotter program among housing-insecure adults in the US Veterans Health Administration (VHA).

Research design: Among veterans on the VHA Homeless Registry in Fiscal Years 2018-2022 (N=1,469,893), we identified those who met criteria for a Hot Spotter Report [ie, ≥1 hospital admissions and/or ≥2 emergency department (ED) visits in at least one quarter], described their patterns of acute care use, and examined differences in patient characteristics and outpatient service use between those who met report criteria in multiple quarters (vs. one).

Results: Thirty percent (N=446,974) met report criteria in at least one quarter; most (56%) met report criteria in ≥2 quarters. Diagnoses of depression (58%) and/or a substance use disorder (51%) were common; however, the rate of hospitalization in an acute medical setting during the cohort period was twice that of being hospitalized in an acute mental health setting (50% vs. 25%). Being on the Hot Spotter Report in multiple quarters (vs. one) was associated with more chronic conditions (M=5.08 vs. 3.29), higher rates of suicidality (23.7% vs. 11.7%), and higher likelihood of all types of outpatient care (P<0.0001).

Conclusions: Given rates of chronic medical conditions and medical hospitalizations, it may behoove hot spotter programs to increase care coordination with medical respite programs to support patients in the postacute phase.

Background: Chronic conditions affect over 60% of US adults and drive nearly 90% of the nation's $4.9 trillion in annual health care costs. Nurse practitioners (NPs), particularly in Full Practice Authority (FPA) states, may be critical to improving outcomes and reducing health care burdens.

Objectives: To evaluate whether nurse practitioner FPA reduces hospital readmissions and emergency department visits related to chronic conditions across the United States.

Research design: A secondary data analysis using restricted Medical Expenditure Panel Survey (MEPS) data (2010-2019) was performed on site at the Agency of Health Research and Quality. We applied incidence rate ratios (IRRs) and difference-in-difference (DiD) models.

Measures: Primary outcomes included readmission and emergency visit rates for five chronic conditions: high cholesterol (n=33,409), high blood pressure (n=38,858), diabetes (n=13,075), emphysema (n=2,509), and asthma (n=17,018). Covariates included county-level socioeconomic factors and rurality.

Results: States with FPA had modestly lower IRRs for high cholesterol (0.9863), high blood pressure (0.9758), diabetes (0.9746), and asthma (0.9710) compared with restricted states. DiD models showed inconsistent effects, with most FPA*Post coefficients lacking statistical significance. However, rural FPA counties frequently showed significantly lower readmission rates, notably for diabetes and high cholesterol.

Conclusions: NP FPA is associated with slight reductions in chronic condition readmissions, particularly in rural areas. While DiD models showed limited policy-specific impact, IRR findings support FPA as a promising strategy to enhance chronic disease management and access to care. Future research should address model limitations and explore causal pathways.

Background: Federally qualified health centers and look-alikes are outpatient care settings that provide primary care and other health services in health professional shortage areas and to their populations. Compiling and disseminating data from these centers that is accessible for patient-centered outcomes research (PCOR) is critical to understanding health care provided at these settings.

Objective: To describe the National Ambulatory Medical Care Survey Health Center (NAMCS HC) Component, and how this redesigned survey can be utilized to understand health care provided at health centers, improve data capacity, and facilitate PCOR.

Methods: Beginning in 2021, the NAMCS HC Component began collecting visit data through electronic health record (EHR) submission from a nationally representative sample of FQHCs and FQHC look-alikes. Resulting datasets are made available for researchers to analyze, used to produce readily available interactive data visualizations, and linked to external datasets.

Results: The NAMCS HC Component and its resulting data resources are described. Availability of restricted and public datafiles is highlighted, with an example of how these can be used to study visits across different patient characteristics. Interactive dashboards are presented, including how researchers, health centers, and patients can view biannual preliminary visit rates/counts. Finally, linkages between the NAMCS HC Component and external data sources are highlighted, including how these linkages can be used to study health outcomes among different populations.

Conclusions: EHR data collected from FQHCs and look-alikes through the redesigned NAMCS HC Component fills a gap to improve PCOR capacity at these unique settings.