JAMA Health Forum最新文献

Importance: There is a strong and increasing focus on redressing structural racism in health care systems. Structural racism persists by separating clinical care sites that treat patients of racial and ethnic minority groups who are disproportionately covered by Medicaid from sites that treat patients who are White and disproportionately covered by commercial insurance. Practice unification refers to efforts to eliminate this form of segregation.

Objective: To define and investigate the facilitators, barriers, and the effects associated with unification of outpatient practices to reduce structural racism in a large urban health system.

Design, setting, and participants: This qualitative study used semistructured interviews conducted within a large urban health system in New York from February to October 2023. Trained researchers interviewed clinical and administrative leaders of outpatient clinical practices that were pursuing unification, and health system leaders overseeing multiple practices.

Main outcomes and measures: Thematic analysis was used to identify facilitators of and barriers to unification, challenges and benefits after unification, and persistent dimensions of segregation within clinics that had nominally unified. These insights were used to create a framework for the unification process.

Results: The thematic analysis included qualitative information from 5 administrative leaders, 12 clinical leaders, and 6 health system leaders, and found that unification facilitators were financial benefit, relocation to new facility spaces, and advocacy by leaders and trainees, while barriers were financial concerns, space constraints, and physician and staff attitudes. After attaining and experiencing some degree of practice unification, interviewees reported financial gain, more support staff, perceptions of greater equity, better educational experiences, and increased practitioner and trainee satisfaction. Challenges reported after unification were changes in staff roles, financial concerns, patient dissatisfaction, and difficulties interfacing with segregated practices within the health system. Partially unified practices maintained dimensions of segregation, by practitioner, payer, and/or scheduling/time (temporal segregation).

Conclusions and relevance: This qualitative study found that outpatient practice unification was perceived to be a financially and equity-driven process with multiple dimensions. However, not all of the unification procedures had been completely implemented. These findings indicate that successful unification of outpatient practices in a large urban health care system requires attention to multiple dimensions, as well as overcoming challenges regarding finances, facility space, reimbursement policies, and patient and staff satisfaction.

Importance: Many of the capabilities needed to deliver accessible, high-quality primary care have been defined, but little is known about how their implementation has changed in US practices over the course of the COVID-19 pandemic or about the factors associated with greater capabilities.

Objective: To describe US primary care practices' accessibility and capabilities and examine recent changes.

Design, setting, and participants: This was a retrospective cohort study across 2 surveys, in 2017 to 2018 and 2022 to 2023, among a national sample of primary care practice leaders in the US. Data were analyzed from January 2023 to September 2024.

Exposures: Degree of integrated practice ownership and accountable care organization (ACO) participation.

Main outcomes and measures: Differences by practice ownership and ACO participation, and changes over time in access to care and care delivery capabilities. These were measured by composite scores of responses standardized to a scale of 0 to 100.

Results: This analysis included 710 practices, of which 234 were independently owned, 105 were physician group owned, and 321 were hospital/health system owned in 2017 to 2018, and 68 practices reported no ACO participation, 107 joined between surveys, and 486 otherwise participated in ACOs. Access to care (measured as extended weekday or weekend hours) was reported to decline from the first survey in 2017 to 2018 to the second in 2022 to 2023. Hospital/health system practices and ACO participants had higher rates of extended weekday hours than their comparators in 2022 to 2023. Average capability scores increased from 51 to 54 (increase of 4 points [95% CI, 1-6 points]). There was wide variation in scores within all ownership and ACO participant or nonparticipant groups. Capability scores were higher on average for more integrated practices (for physician groups compared to independent practices, 12 points [95% CI, 5-19 points] in 2017-2018 and 12 points [95% CI, 7-16 points] in 2022-2023) and for ACO participants compared to nonparticipants (13-point difference [6 to 20] in 2017-2018 and 12-point difference [6 to 18] in 2022-2023).

Conclusions and relevance: In this cohort study, over the time period including the COVID-19 pandemic, primary care practices reported a decline in access to care, while average practice capabilities improved. Integrated practice ownership and ACO participation were both associated with better access and capability scores, suggesting that value-based payment and integrated care delivery support the development of higher-quality primary care. Variations across practices point to large opportunities for improvement overall and underscore the importance of incentives and structures as levers to improve primary care delivery.

Importance: For patients with heart failure with reduced ejection fraction (HFrEF), treatment with sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, has become increasingly preferred over angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs). However, sacubitril-valsartan is much more expensive than generic ACE-I/ARBs. It is unknown whether the high cost of sacubitril-valsartan is offset by lower spending on hospitalizations and other treatments.

Objective: To compare total and out-of-pocket health care spending among Medicare beneficiaries initiating sacubitril-valsartan vs ACE-I/ARBs for HFrEF.

Design, setting, and participants: This was a cohort study using data from Medicare fee-for-service claims with propensity score matching of Medicare beneficiaries with HFrEF. Data analysis was performed from November 2022 to December 2023.

Exposure: Initiation of sacubitril-valsartan or an ACE-I/ARB. Patients were matched by propensity score based on 104 covariates, including demographic characteristics, comorbidities, baseline annual spending, and baseline use of health care services.

Main outcomes and measures: Mean total and out-of-pocket health care expenditures during the 365 days after initiating sacubitril-valsartan or an ACE-I/ARB. Censoring for incomplete follow-up was addressed using Kaplan-Meier probability weighting. Cost differences, cost ratios, and 95% CIs were calculated using a nonparametric bootstrapping method with 500 samples drawn with replacement.

Results: Among 13 755 matched pairs of Medicare patients with HFrEF (mean [SD] age, 77.5 [7.5] years; 5138 [39%] 80 years or older; 9949 females [36%] and 17 561 males [64%]), mean annual total health care spending per person was similar for sacubitril-valsartan initiators and ACE-I/ARB initiators (difference, $701; 95% CI, -$132 to $1593). Sacubitril-valsartan initiators had higher prescription drug costs (difference, $1911; 95% CI, $1704 to $2113), lower inpatient costs (difference, -$790; 95% CI, -$1468 to -$72), lower outpatient costs (difference, -$330; 95% CI, -$664 to -$11), and higher annual out-of-pocket spending (difference, $109; 95% CI, $13 to $208).

Conclusions and relevance: This cohort study found that Medicare beneficiaries initiating sacubitril-valsartan to treat HFrEF had similar total health care spending as those initiating ACE-I/ARBs; higher prescription drug spending was offset by lower inpatient and outpatient spending. However, sacubitril-valsartan use was associated with higher patient out-of-pocket costs, which may exacerbate health disparities and limit access and affordability.