Search

Background: As care shifts from institutional to community settings, family caregivers are providing increasing support to older adults, including complex medical/nursing care. In the mid‐late pandemic, technology advancements such as use of online patient portals present opportunities for communication and care delivery. This study aims to assess the association between caregiver medical/nursing tasks or patient portal use with contact, communication, and training of caregivers by healthcare providers. Methods: We conducted a cross‐sectional analysis of caregiver data from the 2021 National Study of Caregiving (NSOC), linked to the National Health and Aging Trends Study (NHATS). NHATS is nationally‐representative, annual survey of Medicare enrollees; NSOC surveys family/unpaid caregivers of NHATS participants. Logistic regression tested association between whether the caregiver does medical/nursing tasks or uses an online patient portal to contact the medical team (independent variables), and communication with or training by the medical team (dependent variables). Results: Participants were 1590 caregivers of living, community‐dwelling older adults. More than half (54%) reported no contact with the care recipient's medical team in the past year. Caregivers who did medical/nursing tasks (OR = 3.10; 95% CI: 2.16, 4.46) or who used patient portals (OR = 3.28; 95% CI: 1.96, 5.51) had higher odds of contacting the older adult's medical team. Thirty percent of caregivers stated communication was either not at all or just a little helpful. Sixty‐seven percent reported that providers rarely asked if they needed help managing the older adult's treatments. Just 6% of caregivers reported receiving any caregiver training in the last year. Conclusions: Both medical/nursing tasks and online patient portal use were independently associated with contact with health providers. Overall contact, communication, and training were limited or of variable value. Despite recent policy changes and technology advancement, there is still a need for improved integration of caregivers into health teams with ongoing assessment of their needs. [ABSTRACT FROM AUTHOR]

Objective To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up. Design Retrospective cohort study. Setting Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States. Subjects Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018. Methods Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers. Results The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose.73 [95% CI:.72–.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%–70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%–14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]:.56 [95% CI:.48–.67]) and during more recent years (aIRR:.93 per year after 2008 [95% CI:.92–.94]). Conclusions In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018. [ABSTRACT FROM AUTHOR]

Background: Opioid-related mortality continues to rise. Though risks of prescription opioid misuse and abuse are well known, short-term mortality across a range of prescription opioid exposure is unclear.Objective: This study was conducted in order to assess the short-term mortality associated with quantity of reported opioid prescriptions, DESIGN: An observational analysis was performed using data from the Medical Expenditure Panel Survey, years 2005-2015, a population-based, nationally representative household survey.Participants: This study included adults (age 18+) with prescription data and death status reported during their 2-year survey participation.Main Measures: Key exposure is the number of opioid prescriptions (0, 1-5, 6 or more) in year 1 of survey participation. The main outcome is all-cause mortality reported during the 2-year survey participation.Key Results: Of 90,622 participants, 14% reported at least 1 opioid prescription. There were 774 (0.9%) deaths during the survey period, 551 (0.7%) among those not reporting opioids, 127 (1.2%) among those reporting 1-5 opioid prescriptions, and 96 (3.9%) among those reporting 6 or more opioid prescriptions. After adjusting for sociodemographics, health status, and utilization, there was no significant association between category of opioid prescriptions and death during the study period; adjusted odds ratios = 0.86 (95% CI = 0.66, 1.22, p = 0.27) and 0.99 (95% CI = 0.74, 1.34, p = 0.96), respectively, for 1-5 prescriptions and 6 or more prescriptions.Conclusions: In a nationally representative sample, opioid prescriptions were associated with increased short-term mortality only without adjustment for sociodemographics, health status, or utilization. The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination. [ABSTRACT FROM AUTHOR]

Background: How physical and mental health status relate to receipt of opioid prescription remains unclear, creating uncertainty in minimizing opioid harms while avoiding pain under-treatment.Objective: To examine the associations of physical and mental health status with subsequent opioid prescriptions.Design: Observational study of 2005-2015 United States (U.S.) Medical Expenditure Panel Survey data.Participants: Adult respondents (N = 78,563) participating for 2 years. The analyses focused on respondents reporting no opioid prescriptions in year 1 (N = 65,249).Main Measures: In the primary analysis, a negative binomial regression yielding adjusted incidence rate ratios (IRRs), the dependent variable was the number of opioid prescriptions in year 2. In two secondary analyses, both logistic regressions yielding adjusted odds ratios (ORs), the dependent variables were receipt of any opioid prescription (versus none) and receipt of ≥ 6 opioid prescriptions (versus 0-5) in year 2. The key independent variables in all analyses were the SF-12 Physical and Mental Component Summary scores (PCS-12 and MCS-12, respectively; higher scores = better health status). All models adjusted for socio-demographics, health-related variables, and year.Key Results: Primary analysis. With each 10-point decrement in year 1 PCS-12 or MCS-12 score, there were more opioid prescriptions received in year 2 (adjusted IRRs [95% CIs] 1.45 [1.39-1.52] and 1.22 [1.16-1.27], respectively). Secondary analyses. With each 10-point decrement in year 1 PCS-12 or MCS-12 score, there were higher odds in year 2 both of receiving any opioid prescription (adjusted ORs 1.23 [1.19-1.28] and 1.11 [1.08-1.15], respectively) and of receiving ≥ 6 opioid prescriptions (adjusted ORs 1.96 [1.75-2.17] and 1.37 [1.23-1.54], respectively).Conclusions: In a nationally representative U.S. sample, both poorer physical and mental health status independently predicted receiving more opioid prescriptions received in a subsequent year, as well as receiving ≥ 6 prescriptions during the year. Our findings may contribute to a more nuanced picture of the drivers of opioid prescription. [ABSTRACT FROM AUTHOR]

Background: In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation.Objective: To revisit the satisfaction-mortality association in a larger national sample, allowing more precise risk estimates, sequential morbidity adjustment, and exploration of sociodemographic moderation.Design: Prospective cohort study.Participants: 2000-2015 Adult Medical Expenditures Panel Surveys (MEPS) respondents (N = 92,952), each enrolled for 2 consecutive years.Main Measures: We used five Consumer Assessment of Health Plans Survey (CAHPS) items to assess patients' year 1 satisfaction with their clinicians. Death during the 2 years of MEPS participation was determined by proxy report. We modeled the satisfaction-mortality association in sequential regressions: model 1 included sociodemographics, model 2 added health status (approximating recommended CAHPS adjustment), and model 3 added smoking status, disease burden, and healthcare utilization.Key Results: Satisfaction was not associated with mortality in model 1. In model 2, higher satisfaction was associated with higher mortality (hazard ratios [95% CIs] for 2nd, 3rd, and 4th (top) quartiles vs. 1st quartile: 1.28 (1.01, 1.62), P = 0.04; 1.43 (1.12, 1.82), P = 0.004; and 1.57 (1.25, 1.98), P < 0.001, respectively). The associations were not attenuated in model 3. There was a significant interaction between gender and satisfaction (F[3, 443] = 3.62, P = 0.01). The association between satisfaction and mortality was significant in women only, such that their mortality advantage over men was eliminated in the highest satisfaction quartile.Conclusions: The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk. [ABSTRACT FROM AUTHOR]

A survey in the United States revealed that an alarmingly large percentage of university psychologists admitted having used questionable research practices that can contaminate the research literature with false positive and biased findings. We conducted a replication of this study among Italian research psychologists to investigate whether these findings generalize to other countries. All the original materials were translated into Italian, and members of the Italian Association of Psychology were invited to participate via an online survey. The percentages of Italian psychologists who admitted to having used ten questionable research practices were similar to the results obtained in the United States although there were small but significant differences in self-admission rates for some QRPs. Nearly all researchers (88%) admitted using at least one of the practices, and researchers generally considered a practice possibly defensible if they admitted using it, but Italian researchers were much less likely than US researchers to consider a practice defensible. Participants’ estimates of the percentage of researchers who have used these practices were greater than the self-admission rates, and participants estimated that researchers would be unlikely to admit it. In written responses, participants argued that some of these practices are not questionable and they have used some practices because reviewers and journals demand it. The similarity of results obtained in the United States, this study, and a related study conducted in Germany suggest that adoption of these practices is an international phenomenon and is likely due to systemic features of the international research and publication processes. [ABSTRACT FROM AUTHOR]

We have described self-reported exposure to gun violence in an urban community of color to inform the movement toward a public health approach to gun violence prevention. The Community Alliance for Research and Engagement at Yale School of Public Health conducted community health needs assessments to document chronic disease prevalence and risk, including exposure to gun violence. We conducted surveys with residents in six low-income neighborhoods in New Haven, Connecticut, using a neighborhood-stratified, population-based sample (n = 1189; weighted sample to represent the neighborhoods, n = 29 675). Exposure to violence is pervasive in these neighborhoods: 73% heard gunshots; many had family members or close friends hurt (29%) or killed (18%) by violent acts. Although all respondents live in low-income neighborhoods, exposure to violence differs by race/ ethnicity and social class. Residents of color experienced significantly more violence than did White residents, with a particularly disparate increase among young Black men aged 18 to 34 years. While not ignoring societal costs of horrific mass shootings, we must be clear that a public health approach to gun violence prevention means focusing on the dual epidemic of mass shootings and urban violence. [ABSTRACT FROM AUTHOR]

Context: Health plan disenrollment has been associated with higher mortality in patients with opioid use disorder. Insurance loss and health plan disenrollment might be downstream social consequences of opioid misuse and overdose that may heighten patient mortality risks during a period of heightened need for professional assistance. Objective: To test hypotheses that: 1) overdose events in patients prescribed long-term opioids are associated with subsequent health plan disenrollment; and 2) buprenorphine initiation after overdose would attenuate this association. Study Design: Retrospective cohort study. Setting and Dataset: Data from the Optum Labs Data Warehouse which includes deidentified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages, ethnicities, and geographical regions across the United States. Population studied: Adults (aged =18 years) prescribed stable, opioid therapy for a 6-month baseline period (=90% of days covered, <10% monthly fluctuation from 6-month average, average daily dose =10 morphine milligram equivalents). Outcome Measures: Health plan disenrollment during up to one year of follow-up. Negative binomial regression estimated adjusted incidence rate ratios of disenrollment by incident overdose and buprenorphine initiation after overdose. Results: We identified 556,676 patients who were followed up after 1,119,100 stable periods of opioid therapy. During follow-up, 17.5% of personperiods ended in health plan disenrollment. Overdose events during follow-up were associated with health plan disenrollment with a dose-response relationship [adjusted incidence rate ratio (aIRR) for 1 overdose event = 1.29 (95% CI: 1.24-1.35); aIRR for =2 overdose events = 1.51 (1.43-1.59)]. Among patients with overdose events, subsequent buprenorphine initiation was associated with substantially reduced risk of health plan disenrollment [aIRR 0.36 (0.17-0.74)]. Conclusions: Overdose events in patients prescribed long-term opioids may portend other social consequences, such as health insurance loss, which may exacerbate patient risk at a time of heightened need and vulnerability. Buprenorphine may mitigate the risk of health plan disenrollment in opioid-prescribed patients who overdose. [ABSTRACT FROM AUTHOR]

ABSTRACT Using administrative data from the state of Georgia, this paper finds that, on average, across all firms, employing undocumented workers reduces a firm's hazard of exit by 19 percent. The advantage to firms from employing undocumented workers increases as more firms in the industry do so, decreases with the skill level of the firm's workers, increases with the breadth of a firm's market, and increases with the labor intensity of the firm's production process. [ABSTRACT FROM AUTHOR]

In response to the dramatic rise in the number of unauthorized immigrants to the United States, every state has passed some form of immigration legislation. These laws appear to be predicated on a belief that unauthorized immigrants impose greater costs than benefits to state and local communities, including the labor market. The purpose of this paper is to examine some evidence on what workers should expect if the immigration legislation is successful in eliminating undocumented workers from states' labor markets. © 2012 by the Association for Public Policy Analysis and Management. [ABSTRACT FROM AUTHOR]

Objectives. We examined the associations of overall and age-specific suicide rates with business cycles from 1928 to 2007 in the United States. Methods. We conducted a graphical analysis of changes in suicide rates during business cycles, used nonparametric analyses to test associations between business cycles and suicide rates, and calculated correlations between the national unemployment rate and suicide rates. Results. Graphical analyses showed that the overall suicide rate generally rose during recessions and fell during expansions. Age-specific suicide rates responded differently to recessions and expansions. Nonparametric tests indicated that the overall suicide rate and the suicide rates of the groups aged 25 to 34 years, 35 to 44 years, 45 to 54 years, and 55 to 64 years rose during contractions and fell during expansions. Suicide rates of the groups aged 15 to 24 years, 65 to 74 years, and 75 years and older did not exhibit this behavior. Correlation results were concordant with all nonparametric results except for the group aged 65 to 74 years. Conclusions. Business cycles may affect suicide rates, although different age groups responded differently. Our findings suggest that public health responses are a necessary component of suicide prevention during recessions. [ABSTRACT FROM AUTHOR]

Health plan disenrollment may disrupt chronic or preventive care for patients prescribed long-term opioid therapy (LTOT). To assess whether overdose events in patients prescribed LTOT are associated with subsequent health plan disenrollment. Retrospective cohort study. Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages and geographical regions across the United States. Adults prescribed stable opioid therapy (≥10 morphine milligram equivalents/day) for a 6-month baseline period prior to an index opioid prescription from January 1, 2018 to December 31, 2018. Health plan disenrollment during follow-up. The cohort comprised 404,151 patients who were followed up after 800,250 baseline periods of stable opioid dosing. During a mean follow-up of 9.1 months, unadjusted disenrollment rates among primary commercial beneficiaries and Medicare Advantage enrollees were 37.2 and 13.9 per 100 person-years, respectively. Incident overdoses were associated with subsequent health plan disenrollment with a statistically significantly stronger association among primary commercial insurance beneficiaries [adjusted incidence rate ratio (aIRR) 1.48 (95% CI: 1.33–1.64)] as compared to Medicare Advantage enrollees [aIRR 1.15 (95% CI: 1.07–1.23)]. Among patients prescribed long-term opioids, overdose events were strongly associated with subsequent health plan disenrollment, especially among primary commercial insurance beneficiaries. These findings raise concerns about the social consequences of overdose, including potential health insurance loss, which may limit patient access to care at a time of heightened vulnerability. • Among opioid-prescribed patients, overdose strongly predicted health plan disenrollment. • Patients with commercial insurance were at higher risk than Medicare Advantage. • Flu vaccination did not predict disenrollment (negative falsification test). • Health insurance and coverage loss may be a social consequence of overdose. [ABSTRACT FROM AUTHOR]

Importance: Opioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care., Objective: To evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care., Design, Setting, and Participants: A retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes., Exposures: Opioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months., Main Outcomes and Measures: Emergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months' follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control., Results: Among 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level., Conclusions and Relevance: In this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.

Background: Unhealthy alcohol use is a significant health issue for the US population. The US Preventive Services Task Force (USPSTF) recommends screening adults 18 years or older for unhealthy alcohol use during primary care visits., Objectives: To evaluate alcohol screening among ambulatory visits made by US adult primary care patients and identify characteristics predictive of alcohol screening., Design: A series of cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) data collected from 2014 to 2016 was used to examine US primary care providers' use of alcohol screening questionnaires and delivery of counseling on alcohol use., Participants: A total of 19,213 visits made by patients aged 18 years or older to a US primary care physician trained in family medicine or internal medicine., Main Measures: Administration of a validated alcohol screening questionnaire and counseling/education on alcohol use. Variation in alcohol screening by patient demographic characteristics, reason for office visit, length of office visit, chronic medical conditions, evaluation by assigned primary care physician, new patient to practice, and region., Key Results: Alcohol screening with a validated questionnaire occurred during 2.6% (95% Cl: 0.9%, 4.3%) of visits. Alcohol counseling, provided either by the physician or by referral, was documented in 0.8% (95% Cl: 0.3%, 1.3%) of visits. Screening was significantly more likely if patients were seen by their assigned primary care physician (adjOR 4.38 (95% Cl: 1.41, 13.61)), a new patient to the practice (adjOR 4.18 (95% Cl: 2.30, 7.79)), or had several chronic medical conditions (adjOR 3.40 (95% Cl: 1.48, 7.78)). Patients' sex, race/ethnicity, age group, or length of appointment time was not associated with screening for unhealthy alcohol use., Conclusions: Screening for unhealthy alcohol use using a validated questionnaire is uncommonly performed during US primary care visits. Interventions or incentives may be needed to increase uptake of USPSTF alcohol screening recommendations., (© 2022. The Author(s).)

Background: Prior studies examining the association of opioid prescriptions with satisfaction with care involved limited, selected samples with mixed findings. We examined this issue, of relevance to reducing discretionary opioid prescribing, in a US representative sample., Methods: We performed an observational study of adults (N = 69,985) enrolled in the 2005 to 2015 US Medical Expenditure Panel Surveys. We examined the association of high (top quartile) satisfaction with receipt of 0, 1 to 5, or ≥6 opioid prescriptions per year. The base model adjusted for demographics and year; the full model added adjustment for health status (12-item Short Form Survey). A sensitivity analysis further adjusted for outpatient visits., Results: In the base model, respondents who received 1 to 5 or ≥6 opioid prescriptions were each less likely to have high satisfaction than those who received no opioid prescriptions (adjusted odds ratios [AORs] [95% CIs] 0.83 [0.79-0.88] and 0.70 [0.63-0.79], respectively). After adding health status adjustment, compared with respondents receiving no opioid prescriptions, those receiving 1 to 5 were similarly likely and those reporting ≥6 were more likely to have high satisfaction (AORs [95% CIs] 1.00 [0.94-1.06] and 1.44 [1.27-1.63], respectively). The findings were not substantively affected by further adjustment for outpatient visits., Discussion: In a US national sample, individuals who received ≥6 opioid prescriptions in a year were more likely to have top quartile satisfaction than those receiving fewer or no opioid prescriptions after accounting for health status. Whether the high satisfaction among such individuals was driven by the prescriptions themselves or by other personal characteristics requires study, as do the effects of deprescribing., Competing Interests: Conflict of interest: none declared., (© Copyright 2020 by the American Board of Family Medicine.)

Background: In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation., Objective: To revisit the satisfaction-mortality association in a larger national sample, allowing more precise risk estimates, sequential morbidity adjustment, and exploration of sociodemographic moderation., Design: Prospective cohort study., Participants: 2000-2015 Adult Medical Expenditures Panel Surveys (MEPS) respondents (N = 92,952), each enrolled for 2 consecutive years., Main Measures: We used five Consumer Assessment of Health Plans Survey (CAHPS) items to assess patients' year 1 satisfaction with their clinicians. Death during the 2 years of MEPS participation was determined by proxy report. We modeled the satisfaction-mortality association in sequential regressions: model 1 included sociodemographics, model 2 added health status (approximating recommended CAHPS adjustment), and model 3 added smoking status, disease burden, and healthcare utilization., Key Results: Satisfaction was not associated with mortality in model 1. In model 2, higher satisfaction was associated with higher mortality (hazard ratios [95% CIs] for 2nd, 3rd, and 4th (top) quartiles vs. 1st quartile: 1.28 (1.01, 1.62), P = 0.04; 1.43 (1.12, 1.82), P = 0.004; and 1.57 (1.25, 1.98), P < 0.001, respectively). The associations were not attenuated in model 3. There was a significant interaction between gender and satisfaction (F[3, 443] = 3.62, P = 0.01). The association between satisfaction and mortality was significant in women only, such that their mortality advantage over men was eliminated in the highest satisfaction quartile., Conclusions: The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.

Background: Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow-up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow-up appointment with practice access improvements, including patient-centered medical home (PCMH) designations or extended-hours appointments., Methods: We performed a secret-shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow-up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements., Results: Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7days. Practices with PCMH designation were less likely to offer appointments within 7days (23.4% vs. 33.1%, p=0.03). However, callers were more likely to obtain an appointment in 7days from practices offering after-hour appointments (36.3% vs. 27.8%, p=0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7-day appointment availability or appointment wait time., Conclusion: PCMH designation and extended-hours appointments were not associated with improved availability of timely primary care follow-up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices., (Copyright © 2018 Elsevier Inc. All rights reserved.)