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2. Identifying Latent Subgroups of High-Risk Patients Using Risk Score Trajectories

Author

Wong, Edwin S, Yoon, Jean, Piegari, Rebecca I, Rosland, Ann-Marie M, Fihn, Stephan D, and Chang, Evelyn T

Subjects
Health Services and Systems, Health Sciences, Health Services, Clinical Research, 7.3 Management and decision making, Management of diseases and conditions, Good Health and Well Being, Aged, Female, Follow-Up Studies, Hospitalization, Hospitals, Veterans, Humans, Machine Learning, Male, Middle Aged, Prospective Studies, Risk Factors, United States, United States Department of Veterans Affairs, high risk, risk stratification, trajectory, latent subgroups, machine learning, patient-centered medical home, Clinical Sciences, General & Internal Medicine, Clinical sciences, Health services and systems, Public health
Abstract

ObjectiveMany healthcare systems employ population-based risk scores to prospectively identify patients at high risk of poor outcomes, but it is unclear whether single point-in-time scores adequately represent future risk. We sought to identify and characterize latent subgroups of high-risk patients based on risk score trajectories.Study designObservational study of 7289 patients discharged from Veterans Health Administration (VA) hospitals during a 1-week period in November 2012 and categorized in the top 5th percentile of risk for hospitalization.MethodsUsing VA administrative data, we calculated weekly risk scores using the validated Care Assessment Needs model, reflecting the predicted probability of hospitalization. We applied the non-parametric k-means algorithm to identify latent subgroups of patients based on the trajectory of patients' hospitalization probability over a 2-year period. We then compared baseline sociodemographic characteristics, comorbidities, health service use, and social instability markers between identified latent subgroups.ResultsThe best-fitting model identified two subgroups: moderately high and persistently high risk. The moderately high subgroup included 65% of patients and was characterized by moderate subgroup-level hospitalization probability decreasing from 0.22 to 0.10 between weeks 1 and 66, then remaining constant through the study end. The persistently high subgroup, comprising the remaining 35% of patients, had a subgroup-level probability increasing from 0.38 to 0.41 between weeks 1 and 52, and declining to 0.30 at study end. Persistently high-risk patients were older, had higher prevalence of social instability and comorbidities, and used more health services.ConclusionsOn average, one third of patients initially identified as high risk stayed at very high risk over a 2-year follow-up period, while risk for the other two thirds decreased to a moderately high level. This suggests that multiple approaches may be needed to address high-risk patient needs longitudinally or intermittently.

Published
2018

3. Association between Continuity and Team‐Based Care and Health Care Utilization: An Observational Study of Medicare‐Eligible Veterans in VA Patient Aligned Care Team

Author

Reddy, Ashok, Wong, Edwin, Canamucio, Anne, Nelson, Karin, Fihn, Stephan D, Yoon, Jean, and Werner, Rachel M

Subjects
Health Services and Systems, Health Sciences, Clinical Research, Aging, Health Services, Good Health and Well Being, Age Factors, Aged, Ambulatory Care, Continuity of Patient Care, Emergency Service, Hospital, Female, Hospitalization, Humans, Male, Medicare, Patient Acceptance of Health Care, Patient Care Team, Patient-Centered Care, Racial Groups, Retrospective Studies, Sex Factors, Socioeconomic Factors, United States, United States Department of Veterans Affairs, Continuity of care, medical home, primary care, team-based care, Public Health and Health Services, Policy and Administration, Health Policy & Services, Health services and systems, Policy and administration
Abstract

ObjectiveIt remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes.Data sourceLinked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization.Study designRetrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013.Principal findingsA 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p

Published
2018

19. Use of Chronic Care Management Among Primary Care Clinicians

Author

Reddy, Ashok, Marcotte, Leah M., Zhou, Lingmei, Fihn, Stephan D., and Liao, Joshua M.

Subjects
United States. Centers for Medicare and Medicaid Services -- Services, Chronic diseases -- Statistics -- Care and treatment, Medicare -- Statistics -- Usage, Primary health care -- Statistics -- Usage -- Quality management, Health, Science and technology
Abstract

The Centers for Medicare and Medicade Services (CMS) initiated chronic care management (CCM) codes to reimburse clinicians for coordination activities, but little is known about uptake over time. We find that primary care clinicians drove increasing use over 4 years--a trend that may reflect either new coordination activities or new reimbursements for existing activities. That 5% of chronic care management was denied by Medicare underscores the need for future work evaluating facilitators and barriers to use. Such insight is especially vital given the large number of eligible beneficiaries that have not received chronic care management to date, as well as the limited number of clinicians who currently deliver these services. Key words: Medicare; primary care issues; care coordination; chronic care: disease management/care management, INTRODUCTION Nearly two-thirds of the 40 million Medicare fee-for-service patients nationwide live with multiple chronic conditions. (1,2) These individuals incur over 90% of all Medicare spending while frequently having care [...]

Published
2020
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24. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Author

Levine, Glenn N., Bates, Eric R., Bittl, John A., Brindis, Ralph G., Fihn, Stephan D., Fleisher, Lee A., Granger, Christopher B., Lange, Richard A., Mack, Michael J., Mauri, Laura, Mehran, Roxana, Mukherjee, Debabrata, Newby, L. Kristin, O'Gara, Patrick T., Sabatine, Marc S., Smith, Peter K., Smith, Sidney C., Jr., Halperin, Jonathan L., Al-Khatib, Sana M., Birtcher, Kim K., Bozkurt, Biykem, Cigarroa, Joaquin E., Curtis, Lesley H., Gentile, Federico, Gidding, Samuel, Hlatky, Mark A., Ikonomidis, John S., Joglar, José A., Pressler, Susan J., and Wijeysundera, Duminda N.

Published
2016
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27. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

Author

Fihn, Stephan D., Blankenship, James C., Alexander, Karen P., Bittl, John A., Byrne, John G., Fletcher, Barbara J., Fonarow, Gregg C., Lange, Richard A., Levine, Glenn N., Maddox, Thomas M., Naidu, Srihari S., Ohman, E. Magnus, Smith, Peter K., Anderson, Jeffrey L., Halperin, Jonathan L., Albert, Nancy M., Bozkurt, Biykem, Brindis, Ralph G., Curtis, Lesley H., DeMets, David, Guyton, Robert A., Hochman, Judith S., Kovacs, Richard J., Pressler, Susan J., Sellke, Frank W., and Shen, Win-Kuang

Published
2015
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32. Reliance on Medicare Providers by Veterans after Becoming Age-Eligible for Medicare is Associated with the Use of More Outpatient Services

Author

Hebert, Paul L., Batten, Adam S., Gunnink, Eric, Redd, Ashok, Wong, Edwin S., Fihn, Stephan D., and Liu, Chuan-Fen

Subjects
United States. Department of Veterans Affairs -- Services, Medical care -- Supply and demand -- Analysis -- United States, Veterans -- Health aspects, Health care industry -- Services, Health care industry, Business
Abstract

Objective. To estimate the effect of Medicare use on the receipt of outpatient services from 2001 through 2015 for a cohort of Veterans Administration (VA) users who became age-eligible for Medicare in 1998-2000.Data Sources/Study Setting. VA administrative data linked with Medicare claims for veterans who participated in the 1999 Large Health Survey of Enrolled Veterans. Study Design. We coded each veteran as VA-reliant or Medicare-reliant based on the number of visits in each system and compared the health and social risk factors between VA-reliant and Medicare-reliant veterans. We used bivariate probit and instrumental variables models to estimate the association between a veteran's reliance on Medicare and the receipt of outpatient procedures in Medicare and the VA. Principal Findings. Veterans who chose to rely on the VA (n = 4,317) had substantially worse social and health risk factors than Medicare-reliant veterans (n = 2,567). Medicare reliance was associated with greater use of outpatient services for 24 of the 28 types of services considered. Instrumental variable estimates found significant effects of Medicare reliance on receipt of advanced imaging and cardiovascular testing. Conclusions. Expanded access to fee-for-service care in the community may be expensive, while the VA will likely continue to care for the most vulnerable veterans.Key Words. Veterans Administration, medicare, ambulatory procedures, community care, Demand for care has overtaken the capacity of the Department of Veterans Affairs (VA) health care system to provide care, resulting in unacceptably long wait times for care at many [...]

Published
2018
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33. Fee-for-Service Medicare-Enrolled Elderly Veterans Are Increasingly Voting with Their Feet to Use More VA and Less Medicare, 2003-2014

Author

Liu, Chuan-Fen, Batten, Adam, Wong, Edwin S., Fihn, Stephan D., and Hebert, Paul L.

Subjects
United States. Department of Veterans Affairs -- Services, Health care industry -- Services, Veterans -- Health aspects, Health care industry, Business
Abstract

Objective. To examine the long-term reliance on outpatient care at the population (i.e., system) level among fee-for-service Medicare-enrolled elderly veterans in the Department of Veterans Affairs (VA) health care system and Medicare from 2003 to 2014.Data Sources/Study Setting. We analyzed a 5 percent random sample, stratified by facility, age, gender, and race, of Medicare-enrolled veterans enrolled in a VA primary care panel using VA administrative data and Medicare claims.Study Design. We performed a repeated cross-sectional analysis over 48 quarters. VA reliance was defined at the system level as the proportion of total visits (VA + Medicare) that occurred in VA. We examined four visit types and seven high-volume medical subspecialties. We applied direct standardization adjusting for age, gender, and race using the 2010 population distribution of Medicare-enrolled veterans. Principal Findings. Over the 12-year period, VA provided the vast majority of mental health care. Conversely, veterans received slightly more than half of their primary care and most of their specialty care, surgical care, and seven high-volume medical subspecialties through Medicare. However, reliance on VA outpatient care steadily increased over time for all categories of care.Conclusions. Despite the controversies about VA access to care, Medicare-enrolled veterans, who have a choice of using VA or Medicare providers, appear to increase their use of VA care prior to the Choice Act.Key Words. VA, Medicare, primary care, The Department of Veterans Affairs (VA) health care system is one of the largest integrated health care systems in the United States having served 8.4 million veteran enrollees in 2016 [...]

Published
2018
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34. Peer Review in a General Medical Research Journal Before and During the COVID-19 Pandemic

Author

Perlis, Roy H., primary, Kendall-Taylor, Jacob, additional, Hart, Kamber, additional, Ganguli, Ishani, additional, Berlin, Jesse A., additional, Bradley, Steven M., additional, Haneuse, Sebastien, additional, Inouye, Sharon K., additional, Jacobs, Elizabeth A., additional, Morris, Arden, additional, Ogedegbe, Olugbenga, additional, Perencevich, Eli, additional, Shulman, Lawrence N., additional, Trueger, N. Seth, additional, Fihn, Stephan D., additional, Rivara, Frederick P., additional, and Flanagin, Annette, additional

Published
2023
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39. Keeping Meta-analyses Fresh

Author

Berlin, Jesse A., primary, Rubenfeld, Gordon D., additional, O'Cearbhaill, Roisin E., additional, Shah, Amy Sanghavi, additional, and Fihn, Stephan D., additional

Published
2022
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