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Background: During the COVID-19 pandemic, patients with Alzheimer's disease and related dementias (ADRD) were especially vulnerable, and modes of medical care delivery shifted rapidly. This study assessed the impact of the pandemic on care for people with ADRD, examining the use of primary, emergency, and long-term care, as well as deaths due to COVID and to other causes., Methods: Among 4.2 million beneficiaries aged 66 and older with ADRD in traditional Medicare, monthly deaths and claims for routine care (doctors' office and telehealth visits), inpatient/emergency department (ED) visits, and long-term care facility use from March or June 2020 through December 2022 are compared to monthly rates predicted from January-December 2019 using OLS and logistic/negative binomial regression. Correlation analyses examine the association between excess deaths - due to COVID and non-COVID causes - and changes in care use in the beneficiary's state of residence., Results: Increased telehealth visits more than offset reduced office visits, with primary care visits increasing overall (by 9 percent from June 2020 onward relative to the predicted rate from 2019, p < .001). Emergency/inpatient visits declined (by 9 percent, p < .001) and long-term care facility use declined, remaining 14% below the 2019 trend from June 2020 onward (p < .001). Both COVID and non-COVID deaths rose, with 231,000 excess deaths (16% above the prediction from 2019), over 80 percent of which were attributable to COVID. Excess deaths were higher among women, non-White patients, those in rural and isolated zip codes, and those with higher social deprivation index scores. States with the largest increases in primary care visits had the lowest excess deaths (correlation -0.49)., Conclusions: Older adults with ADRD had substantial deaths above pre-pandemic projections during the COVID-19 pandemic, 80 percent of which were attributed to COVID-19. Routine care increased overall due to a dramatic increase in telehealth visits, but this was uneven across states, and mortality rates were significantly lower in states with higher than pre-pandemic visits., (© 2024. The Author(s).)

Background: Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level., Methods: Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting., Results: Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits., Conclusions: A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care., (© 2022 The American Geriatrics Society.)

Objective: To assess trends in primary and specialist care consultation rates and average length of consultation by cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), or cardiometabolic multimorbidity exposure status., Methods: Observational, retrospective cohort study used linked Clinical Practice Research Datalink primary care data from 01/01/2000 to 31/12/2018 to assess consultation rates in 141,328 adults with newly diagnosed T2DM, with or without CVD. Patients who entered the study with either a diagnosis of T2DM or CVD and later developed the second condition during the study are classified as the cardiometabolic multimorbidity group. Face to face primary and specialist care consultations, with either a nurse or general practitioner, were assessed over time in subjects with T2DM, CVD, or cardiometabolic multimorbidity. Changes in the average length of consultation in each group were investigated., Results: 696,255 (mean 4.9 years [95% CI, 2.02-7.66]) person years of follow up time, there were 10,221,798 primary and specialist care consultations. The crude rate of primary and specialist care consultations in patients with cardiometabolic multimorbidity (N = 11,881) was 18.5 (95% CI, 18.47-18.55) per person years, 13.5 (13.50, 13.52) in patients with T2DM only (N = 83,094) and 13.2 (13.18, 13.21) in those with CVD (N = 57,974). Patients with cardiometabolic multimorbidity had 28% (IRR 1.28; 95% CI: 1.27, 1.31) more consultations than those with only T2DM. Patients with cardiometabolic multimorbidity had primary care consultation rates decrease by 50.1% compared to a 45.0% decrease in consultations for those with T2DM from 2000 to 2018. Specialist care consultation rates in both groups increased from 2003 to 2018 by 33.3% and 54.4% in patients with cardiometabolic multimorbidity and T2DM, respectively. For patients with T2DM the average consultation duration increased by 36.0%, in patients with CVD it increased by 74.3%, and in those with cardiometabolic multimorbidity it increased by 37.3%., Conclusions: Annual primary care consultation rates for individuals with T2DM, CVD, or cardiometabolic multimorbidity have fallen since 2000, while specialist care consultations and average consultation length have both increased. Individuals with cardiometabolic multimorbidity have significantly more consultations than individuals with T2DM or CVD alone. Service redesign of health care delivery needs to be considered for people with cardiometabolic multimorbidity to reduce the burden and health care costs., (© 2022. The Author(s).)

The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as resources were reallocated towards pandemic response efforts. Many outpatient clinics have since reopened and are beginning to experience a semblance of pre-pandemic routine, albeit with restrictions in place. We provide an overview of how COVID-19 has affected dermatology practice globally beginning with the rise of teledermatology. A summary of expert recommendations that shape the "new normal" in various domains of dermatology practice, namely, dermatology consultation, procedural dermatology, and phototherapy, is also provided., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To analyze trends for visits to office-based physicians at which opioids were prescribed among adults with arthritis in the US, from 2006 to 2015., Methods: We analyzed nationally representative data on patient visits to office-based physicians from 2006 to 2015 from the National Ambulatory Medical Care Survey (NAMCS). Visit percentages for first- and any-listed diagnosis of arthritis by age groups and sex were reported. Time points were grouped into 2-year intervals to increase the reliability of estimates. Annual percentage point change and 95% confidence intervals (95% CIs) were reported from linear regression models., Results: From 2006 to 2015, the percentage of visits to office-based physicians by adults with a first-listed diagnosis of arthritis increased from 4.1% (95% CI 3.5%, 4.7%) in 2006-2007 to 5.1% (95% CI 3.9%, 6.6%) in 2014-2015 (P = 0.033). Among these visits, the percentage of visits with opioids prescribed increased from 16.5% (95% CI 13.1%, 20.5%) in 2006-2007 to 25.6% (95% CI 17.9%, 34.6%) in 2014-2015 (P = 0.017). The percentage of visits with any-listed diagnosis of arthritis increased from 6.6% (95% CI 5.9%, 7.4%) in 2006-2007 to 8.4% (95% CI 7.0%, 10.0%) in 2014-2015 (P = 0.001). Among these visits, the percentage of visits with opioids prescribed increased from 17.4% (95% CI 14.6%, 20.4%) in 2006-2007 to 25.0% (95% CI 19.7%, 30.8%) in 2014-2015 (P = 0.004)., Conclusion: From 2006 to 2015, the percentage of visits to office-based physicians by adults with arthritis increased and the percentage of opioids prescribed at these visits also increased. NAMCS data will allow continued monitoring of these trends after the implementation of the 2016 Centers for Disease Control and Prevention Guideline for prescribing opioids for chronic pain., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA.)

Background: The COVID-19 public health emergency (PHE) has significantly changed medical practice in the United States, including an increase in the utilization of telemedicine. Here, we characterize change in neuro-ophthalmic care delivery during the early COVID-19 PHE, including a comparison of care delivered via telemedicine and in office., Methods: Neuro-ophthalmology outpatient encounters from 3 practices in the United States (4 providers) were studied during the early COVID-19 PHE (March 15, 2020-June 15, 2020) and during the same dates 1 year prior. For unique patient visits, patient demographics, visit types, visit format, and diagnosis were compared between years and between synchronous telehealth and in-office formats for 2020., Results: There were 1,276 encounters for 1,167 patients. There were 30% fewer unique patient visits in 2020 vs 2019 (477 vs 670) and 55% fewer in-office visits (299 vs 670). Compared with 2019, encounters in 2020 were more likely to be established, to occur via telemedicine and to relate to an efferent diagnosis. In 2020, synchronous telehealth visits were more likely to be established compared with in-office encounters., Conclusions: In the practices studied, a lower volume of neuro-ophthalmic care was delivered during the early COVID-19 public health emergency than in the same period in 2019. The type of care shifted toward established patients with efferent diagnoses and the modality of care shifted toward telemedicine., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by North American Neuro-Ophthalmology Society.)

Objective: The effect of the COVID-19 pandemic on community-based rheumatology care and the use of telehealth is unclear. We undertook this study to investigate the impact of the pandemic on rheumatology care delivery in a large community practice-based network., Methods: Using a community practice-based rheumatologist network, we examined trends in in-person versus telehealth visits versus canceled visits in 3 time periods: pre-COVID-19, COVID-19 transition (6 weeks beginning March 23, 2020), and post-COVID-19 transition (May-August). In the transition period, we compared patients who received in-person care versus telehealth visits versus those who cancelled all visits. We used multivariable logistic regression to identify factors associated with canceled or telehealth visits., Results: Pre-COVID-19, there were 7,075 visits/week among 60,002 unique rheumatology patients cared for by ~300 providers practicing in 92 offices. This number decreased substantially (24.6% reduction) during the COVID-19 transition period for in-person visits but rebounded to pre-COVID-19 levels during the post-COVID-19 transition. There were almost no telehealth visits pre-COVID-19, but telehealth increased substantially during the COVID-19 transition (41.4% of all follow-up visits) and slightly decreased during the post-COVID-19 transition (27.7% of visits). Older age, female sex, Black or Hispanic race/ethnicity, lower socioeconomic status, and rural residence were associated with a greater likelihood of canceling visits. Most factors were also associated with a lower likelihood of having telehealth versus in-office visits. Patients living further from the rheumatologists' office were more likely to use telehealth., Conclusion: COVID-19 led to large disruptions in rheumatology care; these disruptions were only partially offset by increases in telehealth use and disproportionately affected racial/ethnic minorities and patients with lower socioeconomic status. During the COVID-19 era, telehealth continues to be an important part of rheumatology practice, but disparities in access to care exist for some vulnerable groups., (© 2021, American College of Rheumatology.)

Objective: Information about the prediagnosis period in psoriatic arthritis (PsA) is limited. The present study was undertaken to compare health care utilization related to musculoskeletal issues during a 5-year period prior to the diagnosis of PsA versus that of subjects with no prior inflammatory arthritis within a primary care setting., Methods: We conducted a population-based, matched cohort study using electronic medical records and administrative data in Ontario, Canada. Age- and sex-matched cohorts of PsA patients and comparators from the same family physicians were assembled. Comparators were not allowed to have prior spondyloarthritis, ankylosing spondylitis, or rheumatoid arthritis billing code diagnoses. The study outcomes included health care utilization and costs related to nonspecific musculoskeletal issues during a 5-year period prior to the index date., Results: We studied 462 PsA patients and 2,310 matched comparators. The odds ratio (OR) related to visiting a primary care physician for nonspecific musculoskeletal issues in patients with PsA was 2.14 (95% confidence interval 1.73-2.64) in the year immediately preceding the index date and was similarly elevated up to 5 years prior. The OR related to using other musculoskeletal-related health care services, including musculoskeletal specialists visits, joint injections, joint imaging, and emergency department visits, was higher in PsA as early as 5 years preceding the index date. Total and musculoskeletal-related health care costs prior to the index date were higher for patients with PsA versus comparators., Conclusion: A prodromal PsA phase characterized by nonspecific musculoskeletal symptoms may exist. Further study is needed to determine if this represents a window for earlier diagnosis of PsA., (© 2020, American College of Rheumatology.)

Competing Interests: Conflicts of interest None disclosed.

Objectives: To describe real-time changes in medical visits (MVs), visit mode, and patient-reported visit experience associated with rapidly deployed care reorganization during the coronavirus disease 2019 (COVID-19) pandemic., Study Design: Cross-sectional time series from September 29, 2019, through June 20, 2020., Methods: Responding to official public health and clinical guidance, team-based systematic structural changes were implemented in a large, integrated health system to reorganize and transition delivery of care from office-based to virtual care platforms. Overall and discipline-specific weekly MVs, visit mode (office-based, telephone, or video), and associated aggregate measures of patient-reported visit experience were reported. A 38-week time-series analysis with March 8, 2020, and May 3, 2020, as the interruption dates was performed., Results: After the first interruption, there was a decreased weekly visit trend for all visits (β3 = -388.94; P < .05), an immediate decrease in office-based visits (β2 = -25,175.16; P < .01), increase in telephone-based visits (β2 = 17,179.60; P < .01), and increased video-based visit trend (β3 = 282.02; P < .01). After the second interruption, there was an increased visit trend for all visits (β5 = 565.76; P < .01), immediate increase in video-based visits (β4 = 3523.79; P < .05), increased office-based visit trend (β5 = 998.13; P < .01), and decreased trend in video-based visits (β5 = -360.22; P < .01). After the second interruption, there were increased weekly long-term visit trends for the proportion of patients reporting "excellent" as to how well their visit needs were met for all visits (β5 = 0.17; P < .01), telephone-based visits (β5 = 0.34; P < .01), and video-based visits (β5 = 0.32; P < .01). Video-based visits had the highest proportion of respondents rating "excellent" as to how well their scheduling and visit needs were met., Conclusions: COVID-19 required prompt organizational transformation to optimize the patient experience.

Telemedicine is one of the most consequential technologies in modern healthcare. In certain situations, it allows for the delivery of care with high quality and minimal difficulty. This is particularly true in dermatology, in which many dermatological conditions can be treated remotely. The burden on dermatology patients has been greatly reduced for certain pathologies due to telemedicine. Health care providers also achieve improved job satisfaction following the convenience of meeting their patients. This paper details select dermatological conditions, and subsequently divides them into those treatable by telemedicine appointments, and those requiring face to face appointments.

Objective: Psychiatric comorbidity is frequent in rheumatoid arthritis (RA) and complicates treatment. The present study was undertaken to describe the impact of psychiatric comorbidity on health care use (utilization) in RA., Methods: We accessed administrative health data (1984-2016) and identified a prevalent cohort with diagnosed RA. Cases of RA (n = 12,984) were matched for age, sex, and region of residence with 5 controls (CNT) per case (n = 64,510). Within each cohort, we identified psychiatric morbidities (depression, anxiety, bipolar disorder, and schizophrenia [PSYC]), with active PSYC defined as ≥2 visits per year. For the years 2006-2016, annual rates of ambulatory care visits (mean ± SD per person) categorized by provider (family physician [FP], rheumatologist, psychiatrist, other specialist), hospitalization (% of cohort), days of hospitalization (mean ± SD), and dispensed drug types (mean ± SD per person) were compared among 4 groups (CNT, CNT plus PSYC, RA, and RA plus PSYC) using generalized linear models adjusted for age, sex, rural versus urban residence, income quintile, and total comorbidities. Estimated rates are reported with 95% confidence intervals (95% CIs). We tested within-person and RA-PSYC interaction effects., Results: Subjects with RA were mainly female (72%) and urban residents (59%), with a mean ± SD age of 54 ± 16 years. Compared to RA without PSYC, RA with PSYC had more than additive (synergistic) visits (standardized mean difference [SMD] 10.92 [95% CI 10.25, 11.58]), hospitalizations (SMD 13% [95% CI 0.11, 0.14]), and hospital days (SMD 3.63 [95% CI 3.06, 4.19]) and were dispensed 6.85 more medication types (95% CI 6.43, 7.27). Cases of RA plus PSYC had increased visits to FPs (an additional SMD 8.92 [95% CI 8.35, 9.46] visits). PSYC increased utilization in within-person models., Conclusion: Managing psychiatric comorbidity effectively may reduce utilization in RA., (© 2020 The Authors. Arthritis Care & Research published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Telemedicine had been very slowly making inroads into standard clinical practice. The onset of the COVID-19 pandemic resulted in the rapid implementation of telemedicine across most practices. The efficiency and permanence of telemedicine services depends on a multitude of factors including technologic choices, governmental and insurance regulations, reimbursement policies, and staff and patient education and acceptance. Although challenges remain and the extent of implementation is still evolving, it is clear that telemedicine is here to stay and that all those involved in health care need to be familiar with its opportunities and challenges., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Little is known about the impact of oral anticoagulation (OAC) choice on healthcare encounters during venous thromboembolism (VTE) primary treatment. Among anticoagulant-naïve patients with VTE, we tested the hypotheses that healthcare utilization would be lower among users of direct OACs (DOACs; rivaroxaban or apixaban) than among users of warfarin. MarketScan databases for years 2016 and 2017 were used; healthcare utilization was identified in the first 6 months after initial VTE diagnoses. The 23,864 patients with VTE had on average 0.2 ± 0.5 hospitalizations, spent 1.3 ± 5.2 days in the hospital, had 5.7 ± 5.1 outpatient encounters, and visited an emergency department 0.4 ± 1.1 times. As compared to warfarin, rivaroxaban and apixaban were associated with fewer hospitalizations, days hospitalized, outpatient office visits, and emergency department visits after accounting for age, sex, comorbidities, and medications. Hospitalization rates were 24% lower (incidence rate ratio (IRR): 0.76; 95% CI: 0.69, 0.83) with rivaroxaban and 22% lower (IRR: 0.78; 95% CI: 0.71, 0.87) with apixaban, as compared to warfarin (IRR: 1.00 (reference)). Healthcare utilization was similar between apixaban and rivaroxaban users. Patients with VTE prescribed rivaroxaban and apixaban had lower healthcare utilization than those prescribed warfarin, while there was no difference when comparing apixaban to rivaroxaban. These findings complement existing literature supporting the use of DOACs over warfarin.

Importance: Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits., Objective: To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type., Design, Setting, and Participants: This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020., Exposures: Visit paid by Medicaid vs other payment types., Main Outcomes and Measures: Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use., Results: A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02)., Conclusions and Relevance: These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

Background: In December 2012, a media controversy about negative side-effects of oral contraceptives on women's health, also called "pill scare", broke out in France. While several analyses highlighted a change in women's contraceptive practices following this media controversy, no analysis has been conducted to determine the possible changes in their choices of health professionals and its repercussions on their contraceptive use., Methods: Our study is based on data from three population-based cross-sectional surveys conducted in 2010, 2013 and 2016 (Fecond 2010, Fecond 2013 and Baromètre Santé 2016) that collected information on women's contraceptive practices and the specialties of the health professionals having prescribed the methods they were using., Results: Between 2010 and 2016, women went to a gynecologist or a midwife more often than to a general practitioner for prescription of a reversible contraceptive method. However, their changes in visiting prescribers did not explain the changes in their contraceptive practices observed over the period. In 2016, access to health professional remained largely dependent on women's socio-demographic characteristics: older ones and those from a more privileged social background or living in urban areas were more likely to consult a gynecologist for prescription of their contraceptive method. On the other hand, consultations of midwives for contraceptive prescription were more frequent among women with children and among those who relied on public health insurance alone., Conclusion: Following the "pill scare" that occurred in France in December 2012, the decision by some women to use the IUD instead of the pill led them to change health professionals, and also led practitioners to change their prescribing practices., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

The continent of the Americas has the greatest number of people infected and deaths associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the world. Brazil occupies the 2nd position in numbers of infected cases and deaths, preceded only by the United States. Older adults and those with pre-existing chronic illnesses are more vulnerable to the consequences of the virus. The SARS-CoV-2 epidemic has serious consequences for health services. Therefore, an assessment of the pandemic's effect on the older Brazilian population is urgently needed. The study examines the prevalence of COVID-19 related symptoms, care-seeking, and cancellation of surgery or other scheduled medical care among a nationally representative sample of Brazilians aged 50 and over derived from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and a telephone follow-up survey (the ELSI-COVID-19 initiative) between late May and early June 2020. About 10.4% of older adults reported any fever, dry cough or difficulty breathing in the 30 days prior to the interview, with the highest prevalence in the North region (50%). Among individuals with symptoms, only 33.6% sought care. Individuals living in the South or Southeast regions were significantly less likely to seek care for COVID-19 related symptoms. Nearly one in six participants had to cancel scheduled surgery or other medical care; this proportion was higher among women, those with more education, and people with multiple chronic conditions. This paper is among the first to investigate the effect of COVID-19 on health care use in Brazil among older adults. Results highlight the need to adapt health care delivery (such as through telemedicine) to ensure the continuity of care as well as the urgent need for wide dissemination of information to guide the population on disease prevention measures and how to obtain healthcare when needed.

Background: Low-socioeconomic, urban, minority patients with heart failure (HF) often have unique barriers to care. Community health workers (CHWs) are specially trained laypeople who serve as liaisons between underserved communities and the health system. It is not known whether CHWs improve outcomes in low-socioeconomic, urban, minority patients with HF., Hypothesis: CHWs reduce rehospitalizations, emergency department (ED) visits, and healthcare costs for low-socioeconomic urban patients with HF., Methods: Patients admitted with acute decompensated HF were assigned to receive weekly visits by CHW after discharge. Patients were propensity score matched with controls who received usual care. HF-related rehospitalizations, ED visits, and inpatient costs were compared for 12 months following index admission versus the same period before., Results: Twenty-eight patients who received weekly visits from a CHW for 12 months after discharge were matched with 28 control patients who did not receive CHWs. Patients who received a CHW had a 75% decrease in HF-related ED visits (0.71 vs. 0.18 visits per patient, P < 0.001), an 89% decrease in HF-related readmissions (0.64 vs. 0.07 admissions per patient, P < 0.005), and a significant decrease in inpatient cost for HF-related visits. In controls receiving usual care, there was no significant change in hospitalizations, ED visits, or costs., Conclusions: In conclusion, CHWs are associated with reduced rehospitalizations, ED visits, and inpatient costs in low-socioeconomic, urban, minority patients with HF. CHWs may be a cost-effective method to reduce health care utilization and improve outcomes for this population.

Aim: To quantify the relationship between any general practitioner (GP) visit and hazardous alcohol use, and whether this differs by sociodemographic factors., Method: Hazardous alcohol use (scores 8+ Alcohol Use Disorders Identification Test) and any past year GP visits were examined using 2016/17 New Zealand Health Survey data from 13,598 adults. Sub-group analyses examined whether the association differed by age, sex or ethnicity (Māori/non-Māori), and socioeconomic status (NZDep2013) in post-hoc analyses., Results: Results differed for Māori and non-Māori. Regardless of drinking behaviour, Māori males aged 15-24 years were least likely to visit a GP. Among Māori in each demographic group, GP visits were similar for people meeting hazardous drinking criteria and safer drinkers. Conversely, among non-Māori males aged under 45 and non-Māori females aged 15-24 and 45-64 years, GP visits were 10-13 percentage points higher among people meeting hazardous drinking criteria than safer drinkers. GP visits were lower for people meeting hazardous drinking criteria living in more deprived areas., Conclusion: Multiple strategies need to be prioritised to address service access particularly for young Māori, and support people drinking at hazardous levels. This includes increasing access to services in various settings, enhancing existing primary health services (eg, cultural responsiveness, alcohol screening, brief interventions), addressing access barriers, and health promotion., Competing Interests: Nil.

Background: Hospitals achieve growth in surgical caseload primarily from the additive contribution of many surgeons with low caseloads. Such surgeons often see clinic patients in the morning then travel to a facility to do 1 or 2 scheduled afternoon cases. Uncertainty in travel time is a factor that might need to be considered when scheduling the cases of to-follow surgeons. However, this has not been studied. We evaluated variability in travel times within a city with high traffic density., Methods: We used the Google Distance Matrix application programming interface to prospectively determine driving times incorporating current traffic conditions at 5-minute intervals between 9:00 AM and 4:55 PM during the first 4 months of 2018 between 4 pairs of clinics and hospitals in the University of Miami health system. Travel time distributions were modeled using lognormal and Burr distributions and compared using the absolute and signed differences for the median and the 0.9 quantile. Differences were evaluated using 2-sided, 1-group t tests and Wilcoxon signed-rank tests. We considered 5-minute signed differences between the distributions as managerially relevant., Results: For the 80 studied combinations of origin-to-destination pairs (N = 4), day of week (N = 5), and the hour of departure between 10:00 AM and 1:55 PM (N = 4), the maximum difference between the median and 0.9 quantile travel time was 8.1 minutes. This contrasts with the previously published corresponding difference between the median and the 0.9 quantile of 74 minutes for case duration. Travel times were well fit by Burr and lognormal distributions (all 160 differences of medians and of 0.9 quantiles <5 minutes; P < .001). For each of the 4 origin-destination pairs, travel times at 12:00 PM were a reasonable approximation to travel times between the hours of 10:00 AM and 1:55 PM during all weekdays., Conclusions: During mid-day, when surgeons likely would travel between a clinic and an operating room facility, travel time variability is small compared to case duration prediction variability. Thus, afternoon operating room scheduling should not be restricted because of concern related to unpredictable travel times by surgeons. Providing operating room managers and surgeons with estimated travel times sufficient to allow for a timely arrival on 90% of days may facilitate the scheduling of additional afternoon cases especially at ambulatory facilities with substantial underutilized time.

Objective: Practice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing., Design: Temporal ecological study., Setting: Non-federal physician offices., Participants: Patient visits to a physician, PA or NP, spanning years 2007-2016., Methods: A stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007-2011 and 2012-2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type., Results: Within years 2007-2011 and 2012-2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012-2016 compared with years 2007-2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012-2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers., Conclusions: In non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe patterns of postoperative visits reported for Medicare fee-for-service (FFS) patients., Background: Payment for most surgical procedures bundles postoperative visits within a global period of either 10 or 90 days after a procedure. There is concern that payments for some procedures are excessive because the number of postoperative visits provided is less than the number of postoperative visits used to help determine payment. To obtain data to inform this concern, Medicare required select surgeons to report on their postoperative visits starting July 1, 2017., Methods: We analyzed Medicare FFS claims data from surgeons who billed Medicare for 1 or more of the 293 common procedure codes between July 1, 2017 and December 31, 2017 in the 9 states where surgeons were required to report postoperative visits. We examined the share of procedures with any reported postoperative visits and the proportion of expected postoperative visits provided. To address concerns about underreporting, we also examined procedures performed by a subset of surgeons actively reporting postoperative visits., Results: We linked 663,681 procedures to 422,432 postoperative visits. The share of procedures with any postoperative visits was higher for procedures with 90-day global periods (70.1%) than for procedures with 10-day global periods (3.7%). The proportions of expected postoperative visits provided for 90-day global and 10-day global periods were 0.37 and 0.04 respectively. Among surgeons actively reporting postoperative visits, the proportions of expected postoperative visits provided were modestly higher (procedures with 90-day global periods=0.46 and 10-day global periods=0.16)., Conclusions: The proportion of expected postoperative visits that were provided is low. These results support the need for a reassessment of payment for surgical procedures.

Study Design: Longitudinal cohort study OBJECTIVE: To evaluate lifetime variation in healthcare utilization among individuals with a chronic spinal cord injury (SCI)., Setting: Medical university in the Southeastern United States (US)., Methods: Participants were identified from two Midwestern University hospitals and a specialty hospital in the Southeastern US and were enrolled in 1973-1974, 1984-1985, 1993-1994, and 2003-2004. Generalized linear mixed models were used to explore changes in nonroutine physician visits, hospitalizations, and days hospitalized within the 24 months prior to the study., Results: Significant temporal linear spline change was found for nonroutine physician visits. The proportion of participants reporting ≥10 nonroutine physician visits in the 24 months prior to assessment kept relatively constant over the 30 years post injury (p value of trend: p = 0.605) and sharply increased afterwards (p knot = 30 years since injury  = 0.016). The trajectory for hospitalization and days hospitalized followed a quadratic pattern (p years post injury 2  < 0.001) for all participants. The proportion of individuals who had at least one hospitalization and were hospitalized for more than 1 week significantly declined from the onset of SCI to 25-30 years post injury, then significantly increased thereafter., Conclusions: The natural course of changes in three indices of healthcare utilization was curve-linearly, rather than linearly related to years post injury. People with SCI tended to have significant changes in healthcare utilization after about 30 years injury.

Objectives: We investigate the reliability of a survey question on forgone healthcare services for financial reasons, based on analysis of actual healthcare use over the 3-year period preceding response to the question. We compare the actual use of different health services by patients who report having forgone health care to those who do not., Methods: Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services., Results: Compared to controls, forgoing care participants had lower odds of consulting GPs (OR = 0.83; 95% CI 0.73, 0.93), especially specialists outside hospitals (gynecologists: 0.74 (0.69, 0.78); dermatologists: 0.81 (0.78-0.85); pneumologists 0.82 (0.71-0.94); dentists 0.71 (0.68, 0.75)); higher odds of ED visits (OR = 1.25; 95% CI 1.19, 1.31); and no difference in hospital admissions (OR = 1.02; 95% CI 0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care., Conclusions: The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons.

Importance: Primary care is the foundation of pediatric care. While policy interventions have focused on improving access and quality of primary care, trends in overall use of primary care among children have not been described., Objective: To assess trends in primary care visit rates and out-of-pocket costs, to examine variation in these trends by patient and visit characteristics, and to assess shifts to alternative care options (eg, retail clinics, urgent care, and telemedicine)., Design, Setting, and Participants: Observational cohort study of claims data from 2008 to 2016 for children 17 years and younger covered by a large national commercial health plan. Visit rate per 100 child-years was determined for each year overall, by child and geographic characteristics, and by visit type (eg, primary diagnosis), and trends were assessed with a series of child-year Poisson models. Data were analyzed from November 2017 to September 2019., Main Outcomes and Measures: Visits to primary care and other settings., Results: This cohort study included more than 71 million pediatric primary care visits over 29 million pediatric child-years (51% male in 2008 and 2016; 37% between 12-17 years in 2008 and 38% between 12-17 years in 2016). Unadjusted results for primary care visit rates per 100 child-years decreased from 259.6 in 2008 to 227.2 in 2016, yielding a regression-estimated change in primary care visits across the 9 years of -14.4% (95% CI, -15.0% to -13.9%; absolute change: -32.4 visits per 100 child-years). After controlling for shifts in demographics, the relative decrease was -12.8% (95% CI, -13.3% to -12.2%). Preventive care visits per 100 child-years increased from 74.9 in 2008 to 83.2 visits in 2016 (9.9% change in visit rate; 95% CI, 9.0%-10.9%; absolute change: 8.3 visits per 100 child-years), while problem-based visits per 100 child-years decreased from 184.7 in 2008 to 144.1 in 2016 (-24.1%; 95% CI, -24.6% to -23.5%; absolute change: -40.6 visits per 100 child-years). Visit rates decreased for all diagnostic groups except for the behavioral and psychiatric category. Out-of-pocket costs for problem-based primary care visits increased by 42% during the same period. Per 100 child-years, visits to other acute care venues increased from 21.3 to 27.6 (30.3%; 95% CI, 28.5% to 32.1%; absolute change: 6.3 visits per 100 child-years) and visits to specialists from 45.2 to 53.5 (16.4%; 95% CI, 14.8% to 18.0%, absolute change: 8.3 visits per 100 child-years)., Conclusions and Relevance: Primary care visit rates among commercially insured children decreased over the last decade. Increases in out-of-pocket costs and shifts to other venues appear to explain some of this decrease.

Objective: To describe and compare triennial rates of physicians' recommendations for physical therapy (PT), lifestyle counseling, and pain medication for knee osteoarthritis (OA) and to identify patient, physician, and practice factors associated with each treatment recommendation., Methods: We conducted a cross-sectional analysis examining data between 2007 and 2015 from the National Ambulatory Medical Care Survey. Visits to orthopedists and primary care physicians for knee OA were identified and assessed for the following: PT referral, lifestyle counseling, nonsteroidal antiinflammatory drug (NSAID) prescriptions, and narcotics prescriptions. Triennial rates for each treatment were calculated. We examined associations between patient (e.g., race, insurance), physician, and practice factors (e.g., ownership, location) and treatments prescribed using multivariate logistic regression that accounted for complex sampling design., Results: A total of 2,297 physician visits related to knee OA (~67 [±4] million weighted visits) were identified. For visits to orthopedists, PT and lifestyle recommendation rates declined (158 to 88 of 1,000 visits and 184 to 86 of 1,000 visits, respectively), while NSAID and narcotics prescriptions increased (132 to 278 of 1,000 visits and 77 to 236 of 1,000 visits, respectively) over time (P < 0.05). For visits to primary care physicians, there were no significant changes in rates of PT, lifestyle counseling, and narcotics prescriptions over time, while NSAIDs prescriptions increased (221 to 498 of 1,000 visits; P < 0.05). Treatment recommendations were associated with nonclinical factors, including practice type, location, and type of provider., Conclusion: In patients with knee OA, PT and lifestyle counseling seem underutilized, while pain medication prescriptions increased during the investigated timeframe. Variation in treatment choices were associated with nonclinical factors. Future research is necessary to examine ways to improve PT and lifestyle utilization and reduce variation in care for knee OA., (© 2019, American College of Rheumatology.)

Vaccination coverage among older adults is low in the United States. A recommendation from a provider is a strong predictor of vaccine receipt. Using Medicare Fee-For-Service data (2015-2017) this study characterized providers by the number of influenza and pneumococcal vaccines administered in physician offices, age, gender, and professional specialty to determine the volume of vaccines provided by individual providers and characteristics of these providers. Half of all vaccinations were provided by 10% of providers. The mean age of 224,483 and 165,710 unique influenza and pneumococcal providers respectively was 49 years (SD: 12 years) with males and females equally distributed. The highest vaccinating quartile of providers tended to be older, more likely male and more likely general physicians. Those who administered a high volume of one vaccine were likely to administer a high volume of the other. Providers administering vaccines in office-based settings can do more to increase vaccination coverage rates., (Published by Elsevier Ltd.)

Participant-level meta-analyses assessed the age-specific relevance of office blood pressure to cardiovascular complications, but this information is lacking for out-of-office blood pressure. At baseline, daytime ambulatory (n=12 624) or home (n=5297) blood pressure were measured in 17 921 participants (51.3% women; mean age, 54.2 years) from 17 population cohorts. Subsequently, mortality and cardiovascular events were recorded. Using multivariable Cox regression, floating absolute risk was computed across 4 age bands (≤60, 61-70, 71-80, and >80 years). Over 236 491 person-years, 3855 people died and 2942 cardiovascular events occurred. From levels as low as 110/65 mm Hg, risk log-linearly increased with higher out-of-office systolic/diastolic blood pressure. From the youngest to the oldest age group, rates expressed per 1000 person-years increased ( P <0.001) from 4.4 (95% CI, 4.0-4.7) to 86.3 (76.1-96.5) for all-cause mortality and from 4.1 (3.9-4.6) to 59.8 (51.0-68.7) for cardiovascular events, whereas hazard ratios per 20-mm Hg increment in systolic out-of-office blood pressure decreased ( P ≤0.0033) from 1.42 (1.19-1.69) to 1.09 (1.05-1.12) and from 1.70 (1.51-1.92) to 1.12 (1.07-1.17), respectively. These age-related trends were similar for out-of-office diastolic pressure and were generally consistent in both sexes and across ethnicities. In conclusion, adverse outcomes were directly associated with out-of-office blood pressure in adults. At young age, the absolute risk associated with out-of-office blood pressure was low, but relative risk high, whereas with advancing age relative risk decreased and absolute risk increased. These observations highlight the need of a lifecourse approach for the management of hypertension.

Purpose: The use of telemedicine has grown in recent years. As a subset of telemedicine, e-visits typically involve the evaluation and management of a patient by a physician or other clinician through a Web-based or electronic communication system. The national prevalence of e-visits by primary care physicians is unclear as is what factors influence adoption. The purpose of this study was to examine the prevalence of family physicians providing e-visits and associated factors., Methods: A national, cross-sectional practice demographic questionnaire for 7580 practicing family physicians was utilized. Bivariate statistics were calculated and logistic regression was conducted examining both physician level and practice level factors associated with offering e-visits., Results: The overall prevalence of offering e-visits was 9.3% (n = 702). Compared with private practice physicians, other physicians were more likely to offer e-visits if their primary practice was an academic health center/faculty practice (odds ratio [OR], 1.73; 95% CI, 1.03 to 2.91), managed care/health maintenance organization (HMO) practice (OR, 9.79; 95% CI, 7.05 to 13.58), hospital-/health system-owned medical practice (not including managed care or HMO) (OR, 2.50; 95% CI, 1.83 to 3.41), workplace clinic (OR, 2.28; 95% CI, 1.43 to 3.63), or federal (military, Veterans Administration [VA]/Department of Defense) (OR, 4.49; 95% CI, 2.93 to 6.89). Physicians with no official ownership stake (OR, 0.44; 95% CI, 0.28 to 0.68) or other ownership arrangement (OR, 0.29; 95% CI, 0.12 to 0.71) had lower odds of offering e-visits compared with sole owners., Conclusion: Fewer than 10% of family physicians provided e-visits. Physicians in HMO and VA settings (ie, capitated vs noncapitated models) were more likely to provide e-visits, which suggests that reimbursement may be a major barrier., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Objectives: To describe health care use and its associated factors in the chronic phase after stroke., Methods: Patients completed a questionnaire on health care use, 5-8 years after hospital admission for stroke. It comprised the number of visits to physicians or other health care professionals over the past 6 months (Physician-visits; Low ≤1 or High ≥2) and other health care professionals (Low = 0 or High ≥ 1). In addition the Longer-term Unmet Needs after Stroke (LUNS), Frenchay Activity Index (FAI) and Physical and Mental Component Summary Scales of the Short Form 12 (PCS and MCS) were administered. Their associations with health care use (high, low) were determined by means of logistic regression analysis, adjusted for sex and age., Results: Seventy-eight of 145 patients (54%) returned the questionnaires; mean time-since-stroke was 80.3 months (SD10.2), age-at-stroke 61.7 years (SD13.8), and 46 (59%) were male. Physician contacts concerned mainly the general practitioner (58; 79.5%). Forty-one (52.6%) and 37 (47.4%) of the patients had a high use of physician and other health professionals visits, respectively. Worse PCS scores were associated with both high use of physician and other health professionals visits (OR .931; 95%CI .877-.987 and OR .941; 95%CI .891-.993, respectively), whereas the FAI, MCS, or LUNS were not related to health care use., Conclusions: Health care use after stroke is substantial and is related to physical aspects of health status, not to mental aspects, activities or unmet needs, suggesting a mismatch between patients' needs and care delivered., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice-including the use and content of primary care visits-may have contributed., Methods: We analyzed nationally representative data of adult visits to primary care physicians (PCPs) and physician practice characteristics from 2007-2016 (National Ambulatory Medical Care Survey). United States census estimates were used to calculate visits per capita. Measures included visit rates per person year; visit duration; number of medications, diagnoses, and preventive services per visit; percentage of visits with scheduled follow-up; and percentage of physicians with practice capabilities including an electronic medical record (EMR)., Results: Our weighted sample represented 3.2 billion visits (83,368 visits, unweighted). Visits per capita declined by 20% (-0.25 visits per person, 95% CI, -0.32 to -0.19) during this time, while visit duration increased by 2.4 minutes per visit (95% CI, 1.1-3.8). Per visit, PCPs addressed 0.30 more diagnoses (95% CI, 0.16-0.43) and 0.82 more medications (95% CI, 0.59-1.1), and provided 0.24 more preventive services (95% CI, 0.12-0.36). Visits with scheduled PCP followup declined by 6.0% (95% CI, -12.4 to 0.46), while PCPs reporting use of EMR increased by 44.3% (95% CI, 39.1-49.5) and those reporting use of secure messaging increased by 60.9% (95% CI, 27.5-94.3)., Conclusion: From 2008 to 2015, primary care visits were longer, addressed more issues per visit, and were less likely to have scheduled follow-up for certain patients and conditions. Meanwhile, more PCPs offered non-face-to-face care. The decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non-face-to-face care., (© 2019 Annals of Family Medicine, Inc.)

Background: This study examined the effects of variability of four metabolic parameters, namely systolic blood pressure (BP), body mass index (BMI), fasting blood glucose (FBG), and total cholesterol level (TC) on the risk of HF. The effects of metabolic parameter variability on the risk of heart failure (HF) remain unclear., Methods: We studied individuals aged ≥40 years who had undergone ≥3 health check-ups under the Korean National Health Insurance Corporation during 2009 and 2012, and those who did not have hypertension, diabetes, or dyslipidemia. BP, BMI, FBG, and TC were measured at every visit. We defined the variability of each parameter using the variability independent of the mean (VIM) method. VIMs were categorized into four groups according to quartiles. The metabolic variability (MV) score for each subject was defined as the number of VIMs in the highest quartile., Results: Among the 3,820,191 subjects, 17,253 (0.45%) had incident HF during a mean 5.3 ± 1.1 years of follow-up. High variability of each parameter was associated with increased HF risk, which increased according to the MV score. After multivariable adjustment, compared to subjects with MV score = 0, subjects with MV score = 1-4 had an increased risk of HF (adjusted HR [95% CI], 1.15 [1.10-1.19] for MV score = 1, 1.33 [1.28-1.39] for MV score = 2, 1.48 [1.40-1.57] for MV score = 3, 1.74 [1.55-1.96] for MV score = 4 [p-for-trend ≪0.0001])., Conclusions: High variability of BP, BMI, FBG, and TC was synergistically associated with a higher incidence of new-onset HF., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed whether outpatient care with a cardiology provider is associated with evidence-based statin prescription and statin adherence. We identified patients with ASCVD aged ≥18 years receiving primary care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into: (1) patients with at least 1 outpatient cardiology visit and (2) patients with no outpatient cardiology visits in the year before the index primary care visit. We assessed any- and high-intensity statin prescription adjusting for several patient- and facility-level covariates, and statin adherence using proportion of days covered (PDC). We included 1,249,061 patients with ASCVD (mean age: 71.9 years; 98.0% male). After adjusting for covariates, patients who visited a cardiology provider had greater odds of being on a statin (87.4% vs 78.4%; Odds ratio [OR] 1.25, 95% Confidence interval [CI] 1.24 to 1.26), high-intensity statin (34.5% vs 21.2%; OR: 1.21, 95% CI 1.21 to 1.22), and higher statin adherence (mean PDC 0.76 ± 0.29 vs 0.70 ± 0.34, PDC ≥0.8: 62.0% vs 57.3%; OR 1.09, 95% CI 1.09 to 1.11). A dose response relation was seen with a higher number of cardiology visits associated with a higher statin use and statin adherence. In conclusion, compared with outpatient care delivered by primary care providers alone, care delivered by a cardiology provider for patients with ASCVD is associated with a higher likelihood of guideline-based statin use and statin adherence., (Published by Elsevier Inc.)

Objective-This report describes asthma visits to offices of nonfederally employed U.S. physicians. Methods-Asthma visits are defined by the first-listed diagnosis from National Ambulatory Medical Care Survey data. Asthma visit rates among the general population and among persons with asthma (at-risk rates) were estimated. Trends from 2001 through 2016 were assessed. Asthma visit characteristics were assessed for the period 2012-2015 (the diagnostic coding system was changed to the International Classification of Diseases, 10th Revision, Clinical Modification in 2016). The consistency of visit characteristics with national asthma guidelines was also assessed. Results-From 2001 through 2016, population-based asthma visit rates declined from 40.2 to 30.7 visits per 1,000 persons, and at-risk visit rates from 55.5 to 36.7 visits per 100 persons with asthma. During 2012-2015, there was an annual average of 10.2 million asthma visits: 63.5% were by non-Hispanic white persons, 53.8% by female patients, and 32.5% by children under age 15 years. Population and at-risk visit rates were similar across sex and racial and ethnic groups. Children aged 0-4 years had the highest at-risk asthma visit rate. Primary care physicians saw 60.0% of asthma visits. Asthma severity was documented in 34.5% of visits, asthma control in 40.9%, spirometry in 14.9%, and peak flow in 3.3%. Asthma education was provided in 21.4% of asthma visits and asthma action plans in 9.9%. Bronchodilators were the most commonly mentioned medication class (24.9%). A quick-acting relief medication was the most frequently mentioned (albuterol, 16.9%), followed by asthma-control medications (montelukast, 4.7%; fluticasone-salmeterol, 3.7%; and prednisone, 2.7%). Conclusions-Asthma physician office visit rates declined from 2001 through 2016. During 2012-2015, primary care providers saw nearly two-thirds of asthma visits. Physician adherence to documenting asthma severity or control and providing patient education appeared low. Quick-acting relief medication was the most frequently prescribed medication., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Purpose: We examined the relationship between retail clinic use and primary care physician (PCP) continuity among Medicare enrollees in the Houston metropolitan area., Methods: We identified retail clinic providers in the study area using a 2015 health care provider database. Medicare claims data from enrollees who received care from retail clinics in 2015 were compared with propensity score-matched sample of enrollees who received no care from retail clinics., Results: There were 2.32 retail clinic visits per 1000 beneficiaries in a month. Approximately 1.3% of Medicare beneficiaries used retail clinics. Retail clinic users were more likely to be aged 65 to 74 years, female, White, and Medicaid ineligible. In multivariable analyses with adjustments for covariates, significant predictors of retail clinic use included having ≥3 chronic conditions (Odds Ratio [OR], 1.53 vs no condition), living within 1 mile of a retail clinic (OR, 2.44 vs living ≥5 miles), and having no PCP (OR, 1.11 vs having PCP). Compared with propensity-matched controls, among enrollees with an identified PCP, likelihood of seeing their PCP (OR, 0.82; 95% CI, 0.73 to 0.93) and continuity of care was lower (0.75 ± 0.33 vs 0.80 ± 0.31) if they had retail clinic visits., Conclusions: Retail clinic use was lower in the elderly population compared with the previously published rate in the younger populations. The lower rate of continuity of care observed among retail clinic users is concerning, especially for those with chronic medical conditions., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Objectives. To explore the effect of the Affordable Care Act (ACA) on disparities in access to health care based on disability status, as well as age, income, race, and ethnicity. Methods. In this study, I used logistic regression to analyze nationally representative data from 128 000 respondents to the US National Health Interview Survey from 2008 to 2010 and 2015 to 2017. Outcome variables were uninsurance over the previous 12 months, delayed or forgone health care for reasons of cost, and having a regular provider at a doctor's office or health clinic. Results. Over the period when the ACA was implemented, large existing disparities in access to health care were reduced for people with certain types of disabilities, young adults aged 19 to 25 years, and low-income families. Conclusions. The ACA improved overall access to health care and reduced some disparities, but substantial disparities persist. Disability status remains associated with much greater risk of delayed or forgone care, and mental health disability is associated with greater likelihood of uninsurance. Public Health Implications. The ACA partially achieved its goals and must not be weakened or rolled back. Further policy efforts are needed to address the remaining disparities.

Background: As patient care is being increasingly transitioned out of the hospital and into the outpatient setting, there is a growing interest in developing office-based angiography suites, that is, office-based laboratories. Office-based care has been associated with increased efficiency and greater patient satisfaction, with substantially higher reimbursement directly to the physicians providing care. Prior studies have demonstrated a shift of revascularization procedures to office-based laboratories with a concomitant increase in atherectomy use, a procedure with disproportionately high reimbursement in comparison to other peripheral revascularization techniques. We sought to determine provider trends in endovascular procedure volume, settings, and shifts in practice over time, specific to atherectomy., Methods: Using Centers for Medicare & Medicaid Services Provider Utilization and Payment Data Public Use Files from 2013 to 2015, we identified providers who performed diagnostic angiography (DA), percutaneous transluminal angioplasty (PTA), stent placement (stent), and atherectomy, and procedures were aggregated at the provider level. Trends in procedures performed in office-based laboratory and facility-based settings were analyzed. Atherectomy was specifically analyzed using the total number and proportion of office-based laboratory procedures, and providers were stratified into quintiles by case volume., Results: Between 2013 and 2015, 5,298 providers were identified. Over this time period, the number of providers performing atherectomy increased 25.7%, with the highest quintile of atherectomy providers performing an average of 263 cases (range 109-1,455). The proportion of physicians who performed atherectomy only in the office increased from 39.8% to 50.7% from 2013 to 2015, whereas only 20.8% of physicians who performed DA, PTA, or stent in 2015 did so only in an office-based laboratory. Of the physicians with the highest atherectomy volume, 77.8% operated only in the office in 2015, and these physicians increased their atherectomy volume to 114.1% during the study period. Of those physicians who transitioned to a solely office-based laboratory practice over the study period, atherectomy volume increased 63.4%, which was disproportionate compared with the growth of their DA, PTA, and stent volume., Conclusions: Over this short study period, a rapid shift into the office setting for peripheral intervention occurred, with a concomitant increase in atherectomy volume that was disproportionate to the increase in other peripheral interventions. This increase in office-based laboratory atherectomy occurred in the setting of increased reimbursement for the procedure and despite a lack of data supporting superiority over PTA/stent., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Previous reports suggest that adults with inflammatory bowel disease (IBD) receive suboptimal preventive care., Aims: The population-based study compared the receipt of these services by US adults with and without IBD., Methods: Adults aged ≥ 18 years with IBD (1.2%) and without IBD were identified from the 2015 and 2016 National Health Interview Survey (n = 66,610). Age-standardized prevalence of doctor visits, receipt of medical advice, and selected preventive care was calculated for adults with and without IBD. The model-adjusted prevalence ratios were estimated for receipt of preventive care associated with IBD., Results: The prevalence of a doctor visit in the past 12 months was significantly higher among adults with IBD than those without. IBD was also associated with significantly higher prevalence of receiving medical advice about smoking cessation (83.9% vs. 66.4%) and diet (42.9% vs. 32.1%), having colon cancer screening in the past 12 months (44.0% vs. 26.7%), having ever had an HIV test (51.5% vs. 45.4%) or pneumococcal vaccine (75.3% vs. 64.0%), having received a tetanus vaccine in the past 10 years (72.0% vs. 61.8%), and having received a flu vaccine in the past 12 months (48.4% vs. 41.0%), but was not significantly associated with receiving cervical cancer screening and hepatitis A and B vaccines., Conclusions: Adults with IBD were more likely to receive many types of preventive care than adults without IBD. The findings can inform healthcare policy makers to make strategic decisions that enhance multidisciplinary coordination from various medical specialties to ensure optimal preventive care for IBD patients.

Heart failure (HF) outcomes are especially poor in high-risk patients with certain comorbidities including diabetes mellitus (DM), chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD). Whether early specialty or primary care provider (PCP) follow-up after HF discharge affects outcomes in high-risk patients is unknown., Methods: We analyzed patients discharged from a Get With The Guidelines HF-participating hospital from 2007-2012 with linked Medicare claims to investigate the association of medical specialist visit within 14 days of discharge stratified by comorbidity with the primary outcome of 90-day HF readmission. Secondary outcomes included 90-day and 1-year all-cause mortality., Results: Out of 33,243 patients, 39.4% had DM, 19.8% had CKD, 30.0% had COPD, and 36.3% had no key comorbidity. Nephrologist visit in patients with CKD was associated with a 35% reduction in 90-day HF readmission (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.85). Pulmonologist visit in patients with COPD was associated with a 29% reduction in 90-day HF readmission (HR 0.71, 95% CI 0.55-0.91). In patients with no key comorbidity, PCP and Cardiologist visits were associated with decreased 90-day mortality (HR for PCP 0.79, 95% CI 0.66-0.94; HR for Cardiologist 0.78, 95% CI 0.63-0.96). In patients with DM, Endocrinologist visit was associated with a 42% reduction of 90-day mortality (HR 0.58, 95% CI 0.34-0.99)., Conclusions: Specialist and PCP visit in the immediate post-discharge period may improve 90-day HF readmission and mortality in certain high-risk groups of patients with HF., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The United States is currently facing an epidemic of opioid-related deaths, increasingly associated with fentanyl use. Our objective was to characterize rates of fentanyl, general opioid and non-opioid pain medication prescription at a national level in both outpatient and emergency department settings. We used a retrospective cross-sectional research design using data from the 2006-2015 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Between 2006-2015, 66,987 (17.4%) of 390,538 office-based outpatient visits (nationally-representative of 961 million visits) and 134,953 (45.0%) of 305,570 ED visits (nationally-representative of 130 million visits) listed a pain medication prescription. The proportion of all outpatient visits in which any pain medication was prescribed increased from 15.0% in 2006-2007 to 20.5% in 2014-2015 (p < 0.001). The proportion of all outpatient visits in which any fentanyl product was prescribed remained stable at 0.3% and 0.4% (p = 0.32), but increased among ED visits from 0.5% to 1.1% (p = 0.006). In contrast, the proportion of all outpatient visits in which any opioid product was prescribed increased from 6.6% to 9.7% (p < 0.001), but remained relatively stable among ED visits from 26.2% to 24.4% (p = 0.07). Non-opioid pain medication prescription increased in both settings, from 9.7% to 13.7% (p < 0.001) in the outpatient setting and from 25.6% to 27.6% (p = 0.02) in the ED setting between 2006-2007 and 2014-2015, respectively. To address current opioid crisis, both clinical and public health interventions are needed, such as targeted education outreach on evidence-based opioid prescribing and non-opioid alternatives., (Copyright © 2019 Elsevier Inc. All rights reserved.)