Dataset Information

Prescriber Continuity and Disease Control of Older Adults.

ABSTRACT: Medicare beneficiaries with multiple chronic conditions are typically seen by multiple providers, particularly specialists. Clinically appropriate referrals to multiple specialists may compromise the continuity of care for multiple chronic condition beneficiaries and create care plans that patients may find challenging to reconcile, which may impact patient outcomes.The objective was to examine whether glycemic control or lipid control was associated with the number of prescribers of cardiometabolic medications.A retrospective cross-sectional cohort analysis of 51,879 elderly Medicare fee-for-service beneficiaries with diabetes and 129,762 beneficiaries with dyslipidemia living in 10 east coast states. Glycemic control was defined as having an HbA1c<7.5. Lipid control was defined as an low-density lipoprotein<100 for beneficiaries with heart disease or diabetes or an low-density lipoprotein<130 for all other beneficiaries. We examined the association between the number of prescribers of cardiometabolic medications and disease or lipid control in 2011 through logistic regression, controlling for age, sex, race, Medicaid enrollment, 17 chronic conditions and state-fixed effects.Among beneficiaries with diabetes, 76% with one prescriber had well-controlled diabetes in 2011, which decreased to 65% for beneficiaries with 5+ prescribers. In adjusted analyses, Medicare beneficiaries with 3 or more prescribers were less likely to have glycemic control than beneficiaries with a single prescriber. Among those with dyslipidemia, nearly all (91%-92%) beneficiaries had lipid control. After adjustment for demographics and comorbidity burden, beneficiaries with 3 prescribers were less likely to have lipid control than beneficiaries with a single prescriber.Multiple prescribers were associated with worse disease control, possibly because patients with more severe diabetes or dyslipidemia have multiple prescribers or because care fragmentation is associated with worse disease control.

SUBMITTER: Maciejewski ML

PROVIDER: S-EPMC5352484 | biostudies-literature | 2017 Apr

REPOSITORIES: biostudies-literature

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Prescriber Continuity and Disease Control of Older Adults.

Maciejewski Matthew L ML Hammill Bradley G BG Bayliss Elizabeth A EA Ding Laura L Voils Corrine I CI Curtis Lesley H LH Wang Virginia V

Medical care 20170401 4

<h4>Background</h4>Medicare beneficiaries with multiple chronic conditions are typically seen by multiple providers, particularly specialists. Clinically appropriate referrals to multiple specialists may compromise the continuity of care for multiple chronic condition beneficiaries and create care plans that patients may find challenging to reconcile, which may impact patient outcomes.<h4>Objective</h4>The objective was to examine whether glycemic control or lipid control was associated with the ...[more]

PMID: 27755393

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Project description:Care continuity is considered a critical characteristic of high-performing health systems. Few studies have examined the continuity of medication management of complex patients, who often have multiple providers and complex medication regimens.The purpose of this study was to characterize patient factors associated with having more prescribers and the association between number of prescribers and acute care utilization.A retrospective cohort study was conducted of 7,933 Veterans with one to four cardiometabolic conditions (diabetes, hypertension, hyperlipidemia or congestive heart failure) and prescribed medications for these conditions in 2008.The association between number of cardiometabolic conditions and prescribers was modeled using Poisson regression. The number of cardiometabolic conditions and number of prescribers were modeled to predict probability of inpatient admission, probability of emergency room (ER) visits, and number of ER visits among ER users. Demographic characteristics, number of cardiometabolic medications and comorbidities were included as covariates in all models.Patients had more prescribers if they had more cardiometabolic conditions (p < 0.001). The adjusted odds of an ER visit increased with the number of prescribers (two prescribers, Odds Ratio (OR)?= 1.16; three prescribers, OR = 1.21; 4+ prescribers, OR = 1.39), but not with the number of conditions. Among ER users, the number of ER visits was neither associated with the number of prescribers nor the number of conditions. The adjusted odds of an inpatient admission increased with the number of prescribers (two prescribers, OR = 1.27; three prescribers, OR = 1.30; 4+ prescribers, OR = 1.34), but not with the number of conditions.Having more prescribers was associated with greater healthcare utilization for complex patients, despite adjustment for the number of conditions and medications. The number of prescribers may be an appropriate target for reducing acute care utilization by complex patients.

Project description:Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia.To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia.This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1?416?369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included.Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles.Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician).Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22?004 vs $24?371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P?<?.001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups.Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.

Project description:This study represents the first attempt to perform a profiling analysis of the intergenerational differences in the microRNAs (miRNAs) of melanocytic neoplasms in young adult and older adult groups. Our comparative miRNA profiling provides a novel characterization of the miRnomes of melanocytic neoplasms and melanomas of different age groups and identifies a set of potential diagnostic and potential clinico-pathologic biomarkers that may serve as targets for development of novel miR-based modalities in cancer diagnosis and treatment. An exploratory miRNA analysis of 666 miRs was conducted on formalin fixed and paraffin embedded tissues from 10 adults and 10 young adults including conventional melanoma and melanocytic neoplasms of uncertain biological significance. Age-matched benign melanocytic nevi were used as controls. The comparative profiling was intentionally performed at two extremes of age, i.e., less than 30 years (Mel 30) and greater than 60 years (Mel 60). Primary melanoma in patients greater than 60 years old was characterized by the increased expression of miRs regulating TLR-MyD88-NF-kappaB pathway (hsa-miR -199a), RAS/RAB22A pathway (hsa-miR-204); growth differentiation and migration (hsa-miR337), epithelial mesenchymal transition EMT (let-7b, hsa-miR-10b/10bSTAR(*)), invasion and metastasis (hsa-miR-10b/10bSTAR(*), hsa-miR-30a/e*, hsa-miR-29c*; cellular matrix components (hsa-miR-29c*); invasion-cytokinesis (hsa-miR 99b*) compared to melanoma of younger patients. miR 211 was dramatically downregulated in primary melanoma compared to nevi controls, decreased with increasing age and was among the miRs linked to metastatic processes and potentially targeting the inflammatory receptor CCR10; Primary melanoma in young adult patients was characterized by the increased expression of hsa-miR-449a and decreased expression of hsa-miR146b, hsa-miR 214*. Among the miRs expressed at higher levels in control nevi, compared to adult or young adult melanoma, was hsa-miR 574-3p. Only 2 miRs distinguished adult from young adult-pediatric nevi, hsa-miR374a* and has-miR-566. MiR 30a* appeared to be a strong marker of differentiation in clinical stages I-II adult and pediatric melanoma, and could predict classification of melanoma tissue in the two age groups. Furthermore, lymph node status in the two age groups was characterized by the statistically significant expression of hsa-miR-30a* and hsa-miR-204 (F-test, p-value <0.001).

Dataset Information

Prescriber Continuity and Disease Control of Older Adults.

Publications

Prescriber Continuity and Disease Control of Older Adults.

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