Primary Care Visit Regularity and Patient Outcomes: an Observational Study.
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ABSTRACT:
SUBMITTER: Rose AJ
PROVIDER: S-EPMC6318173 | biostudies-literature | 2019 Jan
REPOSITORIES: biostudies-literature
Publications
Primary Care Visit Regularity and Patient Outcomes: an Observational Study.
Rose Adam J AJ Timbie Justin W JW Setodji Claude C Friedberg Mark W MW Malsberger Rosalie R Kahn Katherine L KL
Journal of general internal medicine 20181026 1
<h4>Background</h4>Regular primary care visits may allow an opportunity to deliver high-value, proactive care. However, no previous study has examined whether more temporally regular primary care visits predict better outcomes.<h4>Objective</h4>To examine the relationship between the temporal regularity of primary care (PC) visits and outcomes.<h4>Design</h4>Retrospective cohort study.<h4>Participants</h4>We used Medicare claims for 378,862 fee-for-service Medicare beneficiaries, who received PC ...[more]
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Project description:BackgroundThe effectiveness of health care interventions is co-determined by contextual factors. Unknown is the extent of this impact on patient outcomes. Therefore, the aim of this study is to explore which characteristics of general practices are associated with patient outcomes in a proactive primary care program, the U-PROFIT 2.0.MethodsA longitudinal observational study was conducted from January 2016 till October 2017. Two questionnaires were send out, one to collect characteristics of general practices such as practice neighbourhood socio-economic status, general practice versus healthcare centre (involving multiple primary care professionals), and professional- frail older patient ratio per practice of general practitioners and practice nurses. Regarding delivering the program, the practice or district nurse who delivered the program, number of years since the start of the implementation, and choice of age threshold for frailty screening were collected. Patient outcomes collected by the second questionnaire and send to frail patients were daily functioning, hospital admissions, emergency department visits, and general practice out-of-hours consultations. Linear and generalized linear mixed models were used.ResultsA total of 827 frail older people were included at baseline. Delivery of the program by a district nurse compared to a practice nurse was significantly associated with a decrease in daily functioning on patient-level (β = 2.19; P = < 0.001). Duration since implementation of 3 years compared to 9 years was significantly associated with less out-of-hours consultations to a general practice (OR 0.11; P = 0.001). Applying frailty screening from the age of 75 compared to those targeted from the age of 60 showed a significant increase in emergency visits (OR 5.26; P = 0.03).ConclusionThree associations regarding the organizational context 1) the nurse who delivered the program, 2) the number of years the program was implemented and 3) the age threshold for defining a frail patient are significant and clinically relevant for frail patients that receive a proactive primary care program. In general, contextual factors need more attention when implementing complex primary care programs which can result in better balanced choices to enhance effective proactive care for older people living in the community.
| S-EPMC8527676 | biostudies-literature
Project description:ImportanceVideo or telephone telemedicine can offer patients access to a clinician without arranging for transportation or spending time in a waiting room, but little is known about patient characteristics associated with choosing between telemedicine or office visits.ObjectiveTo examine patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians.Design, setting, and participantsThis cross-sectional study included data from 1 131 722 patients who scheduled a primary care appointment through the Kaiser Permanente Northern California patient portal between January 1, 2016, and May 31, 2018. All completed primary care appointments booked via the patient portal were identified. Only index visits without any other clinical visits within 7 days were included to define a relatively distinct patient-initiated care-seeking episode. Visits for routine physical, which are not telemedicine-eligible, were excluded. Data were analyzed from July 1, 2018, to December 31, 2019.Main outcomes and measuresPatient choice between an office, video, or telephone visit. Relative risk ratios (RRRs) for patient sociodemographic characteristics (age, sex, race/ethnicity, neighborhood socioeconomic status, language preference), technology access (neighborhood residential internet, mobile portal use), visiting the patient's own personal primary care clinician, and in-person visit barriers (travel-time, parking, cost-sharing), associated with choice of video or telephone telemedicine (vs office visit).ResultsOf 2 178 440 patient-scheduled primary care visits scheduled by 1 131 722 patients, 86% were scheduled as office visits and 14% as telemedicine visits, with 7% of the telemedicine visits by video. Choosing telemedicine was statistically significantly associated with patient sociodemographic characteristics. For example, patients aged 65 years and over were less likely than patients aged 18 to 44 years to choose telemedicine (RRR, 0.24; 95% CI, 0.22-0.26 for video visit; RRR 0.55; 95% CI, 0.54-0.57 for telephone visit). Choosing telemedicine was also statistically significantly associated with technology access (patients living in a neighborhood with high rates of residential internet access were more likely to choose a video visit than patients whose neighborhoods had low internet access: RRR, 1.10; 95% CI, 1.06-1.14); as well as in-person visit barriers (patients whose clinic had a paid parking structure were more likely to choose a telemedicine visit than patients whose facility had free parking: RRR, 1.70; 95% CI, 1.41-2.05 for video visit; and RRR, 1.73, 95% CI, 1.61-1.86 for telephone visit).Conclusions and relevanceIn this cross-sectional study, patients usually chose an in-person visit when scheduling an appointment online through the portal. Telemedicine may offer the potential to reach vulnerable patient groups and improve access for patients with transportation, parking, or cost barriers to clinic visits.
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Project description:A longitudinal study using data collected at the time of liver biopsy, the final eligibility assessment for participation in iWITH (NCT01638559), an immunosuppression withdrawal trial. Microarrays were used to understand the gene expression profile differences between IS withdrawal outcomes (Tolerant and Non-tolerant)
2021-03-15 | GSE159949 | GEO
Project description:BackgroundmHealth tablet-based interventions are increasingly being studied and deployed in various health care settings, yet little knowledge exists regarding patient uptake and acceptance or how patient demographics influence these important implementation metrics.ObjectiveTo determine which factors influence the uptake and successful completion of an mHealth tablet questionnaire by analyzing its implementation in a primary care setting.MethodsWe prospectively studied a patient-facing electronic touch-tablet asthma questionnaire deployed as part of the Electronic Asthma Management System. We describe tablet uptake and completion rates and corresponding predictor models for these behaviors.ResultsThe tablet was offered to and accepted by patients in 891/1715 (52.0%) visits. Patients refused the tablet in 33.0% (439/1330) visits in which it was successfully offered. Patients aged older than 65 years of age (odds ratio [OR] 2.30, 95% CI 1.33-3.95) and with concurrent chronic obstructive pulmonary disease (OR 2.22, 95% CI 1.05-4.67) were more likely to refuse the tablet, and those on an asthma medication (OR 0.55, 95% CI 0.30-0.99) were less likely to refuse it. Once accepted, the questionnaire was completed in 784/891 (88.0%) instances, with those on an asthma medication (OR 0.53, 95% CI 0.32-0.88) being less likely to leave it incomplete.ConclusionsOlder age predicted initial tablet refusal but not tablet questionnaire completion, suggesting that perceptions of mHealth among older adults may negatively impact uptake, independent of usability. The influence of being on an asthma medication suggests that disease severity may also mediate mHealth acceptance. Although use of mHealth questionnaires is growing rapidly across health care settings and diseases, few studies describe their real-world acceptance and its predictors. Our results should be complemented by qualitative methods to identify barriers and enablers to uptake and may inform technological and implementation strategies to drive successful usage.
| S-EPMC7532461 | biostudies-literature
Project description:ImportanceMedical practices increasingly allow patients to schedule their own visits through online patient portals, yet little is known about who adopts direct scheduling or how this service is used.ObjectiveTo determine patient and visit characteristics associated with direct scheduling, visit patterns, and potential implications for access and continuity in the primary care setting.Design, setting, and participantsThis cross-sectional study used electronic health record (EHR) data from 17 adult primary care practices in a large academic medical center in the Boston, Massachusetts, area. Participants included patients 18 years or older who were attributed in the EHR to an active primary care physician at 1 of the included primary care practices, were enrolled in the patient portal, and had at least 1 visit to 1 of these practices between March 1, 2018, and March 1, 2019, the period of analysis. Data were analyzed from October 25, 2019, to April 14, 2020.Main outcomes and measuresAdoption of direct scheduling, defined as at least 1 use during the study period. Usual scheduling was defined as scheduling with clinic staff by telephone or in person.ResultsWe examined 134 225 completed visits by 62 080 patients (mean [SD] age, 51.1 [16.4] years, 37 793 [60.9%] women) attributed to 140 primary care physicians at 17 primary care practices. A total of 5020 patients (8.1% [95% CI, 7.9%-8.3%]) adopted direct scheduling, with an age range of 18 to 95 years. Compared with nonadopters in the same practices, adopters were younger (adjusted odds ratio [AOR] per additional year, 0.98 [95% CI, 0.98-0.99]) and were more likely to be White (AOR, 1.09 [95% CI, 1.01-1.17]) and commercially insured (AOR vs uninsured, 1.40 [95% CI, 1.11-1.76]) and to have more comorbidities (AOR per additional comorbidity, 1.07 [95% CI, 1.04-1.11]). Compared with usually scheduled visits, directly scheduled visits were more likely to be for general medical examinations (1979 visits [36.7%] vs 26 519 visits [21.9%]; P < .001) and with one's own primary care physician (5267 visits [95.2%] vs 94 634 visits [73.5%]; P < .001).Conclusions and relevanceThese findings suggest that direct scheduling was associated with greater primary care continuity. Early adopters were more likely to be young, White, and commercially insured, and to the extent these differences persist as direct scheduling is used more widely, this service may widen socioeconomic disparities in primary care access.
| S-EPMC7453311 | biostudies-literature
Project description:ObjectivesGiven the numerous recent changes in ICU practices and protocols, we sought to confirm whether favorable effects of telemedicine ICU interventions on ICU mortality and length of stay can be replicated by a more recent telemedicine ICU intervention.Design setting and patientsObservational before-after telemedicine ICU intervention study in seven adult ICUs in two hospitals. The study included 1,403 patients in the preintervention period (October 2014 to September 2015) and 14,874 patients in the postintervention period (January 2016 to December 2018).InterventionTelemedicine ICU implementation.Measurements and main resultsICU and hospital mortality and length of stay, best practice adherence rates, and telemedicine ICU performance metrics. Unadjusted ICU and hospital mortality and lengths of stay were not statistically significantly different. Adjustment for Acute Physiology and Chronic Health Evaluation Version IVa score, ICU type, and ICU admission time via logistic regression yielded significantly lower ICU and hospital mortality odds ratios of 0.58 (95% CI, 0.45-0.74) and 0.66 (95% CI, 0.54-0.80), respectively. When adjusting for acuity by comparing observed-over-expected length of stay ratios through Acute Physiology and Chronic Health Evaluation IVa methodology, we found significantly lower ICU and hospital length of stay in the postintervention group. ICU mortality improvements were driven by nighttime ICU admissions (odds ratio 0.45 [95% CI, 0.33-0.61]) as compared to daytime ICU admissions (odds ratio 0.81 [95% CI, 0.55-1.20]), whereas hospital mortality improvements were seen in both subgroups but more prominently in nighttime ICU admissions (odds ratio 0.57 [95% CI, 0.44-0.74]) as compared to daytime ICU admissions (odds ratio 0.73 [95% CI, 0.55-0.97]), suggesting that telemedicine ICU intervention can effectively supplement low intensity bedside staffing hours (nighttime).ConclusionsIn this pre-post observational study, telemedicine ICU intervention was associated with improvements in care standardization and decreases in ICU and hospital mortality and length of stay. The mortality benefits were mediated in part through telemedicine ICU supplementation of low intensity bedside staffing hours.
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Project description:BackgroundChronic spinal pain is prevalent and long-lasting. Although provider-based nonpharmacologic therapies, such as chiropractic care, have been recommended, healthcare and coverage policies provide little guidance or evidence regarding long-term use of this care.ObjectiveTo determine the relationships between visit frequency and outcomes for patients using ongoing chiropractic care for chronic spinal pain.Study designObservational 3-month longitudinal study.SettingData collected from patients of 124 chiropractic clinics in 6 United States regions.MethodsWe examined the impact of visit frequency and patient characteristics on pain (pain 0-10 numeric rating scale) and functional outcomes (Oswestry Disability Index [ODI] for low-back pain and Neck Disability Index [NDI] for neck pain, both 0-100 scale) using hierarchical linear modeling (HLM) in a large national sample of chiropractic patients with chronic low back pain (CLBP) and/or chronic neck pain (CNP). This study was approved by the RAND Human Subjects Protection Committee and registered under ClinicalTrials.gov Identifier: NCT03162952.ResultsOne thousand, three hundred, sixty-two patients with CLBP and 1,214 with CNP were included in a series of HLM models. Unconditional (time-only) models showed patients on average had mild pain and function, and significant, but slight improvements in these over the 3-month observation period: back and neck pain decreased by 0.40 and 0.44 points, respectively; function improved by 2.7 (ODI) and 3.0 points (NDI) (all P < 0.001). Adding chiropractic visit frequency to the models revealed that those with worse baseline pain and function used more visits, but only visits more than once per week for those with CLBP were associated with significantly better improvement. These relationships remained when other types of visits and baseline patient characteristics were included.LimitationsThis is an observational study based on self-reported data from a sample representative of chiropractic patients, but not all patients with CLBP or CNP.ConclusionsThis 3-month window on chiropractic patients with CLBP and/or CNP revealed that they were improving, although slowly; may have reached maximum therapeutic improvement; and are possibly successfully managing their chronic pain using a variety of chiropractic visit frequencies. These results may inform payers when building coverage policies for ongoing chiropractic care for patients with chronic pain.
| S-EPMC8667562 | biostudies-literature
Project description:ImportanceReducing Medicare expenditures is a key objective of Medicare's transition to value-based reimbursement models. Improving access to primary care is an important way to reduce expenditures, yet less is known about how visits should be organized to maximize savings.ObjectiveTo examine the association between Medicare savings and primary care visit patterns.Design, setting, and participantsThis retrospective cohort study used data from a 5% sample of traditional Medicare claims from 2016 to 2019. Participants had at least 3 primary care visits with at least 180 days between the first and the last visit, were not enrolled in Medicare Advantage, did not have end-stage kidney disease, and were not institutionalized. Data were analyzed from June 2022 to April 2023.ExposuresPrimary care visit patterns: visit frequency, regularity, continuity of care.Main outcomes and measuresSavings in Medicare expenditures; risk-adjusted Medicare expenditures, number of emergency department (ED) visits, and hospitalizations.ResultsAmong 504 471 beneficiaries (298 422 [59.16%] women; mean [SD] age, 74.26 [10.41] years), temporally regular visits with higher continuity were associated with the highest savings. For these patients, the savings increased with increasing visit frequencies, with peak savings observed at higher visit frequencies as clinical complexity increased. As regularity and continuity decreased, the association between savings and visit frequencies progressively inverted. The group with a regular and highly continuous pattern was associated with greater savings (175.87%; 95% CI, 167.40% to 184.33%; P < .001), lower risk-adjusted expenditures (-16.61%; 95% CI, -16.73% to -16.48%; P < .001), fewer risk-adjusted ED visits (-40.49%; 95% CI, -40.55% to -40.43%; P < .001), and fewer risk-adjusted hospitalizations (-53.32%; 95% CI, -53.49% to -53.14%; P < .001) compared with the irregular noncontinuous group.Conclusions and relevanceIn this cohort study, savings in Medicare expenditures and improvements in acute care utilization were associated with visit frequency, regularity, and continuity in primary care in an interrelated fashion such that optimization of primary care visit patterns along each axis were associated with the largest improvement in outcomes. Demonstrating the magnitude and interdependence of these associations is useful for health care professionals and policymakers as Medicare continues its transition to value-based reimbursement models.
| S-EPMC10442711 | biostudies-literature
Project description:ObjectiveAlthough high visit-to-visit blood pressure variability (BPV) is an independent risk factor for cardiovascular events, the frequency of high BPV is unknown. We conducted this study to define the frequency of high BPV in primary care patients, clinical correlates, and association with antihypertensive therapies.MethodsRetrospective cohort study using electronic medical record data (with previously validated case definitions based on billing codes, free text analysis of progress notes, and prescribing data) from the Canadian Primary Care Sentinel Surveillance Network of 221,803 adults with multiple clinic visits over a 2-year period. We a priori defined a standard deviation>13.0 mm Hg in visit-to-visit systolic blood pressure (SBP) as "high BPV" based on prior literature.ResultsOverall, 85,455 (38.5%) patients had hypertension (mean 6.56 visits with SBP measurement, mean SBP 134.4 with Standard Deviation [SD] 11.3, 33.2% exhibited high BPV) and 136,348 did not (mean 3.96 visits with SBP measurement, mean SBP 120.9 with SD 8.2, 16.5% had high BPV). BPV increased with age regardless of whether individuals had hypertension or not; at all ages BPV varied across antihypertensive treatment regimens and was greater in those receiving renin angiotensin blockers or beta-blockers (p<0.001). High BPV was more frequent in patients with diabetes, chronic kidney disease, dementia, depression, chronic obstructive pulmonary disease, or Parkinson's disease.ConclusionsHigh visit-to-visit BPV is present in one sixth of non-hypertensive adults and one third of hypertensive individuals and is more common in those with comorbidities. The frequency of high BPV varies across antihypertensive treatment regimens.
| S-EPMC8018659 | biostudies-literature
Project description:PurposeHealth insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity.MethodsWe undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured).ResultsAfter the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78).ConclusionThe lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
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