Publications by authors named "Chiang-Hua Chang"

34 Publications

Medicare beneficiary panel characteristics associated with high Part D biologic disease-modifying anti-rheumatic drug prescribing for older adults among rheumatologists.

Medicine (Baltimore) 2021 Apr;100(16):e25644

University of Michigan, Ann Arbor, MI.

Abstract: The aim of this study was to investigate beneficiary panel characteristics associated with rheumatologists' prescribing of biologic DMARDs (bDMARDs) for older adults.In this retrospective observational study, we used Medicare Public Use Files (PUFs) to identify rheumatologists who met criteria for high-prescribing, defined as bDMARD prescription constituting ≥20% of their DMARD claims for beneficiaries ≥65 years of age. We first used descriptive analysis then multivariable regression model to test the association of high prescribing of bDMARDs with rheumatologists' panel size and beneficiary characteristics. In particular, we quantified the proportion of panel beneficiaries ≥75 years of age to assess how caring for an older panel correlate with prescribing of bDMARDs.We identified 3197 unique rheumatologists, of whom 405 (13%) met criteria for high prescribing of bDMARDs for Medicare beneficiaries ≥65 years of age. The high-prescribers provided care to 12% of study older adults, and yet accounted for 21% of bDMARD prescriptions for them. High prescribing of bDMARDs was associated with smaller panel size, and their beneficiaries were more likely to be non-black, ≥75 years of age, non-dual eligible, have diagnosis of CHF, however, less likely to have CKD.Rheumatologists differ in their prescribing of bDMARDs for older adults, and those caring for more beneficiaries ≥75 years of age are more likely to be high-prescribers. Older adults are more prone to the side-effects of bDMARDs and further investigation is warranted to understand drivers of differential prescribing behaviors to optimize use of these high-risk and high-cost medications.
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April 2021

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

JAMA 2021 03;325(10):952-961

School of Social Policy and Practice, University of Pennsylvania, Philadelphia.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death.

Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US.

Design, Setting, And Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018.

Exposures: Part D coverage during the observation year (January 1-December 31, 2018).

Main Outcomes And Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined.

Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days.

Conclusions And Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.
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March 2021

Thyroid Cancer Active Surveillance Program Retention and Adherence in Japan.

JAMA Otolaryngol Head Neck Surg 2021 01;147(1):77-84

Department of Surgery, Kuma Hospital, Kobe, Hyogo, Japan.

Importance: Small papillary thyroid cancers are the most common type of thyroid cancer, with the incidence increasing across the world. Active surveillance of appropriate cancers has the potential to reduce harm from overtreatment but is a significant de-escalation from prior practice. Mechanisms that inform the rates of retention and adherence have not been described and need to be understood if broader uptake is to be considered.

Objective: To evaluate patient retention, adherence, and experience in the largest and most long-standing thyroid cancer active surveillance program, to our knowledge.

Design, Setting, And Participants: A cohort study using convergent design mixed-methods analysis of attendance data, semistructured interviews, and field observation was conducted at Kuma Hospital, Kobe, Japan. Participants included 1179 patients who were enrolled in surveillance between February 1, 2005, and August 31, 2013, and followed up through December 31, 2017. Data analysis was performed from January 25, 2018, through September 30, 2020.

Main Outcomes And Measures: Patients were considered adherent if they underwent ultrasonography within at least 13 months of the previous ultrasonographic examination. Patients were considered retained if they continued surveillance with an ultrasonographic examination at least every 2 years, without having had surgery for patient preference or clinical reasons.

Results: Of the 1179 patients included in the study, 1037 (88%) were women. The mean (SD) age was 56 (13.5) years (median, 57 years). Patients were followed up for up to 12.76 years (median, 5.97 years) and underwent a median of 9 ultrasonographic examinations (range, 2-50); 76 patients (6.4%) had surgery for clinical reasons. In analysis of retention, 53 of 1179 patients (4.5%) changed to surgery after a mean (SD) of 2.14 (1.53) years (median, 1.47; range, 0.14-7.17 years); at the study end point, 101 of 1179 patients (8.6%) had not been seen at Kuma Hospital in at least the past 2 years. Kaplan-Meier analysis to 10 years of follow-up time without structural progression estimated that 21.5% (95% CI, 17.0%-28.2%) of patients would not have had an ultrasonographic examination within at least the past 2 years. Mean adherence over a surveillance period of 10 follow-up ultrasonographic examinations (8878 person-examinations) was 91% (range, 85%-95%). Receipt of detailed test results, education regarding active surveillance, and supportive/collaborative style interactions with their physician were identified by patients as key factors for continuing surveillance.

Conclusions And Relevance: For patients with low-risk papillary thyroid cancer participating in active surveillance, retention in the program and adherence to follow-up ultrasonographic examination do not appear to be barriers to broader implementation of surveillance. The program's success may benefit from an approach analogous to traveler (patient) and their guide (clinician): the clinician advising on options, advocating for the optimal path over time, and supportively reaffirming the care plan or recommending alternatives as conditions change.
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January 2021

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations.

J Am Med Dir Assoc 2021 02 18;22(2):406-412. Epub 2020 Jul 18.

Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.

Objectives: Nursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use.

Design: Observational propensity-matched study.

Setting And Participants: Medicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration.

Methods: ACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending.

Results: Nearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents' attribution status switched (14.6%), either into or out of an ACO.

Conclusions And Implications: ACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.
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February 2021

Association of Receiving Multiple, Concurrent Fracture-Associated Drugs With Hip Fracture Risk.

JAMA Netw Open 2019 11 1;2(11):e1915348. Epub 2019 Nov 1.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire.

Importance: Many prescription drugs increase fracture risk, which raises concern for patients receiving 2 or more such drugs concurrently. Logic suggests that risk will increase with each additional drug, but the risk of taking multiple fracture-associated drugs (FADs) is unknown.

Objective: To estimate hip fracture risk associated with concurrent exposure to multiple FADs.

Design, Setting, And Participants: This cohort study used a 20% random sample of Medicare fee-for-service administrative data for age-eligible Medicare beneficiaries from 2004 to 2014. Sex-stratified Cox regression models estimated hip fracture risk associated with current receipt of 1, 2, or 3 or more of 21 FADs and, separately, risk associated with each FAD and 2-way FAD combination vs no FADs. Models included sociodemographic characteristics, comorbidities, and use of non-FAD medications. Analyses began in November 2018 and were completed April 2019.

Exposure: Receipt of prescription FADs.

Main Outcomes And Measures: Hip fracture hospitalization.

Results: A total of 11.3 million person-years were observed, reflecting 2 646 255 individuals (mean [SD] age, 77.2 [7.3] years, 1 615 613 [61.1%] women, 2 136 585 [80.7%] white, and 219 579 [8.3%] black). Overall, 2 827 284 person-years (25.1%) involved receipt of 1 FAD; 1 322 296 (11.7%), 2 FADs; and 954 506 (8.5%), 3 or more FADs. In fully adjusted, sex-stratified models, an increase in hip fracture risk among women was associated with the receipt of 1, 2, or 3 or more FADs (1 FAD: hazard ratio [HR], 2.04; 95% CI, 1.99-2.11; P < .001; 2 FADs: HR, 2.86; 95% CI, 2.77-2.95; P < .001; ≥3 FADs: HR, 4.50; 95% CI, 4.36-4.65; P < .001). Relative risks for men were slightly higher (1 FAD: HR, 2.23; 95% CI, 2.11-2.36; P < .001; 2 FADs: HR, 3.40; 95% CI, 3.20-3.61; P < .001; ≥3 FADs: HR, 5.18; 95% CI, 4.87-5.52; P < .001). Among women, 2 individual FADs were associated with HRs greater than 3.00; 80 pairs of FADs exceeded this threshold. Common, risky pairs among women included sedative hypnotics plus opioids (HR, 4.90; 95% CI, 3.98-6.02; P < .001), serotonin reuptake inhibitors plus benzodiazepines (HR, 4.50; 95% CI, 3.76-5.38; P < .001), and proton pump inhibitors plus opioids (HR, 4.00; 95% CI, 3.56-4.49; P < .001). Receipt of 1, 2, or 3 or more non-FADs was associated with a small, significant reduction in fracture risk compared with receipt of no non-FADs among women (1 non-FAD: HR, 0.93; 95% CI, 0.90-0.96; P < .001; 2 non-FADs: HR, 0.84; 95% CI, 0.81-0.87; P < .001; ≥3 non-FADs: HR, 0.74; 95% CI, 0.72-0.77; P < .001).

Conclusions And Relevance: Among older adults, FADs are commonly used and commonly combined. In this cohort study, the addition of a second and third FAD was associated with a steep increase in fracture risk. Many risky pairs of FADs included potentially avoidable drugs (eg, sedatives and opioids). If confirmed, these findings suggest that fracture risk could be reduced through tighter adherence to long-established prescribing guidelines and recommendations.
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November 2019

Inclusion of Nursing Homes and Long-term Residents in Medicare ACOs.

Med Care 2019 12;57(12):990-995

Department of Internal Medicine, University of Michigan Medical School.

Background: Long-term nursing home residents have complex needs that often require services from acute care settings. The accountable care organization (ACO) model provides an opportunity to improve care by creating payment incentives for more coordinated, higher quality care.

Objectives: To assess the extent of nursing home participation in ACOs, and the characteristics of residents and their nursing homes connected to ACOs.

Research Design: This was a cross-sectional study.

Subjects: Medicare nursing home residents identified from 2014 Minimum Data Set assessments. Residents were attributed to ACOs based on Medicare methods.

Measures: Individuals' demographics, clinical characteristics, health care utilization, and nursing home characteristics.

Results: Among 660,780 nursing home residents, a quarter of them were attributed to ACOs. ACO residents had only small differences from non-ACO residents: age 85 years and older (47.1% vs. 45.3%), % black (10.5% vs. 12.7%), % dual eligible (74.3% vs. 75.8%), and emergency department visits (55.1 vs. 57.3 per 100). Of the 14,868 nursing homes with study residents, few were ACO providers (N=222, 1.6% of total residents) yet many had at least one ACO resident (N=8077, 76.4% of total residents); one-fifth had at least 20 (N=2839, 33.4% of total residents). ACO-provider homes were more likely than other homes to have a 5-star rating, be hospital-based and have Medicare as the primary payer.

Conclusions: With a quarter of long-term nursing home residents attributed to an ACO, and one-fifth of nursing homes caring for a large number of ACO residents, outcomes and spending in this setting are important for ACOs to consider when designing patient care strategies.
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December 2019

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries.

JAMA Intern Med 2019 Sep;179(9):1211-1219

Department of Medicine, Harvard Medical School, Boston, Massachusetts.

Importance: Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

Objective: To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

Design, Setting, And Participants: Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

Exposures: Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

Main Outcomes And Measures: Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

Results: Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

Conclusions And Relevance: Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
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September 2019

Geographic Expansion of Federally Qualified Health Centers 2007-2014.

J Rural Health 2019 06 23;35(3):385-394. Epub 2018 Oct 23.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Purpose: Federally Qualified Health Centers (FQHCs), which were expanded under the Affordable Care Act, are federally funded health centers that aim to improve access to primary care in underserved areas. With continued federal support, the number of FQHCs in the United States has increased >80% within a decade. However, the expansion patterns and their impact on the population served are unknown.

Methods: A pre (2007)-post (2014) study of FQHC locations. FQHC locations were identified from the Provider of Services Files then linked to primary care service areas (PCSAs), which represent the service markets that FQHCs served. Road-based travel time was estimated from each 2007 FQHC to the nearest new FQHC as an indicator of geographic expansion in access. PCSA-level characteristics were used to compare 2007 and 2014 FQHC service markets.

Findings: Between 2007 and 2014, there was greater expansion in the number of FQHCs (3,489 vs 6,376; 82.7%) than in the number of service markets (1,835 vs 2,695; 46.9%). Nearly half of 2007 FQHCs (47%) had at least one new FQHC within 30 minutes travel time. Most newly certified FQHCs (81%) were located in urban areas. Compared to 2007 service markets, the new 2014 markets (N = 174) were much less likely to be in areas with >20% of the population below poverty (31.4% vs 14.9%, P < .001).

Conclusions: The latest expansion of FQHCs was less likely to be in rural or high poverty areas, suggesting the impact of expansion may have limitations in improving access to care among the most financially disadvantaged populations.
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June 2019

Forgotten patients: ACO attribution omits those with low service use and the dying.

Am J Manag Care 2018 07 1;24(7):e207-e215. Epub 2018 Jul 1.

The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5, 1 Medical Center Dr, Lebanon, NH 03756. Email:

Objectives: Alternative payment models, such as accountable care organizations, hold provider groups accountable for an assigned patient population, but little is known about unassigned patients. We compared clinical and utilization profiles of patients attributable to a provider group with those of patients not attributable to any provider group.

Study Design: Cross-sectional study of 2012 Medicare fee-for-service beneficiaries 21 years and older.

Methods: We applied the Medicare Shared Savings Program attribution approach to assign beneficiaries to 2 mutually exclusive categories: attributable or unattributable. We compared attributable and unattributable beneficiaries according to demographics, dual eligibility for Medicaid, nursing home residency, clinical comorbidities, annual service utilization, annual spending, and 1- and 2-year mortality. We estimated multivariate regression models describing correlates of attribution status.

Results: Most beneficiaries (88%) were attributable to a provider group. The remaining 12% were unattributable. Beneficiaries unattributable to any provider group were more likely to be younger, male, and from a minority group; to have disability as the basis for enrollment; and to live in high-poverty areas. Unattributable beneficiaries included 3 distinct subgroups: nonusers of care, decedents, and those with healthcare service use but no qualifying evaluation and management visits. Many unattributable Medicare beneficiaries had minimal use of healthcare services, with the exception of a small subgroup of beneficiaries who died within the attribution year.

Conclusions: Attribution approaches that more fully capture unattributable patients with low service use and patients near the end of life should be considered to reward population health efforts and improve end-of-life care.
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July 2018

Direct oral anticoagulant and antiplatelet combination therapy: Hemorrhagic events in coronary artery stent recipients.

J Clin Neurosci 2018 Apr 1;50:24-29. Epub 2018 Feb 1.

The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, Geisel School of Medicine at Dartmouth, Hanover, NH, United States; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States.

Direct oral anticoagulant (DOAC) use is growing as monotherapy and combined with platelet inhibitors. The safety of such combination therapy, especially in comparison to regimens including warfarin, in real world populations remains uncertain. We investigated hemorrhage associated with DOAC and antiplatelet combination therapy in a cohort of elderly coronary artery stent recipients. We employed Medicare data 2010-2013 for a 40% random sample of beneficiaries enrolled in inpatient, outpatient and prescription benefits. We used Cox proportional hazards models to examine the association of the combination anticoagulant (DOAC or warfarin) plus antiplatelets with major hemorrhage events (upper gastrointestinal or intracranial) in the 12 months following stent placement. We identified 70,900 stent recipients. 14.4% had atrial fibrillation (AF) diagnosis preoperatively. Among the 24.5 million observation days, exposure distribution was: 73.8% antiplatelets only, 4.7% antiplatelets plus warfarin, 0.6% antiplatelets plus DOAC, 2.2% warfarin only, 0.3% DOAC only and 18.4% no observed antiplatelets or anticoagulant. Overall, 8,029 patients (11.3%) experienced major hemorrhage. Among AF patients, compared to antiplatelets only, DOAC plus antiplatelets was associated with increased hemorrhage risk (HR, 1.94; 95%CI, 1.48-2.54); warfarin plus antiplatelets conferred comparable bleed risk (HR, 1.69; 95%CI, 1.47-1.94). In the non-AF group, compared to antiplatelets alone, combination DOAC plus antiplatelets (HR, 3.09; 95%CI, 2.15-4.46), and warfarin plus antiplatelets (HR, 2.21; 95%CI, 1.97-2.48) conferred greater bleed risk. Among elderly coronary artery stent recipients with AF, the two drug combinations, DOAC plus antiplatelets and warfarin plus antiplatelets, were associated with similarly increased risk of major hemorrhage compared to antiplatelets alone.
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April 2018

Atrial Fibrillation and Stent Selection (Bare Metal vs Drug Eluting) (from Medicare Claims).

Am J Cardiol 2017 Nov 1;120(9):1557-1561. Epub 2017 Aug 1.

The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

In treating coronary artery disease, many factors influence the choice of bare metal stent (BMS) or drug-eluting stent (DES), including bleed risk and suitability for prolonged dual antiplatelet therapy. Atrial fibrillation (AF) further complicates this choice, due to common use of anticoagulation. We examined stent selection in the United States by AF status and across academic medical centers (AMCs) to explore how cardiologists are managing this complex choice. Using a 100% Medicare denominator file and associated claims (2008 to 2012), we identified patients over age 65 receiving inpatient coronary artery stents. We measured BMS and DES use in patients with AF and in patients without AF and assessed variation in stent choice across AMCs, adjusting for differences in age, gender, and race. We identified 898,788 stent episodes among elderly Medicare beneficiaries. BMS, as a percentage of total inpatient stent episodes, decreased from 2008 to 2012, in patients with AF (42% to 34%) and in patients without AF (32% to 23%). Across AMCs, adjusted stent choice varied substantially, but more so for patients with AF (2008 to 2012 median BMS 44% to 39%, annual interquartile ratios range 1.8 to 2.3) than patients without AF (2008 to 2012 median BMS 33% to 25%, annual interquartile ratios range 2.0 to 1.8). In conclusion, among stent recipients, patients with AF are more likely to receive BMS than patients without AF but treatment varies across systems, suggesting a lack of consensus. Studies of stent choice and outcomes among patients with AF are needed to guide care decisions and optimize outcomes.
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November 2017

Outcomes in Older Adults with Multimorbidity Associated with Predominant Provider of Care Specialty.

J Am Geriatr Soc 2017 Sep 8;65(9):1916-1923. Epub 2017 Apr 8.

Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire.

Objectives: To determine whether receiving the predominance of ambulatory visits from a primary care provider compared to a specialty provider is associated with better outcomes in older adults with multi morbidity.

Design: Observational study using propensity score matching.

Setting: Medicare fee-for-service, 2011-12.

Participants: Beneficiaries aged 65 and older with multimorbidity.

Measurements: The independent variable was an indicator for having a specialty (versus primary care) as the predominant provider of care (PPC). Main outcomes were 1-year mortality, hospitalization, standardized expenditures, and ambulatory visit patterns.

Results: Two-thirds of 3,934,942 beneficiaries with multimorbidity had a primary care provider as their PPC. Individuals with a specialty PPC had more hospitalizations (40.3 more per 1,000) and higher spending ($1,781 more per beneficiary) than those with a primary care PPC, but there was little difference in mortality (0.2% higher) or preventable hospitalizations. Spending differences were largest for professional fees ($769 higher per beneficiary), inpatient stays ($572 higher per beneficiary), and outpatient facilities ($510 higher per beneficiary) (all P < .001). In addition, people with a specialist PPC had lower continuity of care and saw more providers.

Conclusions: Older adults with multimorbidity with a specialist as their main ambulatory care provider had higher spending and lower continuity of care than those whose PPC was in primary care but similar clinical outcomes.
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September 2017

Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations.

J Womens Health (Larchmt) 2016 Oct 18;25(10):1030-1037. Epub 2016 Jul 18.

1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire.

Background: It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50-74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries.

Materials And Methods: Cohort study of 12 million Medicare fee-for-service women aged 65-74 and 75 and older to measure changes in 3-year screening use, 2007-2009 (before) and 2010-2012 (after), defined by two measures-proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region.

Results: Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65-74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65-74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening).

Conclusions: Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.
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October 2016

Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare.

JAMA Intern Med 2016 09;176(9):1371-8

The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Importance: Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia.

Objective: To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia.

Design, Setting, And Participants: 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.

Exposures: 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.

Main Outcomes And Measures: 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).

Results: 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.

Conclusions And Relevance: 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.
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September 2016

Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries.

JAMA Intern Med 2016 08;176(8):1167-75

The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

Importance: Accountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients. Focusing on clinically vulnerable patients, those with serious conditions who are responsible for the greatest proportion of spending, may result in the largest effects on both patient outcomes and financial rewards for participating physician groups.

Objective: To estimate the effect of Medicare accountable care organization (ACO) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinically vulnerable beneficiaries.

Design, Setting, And Participants: For this cohort study, 2 study populations were defined: the overall Medicare population and the clinically vulnerable subgroup of Medicare beneficiaries. The overall Medicare population was based on a random 40% sample drawn from continuously enrolled fee-for-service beneficiaries with at least 1 evaluation and management visit in a calendar year. The clinically vulnerable study population included all Medicare beneficiaries 66 years or older who had at least 3 Hierarchical Condition Categories (HCCs). Beneficiaries entered the cohort during the quarter between January 2009 to December 2011 when they first had at least 3 HCCs and remained in the cohort until death. Cohort entry was restricted to the preperiod to account for potential changes in coding practices after ACO implementation. Difference-in-difference estimations were used to compare changes in health care outcomes for Medicare beneficiaries attributed to physicians in ACOs with those attributed to non-ACO physicians from January 2009 to December 2013.

Exposures: Medicare ACOs beginning contracts in January 2012, April 2012, July 2012, and January 2013 through the Pioneer and Medicare Shared Savings Programs.

Main Outcomes And Measures: Total spending per beneficiary-quarter, spending categories, use of hospitals and emergency departments, ambulatory care sensitive admissions, and 30-day readmissions.

Results: Total spending decreased by $34 (95% CI, -$52 to -$15) per beneficiary-quarter after ACO contract implementation across the overall Medicare population (n = 15 592 600) and decreased $114 in clinically vulnerable patients (n = 8 673 823) (95% CI, -$178 to -$50). In the overall Medicare cohort, hospitalizations and emergency department visits decreased by 1.3 and 3.0 events per 1000 beneficiaries per quarter, respectively (95% CIs: -2.1 to -0.4 and -4.8 to -1.3), and hospitalizations and emergency department visits decreased in the clinically vulnerable cohort by 2.9 and 4.1 events per 1000 beneficiaries per quarter, respectively (95% CIs: -5.2 to -0.7 and -7.1 to -1.2). Changes in total spending associated with ACOs did not vary by clinical condition of beneficiaries.

Conclusions And Relevance: Medicare ACO programs are associated with modest reductions in spending and use of hospitals and emergency departments. Savings were realized through reductions in use of institutional settings in clinically vulnerable patients.
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August 2016

Who Is Providing the Predominant Care for Older Adults With Dementia?

J Am Med Dir Assoc 2016 09 11;17(9):802-6. Epub 2016 Jun 11.

The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH. Electronic address:

Objectives: To identify which clinical specialties are most central for care of people with dementia in the community and long-term care (LTC) settings.

Design: Cross-sectional analysis.

Participants: Fee-for-service Medicare beneficiaries aged ≥65 years with dementia.

Measurements: Specialty, categorized into primary care (internal or family medicine, geriatrics, or nurse practitioners [NPs]) versus other specialties, of the predominant provider of care (PPC) for each patient, defined by providing the most ambulatory visits.

Results: Among 2,598,719 beneficiaries with dementia, 74% lived in the community and 80% had a PPC in primary care. In LTC, 91% had primary care as their PPC compared with 77% in the community (P < .001). Cardiology and neurology were the most frequent specialties. NPs were PPCs for 19% of dementia patients in LTC versus 7% in the community (P < .001).

Conclusion: It is unknown whether specialists are aware of their central role for many dementia patients' care needs. In LTC, NPs play the lead role as PPCs.
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September 2016

Association between Temporal Changes in Primary Care Workforce and Patient Outcomes.

Health Serv Res 2017 04 3;52(2):634-655. Epub 2016 Jun 3.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.

Objective: To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes.

Data Sources: 2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims.

Study Design/methods: We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care-sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models.

Principal Findings: An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p < .05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p < .05).

Conclusions: Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.
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April 2017

Characteristics and Service Use of Medicare Beneficiaries Using Federally Qualified Health Centers.

Med Care 2016 Aug;54(8):804-9

*The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover †Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Background: Federally Qualified Health Centers (FQHCs) provide primary care for millions of Americans, but little is known about Medicare beneficiaries who use FQHCs.

Objective: To compare patient characteristics and health care service use among Medicare beneficiaries stratified by FQHC use.

Research Design: Cross-sectional analysis of 2011 Medicare fee-for-service beneficiaries aged 65 years and older.

Subjects: Subjects included beneficiaries with at least 1 evaluation and management (E&M) visit in 2011, categorized as FQHC users (≥1 E&M visit to FQHCs) or nonusers living in the same primary care service areas as FQHC users. Users were subclassified as predominant if the majority of their E&M visits were to FQHCs.

Measures: Demographic characteristics, physician visits, and inpatient care use.

Results: Most FQHC users (56.6%) were predominant users. Predominant and nonpredominant users, compared with nonusers, markedly differed by prevalence of multiple chronic conditions (18.2%, 31.7% vs. 22.7%) and annual mortality (2.8%, 3.8% vs. 4.0%; all P<0.05). In adjusted analyses (reference: nonusers), predominant users had fewer physician visits (RR=0.81; 95% CI, 0.81-0.81) and fewer hospitalizations (RR=0.84; 95% CI, 0.84-0.85), whereas nonpredominant users had higher use of both types of service (RR=1.18, 95% CI, 1.18-1.18; RR=1.09, 95% CI, 1.08-1.10, respectively).

Conclusions: Even controlling for primary care delivery markets, nonpredominant FQHC users had a higher burden of chronic illness and service use than predominant FQHC users. It will be important to monitor Medicare beneficiaries using FQHCs to understand whether primary care only payment incentives for FQHCs could induce fragmented care.
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August 2016

Prescription Use among Children with Autism Spectrum Disorders in Northern New England: Intensity and Small Area Variation.

J Pediatr 2016 Feb 11;169:277-83.e2. Epub 2015 Nov 11.

Geisel School of Medicine at Dartmouth, Hanover, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Objective: To measure prescription use intensity and regional variation of psychotropic and 2 important nonpsychotropic drug groups among children with autism spectrum disorders (ASDs) compared with children in the general population.

Study Design: Cross-sectional study of ambulatory prescription fills from Maine, Vermont, and New Hampshire all-payer administrative data, 2007-2010.

Results: Overall there were 13,100 children diagnosed with ASD (34,584 person years [PYs]) and 936,721 (1.7 million PYs) without ASD diagnosis. The overall prescription fill rate was 16.6 per PY in children with ASD and 4.1 per PY in the general population. Psychotropic use among children with ASDs was 9-fold the general population rate (7.80 vs 0.85 fills per PY); these children comprised 2.0% of the pediatric population but received 15.6% of psychotropics. Nonpsychotropic drug use was also higher in the population with ASD, particularly the youngest: among those under age 3 years, antibiotic use was 2-fold and antacid use nearly 5-fold the general population rate (3.2 vs 1.4 and 1.0 vs 0.2 per PY, respectively). Among children with ASDs, prescription use varied substantially across hospital service areas, as much as 3-fold for antacids and alpha agonists, more than 4-fold for benzodiazepines (5th to 95th percentile).

Conclusions: The overall psychotropic and nonpsychotropic prescription intensity among children with ASDs is characterized by broad regional variation, suggesting diverse provider responses to pharmacotherapeutic uncertainty. This variation highlights a need for more research, practice-based learning, and shared decision making with caregivers surrounding therapy for children with ASDs.
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February 2016

Small geographic area variations in prescription drug use.

Pediatrics 2014 Sep 11;134(3):563-70. Epub 2014 Aug 11.

Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; and Department of Community and Family Medicine Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.

Background: Despite the frequency of pediatric prescribing little is known about practice differences across small geographic regions and payer type (Medicaid and commercial).

Objective: The goal of this research was to quantify variation in prescription drug use among northern New England children.

Methods: Northern New England, all-payer administrative data (2007-2010) permitted study of prescriptions for 949 821 children ages 0 to 17 years (1.75 million person-years [PYs]; 54% Medicaid, 46% commercial). Age- and gender adjusted overall and drug group-specific prescription use was quantified according to payer type (Medicaid or commercial) and within payer type across 69 hospital service areas (HSAs). We measured prescription fills per PY (rate) and annual, mean percentage of the population with any drug group-specific fills (prevalence).

Results: Overall mean annual prescriptions per PY were 3.4 (commercial) and 5.5 (Medicaid). Generally, these payer type differences were smaller than HSA-level variation within payer type. HSA-level rates of attention-deficit/hyperactivity disorder drug use (5th-95th percentile) varied twofold in Medicaid and more than twofold in commercially insured children; HSA-level antidepressant use varied more than twofold within each payer type. Antacid use varied threefold across HSAs and was highest in infants where commercial use paradoxically exceeded Medicaid. Prevalence of drug use varied as much as rates across HSAs.

Conclusions: Prescription use was higher among Medicaid-insured than commercially insured children. Regional variation generally exceeded payer type differences, especially for drugs used in situations of diagnostic and therapeutic uncertainty. Efforts should advance best pediatric prescribing discussions and shared decision-making.
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September 2014

Health system characteristics and rates of readmission after acute myocardial infarction in the United States.

J Am Heart Assoc 2014 May 20;3(3):e000714. Epub 2014 May 20.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH (J.R.B., C.H.C., W.Z., T.A.M.K., D.J.M., D.C.G.) Department of Pediatrics, Geisel School of Medicine, Lebanon, NH (D.C.G.).

Background: Interventions to reduce early readmissions have focused on patient characteristics and the importance of early follow-up; however, less is known about the characteristics of health systems, including quality, capacity, and intensity, and their influence on readmission rates in the United States. Therefore, we examined the association of hospital patterns of medical care with rates of 30-day readmission.

Methods And Results: Medicare beneficiaries hospitalized for an AMI (n=188 611) between 2008 and 2009 in 1088 hospitals in the United States were included in our cohort. We tested the association between hospital patterns of medical care quality (discharge planning care quality), capacity (hospital size measured as the number of beds, hospital-level Medicare all medical admission rates, supply of primary care physicians and cardiologists), and intensity (measures of care during the last 6 months of life) on CMS risk-adjusted rates of 30-day readmission using Poisson multilevel mixed-effects models adjusting for patient- and hospital-level covariates. There were 38 350 readmissions at 30-days (20.3%) AMI discharges. Controlling for patient characteristics, measures of hospital care associated with higher rates of readmission included higher hospital-level rates for all medical admissions, per capita primary care physicians and cardiologists, and last 6 months of life care intensity measures including increased number of hospital days, number of ICU days, number of physician visits, and 10 or more different physicians seen during the last 6 months of life. Better discharge quality and larger hospitals were associated with lower rates of readmission.

Conclusions: In addition to quality of care, high 30-day readmission rates are associated with hospital-level measures of capacity and intensity. Efforts to reduce readmission rates may need to address these broader patterns of medical care.
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May 2014

End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely.

Health Aff (Millwood) 2012 Apr;31(4):786-96

Dartmouth Medical School, Lebanon, New Hampshire, USA.

Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.
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April 2012

Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer.

J Palliat Med 2012 May 2;15(5):548-54. Epub 2012 Apr 2.

Maine Medical Center Research Institute, Maine Medical Center, Portland, Maine, USA.

Purpose: To measure intensity of end-of-life (EOL) care for Medicare cancer patients and variations in care by age, gender, and race.

Patients And Methods: This retrospective cohort analysis of Medicare claims (20% sample) examined 235,821 Medicare Parts A and B fee-for-service patients dying with poor-prognosis cancers between 2003 and 2007. Logistic regression models quantified associations between care intensity and age, gender, and race. Measures included hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, in-hospital deaths, late-life chemotherapy administration, overall and late hospice enrollment within six months of death.

Results: Within 30 days of death, 61.3% of patients were hospitalized, 10.2% were hospitalized more than once, 10.2% visited an ED more than once, 23.7% had ICU admissions, and 28.8% died in-hospital. Within two weeks of death, 6% received chemotherapy. In their final six months, 55.2% accessed hospice, 15.1% within three days of death. Older age (≥75 versus <75) was associated with lower odds ratios (ORs) of 0.49 to 0.89 for aggressive care, and an OR of 0.92 (95% CI 0.89-0.95) for late hospice enrollment. Female gender was associated with lower ORs (0.82 to 0.86) for aggressive care, and an OR of 0.84 (95% CI 0.81-0.86) for late hospice enrollment. Black (versus nonblack) race was associated with higher ORs (1.08 to 1.38) for aggressive acute care, lower ORs for late chemotherapy, OR 0.76 (95% CI 0.71-0.81), and late hospice enrollment, OR 0.81 (95% CI 0.76-0.86).

Conclusions: Seniors dying with poor-prognosis cancer experience high-intensity care with rates varying by age, gender, and race.
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May 2012

Primary care physician workforce and Medicare beneficiaries' health outcomes.

JAMA 2011 May;305(20):2096-104

Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, NH 03766, USA.

Context: Despite a widespread interest in increasing the numbers of primary care physicians to improve care and to moderate costs, the relationship of the primary care physician workforce to patient-level outcomes remains poorly understood.

Objective: To measure the association between the adult primary care physician workforce and individual patient outcomes.

Design, Setting, And Participants: A cross-sectional analysis of the outcomes of a 2007 20% sample of fee-for-service Medicare beneficiaries aged 65 years or older (N = 5,132,936), which used 2 measures of adult primary care physicians (general internists and family physicians) across Primary Care Service Areas (N = 6542): (1) American Medical Association (AMA) Masterfile nonfederal, office-based physicians per total population and (2) office-based primary care clinical full-time equivalents (FTEs) per Medicare beneficiary derived from Medicare claims.

Main Outcome Measures: Annual individual-level outcomes (mortality, ambulatory care sensitive condition [ACSC] hospitalizations, and Medicare program spending), adjusted for individual patient characteristics and geographic area variables.

Results: Marked variation was observed in the primary care physician workforce across areas, but low correlation was observed between the 2 primary care workforce measures (Spearman r = 0.056; P < .001). Compared with areas with the lowest quintile of primary care physician measure using AMA Masterfile counts, beneficiaries in the highest quintile had fewer ACSC hospitalizations (74.90 vs 79.61 per 1000 beneficiaries; relative rate [RR], 0.94; 95% confidence interval [CI], 0.93-0.95), lower mortality (5.38 vs 5.47 per 100 beneficiaries; RR, 0.98; 95% CI, 0.97-0.997), and no significant difference in total Medicare spending ($8722 vs $8765 per beneficiary; RR, 1.00; 95% CI, 0.99-1.00). Beneficiaries residing in areas with the highest quintile of primary care clinician FTEs compared with those in the lowest quintile had lower mortality (5.19 vs 5.49 per 100 beneficiaries; RR, 0.95; 95% CI, 0.93-0.96), fewer ACSC hospitalizations (72.53 vs 79.48 per 1000 beneficiaries; RR, 0.91; 95% CI, 0.90-0.92), and higher overall Medicare spending ($8857 vs $8769 per beneficiary; RR, 1.01; 95% CI, 1.004-1.02).

Conclusion: A higher level of primary care physician workforce, particularly with an FTE measure that may more accurately reflect ambulatory primary care, was generally associated with favorable patient outcomes.
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May 2011

Seniors' perceptions of health care not closely associated with physician supply.

Health Aff (Millwood) 2011 Feb;30(2):219-27

Office of Research, Development, and Information, Centers for Medicare and Medicaid Services, in Baltimore, Maryland, USA.

We conducted a national random survey of Medicare beneficiaries to better understand the association between the supply of physicians and patients' perceptions of their health care. We found that patients living in areas with more physicians per capita had perceptions of their health care that were similar to those of patients in regions with fewer physicians. In addition, there were no significant differences between the groups of patients in terms of numbers of visits to their personal physician in the previous year; amount of time spent with a physician; or access to tests or specialists. Our results suggest that simply training more physicians is unlikely to lead to improved access to care. Instead, focusing health policy on improving the quality and organization of care may be more beneficial.
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February 2011

Geographic maldistribution of primary care for children.

Pediatrics 2011 Jan 20;127(1):19-27. Epub 2010 Dec 20.

Dartmouth Institute for Health Policy and Clinical Practice, 35 Centerra Parkway, Suite 202, Lebanon, NH 03766, USA.

Objectives: This study examines growth in the primary care physician workforce for children and examines the geographic distribution of the workforce.

Methods: National data were used to calculate the local per-capita supply of clinically active general pediatricians and family physicians, measured at the level of primary care service areas.

Results: Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution.

Conclusions: Undirected growth of the aggregate child physician workforce has resulted in profound maldistribution of physician resources. Accountability for public funding of physician training should include efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to primary care physicians for children.
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January 2011

Accessibility of family planning services: impact of structural and organizational factors.

Matern Child Health J 2007 Jan 28;11(1):19-26. Epub 2006 Nov 28.

Institute for Child, Youth and Family Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, 02454-9110, USA.

Objectives: This study sought to determine whether selected structural and organizational characteristics of publicly available family planning facilities are associated with greater availability.

Methods: A survey was sent to 726 publicly available family planning facilities in four states. These included local health departments, federally qualified health centers (FQHC), Planned Parenthood sites, hospital outpatient departments, and freestanding women's health centers. Usable responses were obtained from 526 sites for a response rate of 72.5%. Availability variables included the provision of primary care services; the contraceptives offered; professional staffing; scheduling, waiting time, and transportation; and cultural congruence and competency. The structural and organizational variables were state, type of organization, and funding source.

Results: Some states were more likely to offer emergency contraception while others were more likely to have weekend hours. FQHCs were most likely to provide primary care and Planned Parenthood sites most likely to offer emergency contraception. Title X funding was associated with increased likelihood of providing emergency contraception and staffing by midlevel practitioners and registered nurses.

Conclusions: This study found that availability varied by structural and organizational variables, many of which are determined by federal and state policies. Revising some of these policies might increase utilization of family planning facilities.
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January 2007

Geographic access to family planning facilities and the risk of unintended and teenage pregnancy.

Matern Child Health J 2007 Mar 28;11(2):145-52. Epub 2006 Nov 28.

The Center for the Evaluative Clinical Sciences and the Department of Pediatrics, Dartmouth Medical School, 7251 Strasenburgh Hall, Hanover, NH 03755, USA.

Objectives: This study tested the hypotheses that greater geographic access to family planning facilities is associated with lower rates of unintended and teenage pregnancies.

Methods: State Pregnancy Risk Assessment Monitoring System (PRAMS) and natality files in four states were used to locate unintended and teenage births, respectively. Geographic availability was measured by cohort travel time to the nearest family planning facility, the presence of a family planning facility in a ZIP area, and the supply of primary care physicians and obstetric-gynecologists.

Results: 83% of the PRAMS cohort and 80% of teenagers lived within 15 min or less of a facility and virtually none lived more than 30 min. Adjusted odds ratios did not demonstrate a statistically significant trend to a higher risk of unintended pregnancies with longer travel time. Similarly there was no association with unintended pregnancy and the presence of a family planning facility within the ZIP area of maternal residence, or with the supply of physicians capable of providing family planning services. Both crude and adjusted relative rates of teenage pregnancies were significantly lower with further distance from family planning sites and with the absence of a facility in the ZIP area of residence. In adjusted models, the supply of obstetricians-gynecologists and primary care physicians was not significantly associated with decreased teen pregnancies.

Conclusions: This study found no relationship between greater geographic availability of family planning facilities and a risk of unintended pregnancies. Greater geographic availability of family planning services was associated with a higher risk of teenage pregnancy, although these results may be confounded by facilities locating in areas with greater family planning needs.
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March 2007

End-of-life care at academic medical centers: implications for future workforce requirements.

Health Aff (Millwood) 2006 Mar-Apr;25(2):521-31

Center for the Evaluative Clinical Sciences (CECS), Dartmouth Medical School, Hanover, New Hampshire, USA.

The expansion of U.S. physician workforce training has been justified on the basis of population growth, technological innovation, and economic expansion. Our analyses found threefold differences in physician full-time-equivalent (FTE) inputs for Medicare cohorts cared for at academic medical centers (AMCs); AMC inputs were highly correlated with the number of physician FTEs per Medicare beneficiary in AMC regions. Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020, with adoption of the workforce deployment patterns now seen among AMCs and regions dominated by large group practices.
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October 2006