Practice‐site‐level measures of primary care comprehensiveness and their associations with patient outcomes

ObjectivesTo develop two practice‐site‐level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician‐level measures.Data SourcesMedicare fee‐for‐service claims.Study DesignWe calculated practice‐site‐level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices’ attributed beneficiaries’ 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs’ comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice‐site and PCP‐level measures with outcomes.Principal FindingsThe measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P < .01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P < .05); 8.84 (3.0%) fewer hospitalizations (P < .001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P < .01). PCP comprehensiveness varied more within than between practices.ConclusionsMore comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice‐site level comprehensiveness measures had strong construct and predictive validity; PCP‐level measures were more precise.     

Differences in patient perceptions of integrated care among black,hispanic, and white Medicare beneficiaries

ObjectiveThis study sought to identify potential disparities among racial/ethnic groups in patient perceptions of integrated care (PPIC) and to explore how methodological differences may influence measured disparities.Data SourceData from Medicare beneficiaries who completed the 2015 Medicare Current Beneficiary Survey (MCBS) and were enrolled in Part A benefits for an entire year.Study DesignWe used 4‐point measures of eight dimensions of PPIC and assessed differences in dimensions among racial/ethnic groups. To estimate differences, we applied a “rank and replace” method using multiple regression models in three steps, balancing differences in health status among racial groups and adjusting for differences in socioeconomic status. We reran all analyses with additional SES controls and using standard multiple variable regression.Data Collection/Extraction MethodsNot applicable.Principal FindingsWe found several significant differences in perceived integrated care between Black versus White (three of eight measures) and Hispanic versus White (one of eight) Medicare beneficiaries. On average, Black beneficiaries perceived more integrated support for self‐care than did White beneficiaries (mean difference = 0.14, SE = 0.06, P =.02). Black beneficiaries perceived more integrated specialists’ knowledge of past medical history than did White beneficiaries (mean difference = 0.12, SE = 0.06, P =.01). Black and Hispanic beneficiaries also each reported, on average, 0.18 more integrated medication and home health management than did White beneficiaries (P <.01 and P <.01). These findings were robust to sensitivity analyses and model specifications.ConclusionsThere exist some aspects of care for which Black and Hispanic beneficiaries may perceive greater integrated care than non‐Hispanic White beneficiaries. Further studies should test theories explaining why racial/ethnic groups perceive differences in integrated care.     

Development of claims‐based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care

ObjectiveTo develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays.Data SourcesMedicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee‐for‐service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices.Study DesignGiven the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims‐based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30‐day unplanned readmissions, using CPC+ data.Principal FindingsRepeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%‐40% lower for the new measures than for the standard 30‐day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions.ConclusionsThis study introduces two new claims‐based measures to assess quality of care during a patient''s vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30‐day readmissions measure, and yielding greater statistical power.     

The impact of urgent care centers on nonemergent emergency department visits

ObjectiveTo estimate the impact of urgent care centers on emergency department (ED) use.Data SourcesSecondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.Study DesignWe used a difference‐in‐differences design to examine ZIP code‐level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.Data Collection/Extraction MethodsUrgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.Principal FindingsWe found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.ConclusionsDuring the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.     

Does Medicaid coverage of Medicare cost sharing affect physician care for dual‐eligible Medicare beneficiaries?

ObjectiveTo assess changes in physicians’ provision of care to duals (low‐income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare''s cost sharing for office visits with these patients. This policy—a provision of the Affordable Care Act—effectively increased payments for office visits with duals by 0%‐20%, depending on the state, in 2013 and 2014.Data SourcesFee‐for‐service claims for a 5% random sample of Medicare beneficiaries in 2010‐2016.Study DesignWe conducted a difference‐in‐differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)—the largest subpopulation of duals for whom payment rates were affected by this policy—to changes among other low‐income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple‐differences analysis that compared changes between QMBs and other low‐income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases.Data CollectionThe study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low‐income Medicare beneficiaries (1 914 073 beneficiary‐years from 2010 to 2016).Principal FindingsNationally, we did not find a differential increase in office visits among QMBs versus other low‐income beneficiaries that coincided with this payment change. In the triple‐differences analysis, we did not observe a greater increase in visits among QMBs vs other low‐income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple‐differences estimate: −0.12 annual visits, 95% CI: −0.28, 0.04; P = 0.15).ConclusionsPhysicians’ provision of care to low‐income Medicare beneficiaries may not be responsive to short‐run payment changes.     

Opt‐in or opt‐out health‐care communication? A cross‐sectional study

BackgroundPatients need medication and medical condition‐related information to better self‐manage their health. Health‐care professionals (HCPs) should be able to actively provide information outside of one‐on‐one consultations; however, patient consent may be required.ObjectiveTo investigate the Australian public''s preferences, and factors that may influence their preferences, towards an opt‐in versus an opt‐out approach to health communication.DesignA cross‐sectional study using a structured questionnaire administered via Computer‐Assisted Telephone Interviewing.Setting and participantsParticipants across Australia who were adults, English‐speaking and had a long‐term medical condition.Main outcome measuresPreferences for opt‐in vs opt‐out approach to receiving follow‐up tailored information.ResultsA total of 8683 calls were made to achieve the required sample size of 589 completed surveys. Many (346/589; 58.7%) indicated that they were interested in receiving tailored, ongoing follow‐up information from their HCP. Nearly half (n = 281; 47.7%) preferred an opt‐in service and 293/589 (49.7%) an opt‐out service for receiving follow‐up information. Reasons for preferring an opt‐in service were being in control of the information received (n = 254); able to make a decision that is best for them (n = 245); opt‐in service would save time for HCPs (n = 217); they may not want or need the information (n = 240). Many (n = 255) felt that an opt‐out service should be part of the normal duty of care of their HCP and believed (n = 267) that this approach would ensure that everyone has access to information.ConclusionsRespondents were interested in receiving tailored information outside of consultation times. However, preferences for an opt‐in or opt‐out approach were divided.     

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity

ObjectiveTo assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.Data sourcesFive percent random sample of Medicare claims from 2009 to 2016.Study designWe compared Medicare beneficiaries in MSSP ACOs to non‐MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference‐in‐difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference‐in‐difference‐in‐differences (DDD) design.Data collection/extraction methodsNot applicable.Principal findingsMSSP ACOs were associated with small reductions in outpatient mental health (Coeff: −0.012, P < .001) and substance use (Coeff: −0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability‐ and age‐eligible populations (Coeff: −0.028, P < .001; Coeff: −0.012, P < .001, respectively). MSSP ACO''s were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability‐ and age‐eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:‐0.004, P < .001, and Coeff:‐0.0002, P < .01 for disability‐ and age‐eligible populations, respectively) and substance use‐related stays for disability‐eligible populations (Coeff:‐0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.ConclusionsWe found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population‐based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.     

Changes in health insurance coverage,access to care,and health services utilization by sexual minority status in the United States, 2013‐2018

ObjectiveTo examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013‐2014 and 2017‐2018.Data SourcesData on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18‐64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys.Study DesignUnadjusted and regression‐adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression‐adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics.Principal FindingsUninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013‐2014 and 2017‐2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017‐2018 compared with 2013‐2014. Low‐income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults.ConclusionsSexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.     

Advance care directive prevalence among older Australians and associations with person‐level predictors and quality indicators

BackgroundAdvance care planning (ACP) conversations may result in preferences for medical care being documented.ObjectiveTo explore the uptake and quality of advance care directives (ACDs) among older Australians accessing health and aged care services, by overall ACP documentation prevalence, person‐level predictors and ACD quality indicators.Design and SettingNational multi‐centre health record audit in general practices (GP), hospitals and residential aged care facilities (RACF).ParticipantsA total of 4187 people aged ≥65 years attending their GP (n = 676), admitted to hospital (n = 1122) or residing in a RACF (n = 2389).Main Outcome MeasuresACP documentation prevalence by setting and type including person‐completed ACDs and non‐ACD documents (completed by a health professional or someone else); person‐level predictors and quality indicators of ACDs.ResultsOverall ACP documentation prevalence was 46.5% (29.2% weighted). ACD prevalence was 25.3% (14.2% weighted). Unweighted ACD prevalence was higher in RACFs (37.7%) than in hospitals (11.1%) and GPs (5.5%). 35.8% of ACP documentation was completed by a health professional (9.7% weighted), and 18.1% was completed by someone else (10.6% weighted). Having an ACD was positively associated with being female, older, having two or more medical conditions, receiving palliative care, being divorced/separated and being in a RACF. Only 73% of ACDs included full name, signature, document date and witnessing.Conclusions and ContributionLow ACP documentation prevalence and a lack of accessible, person‐completed and quality ACDs represent an important ACP implementation issue. Low prevalence is complicated by poor document quality and a higher prevalence of documents being completed by someone other than the person.     

Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach

BackgroundPeople who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not‐for‐profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population.ObjectivesTo evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service.MethodsThe evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi‐structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted.ResultsBy 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health‐care team attitudes as key factors influencing service utilization and continuity of care.ConclusionsThis study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels.     

The one‐year impact of accountable care networks among Washington State employees

ObjectiveTo estimate the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families.Data Sources/Study SettingAdministrative data (January 2013‐December 2016) on Washington State employees.Study DesignWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64).Data Collection/Extraction MethodsWe used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.Principal FindingsWe estimate a 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19‐26 were also responsive with inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.ConclusionsWashington''s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.     

Physician trajectories of abandoning long‐course breast radiotherapy and their cost impact

ObjectiveTo examine variation in trajectories of abandoning conventionally fractionated whole‐breast irradiation (CF‐WBI) for adjuvant breast radiotherapy among physician peer groups and the associated cost implications.Data SourcesMedicare claims data were obtained from the Chronic Conditions Data Warehouse for fee‐for‐service beneficiaries with breast cancer in 2011‐2014.Study DesignWe used social network methods to identify peer groups of physicians that shared patients. For each physician peer group in each time period (T1 = 2011‐2012 and T2 = 2013‐2014), we calculated a risk‐adjusted rate of CF‐WBI use among eligible women, after adjusting for patient clinical characteristics. We applied a latent class growth analysis to these risk‐adjusted rates to identify distinct trajectories of CF‐WBI use among physician peer groups. We further estimated potential savings to the Medicare program by accelerating abandonment of CF‐WBI in T2 using a simulation model.Data Collection/Extraction MethodsUse of conventionally fractionated whole‐breast irradiation was determined from Medicare claims among women ≥ 66 years of age who underwent adjuvant radiotherapy after breast conserving surgery.Principal FindingsAmong 215 physician peer groups caring for 16 988 patients, there were four distinct trajectories of abandoning CF‐WBI: (a) persistent high use (mean risk‐adjusted utilization rate: T1 = 94.3%, T2 = 90.6%); (b) decreased high use (T1 = 81.3%, T2 = 65.3%); (c) decreased medium use (T1 = 60.1%, T2 = 44.0%); and (d) decreased low use (T1 = 31.6%, T2 = 23.6%). Peer groups with a smaller proportion of patients treated at free‐standing radiation facilities and a larger proportion of physicians that were surgeons tended to follow trajectories with lower use of CF‐WBI. If all physician peer groups had practice patterns in T2 similar to those in the “decreased low use” trajectory, the Medicare program could save $83.3 million (95% confidence interval: $58.5 million‐$112.2 million).ConclusionsPhysician peer groups had distinct trajectories of abandoning CF‐WBI. Physician composition and setting of radiotherapy were associated with the different trajectories. Distinct practice patterns across the trajectories had important cost implications.     

Pathways to reduced emergency department and urgent care center use: Lessons from the comprehensive primary care initiative

ObjectiveTo determine the association between a large‐scale, multi‐payer primary care redesign—the Comprehensive Primary Care (CPC) Initiative—on outpatient emergency department (ED) and urgent care center (UCC) use and to identify the types of visits that drive the overall trends observed.Data SourcesMedicare claims data capturing characteristics and outcomes of 565 674 Medicare fee‐for‐service (FFS) beneficiaries attributed to 497 CPC practices and 1 165 284 beneficiaries attributed to 908 comparison practices.Study DesignWe used an adjusted difference‐in‐differences framework to test the association between CPC and beneficiaries’ ED and UCC use from October 2012 through December 2016. Regression models controlled for baseline practice and patient characteristics and practice‐level clustering of standard errors. Our key outcomes were all‐cause and primary care substitutable (PC substitutable) outpatient ED and UCC visits, and potentially primary care preventable (PPC preventable) ED visits, categorized by the New York University Emergency Department Algorithm. We used a propensity score‐matched comparison group of practices that were similar to CPC practices before CPC on multiple dimensions. Both groups of practices had similar growth in ED and UCC visits in the two‐year period before CPC.Principal FindingsComprehensive Primary Care practices had 2% (P = .06) lower growth in all‐cause ED visits than comparison practices. They had 3% (P = .02) lower growth in PC substitutable ED visits, driven by lower growth in weekday PC substitutable visits (4%, P = .002). There was 3% (P = .04) lower growth in PPC preventable ED visits with no weekday/nonweekday differential. As expected, our falsification test showed no difference in ED visits for injuries. UCC visits had 9% lower growth for both all‐cause (P = .08) and PC substitutable visits (P = .07).ConclusionsOur results suggest that greater access to the practice and more effective primary care both contributed to the lower growth in ED and UCC visits during the initiative.     

People’s preferences for self‐management support

ObjectiveTo identify and assess the preferences of people with long‐term health conditions toward generalizable characteristics of self‐management support interventions, with the objective to inform the design of more person‐centered support services.Data SourcesPrimary qualitative and quantitative data collected on a representative sample of individuals with at least one of the fifteen most prevalent long‐term conditions in the UK.Study DesignTargeted literature review followed by a series of one‐to‐one qualitative semistructured interviews and a large‐scale discrete choice experiment.Data CollectionDigital recording of one‐to‐one qualitative interviews, one‐to‐one cognitive interviews, and a series of online quantitative surveys, including two best‐worst scaling and one discrete choice experiment, with individuals with long‐term conditions.Principal FindingsOn average, patients preferred a self‐management support intervention that (a) discusses the options available to the patient and make her choose, (b) is individual‐based, (c) face to face (d) with doctor or nurse, (e) at the GP practice, (f) sessions shorter than 1 hour, and (g) occurring annually for two‐third of the sample and monthly for the rest. We found heterogeneity in preferences via three latent classes, with class sizes of 41% (C1), 30% (C2), and 29% (C3). The individuals’ gender [P < 0.05(C1), P < 0.01(C3)], age [P < 0.05(C1), P < 0.05(C2)], type of long‐term condition [P < 0.05(C1), P < 0.01(C3)], and presence of comorbidity [P < 0.01(C1), P < 0.01(C3), P < 0.01(C3)] were able to characterize differences between these latent classes and help understand the heterogeneity of preferences toward the above mentioned features of self‐management support interventions. These findings were then used to profile individuals into different preference groups, for each of whom the most desirable form of self‐management support, one that was more likely to be adopted by the recipient, could be designed.ConclusionsWe identified several factors that could be used to inform a more nuanced self‐management support service design and provision that take into account the recipient''s characteristics and preferences.     

Impact of the 1115 behavioral health Medicaid waiver on adult Medicaid beneficiaries in New York State

ObjectiveTo evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State.Data Sources2013‐2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system.Study DesignWe used a difference‐in‐difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre‐ (2013‐2015) versus post‐ (2016‐2018) intervention periods, and rest of the state (ROS) pre‐ (2014‐2016) versus post‐ (2017‐2019) intervention periods.Data Collection/Extraction MethodsNot applicable.Principal FindingsHARPs were associated with a relative decrease in all‐cause (RR = 0.78, 95% CI 0.68‐0.90), behavioral health‐related (RR = 0.76, 95% CI 0.60‐0.96), and nonbehavioral‐related (RR = 0.87, 95% CI 0.78‐0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all‐cause (RR = 0.87, 95% CI 0.80‐0.94) and behavioral health‐related (RR = 0.80, 95% CI 0.70‐0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13‐1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01‐1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32‐1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11‐1.25) clinic visits.ConclusionsCompared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre‐ to postperiod.     

Costs of using evidence-based implementation strategies for behavioral health integration in a large primary care system

ObjectiveTo describe the cost of using evidence‐based implementation strategies for sustained behavioral health integration (BHI) involving population‐based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015‐2018).Data Sources/Study SettingProject records, surveys, Bureau of Labor Statistics compensation data.Study DesignLabor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback.Data Collection/Extraction MethodsPersonnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members.Principal FindingImplementation involved 286 persons, 18 131 person‐hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person‐hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites.ConclusionsWhen spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population‐based BHI.     

Do dual eligible beneficiaries experience better health care in special needs plans?

ObjectiveDual Eligible Special Needs Plans (D‐SNPs) were intended to provide better care for beneficiaries eligible for both Medicare and Medicaid through better coordination of these two programs.Data Sources671 913 dual eligible (DE) respondents to the 2009‐2019 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.Study DesignWe compared the 2015‐2019 experiences of DE beneficiaries in D‐SNPs relative to fee‐for‐service Medicare (FFS) and non‐SNP Medicare Advantage (MA) using propensity‐score weighted linear regression. Comparisons were made to 2009‐2014. 12 patient experience measures were considered.Data Collection MethodsAnnual mail survey with telephone follow‐up of non‐respondents.Principal FindingsMore than 65% of DE beneficiaries enrolled in FFS. Of 12 measures, D‐SNP performance was higher than non‐SNP MA on two (P < .05), lower than non‐SNP MA on two (P < .05), and higher than FFS on four (P < .01). DE beneficiaries did not report better coordination of care in D‐SNPs. D‐SNP performance was often worse than other coverage types in prior periods.ConclusionsRelative to FFS Medicare, DE beneficiaries report higher immunization rates in D‐SNPs, but slight or no better performance on other dimensions of patient experience. New requirements in 2021 may help D‐SNPs attain their goal of better care coordination.     

Did Medicaid slow declines in access to health care during the great recession?

ObjectiveWe examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.Data Source2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).Study DesignFlexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.Data Collection/Extraction MethodsNonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state''s 2007 Medicaid guidelines using data from the 2007 Current Population Survey''s Annual Social and Economic Supplement.Principal FindingsA percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.ConclusionsIncreased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.     

Awareness of diagnosis,treatment and risk of late effects in Chinese survivors of childhood cancer in Hong Kong

BackgroundFor survivors of childhood cancer, awareness of personal health risks is a critical component of long‐term health management.ObjectiveTo evaluate the awareness of the diagnosis, treatment and risk of late effects among survivors of childhood cancer in Hong Kong.MethodsBetween June 2019 and March 2020, this cross‐sectional study recruited 155 adult survivors (mean age = 26.9, standard deviation [SD] = 6.4 years) and 45 parents of paediatric survivors (mean age = 11.1, SD = 3.6 years) from a long‐term follow‐up clinic. At >10 years post‐treatment (mean = 13.4, SD = 7.6 years), they completed a structured questionnaire to report their cancer‐specific knowledge. Multiple linear regression analysis was conducted to identify clinical, socioeconomic and behavioural factors associated with poor awareness.ResultsThe majority of participants accurately recalled their diagnoses (73.5%) and major treatment modalities (chemotherapy 92.4%, radiation 82.9% and surgery 88.2%). However, less than half (45%) of the participants recognized more than 25% of the total late effects for which they were at risk. The highest levels of awareness were reported for endocrine problems (49%), neurocognitive impairment (44%) and secondary cancers (43%), and the lowest for peripheral neuropathy (21%) and vision problems (23%). Compared with survivors of haematological malignancies, those of central nervous system (CNS) tumours (standardized estimate [B] = −9.33, 95% confidence interval [95% CI]: −13.41 to −5.26) and non‐CNS solid tumours (B = −8.47, 95% CI: −12.39 to −4.94) had less knowledge about their diagnosis. Retaining medical records (P < .0001) and better medical information‐seeking habits (P = .048) were associated with better awareness.ConclusionsSurvivors of childhood cancer in Hong Kong have deficient awareness of their personal health risks. They may benefit from the provision of a survivorship care plan and personalized education regarding treatment‐related late effects.Patient ContributionPatients contributed in designing the study tools. Results were presented at a non‐governmental organization.     

Knowledge sharing to support long‐term condition self‐management—Patient and health‐care professional perspectives

BackgroundIncreased self‐management is a suggested solution to the burden on health‐care services of long‐term conditions (LTCs). This requires effective sharing of knowledge between health‐care professionals and patients, and is an underexplored area.ObjectiveTo understand how patients and health‐care professionals (HCPs) share and utilize knowledge in the social context of health‐care interactions within long‐term condition management.MethodsThematic analysis of 93 hours of observations of health‐care interactions and 33 semi‐structured interviews involving patients, carers and HCPs.Results3 themes were identified: normative social roles, differing professional roles and the value of knowledge. Knowledge sharing was a complex process heavily influenced by social and cultural norms within the health‐care context. Not all knowledge was easily shared within routine health‐care interactions.DiscussionThe social context in which health‐care is practised influences what knowledge is shared and how this is achieved. It favours sharing of clinical knowledge from HCPs to patients and disadvantages patients in their ability to share their unique knowledge based on lived experience of illness. The opportunities for patients to be supported in their knowledge, skills and confidence within routine health‐care interactions are limited.ConclusionBoth patients and HCPs need support to recognize the characteristics of the social context of health care and their understandings of their roles within this in order for them to move beyond accepted behaviours to develop more effective partnership working.Patient or Public ContributionPatients were involved in initial design of the study, particularly ethics of ethnographic observation.