The Burden of Inappropriate Emergency Department Pediatric Visits: Why Italy Needs an Urgent Reform

Objective

To better understand the issue of inappropriate pediatric Emergency Department (ED) visits in Italy, including the impact of the last National Health System reform.

Study Design

A retrospective cohort study was conducted with five health care providers in the Veneto region (Italy) in a 2-year period (2010–2011). ED visits were considered “inappropriate” by evaluating both nursing triage and resource utilization, as addressed by the Italian Ministry of Health in 2007. Factors associated with inappropriate ED visits were identified. The cost of each visit was calculated.

Principal Findings

In total, 134,358 ED visits with 455,650 performed procedures were recorded in the 2-year period; of these, 76,680 (57.1 percent) were considered inappropriate ED visits. Patients likely to make inappropriate ED visits were younger, female, visiting the ED during night or holiday, when the primary care provider (PCP) is not available.

Conclusion

The National Health System reform aims to improve efficiency, effectiveness, and costs by opening PCP offices 24 hours a day and 7 days a week. This study highlights the need for a deep reorganization of the Italian Primary Care System not only providing a larger time availability but also treating the parents'' lack of education on children''s health.     

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program

Objective

To estimate the relationship between physicians'' acceptance of new Medicaid patients and access to health care.

Data Sources

The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.

Study Design

Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children''s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.

Principal Findings

Nearly 16 percent of children with a significant health condition or development delay had a doctor''s office or clinic indicate that the child''s health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar.

Conclusions

Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients.     

Using Computer‐Extracted Data from Electronic Health Records to Measure the Quality of Adolescent Well‐Care

Objective

To determine whether quality measures based on computer-extracted EHR data can reproduce findings based on data manually extracted by reviewers.

Data Sources

We studied 12 measures of care indicated for adolescent well-care visits for 597 patients in three pediatric health systems.

Study Design

Observational study.

Data Collection/Extraction Methods

Manual reviewers collected quality data from the EHR. Site personnel programmed their EHR systems to extract the same data from structured fields in the EHR according to national health IT standards.

Principal Findings

Overall performance measured via computer-extracted data was 21.9 percent, compared with 53.2 percent for manual data. Agreement measures were high for immunizations. Otherwise, agreement between computer extraction and manual review was modest (Kappa = 0.36) because computer-extracted data frequently missed care events (sensitivity = 39.5 percent). Measure validity varied by health care domain and setting. A limitation of our findings is that we studied only three domains and three sites.

Conclusions

The accuracy of computer-extracted EHR quality reporting depends on the use of structured data fields, with the highest agreement found for measures and in the setting that had the greatest concentration of structured fields. We need to improve documentation of care, data extraction, and adaptation of EHR systems to practice workflow.     

Total Cost of Care Lower among Medicare Fee‐for‐Service Beneficiaries Receiving Care from Patient‐Centered Medical Homes

Objective

To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition.

Data Sources

Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare''s Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file.

Study Design

This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008–June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition.

Data Collection Methods

Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008.

Principal Findings

Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.

Conclusions

This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care.     

Projecting US Primary Care Physician Workforce Needs: 2010-2025

PURPOSE

We sought to project the number of primary care physicians required to meet US health care utilization needs through 2025 after passage of the Affordable Care Act.

METHODS

In this projection of workforce needs, we used the Medical Expenditure Panel Survey to calculate the use of office-based primary care in 2008. We used US Census Bureau projections to account for demographic changes and the American Medical Association''s Masterfile to calculate the number of primary care physicians and determine the number of visits per physician. The main outcomes were the projected number of primary care visits through 2025 and the number of primary care physicians needed to conduct those visits.

RESULTS

Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce.

CONCLUSIONS

Population growth will be the greatest driver of expected increases in primary care utilization. Aging and insurance expansion will also contribute to utilization, but to a smaller extent.Key words: health policy research, primary care issues, insurance, Affordable Care Act, workforce, physician shortage     

A Decade in Dental Care Utilization among Adults and Children (2001–2010)

Objective

To decompose the change in pediatric and adult dental care utilization over the last decade.

Data

2001 through 2010 Medical Expenditure Panel Survey.

Study Design

The Blinder-Oaxaca decomposition was used to explain the change in dental care utilization among adults and children. Changes in dental care utilization were attributed to changes in explained covariates and changes due to movements in estimated coefficients. Controlling for demographics, overall health status, and dental benefits variables, we estimated year-specific logistic regression models. Outputs from these models were used to compute the Blinder-Oaxaca decomposition.

Principal Findings

Dental care utilization decreased from 40.5 percent in 2001 to 37.0 percent in 2010 for adults and increased from 43.2 percent in 2001 to 46.3 percent in 2010 for children (p < .05). Among adults, changes in insurance status, race, and income contributed to a decline in adult dental care utilization (−0.018, p < .01). Among children, changes in controlled factors did not substantially change dental care utilization, which instead may be explained by changes in policy, oral health status, or preferences.

Conclusions

Dental care utilization for adults has declined, especially among the poor and uninsured. Without further policy intervention, disadvantaged adults face increasing barriers to dental care.     

Health Care Utilization and Receipt of Preventive Care for Patients Seen at Federally Funded Health Centers Compared to Other Sites of Primary Care

Objective

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.

Data Sources

A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004–2008).

Study Design

HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.

Principal Findings

Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.

Conclusions

Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.     

Effects of the Ten Percent Cap in Medicare Home Health Care on Treatment Intensity and Patient Discharge Status

Objective

To estimate the effect of the 10 percent cap introduced to Medicare home health care on treatment intensity and patient discharge status.

Data Sources

Medicare Denominator, Medicare Home Health Claims, and Medicare Provider of Services Files from 2008 through 2010.

Study Design

We used agency-level variation in the proportion of outlier payments prior to the implementation of the 10 percent cap to identify how home health agencies adjusted the number of home health visits and patient discharge status under the new law.

Principal Findings

Under the 10 percent cap, agencies dramatically decreased the number of service visits. Agencies also dropped relatively healthy patients and sent sicker patients to nursing homes.

Conclusions

The drastic reduction in the number of service visits and discontinuation of relatively healthy patients from home health care suggest that the 10 percent cap improved the efficiency of home health services as intended. However, the 10 percent cap increased other types of health care expenditures by pushing sicker patients to use more expensive health services.     

Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

Patients' Ratings of the Quality of their Outpatient Visit to Clinical Officers in Kenya

Background

Lack of data on the quality of care offered by Clinical Officers (COs) compromises the current efforts on health reforms in Kenya. The objective of this study was to assess patients'' satisfaction with their outpatient visit to Clinical Officers.

Methods

This was an exit survey of adult outpatients who visited Clinical Officers between September 2009 and May 2010. A total of 326 Clinical Officers were assessed by 2118 randomly selected patients across the country using a modified Visit-Specific Satisfaction Questionnaire (VSQ-9). Responses on patients'' satisfaction were summarized using the average score method. This involved calculation of the mean across all the response categories and transforming them linearly to a 0 to 100 scale. Interpretation involved comparisons to best practice (excellent).

Results

Generally, patients view the quality of their outpatient visit from two dimensions: interaction with Clinical Officers and access to care. The patients were relatively more satisfied with their interaction with Clinical Officers (rated at 67 percent) than with access to care (61 percent). The average age of the patients was 31.31 years (SD = 13.64). Most patients were female (58 percent), married (51 percent) and most had secondary level education (38 percent). Regression results showed that these sociodemographic characteristics had no significant association with patients'' satisfaction.

Conclusion

Overall patients see ample room for improvement in their visits to Clinical Officers. The need to train Clinical Officers on client handling and patient-centeredness is apparent.     

Take-Up of Public Insurance and Crowd-Out of Private Insurance under Recent CHIP Expansions to Higher Income Children

Objective

To analyze the effects of states'' expansions of Children''s Health Insurance Program (CHIP) eligibility to children in higher income families on health insurance coverage outcomes.

Data Sources

2002–2009 Current Population Survey linked to multiple secondary data sources.

Study Design

Instrumental variables estimation of linear probability models. Outcomes are whether the child had any public insurance, any private insurance, or no insurance coverage during the year.

Principal Findings

Among children in families with incomes between two and four times the federal poverty line (FPL), four enrolled in CHIP for every 100 who became eligible. Roughly half of the newly eligible children who took up public insurance were previously uninsured. The upper bound “crowd-out” rate was estimated to be 46 percent.

Conclusions

The CHIP expansions to children in higher income families were associated with limited uptake of public coverage. Our results additionally suggest that there was crowd-out of private insurance coverage.     

Health Care Utilization and Costs Associated with Adherence to Clinical Practice Guidelines for Early Magnetic Resonance Imaging among Workers with Acute Occupational Low Back Pain

Objective

To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP).

Data Sources

Washington State Disability Risk Identification Study Cohort (D-RISC), consisting of administrative claims and patient interview data from workers’ compensation claimants (2002–2004).

Study Design

In this prospective, population-based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags).

Data Collection/Extraction Methods

We identified workers (age >18) with work-related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury.

Principal Findings

Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52–54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18 percent).

Conclusions

Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.     

A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy

Objective

To compare patient profiles and health care use for physician-referred and self-referred episodes of outpatient physical therapy (PT).

Data Source

Five years (2003–2007) of private health insurance claims data, from a Midwest insurer, on beneficiaries aged 18–64.

Study Design

Retrospective analyses of health care use of physician-referred (N = 45,210) and self-referred (N = 17,497) ambulatory PT episodes of care was conducted, adjusting for age, gender, diagnosis, case mix, and year.

Data Collection/Extraction

Physical therapy episodes began with the physical therapist initial evaluation and ended on the last date of service before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of PT.

Principal Findings

The self-referred group was slightly younger, but the two groups were very similar in regard to diagnosis and case mix. Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00), after covariate adjustment, but did not differ in related health care utilization after PT.

Conclusions

Health care use during PT episodes was lower for those who self-referred, after adjusting for key variables, but did not differ after the PT episode.     

Clinical Quality Performance in U.S. Health Centers

Objective

To describe current clinical quality among the nation''s community health centers and to examine health center characteristics associated with performance excellence.

Data Sources

National data from the 2009 Uniform Data System.

Data Collection/Extraction Methods

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

Study Design

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

Principal Findings

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

Conclusions

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.     

The Patient‐Centered Medical Home and Patient Experience

Objective

To examine the relationship between practices'' reported use of patient-centered medical home (PCMH) processes and patients'' perceptions of their care experience.

Data Source

Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.

Study Design

This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients'' care experience and the use of PCMH processes in the practices where they receive care.

Data Collection

We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.

Principal Findings

We found that practices'' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.

Conclusions

In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.     

The effect of renewal policy changes on SCHIP disenrollment

Objective

To examine the impact of changing from a passive renewal process to an active renewal process in Florida''s State Children''s Health Insurance Program (SCHIP) on disenrollment.

Data Sources

Administrative records, containing enrollment and demographic data, were used to identify 414,396 enrollment spells from January 2004 through February 2006. Health care claims data were used to classify the children''s health status.

Study Design

A Cox proportional hazards model was used to analyze the impact of changing to an active renewal process on the children''s risk of disenrolling, controlling for the children''s sociodemographic characteristics. Differential effects of the policy change by the children''s health status were examined, and transfers to other public health insurance programs were taken into account.

Principal Findings

Children faced almost a 10-fold greater risk of disenrolling in their renewal month under active renewal than under passive renewal. We did not detect differential impacts of the policy change across children with different health status levels.

Conclusions

The switch to an active renewal process in Florida''s SCHIP significantly increased disenrollment rates, and the effect of this policy change does not appear to vary by health status.