Trends and Quality of Care in Outpatient Visits to Generalist and Specialist Physicians Delivering Primary Care in the United States, 1997–2010

BACKGROUND

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

OBJECTIVE

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

DESIGN

Cross-sectional study and time trend analysis.

DATA

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997–2010.

MAIN MEASURES

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

KEY RESULTS

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p?=?0.04). The proportion of medical specialist visits in which the physician self-identified as the patient’s PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p?<?0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p?<?0.01), primarily for preventive care (54.0 %, p?<?0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

CONCLUSIONS

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.     

Increasing Incidence of Ehrlichiosis in the United States: A Summary of National Surveillance of Ehrlichia chaffeensis and Ehrlichia ewingii Infections in the United States, 2008–2012

Human ehrlichiosis is a potentially fatal disease caused by Ehrlichia chaffeensis and Ehrlichia ewingii. Cases of ehrlichiosis are reported to Centers for Disease Control and Prevention through two national surveillance systems: Nationally Notifiable Diseases Surveillance System (NNDSS) and Case Report Forms. During 2008–2012, 4,613 cases of E. chaffeensis infections were reported through NNDSS. The incidence rate (IR) was 3.2 cases per million person-years (PYs). The hospitalization rate (HR) was 57% and the case fatality rate (CFR) was 1%. Children aged < 5 years had the highest CFR of 4%. During 2008–2012, 55 cases of E. ewingii infection were reported through NNDSS. The national IR was 0.04 cases per million PY. The HR was 77%; no deaths were reported. Immunosuppressive conditions were reported by 26% of cases. The overall rate for ehrlichiosis has increased 4-fold since 2000. Although previous literature suggests E. ewingii primarily affects those who are immunocompromised, this report shows most cases occurred among immunocompetent patients. This is the first report to show children aged < 5 years with ehrlichiosis have an increased CFR, relative to older patients. Ongoing surveillance and reporting of tick-borne diseases are critical to inform public health practice and guide disease treatment and prevention efforts.     

Trends in prevalence of probable fibrotic non-alcoholic steatohepatitis in the United States, 1999–2016

Data are limited on the epidemiology of fibrotic non-alcoholic steatohepatitis (NASH). We applied the recently proposed Fibrotic NASH Index (FNI) to estimate trends in the prevalence of probable fibrotic NASH in the general United States population using data from the 1999–2016 cycles of the National Health and Nutrition Examination Survey. A total of 40 273 participants aged 20 years and older were included in the analysis. The prevalence of probable fibrotic NASH (FNI ≥0.33) in the overall population was 8.4% (95% CI 8.0–8.8), with higher values found in males and in Hispanic participants. It increased from 6.9% (95% CI 6.3–7.6) in 1999–2004 to 9.2% (95% CI 8.4–10.0) in 2011–2016. This positive trend was evident in both sexes and in participants with obesity and diabetes. Finally, it increased progressively with increasing age, body mass index and worse glucose tolerance. NASH prevalence is increasing in the general US population, synchronous with increasing rates of obesity and type 2 diabetes.     

Socioeconomic Position and Cardiovascular Disease in Adults with and Without Diabetes: United States Trends, 1997–2005

Background  Diabetes and its cardiovascular complications are more common in adults of low socioeconomic position (SEP). In the US, the past decade has seen the establishment of many programs to reduce cardiovascular risk in persons with diabetes, but their effect on socioeconomic disparities is uncertain. Objective  We sought to investigate recent time trends in socioeconomic disparities in cardiovascular disease (CVD) among persons with and without diabetes. Participants and Design   Two hundred fifty-five thousand nine hundred sixty-six individuals aged 25 years or older included in the National Health Interview Survey between 1997 and 2005. Measurements  Educational attainment was used as a marker for SEP and self-reported history of CVD as the main outcome. Educational disparities were measured using prevalence rate ratios (PRR) and the relative index of inequalities (RII). Main Results  Among adults with diabetes, CVD prevalence was persistently higher in those who did not complete high school (HS) than in college graduates (adjusted PRR [aPRR] 1.20, 95% confidence interval [95%CI] 1.05–1.38 in 1997–1999, and aPRR 1.12, 95% CI 1.00–1.25 in 2003–2005). However, the HS vs. college graduates disparity in CVD declined from 1997–1999 (aPRR 1.20, 95% CI 1.04–1.37) to 2003–2005 (aPRR 1.01, 95% CI 0.90–1.12). Among adults without diabetes educational disparities in CVD widened markedly over time. Conclusions  Concurrently with improvements in diabetes management, the widening of socioeconomic health disparities has remained limited in the diabetic population during the past decade. This provides evidence for the potential impact of improvements in disparities in health care access and process, such as experienced among persons with diabetes, in limiting socioeconomic health disparities.     

Hospitalization for Achalasia in the United States 1997–2006

Background and Aims  The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) was used to study the demographic characteristics of achalasia patients. Methods  HCUP data from 1997 to 2006 were stratified by categories pertaining to patient demographics, such as age, sex, race, income, residence in metropolitan area, and region of the United States, as well as categories pertaining to hospital characteristics, such teaching status, location, and bed size. The distributions of inpatients among different categories were compared between achalasia and all other diagnoses, using odds ratios and their 95% confidence intervals for comparison. Results  The annual hospitalization rates of achalasia revealed a clear-cut age-dependent rise between the youngest age group less than 18 years old (0.25/100,000) and the oldest age group over 85 years old (37.35/100,000). Between 1997 and 2007, the rates of hospitalization remained largely unchanged for all age groups alike. Achalasia was equally distributed among men and women and among various ethnic groups. Compared with other diagnoses, achalasia was more frequent among hospitalized patients from zip codes associated with a higher average income (1.26, 1.23–1.29), living in metropolitan areas (1.12, 1.09–1.15), and living in the northeast region of the United States (1.27, 1.25–1.30). Achalasia patients were mostly seen in large hospitals (1.22, 1.19–1.26), teaching hospitals (1.73, 1.70–1.76), and hospitals located in metropolitan areas (1.15, 1.14–1.15). Conclusions  With exception of its striking age-dependence, the epidemiology of achalasia does not reveal any clues about its yet unsolved etiology.     

Strongyloidiasis-Related Deaths in the United States, 1991–2006

The objective of this study was to 1) assess the incidence of strongyloidiasis in the United States, 2) evaluate demographic and regional associations, and 3) identify comorbid conditions as risk factors for death. A population-based case–control study was performed by using mortality data during 1991–2006. We identified 347 strongyloidiasis deaths (0.79 per 10 million deaths, 14–29 deaths per year), which decreased slightly over time. Deaths occurred primarily among older (median age = 66.0 years), white (57.6%) and Hispanic (22.2%) men (69.2%), residing in the Southeastern United States (49.3%). Associated health conditions included chronic obstructive pulmonary disease (28.7%, odds ratio [OR] = 4.0, 95% confidence interval [CI] = 3.0–5.4) and infection with human immunodeficiency virus (12.5%, OR = 4.6, 95% CI = 2.7–7.9). Strongyloidiasis deaths in the second half of the study period (1999–2006) were less likely to be associated with chronic obstructive pulmonary disease (19.4%, OR = 1.2, 95% CI = 0.7–1.9), but continued to be associated with human immunodeficiency virus infection (12.9%, OR = 2.8, 95% CI = 1.3–6.0). Early detection and treatment of at-risk patients with latent strongyloidiasis infections is needed to reduce strongyloidiasis mortality.     

Cysticercosis-Related Hospitalizations in the United States, 1998–2011

Cysticercosis has become increasingly recognized as an important infection in the United States in recent decades. Despite its potential impact, there is a lack of comprehensive information on the nationwide burden of disease. To better define the burden of cysticercosis in the United States, we analyzed in-patient records using the Nationwide Inpatient Sample for 1998–2011 to estimate cysticercosis-related hospitalizations and patient/institutional characteristics. There were an estimated 33,060 (95% confidence interval [95% CI] = 29,610.5–36,510.3) cysticercosis-related hospitalizations nationwide, representing a hospitalization rate of 8.03 per million population. The highest proportion of cases were male (54.8%), Hispanic (62.0%), aged 18–44 (58.8%), and occurred in the West (45.1%). An estimated 459 deaths occurred, representing an in-hospital case-fatality rate of 1.4%. These findings indicate the burden of cysticercosis-related hospitalizations in the United States is considerable and may be greater than currently appreciated. Cysticercosis should be a nationally reportable disease.     

Meteorological Conditions Associated with Increased Incidence of West Nile Virus Disease in the United States, 2004–2012

West Nile virus (WNV) is a leading cause of mosquito-borne disease in the United States. Annual seasonal outbreaks vary in size and location. Predicting where and when higher than normal WNV transmission will occur can help direct limited public health resources. We developed models for the contiguous United States to identify meteorological anomalies associated with above average incidence of WNV neuroinvasive disease from 2004 to 2012. We used county-level WNV data reported to ArboNET and meteorological data from the North American Land Data Assimilation System. As a result of geographic differences in WNV transmission, we divided the United States into East and West, and 10 climate regions. Above average annual temperature was associated with increased likelihood of higher than normal WNV disease incidence, nationally and in most regions. Lower than average annual total precipitation was associated with higher disease incidence in the eastern United States, but the opposite was true in most western regions. Although multiple factors influence WNV transmission, these findings show that anomalies in temperature and precipitation are associated with above average WNV disease incidence. Readily accessible meteorological data may be used to develop predictive models to forecast geographic areas with elevated WNV disease risk before the coming season.     

Rocky Mountain Spotted Fever in the United States, 2000–2007: Interpreting Contemporary Increases in Incidence

Rocky Mountain spotted fever (RMSF), a potentially fatal tick-borne infection caused by Rickettsia rickettsii, is considered a notifiable condition in the United States. During 2000 to 2007, the annual reported incidence of RMSF increased from 1.7 to 7 cases per million persons from 2000 to 2007, the highest rate ever recorded. American Indians had a significantly higher incidence than other race groups. Children 5–9 years of age appeared at highest risk for fatal outcome. Enzyme-linked immunosorbent assays became more widely available beginning in 2004 and were used to diagnose 38% of cases during 2005–2007. The proportion of cases classified as confirmed RMSF decreased from 15% in 2000 to 4% in 2007. Concomitantly, case fatality decreased from 2.2% to 0.3%. The decreasing proportion of confirmed cases and cases with fatal outcome suggests that changes in diagnostic and surveillance practices may be influencing the observed increase in reported incidence rates.     

Outpatient Management of Heart Failure in the United States, 2006–2008

Better outpatient management of heart failure might improve outcomes and reduce the number of rehospitalizations. This study describes recent outpatient heart-failure management in the United States.We analyzed data from the National Ambulatory Medical Care Survey of 2006–2008, a multistage random sampling of non-Federal physician offices and hospital outpatient departments.Annually, 1.7% of all outpatient visits were for heart failure (51% females and 77% non-Hispanic whites; mean age, 73 ± 0.5 yr). Typical comorbidities were hypertension (62%), hyperlipidemia (36%), diabetes mellitus (35%), and ischemic heart disease (29%). Body weight and blood pressure were recorded in about 80% of visits, and health education was given in about 40%. The percentage of patients taking β-blockers was 38%; the percentage taking angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) was 32%. Medication usage did not differ significantly by race or sex. In multivariate-adjusted logistic regression models, a visit to a cardiologist, hypertension, heart failure as a primary reason for the visit, and a visit duration longer than 15 minutes were positively associated with ACEI/ARB use; and a visit to a cardiologist, heart failure as a primary reason for the visit, the presence of ischemic heart disease, and visit duration longer than 15 minutes were positively associated with β-blocker use. Chronic obstructive pulmonary disease was negatively associated with β-blocker use. Approximately 1% of heart-failure visits resulted in hospitalization.In outpatient heart-failure management, gaps that might warrant attention include suboptimal health education and low usage rates of medications, specifically ACEI/ARBs and β-blockers.