Association between Timing of Clinical Evaluation by a Physician or Advanced Practitioner and Risk of Rehospitalization in Older Adults Admitted to a Skilled Nursing Facility Following Hospitalization: A Cohort Study.

OBJECTIVES: How transitional care services are provided to patients receiving post-acute care in skilled nursing facilities (SNFs) is not well understood. We aimed to determine the association of timing of physician or advanced practice provider (APP) visit after SNF admission with rehospitalization risk in a national cohort of older adults. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 2,482,616 Medicare fee-for-service beneficiaries aged ≥66 years who entered an SNF for post-acute care following hospitalization. METHODS: We measured the relative risk of being rehospitalized within 14 days of SNF admission as a function of time to the first PAP visit, using time to follow-up as a time-dependent covariate, adjusted for patient demographics and clinical characteristics. We also evaluated whether findings extended across groups with different SNF prognosis on admission. RESULTS: Patients seen sooner after admission to an SNF (0-1 days) were less likely to be rehospitalized compared to patients seen later (≥2 days). The relative difference was similar across different risk groups. CONCLUSIONS AND IMPLICATIONS: Timely evaluation by a physician or APP after SNF admission may protect against rehospitalization. Investment in the workforce such as training programs, practice innovations, and equitable reimbursement for SNF visits after hospital discharge may mitigate labor shortages that were exacerbated by the COVID pandemic.

Could high continuity of care (COC) have a negative impact on subjective health of hypertensive patients? A Japanese perspective.

BACKGROUND: Cardiovascular diseases, such as stroke and ischemic heart disease attributable to hypertension, are major causes of premature death in Japan and worldwide. Nevertheless, a low rate of blood pressure control among hypertensive patients has been observed in most countries. No previous studies have explored the effectiveness of physician visits among hypertensive patients in Japan. METHODS: To quantify the effects of persistence in physician visits among hypertensive patients, we evaluated the causal effect of physician visits on the health of hypertensive patients. We used 16 waves of nationally representative longitudinal data drawn from the Longitudinal Survey of Middle-aged and Elderly Persons in Japan (2005-2020). To examine the causal effect of physician visits on patients' health outcomes, we used inverse probability treatment weights and doubly robust estimation and obtained the estimates of the average treatment effects on the treated (ATETs). RESULTS: Covariates were well balanced among patients who had physician visits during the past two consecutive years (N = 67,210; 64.9% among hypertensive patients). The estimated ATETs suggest that three consecutive years of physician visits had a negative impact on poor subjective health. Furthermore, patients without habitual exercise tended to not continue physician visits and perceived poor subjective health. CONCLUSIONS: Although the impact of frequent physician visits on blood pressure stability remains uncertain, regular appointments every 30 days can be effective for individuals with hypertension, particularly if they receive continuous instruction from their family physician. Because it is important for physicians to strengthen hypertensive patients' blood pressure control, promoting consecutive physician visits to hypertensive patients with diabetes, lower educational attainment, or smoking habits is needed.

Determinants of Out-of-Network Utilization of Care Among Insured Clients Under the National Health Insurance Fund of Sudan.

Purpose: Knowledge of insured clients' utilization behavior is essential for developing evidence-based interventions for reform activities. This study explored the magnitude and determinants of voluntary out-of-network physician visit utilization among an insured population under the National Health Insurance Fund (NHIF) of Sudan. Methods: This study was a cross-sectional survey conducted at the primary healthcare centers of NHIF in Al Jazirah state in Sudan. A structured interview questionnaire was used to collect data related to socio-economic and health insurance characteristics of NHIF clients and to assess their utilization behavior. Data were collected from September to October 2021. Results: Of 768 NHIF clients who were interviewed (mean age 46 years, 55.1% females), 63.2% reported using out-of-network physician visits during the last six months prior to the interview. The median out-of-pocket payment for the last out-of-network physician visit was 5000 Sudanese pounds. The regression analysis revealed that clients' gender, marital status, self-reported health, overall rating of the quality of care, rating of the general practitioner care, and ease of referral to a specialist were the significant determinants for seeking out-of-network physician care. Conclusion: A high magnitude of out-of-network physician visit utilization was found among the insured NHIF clients of Al Jazirah state in Sudan. Policymakers should address issues identified in the current study to reduce patients' leakage to out-of-network services.

Non-utilisation of health care services during the COVID-19 pandemic: Results of the CoMoLo study.

Based on data from the CORONA-MONITORING lokal (CoMoLo) study conducted in four municipalities particularly affected by the COVID-19 pandemic, this article investigates the non-utilisation of health care services in the population aged 18 years and older (n=9,002) in relation to the period after the introduction of the containment measures in March 2020. The results show that about one third of the respondents (35.5%) gave up at least one of the surveyed health care services. The most frequent cancellations were dental (15.2%) and specialist check-ups (11.8%), followed by postponement of physiotherapy, ergotherapy or speech therapy (6.1%), cancellation of general practitioner (GP) check-ups (5.8%), postponement of psychotherapy (2.0%), postponement of planned hospital treatment (1.8%) and not going to an emergency room (0.7%). Almost 10% of the respondents reported not visiting a physician despite health complaints. Compared to respondents without such a waiver, these respondents were more often female and younger than 35 years, less often rated their health as very good or good, more often had a diagnosis of depression and more often used telemedical contacts as an alternative to visiting the practice during the pandemic. Further analyses of trends in utilisation behaviour and changes in health status over the course of the COVID-19 pandemic are important.

Health care utilization among beneficiaries with diabetes from federally qualified health centers: Analysis from a Medicaid managed care organization.

We examined health care utilization among federally qualified health center (FQHCs) users from a Medicaid managed care organization based on 2016 administrative claims data (n = 8,402). FQHC users had fewer primary care visits (Adjusted Incidence Rate Ratios (aIRR): 0.82; 95% CI: 0.76-0.88) compared with non-FQHC users. Statistically significant differences were not observed in emergency department visits (aIRR: 1.19; 95% CI: 0.98-1.46) and hospitalizations (aIRR: 1.03; 95% CI: 0.80-1.34). FQHCs provide comprehensive primary care to Medicaid managed care beneficiaries with diabetes in fewer PCP visits. Results provide evidence to health policy experts and MCOs to increase provider network contracting with FQHCs.

Effects of physician visit frequency for Parkinson's disease treatment on mortality, hospitalization, and costs: a retrospective cohort study.

BACKGROUND: The number of patients with Parkinson's disease among older adults is rapidly increasing. Such patients mostly take medication and require regular physician visits. However, the effect of physician visit frequency for the treatment for Parkinson's disease has not been evaluated. This study aimed to evaluate the impact of physician visit frequency for Parkinson's disease treatment on mortality, healthcare days, and healthcare and long-term care costs among older adults. METHODS: This study employed a retrospective cohort design utilizing claims data from the Fukuoka Prefecture Wide-Area Association of Latter-Stage Elderly Healthcare Insurance and Long-Term Care Insurance. Patients aged ≥75 years who were newly diagnosed with Parkinson's disease in 2014 were included in this study, following the onset of Parkinson's disease to March 31, 2019. We calculated the restricted mean survival time to evaluate mortality, focusing on the frequency of physician visits for Parkinson's disease treatment. Inpatient days, outpatient days, and healthcare and long-term care costs per month were calculated using a generalized linear model. RESULTS: There were 2224 participants, with 46.5% mortality among those with a higher frequency of physician visits and 56.4% among those with a lower frequency of physician visits. A higher frequency of physician visits was associated with a significant increase in survival time (1.57 months at 24 months and 5.00 months at 60 months) after the onset of Parkinson's disease and a decrease in inpatient days and healthcare costs compared to a lower frequency of physician visits. CONCLUSIONS: A higher frequency of physician visits was significantly associated with longer survival time, fewer inpatient days, and lower healthcare costs. Caregivers should support patients with Parkinson's disease to visit physicians regularly for their treatment.

A Claims-Based Cohort Study on the Treatment Patterns of Japanese Patients with Type 2 Diabetes Mellitus and the Association of Early First Physician Visit with Time to Prescription of Oral Hypoglycemic Agents.

INTRODUCTION: This study aimed to investigate the relationships between timing of the first physician visit after detection of an abnormal glycated hemoglobin (HbA1c) value at routine annual check and the time to antidiabetic treatment prescription; and understand treatment patterns in patients newly diagnosed with type 2 diabetes mellitus (T2DM). METHODS: This retrospective, longitudinal, observational cohort study examined data from JMDC Inc., an administrative claims database. Patients with HbA1c value of at least 6.5% at routine annual check, aged 20 years or older, and prescribed at least one antidiabetic drug were included. This cohort was classified into early physician visit and delayed physician visit groups based on the timing of the first physician visit relative to the median. Patients were monitored from the date of first HbA1c checkup of at least 6.5% to the date of first physician visit with an HbA1c test, and from the date of the first physician visit to the date of prescription of first-line and second-line T2DM treatments. The time to first prescription of antidiabetic treatment for the two groups was then compared. RESULTS: Of 4798 eligible patients, 54.8% were prescribed first-line T2DM therapy less than 2 months from the first physician visit for T2DM diagnosis. A lower percentage of the early group compared with the delayed group required T2DM pharmacological therapy in less than 2 months (46.1% vs. 63.4%). The early group had a longer median time to prescription of first-line therapy [92 days vs. 15 days, p < 0.0001; hazard ratio (HR) 1.31, 95% confidence interval (CI) 1.24, 1.39] and second-line therapy (1599 days vs. 1315 days, p < 0.0001; HR 1.22, 95% CI 1.11, 1.34) compared with the delayed group. CONCLUSION: In Japanese patients with T2DM, early physician visit after abnormal HbA1c detection at routine annual check is associated with a longer period before T2DM medication requirement, and may improve disease course.

The Association Between Health Information Seeking on the Internet and Physician Visits (The Seventh Tromsø Study - Part 4): Population-Based Questionnaire Study.

BACKGROUND: The internet is being widely used for seeking health information. However, there is no consensus on the association between health information seeking on the internet and the use of health care services. OBJECTIVE: We examined the association between health information seeking via the internet and physician visits. In addition, we investigated the association between online health information seeking and the decisions to visit and not to visit a physician. METHODS: We used the cross-sectional electronic health (eHealth) data of 18,197 participants from the seventh survey of the Tromsø Study (Tromsø 7). The participants were aged ≥40 years and living in Tromsø, Norway. We used logistic regression models to examine the association between online health information seeking and physician visits, the decision to visit a physician, and the decision not to visit a physician, with adjustment for the demographic status, socioeconomic status, and health status of the participants. RESULTS: The use of Web search engines was associated with a physician visit. However, the association was moderated by age, and the OR decreased as age increased. The ORs for the use of Web search engines were 1.99 (95% CI 1.94-2.02) and 1.07 (95% CI 1.03-1.12) at ages 40 and 80 years, respectively. The decision to visit a physician was associated with the use of Web search engines (OR 2.95, 95% CI 2.03-4.46), video search engines (OR 1.43, 95% CI 1.21-1.70), and health apps (OR 1.26, 95% CI 1.13-1.42). The association between social media use and the decision to visit a physician was moderated by gender. Women who used social media had 1.42 (95% CI 1.31-1.55) times higher odds of deciding to visit a physician, whereas the decision to visit a physician was not different between men who used social media and those who did not use social media. Conversely, the decision not to visit a physician was associated with the use of Web search engines (OR 2.78, 95% CI 1.92-4.18), video search engines (OR 1.27, 95% CI 1.07-1.51), social media (OR 1.28, 95% CI 1.10-1.49), and health apps (OR 1.20, 95% CI 1.07-1.35). CONCLUSIONS: Health information found on the internet was positively associated with both the decision to visit a physician and the decision not to visit a physician. However, the association of health information seeking with the decision to visit a physician was slightly stronger than the association with the decision not to visit a physician. This could imply that the use of eHealth services is associated with a resultant increase in physician visits. In summary, our findings suggest that the internet serves as a supplement to health care services rather than as a replacement.

Reassessing the Ecology of Medical Care in Japan.

Studies on ecology of medical care can provide valuable information on how people seek healthcare in a specific geographic area. The objective of this study was to update a 2003 report on the ecology of medical care in Japan, identifying relevant changes in healthcare patterns. We collected information based on a prospective health diary recorded for a month in 2013 (n = 4548; 3787 adults and 797 children) using a population-weighted random sample from a nationally representative panel. We compared our overall and stratified findings with a similar study conducted in 2003. During a one-month period, per 1000 adults and children living in Japan, we estimated that 794 report at least one symptom, 447 use an over-the-counter (OTC) drug, 265 visit a physician's office, 117 seek help from a professional provider of complementary or alternative medicine (CAM), 70 visit a hospital outpatient clinic (60 community-based and 10 university-based), 6 are hospitalized, and 4 visit a hospital emergency department. After adjusting for demographic variables, we found that healthcare seeking behaviors were influenced by age, gender and area of living. Compared with the 2003 study, participants in this study had fewer symptoms, fewer physician and emergency room visits, and less OTC use, but reported higher frequency of CAM use (p < .01 for all). Compared with 2003, reported symptoms, physician visits and OTC use has decreased, while CAM use has increased. Our findings may be useful to policymakers in Japan in a context where healthcare expenditure and a rapidly aging population are two challenging issues.

The ecology of medical care on an isolated island in Okinawa, Japan: a retrospective open cohort study.

BACKGROUND: We aimed to describe the ecology of medical care on an isolated island with limited access to secondary care, and to evaluate the gatekeeping function of the island's primary care clinic through comparison with a previous nationwide survey. METHODS: We conducted this retrospective, open cohort study on Iheya, an isolated island in Okinawa Prefecture that has one primary care clinic. We considered Iheya as unique location in which to examine the role of primary care in Japan. Participants were patients who visited the island's clinic between February 1, 2013 and January 31, 2014. We calculated the number of visits to the clinic and referrals to off-island medical facilities using electronic medical records. We also compared data for Iheya with a nationwide survey conducted in 2003. RESULTS: Iheya had 1314 inhabitants in 2013. Of the 5682 visits to the clinic in the 1-year study period, 290 people were referred to off-island medical institutions. There were 64 referrals to emergency departments; of these, 57 people were admitted to hospital. The rate of visits to the clinic per month per 1000 inhabitants was 360.4 visits (95% confidence interval: 351.0-369.7). Of these, 18.4 (16.3-20.5) were referred off-island, with 4.1 (3.1-5.1) referrals to emergency departments and 3.6 (2.6-4.6) hospitalizations. Despite the high incidence of visits to the primary care clinic, the rates of hospital-based outpatient clinic visits, emergency department visits, and hospitalizations were lower than rates reported in a previous Japanese study. CONCLUSIONS: This suggests that several dimensions of primary care, its gatekeeping function in particular, are likely to play important roles in this geographical setting.

Specialist visits and initiation of cancer-directed treatment among a large cohort of men diagnosed with prostate cancer.

BACKGROUND: The urologist generally manages the treatment of men immediately following the diagnosis of prostate cancer (PCa). The role of other physician specialists in this setting is less clear. We investigated whether involvement of other physician specialty types immediately following diagnosis affects initiation of cancer-directed treatment. METHODS: This is a retrospective cohort study using linked cancer registry and claims data from 1999 to 2009, excluding stage I/II PCa. A physician visit index (PVI) served as the exposure variable and captured the "dispersion of care" across specialties, that is, the extent to which patient care involved different types of physician specialties such as the primary care physician, urologist, or oncologist. The PVI score was calculated using visits occurring within 30 days postdiagnosis. This score was dichotomized to measure "low PVI" (reflects seeing multiple specialist types). Competing risk Cox proportional hazard regression models provided adjusted hazard ratios (HR) for treatment receipt associated with a low PVI. RESULTS: The sample included 33,380 patients: 4,910 metastatic and 28,470 nonmetastatic groups. The top 3 visit categories within 30 days postdiagnosis were "urologist only" (59%) and "urologist plus primary care physician" (21%) and no visit (6%). The median time to receipt of cancer-directed treatment was 51 days. Overall, 29% of individuals in the metastatic group and 38% in the nonmetastatic group were categorized as low PVI. A low PVI was associated with a shorter time to treatment receipt in the nonmetastatic (HR = 1.12 [95% CI: 1.09-1.15]) and metastatic (HR = 1.21 [95% CI: 1.14-1.29]) groups. CONCLUSIONS: Multispecialist involvement in the weeks following diagnosis is associated with a shorter time to treatment initiation, highlighting a role for exposure to different specialty types in the weeks following an initial diagnosis of PCa. This study provides important baseline data for future studies examining coordination of care across cancer and noncancer specialists.

From Visiting a Physician to Expecting Antibiotics: Korean Perspectives and Practices toward Respiratory Tract Infections.

Antibiotic resistance is steadily rising worldwide. Respiratory tract infections (RTIs) are common indications, mostly imprudent, for antibiotic prescriptions in outpatient setting. In Korea, antibiotic prescription rate for RTIs is still high. As physician visit and antibiotic prescribing are influenced by patient's perceptions and beliefs, we aimed to explore the general public's perspectives and practices toward RTIs and to develop the 'RTI clinical iceberg.' A cross-sectional survey was conducted in Wonju Severance Christian Hospital (WSCH) among 550 adults attending outpatient departments during January 2016. Differences in distributions between groups were examined using two-tailed Pearson χ² test. Using the Andersen's behavioral model as a conceptual framework, we constructed logistic regression models to assess factors associated with physician visit. Of 547 participants with complete questionnaires, 62.9% reported having experienced an RTI in the previous six months; 59.3% visited a physician for the illness, most commonly because the symptoms were severe or prolonged, and approximately 16% of them expected an antibiotic prescription from the visit. Perceptions of symptoms severity, the need factor, most strongly influenced physician visit. Predisposing and enabling factors such as inappropriate expectations for antibiotic for a sore throat or having national health insurance also influenced physician visit. Almost all participants who reported asking for an antibiotic were prescribed one, with a 37.1% non-adherence rate. Conclusively, public education on self-care for RTI symptoms that addresses their main concerns may reduce physician visits. Improving physician-patient relationship and informing patients about the lack of antibiotic benefit for most RTIs may also reduce antibiotic prescriptions.

Hemodialysis Hospitalizations and Readmissions: The Effects of Payment Reform.

BACKGROUND: In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits. STUDY DESIGN: We used a retrospective cohort interrupted time-series study design to examine whether the 2004 nephrologist reimbursement reform led to reduced hospitalizations and rehospitalizations. We also used published data to estimate a range of annual economic costs associated with more frequent visits. SETTING & PARTICIPANTS: Medicare beneficiaries in the United States receiving hemodialysis in the 2 years prior to and following reimbursement reform. PREDICTOR: The 2 years following nephrologist reimbursement reform. OUTCOMES: Odds of hospitalization and 30-day hospital readmission for all causes and fluid overload; US dollars. RESULTS: We found no significant change in all-cause hospitalization or rehospitalization and slight reductions in fluid overload hospitalization and rehospitalization following reimbursement reform; the estimated economic cost associated with additional visits ranged from $13 to $87 million per year, depending on who (physicians or advanced practitioners) spent additional time visiting patients and how much additional effort was involved. LIMITATIONS: Due to limited information about how much additional time providers spent seeing patients after reimbursement reform, we could only examine a range of potential economic costs associated with the reform. CONCLUSIONS: A Medicare reimbursement policy designed to encourage more frequent visits during outpatient hemodialysis may have been costly. The policy was associated with fewer hospitalizations and rehospitalizations for fluid overload, but had no effect on all-cause hospitalizations or rehospitalizations.

Office-Based Tools and Primary Care Visit Communication, Length, and Preventive Service Delivery.

BACKGROUND: The use of physician office-based tools such as electronic health records (EHRs), health risk appraisal (HRA) instruments, and written patient reminder lists is encouraged to support efficient, high-quality, patient-centered care. We evaluate the association of exam room use of EHRs, HRA instruments, and self-generated written patient reminder lists with patient-physician communication behaviors, recommended preventive health service delivery, and visit length. RESEARCH METHODS: Observational study of 485 office visits with 64 primary care physicians practicing in a health system serving the Detroit metropolitan area. Study data were obtained from patient surveys, direct observation, office visit audio-recordings, and automated health system records. Outcome measures included visit length in minutes, patient use of active communication behaviors, physician use of supportive talk and partnership-building communication behaviors, and percentage of delivered guideline-recommended preventive health services for which patients are eligible and due. Simultaneous linear regression models were used to evaluate associations between tool use and outcomes. Adjusted models controlled for patient characteristics, physician characteristics, characteristics of the relationship between the patient and physician, and characteristics of the environment in which the visit took place. RESULTS: Prior to adjusting for other factors, visits in which the EHR was used on average were significantly (p < .05) longer (27.6 vs. 23.8 minutes) and contained fewer preventive services for which patients were eligible and due (56.5 percent vs. 62.7 percent) compared to those without EHR use. Patient written reminder lists were also significantly associated with longer visits (30.0 vs. 26.5 minutes), and less use of physician communication behaviors facilitating patient involvement (2.1 vs. 2.6 occurrences), but more use of active patient communication behaviors (4.4 vs. 2.6). Likewise, HRA use was significantly associated with increased preventive services delivery (62.1 percent vs. 57.0 percent). All relationships remained significant (p > .05) in adjusted models with the exception of that between HRA use and preventive service delivery. DISSEMINATION AND IMPLEMENTATION IMPLICATIONS: Office-based tools intended to facilitate the implementation of desired primary care practice redesign are associated with both positive and negative cost and quality outcomes. Findings highlight the need for monitoring both intended and unintended consequences of office-based tools commonly used in primary care practice redesign.