Black-White Disparities in Asthma Hospitalizations and ED Visits Among Medicaid-Enrolled Children.

BACKGROUND AND OBJECTIVES: Asthma is a common, potentially serious childhood chronic condition that disproportionately afflicts Black children. Hospitalizations and emergency department (ED) visits for asthma can often be prevented. Nearly half of children with asthma are covered by Medicaid, which should facilitate access to care to manage and treat symptoms. We provide new evidence on racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children. METHODS: We used comprehensive Medicaid claims data from the Transformed Medicaid Statistical Information System. Our study population included 279 985 Medicaid-enrolled children with diagnosed asthma. We identified asthma hospitalizations and ED visits occurring in 2019. We estimated differences in the odds of asthma hospitalizations and ED visits for non-Hispanic Black versus non-Hispanic white children, adjusting for sex, age, Medicaid eligibility group, Medicaid plan type, state, and rurality. RESULTS: In 2019, among Black children with asthma, 1.2% had an asthma hospitalization and 8.0% had an asthma ED visit compared with 0.5% and 3.4% of white children with a hospitalization and ED visit, respectively. After adjusting for other characteristics, the rates for Black children were more than twice the rates for white children (hospitalization adjusted odds ratio 2.45, 95% confidence interval 2.23-2.69; ED adjusted odds ratio 2.42; 95% confidence interval 2.33-2.51). CONCLUSIONS: There are stark racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children with asthma. To diminish these disparities, it will be important to implement solutions that address poor quality care, discriminatory treatment in health care settings, and the structural factors that disproportionately expose Black children to asthma triggers and access barriers.

Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study.

OBJECTIVE: To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics. DESIGN: Cross-sectional time series study. SETTING: National data from the traditional Medicare insurance program in the USA. PARTICIPANTS: Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken. MAIN OUTCOME MEASURES: The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis. RESULTS: From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%). CONCLUSION: The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

Assessing patterns in cancer screening use by race and ethnicity during the coronavirus pandemic using electronic health record data.

BACKGROUND: Efforts to prevent the spread of the coronavirus led to dramatic reductions in nonemergency medical care services during the first several months of the COVID-19 pandemic. Delayed or missed screenings can lead to more advanced stage cancer diagnoses with potentially worse health outcomes and exacerbate preexisting racial and ethnic disparities. The objective of this analysis was to examine how the pandemic affected rates of breast and colorectal cancer screenings by race and ethnicity. METHODS: We analyzed panels of providers that placed orders in 2019-2020 for mammogram and colonoscopy cancer screenings using electronic health record (EHR) data. We used a difference-in-differences design to examine the extent to which changes in provider-level mammogram and colonoscopy orders declined over the first year of the pandemic and whether these changes differed across race and ethnicity groups. RESULTS: We found considerable declines in both types of screenings from March through May 2020, relative to the same months in 2019, for all racial and ethnic groups. Some rebound in screenings occurred in June through December 2020, particularly among White and Black patients; however, use among other groups was still lower than expected. CONCLUSIONS: This research suggests that many patients experienced missed or delayed screenings during the first few months of the pandemic, which could lead to detrimental health outcomes. Our findings also underscore the importance of having high-quality data on race and ethnicity to document and understand racial and ethnic disparities in access to care.

Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children.

OBJECTIVE: To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously. DATA SOURCES: We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation. STUDY DESIGN: We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state. DATA EXTRACTION METHODS: We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions. PRINCIPAL FINDINGS: Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations. CONCLUSIONS: Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

The effect of nurse practitioner scope of practice laws on primary care delivery.

Nurse practitioners (NPs) are an increasingly integral part of the primary care workforce. NPs' authority to practice without physician oversight is regulated by state-level scope of practice (SOP) restrictions. To the extent that SOP restrictions prevent NPs from practicing to their full abilities and capacity, they could create inefficiencies and restrict access to health care. In this paper, I study what happens at primary care practices when states relax their SOP laws. Using a novel dataset of claims and electronic health records paired with a difference-in-differences research design, I quantify the effects of relaxing SOP laws on: (1) NPs' autonomy in their day-to-day jobs; (2) total workload and patient allocation between NPs and physicians; and (3) the provision of low-value services at primary care practices. I find some evidence that NPs practice more autonomously following SOP changes, but I find no evidence that relaxing SOP laws changes the volume nor allocation of patients to NPs, nor the provision of low-value services. Given the lower reimbursement that NPs typically receive, these findings suggest that allowing NPs to practice without physician oversight could reduce health care spending, without harming patients.

The effect of a public transportation expansion on no-show appointments.

OBJECTIVE: To test whether there were fewer missed medical appointments ("no-shows") for patients and clinics affected by a significant public transportation expansion. STUDY SETTING: A new light rail line was opened in a major metropolitan area in June 2014. We obtained electronic health records data from an integrated health delivery system in the area with over three million appointments at 97 clinics between 2013 and 2016. STUDY DESIGN: We used a difference-in-differences research design to compare whether no-show appointment rates differentially changed among patients and clinics located near versus far from the new light rail line after it opened. Models included fixed effects to account for underlying differences across clinics, patient zip codes, and time. DATA EXTRACTION METHODS: We obtained data from an electronic health records system representing all appointments scheduled at 97 outpatient clinics in this system. We excluded same-day, urgent care, and canceled appointments. PRINCIPAL FINDINGS: The probability of no-show visits differentially declined by 0.5 percentage points (95% confidence interval [CI]: -0.9 to -0.1), or 4.5% relative to baseline, for patients living near the new light rail compared to those living far from it, after the light rail opened. The effects were stronger among patients covered by Medicaid (-1.6 percentage points [95% CI: -2.4 to -0.8] or 9.5% relative to baseline). CONCLUSIONS: Improvements to public transit may improve access to health care, especially for people with low incomes.

Physician Network Connections Associated With Faster De-Adoption of Dronedarone for Permanent Atrial Fibrillation.

BACKGROUND: Physicians' professional networks are an important source of new medical information and have been shown to influence the adoption of new treatments, but it is unknown how physician networks impact the de-adoption of harmful practices. METHODS: We analyzed changes in physicians' use of dronedarone after the PALLAS trial (Palbociclib Collaborative Adjuvant Study; November 2011) showed that dronedarone increased the risk of death from cardiovascular events among patients with permanent atrial fibrillation. Deidentified administrative claims from the OptumLabs Data Warehouse were combined with physicians' demographic information from the Doximity database and publicly available data on physicians' patient-sharing relationships compiled by the Centers for Medicare and Medicaid Services. We used a linear probability model with an interrupted linear time trend specification to model the impact of the PALLAS trial on physicians' dronedarone usage between 2009 and 2014. RESULTS: Before the PALLAS trial, the use of dronedarone was increasing by 0.22 percentage points per quarter (95% CI, 0.19-0.25) in our Medicare Advantage sample (N=343 429 patient-quarter observations) and 0.63 percentage points per quarter (95% CI, 0.52-0.75) in our commercially insured sample (N=44 402 patient-quarter observations). After the PALLAS trial and subsequent United States Food and Drug Administration black box warning, physicians in the Medicare Advantage sample with an above-median number of network connections to other physicians decreased their quarterly usage of dronedarone by 0.12 percentage points more per quarter (95% CI, -0.20 to -0.04; P=0.031) than physicians with equal to or below the median number of network connections. Similar patterns existed in the commercially insured sample (P=0.0318). CONCLUSIONS: After controlling for a wide range of patient, physician, and geographic characteristics, physicians with a greater number of network connections were faster de-adopters of dronedarone for patients with permanent atrial fibrillation after the PALLAS trial and subsequent United States Food and Drug Administration black box warning detailed the harmfulness of dronedarone for these patients. Policies for improving physicians' responsiveness to new medical information should consider utilizing the influence of these important professional network relationships.

Docs with their eyes on the clock? The effect of time pressures on primary care productivity.

This paper examines how time pressure, an important constraint faced by medical care providers, affects productivity in primary care. We generate empirical predictions by incorporating time pressure into a model of physician behavior by Tai-Seale and McGuire (2012). We use data from the electronic health records of a large integrated delivery system and leverage unexpected schedule changes as variation in time pressure. We find that greater time pressure reduces the number of diagnoses recorded during a visit and increases both scheduled and unscheduled follow-up care. We also find some evidence of increased low-value care, decreased preventive care, and decreased opioid prescribing.

Physician variation in the de-adoption of ineffective statin and fibrate therapy.

OBJECTIVE: To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence. DATA SOURCES: We analyzed 2007-2015 claims data from OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. STUDY DESIGN: We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty. DATA EXTRACTION: We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs. PRINCIPAL FINDINGS: Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R2  = 0.000). CONCLUSION: On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings.

Nurse Practitioner Autonomy and Complexity of Care in Rural Primary Care.

The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas.

Measuring Primary Care Exam Length Using Electronic Health Record Data.

BACKGROUND: Physicians' time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length. OBJECTIVE: To measure how much time primary care physicians spend with their patients, during each visit. RESEARCH DESIGN: We used a national source of EHR data for primary care practices, from a large health information technology company. We calculated exam length and schedule deviations based on timestamps recorded by the EHR, after implementing sequential data refinements to account for non-real-time EHR use and clinical multitasking. Observational analyses calculated and plotted the mean, median, and interquartile range of exam length and exam length relative to scheduled visit length. SUBJECTS: A total of 21,010,780 primary care visits in 2017. MEASURES: We identified primary care visits based on physician specialty. For these visits, we extracted timestamps for EHR activity during the exam. We also extracted scheduled visit length from the EHR's practice management functionality. RESULTS: After data refinements, the average primary care exam was 18.0 minutes long (SD=13.5 min). On average, exams ran later than their scheduled duration by 1.2 minutes (SD=13.5 min). Visits scheduled for 10 or 15 minutes were more likely to exceed their allotted time than visits scheduled for 20 or 30 minutes. CONCLUSIONS: Time-stamped EHR data offer researchers and health systems an opportunity to measure exam length and other objects of interest related to time.

Practice Patterns of Physicians and Nurse Practitioners in Primary Care.

BACKGROUND: Primary care practices increasingly include nurse practitioners (NPs), in addition to physicians. Little is known about how the patient mix and clinical activities of colocated physicians and NPs compare. OBJECTIVES: To describe the clinical activities of NPs, compared with physicians. RESEARCH DESIGN: We used claims and electronic health record data from athenahealth Inc., on primary care practices in 2017 and a cross-sectional analysis with practice fixed effects. SUBJECTS: Patients receiving treatment from physicians and NPs within primary care practices. MEASURES: First, we measured patient characteristics (payer, age, sex, race, chronic condition count) and visit characteristics (new patient, scheduled duration, same-day visit, after-hours visit). Second, we measured procedures performed and diagnoses recorded during each visit. Finally, we measured daily quantity (visit volume, minutes scheduled for patient care, total work relative value units billed) of care. RESULTS: Relative to physicians, NPs treated younger and healthier patients. NPs also had a larger share of patients who were female, non-White, and covered by Medicaid, commercial insurance, or no insurance. NPs scheduled longer appointments and treated more patients on a same-day or after-hours basis. On average, "overlapping" services-those performed by NPs and physicians within the same practice-represented 92% of all service volume. The small share of services performed exclusively by physicians reflected greater clinical intensity. On a daily basis, NPs provided fewer and less intense visits than physicians within the same practice. CONCLUSIONS: Our findings suggest considerable overlap between the clinical activities of colocated NPs and physicians, with some differentiation based on intensity of services provided.

Patient and provider-level factors associated with changes in utilization of treatments in response to evidence on ineffectiveness or harm.

High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI - 0.02 to - 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI - 0.15 to - 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P < 0.001), among patients seen by male providers compared to female providers (P = 0.01), and among patients seen by cardiologists compared to primary care providers (P < 0.001).