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BACKGROUND: Remote patient monitoring (RPM) is a promising tool for improving chronic disease management. Use of RPM for hypertension monitoring is growing rapidly, raising concerns about increased spending. However, the effects of RPM are still unclear. OBJECTIVE: To estimate RPM's effect on hypertension care and spending. DESIGN: Matched observational study emulating a longitudinal, cluster randomized trial. After matching, effect estimates were derived from a regression analysis comparing changes in outcomes from 2019 to 2021 for patients with hypertension at high-RPM practices versus those at matched control practices with little RPM use. SETTING: Traditional Medicare. PATIENTS: Patients with hypertension. INTERVENTION: Receipt of care at a high-RPM practice. MEASUREMENTS: Primary outcomes included hypertension medication use (medication fills, adherence, and unique medications received), outpatient visit use, testing and imaging use, hypertension-related acute care use, and total hypertension-related spending. RESULTS: 192 high-RPM practices (with 19 978 patients with hypertension) were matched to 942 low-RPM control practices (with 95 029 patients with hypertension). Compared with patients with hypertension at matched low-RPM practices, patients with hypertension at high-RPM practices had a 3.3% (95% CI, 1.9% to 4.8%) relative increase in hypertension medication fills, a 1.6% (CI, 0.7% to 2.5%) increase in days' supply, and a 1.3% (CI, 0.2% to 2.4%) increase in unique medications received. Patients at high-RPM practices also had fewer hypertension-related acute care encounters (-9.3% [CI, -20.6% to 2.1%]) and reduced testing use (-5.9% [CI, -11.9% to 0.0%]). However, these patients also saw increases in primary care physician outpatient visits (7.2% [CI, -0.1% to 14.6%]) and a $274 [CI, $165 to $384]) increase in total hypertension-related spending. LIMITATION: Lacked blood pressure data; residual confounding. CONCLUSION: Patients in high-RPM practices had improved hypertension care outcomes but increased spending. PRIMARY FUNDING SOURCE: National Institute of Neurological Disorders and Stroke.
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Hipertensión , Medicare , Humanos , Anciano , Estados Unidos , Hipertensión/tratamiento farmacológico , Presión Sanguínea , Monitoreo FisiológicoRESUMEN
Cancer screening rates declined sharply early in the COVID-19 pandemic. The impact of the pandemic may have exacerbated existing disparities in cancer screening due to the disproportionate burden of illness and job loss among racial/ ethnic minorities, and potentially, uneven resumption of care between different racial/ ethnic groups. Using electronic health record data from Mass General Brigham (MGB), we assessed changes in rates of breast, cervical, colorectal and lung cancer screening before and during the pandemic. Among patients who received primary care in an MGB-affiliated primary care practice, cancer screening rates were calculated as the number of individuals who received a screening test for each cancer type over the number of individuals due for each test, during each month between April 2019-November 2020. We conducted an interrupted time-series analysis to test for changes in screening rates by race/ethnicity before and during the pandemic. Prior to the pandemic, relative to White individuals, Asian women were less likely to receive breast cancer screening (p < 0.001), and Latinx and Black individuals were less likely to screen for lung cancer (p < 0.001 and p = 0.02). Our results did not show significant improvement or worsening of racial/ethnic disparities for any cancer screening type as screening resumed. However, as of November 2020 rates of screening for breast cancer were lower than pre-pandemic levels for Latinx individuals, and lung cancer screening rates were higher than baseline for Latinx, Black or White individuals. Further monitoring of disparities in cancer screening is warranted as the pandemic evolves.
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COVID-19 , Neoplasias Pulmonares , Detección Precoz del Cáncer , Etnicidad , Femenino , Disparidades en Atención de Salud , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiología , Pandemias , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Diabetes mellitus has reached epidemic proportions in the United States. As the prevalence of diabetes continues to rise, the burden of disease is divided unevenly among different populations. Racial/ethnic disparities in diabetes care are pervasive, including the provision of care for prevention of complications. Prevention efforts should be focused on the time that immediately follows a diagnosis of diabetes. The aim of this study was to assess racial/ethnic differences in the receipt of guideline-directed diabetes care for complication prevention by individuals recently diagnosed with diabetes. METHODS: We used repeated cross-sections of individuals recently diagnosed with diabetes (within the past 5 years) from the National Health Interview Survey from 2011 to 2017. Multivariate regression was used to estimate the associations between race/ethnicity (non-Hispanic White, non-Hispanic Black and Hispanic) and guideline-directed process measures for prevention of diabetes complications (visits to an eye and foot specialist, and blood pressure and cholesterol checks by a health professional - each in the prior year). We assessed effect modification of these associations by socioeconomic status (SES). RESULTS: In a sample of 7,341 participants, Hispanics had lower rates of having any insurance coverage (75.9 %) than Non-Hispanic Whites (93.2 %) and Blacks (88.1 %; p<0.001). After adjustment for demographics, total comorbidities, SES, and health insurance status, Hispanics were less likely to have an eye exam in the prior year (OR 0.80; (95 % CI 0.65-0.99); p=0.04) and a blood pressure check (OR 0.42; (95 % CI 0.28-0.65); p<0.001) compared to Non-Hispanic Whites. There was no significant effect modification of race/ethnicity by SES. CONCLUSIONS: Hispanics recently diagnosed with diabetes were less likely to receive some indicators of guideline-directed care for the prevention of complications. Lack of insurance and SES may partially explain those differences. Future work should consider policy change and providers' behaviors linked to racial/ethnic disparities in diabetes care.
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Diabetes Mellitus , Etnicidad , Negro o Afroamericano , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Diabetes Mellitus/prevención & control , Hispánicos o Latinos , Humanos , Clase Social , Estados Unidos/epidemiologíaAsunto(s)
Diabetes Mellitus , Salud Digital , Equidad en Salud , Humanos , Diabetes Mellitus/terapiaRESUMEN
BACKGROUND: There is concern that mental and physical fatigue among endoscopists over the course of the day will lead to lower adenoma detection rate (ADR). There are mixed findings in the prior literature on whether such an association exists. AIMS: The aim of this study was to measure the association between the number of colonoscopies performed in a day and ADR and withdrawal time. METHODS: We analyzed 86,624 colonoscopy and associated pathology reports between October 2013 and September 2015 from 131 physicians at two medical centers. A previously validated natural language processing program was used to abstract relevant data. We identified the order of colonoscopies performed in the physicians' schedule and calculated the ADR and withdrawal time for each colonoscopy position. RESULTS: The ADR for our overall sample was 29.9 (CI 29.6-30.2). The ADR for colonoscopies performed at the 9th + position was significantly lower than those at the 1st-4th or 5th-8th position, 27.2 (CI 25.8-28.6) versus 29.9 (CI 29.5-30.3), 30.2 (CI 29.6-30.9), respectively. Withdrawal time steadily decreased by colonoscopy position going from 11.6 (CI 11.4-11.9) min for the 1st colonoscopy to 9.6 (8.9-10.3) min for the 9th colonoscopy. CONCLUSION: In our study population, ADR and withdrawal time decrease by roughly 7 and 20%, respectively, by the end of the day. Our results imply that rather than mental or physical fatigue, lower ADR at the end of the day might be driven by endoscopists rushing.
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Adenoma/diagnóstico , Neoplasias del Colon/diagnóstico , Colonoscopía , Competencia Clínica , Fatiga , Humanos , Procesamiento de Lenguaje Natural , Tempo Operativo , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de Tiempo , Carga de TrabajoRESUMEN
BACKGROUND: The adenoma detection rate (ADR) is a validated and widely used measure of colonoscopy quality. There is uncertainty in the published literature as to which colonoscopy examinations should be excluded when measuring a physician's ADR. OBJECTIVE: To examine the impact of varying the colonoscopy exclusion criteria on physician ADR. DESIGN: We applied different exclusion criteria used in 30 previous studies to a dataset of endoscopy and pathology reports. Under each exclusion criterion, we calculated physician ADR. SETTING: A private practice colonoscopy center affiliated with the University of Illinois College of Medicine. PATIENTS: Data on 20,040 colonoscopy examinations performed by 11 gastroenterologists from July 2009 to May 2013 and associated pathology notes. MAIN OUTCOME MEASUREMENTS: ADRs across all colonoscopy examinations, each physician's ADR, and ADR ranking. RESULTS: There were 28 different exclusion criteria used when measuring the ADR. Each study used a different combination of these exclusion criteria. The proportion of all colonoscopy examinations in the dataset excluded under these combinations of exclusion criteria ranged from 0% to 92.2%. The mean ADR across all colonoscopy examinations was 39.1%. The change in mean ADR after applying the 28 exclusion criteria ranged from -5.5 to +3.0 percentage points. However, the exclusion criteria affected each physician's ADR relatively equally, and therefore physicians' rankings via the ADR were stable. LIMITATIONS: ADR assessment was limited to a single private endoscopy center. CONCLUSION: There is wide variation in the exclusion criteria used when measuring the ADR. Although these exclusion criteria can affect overall ADRs, the relative rankings of physicians by ADR were stable. A consensus definition of which exclusion criteria are applied when measuring ADR is needed.
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Adenoma/diagnóstico , Competencia Clínica/estadística & datos numéricos , Colonoscopía/normas , Neoplasias Colorrectales/diagnóstico , Gastroenterología/normas , Selección de Paciente , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colonoscopía/estadística & datos numéricos , Femenino , Gastroenterología/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
BACKGROUND: Many adolescents do not receive basic preventive care such as influenza vaccinations. The Affordable Care Act (ACA) temporarily increased Medicaid reimbursements for primary care services, including vaccine administration, in 2013 to 2014. The objective of this study is to assess the impact of reimbursement increases on influenza vaccination rates among adolescents with Medicaid. METHODS: This repeated cross-sectional study used a difference-in-difference approach to compare changes in annual influenza vaccination rates for 20,884 adolescents 13 to 17 years old covered by Medicaid with adequate provider-reported data in 18 states with larger extended (>$5, 2013 to 2019) versus larger temporary (2013 to 2014 only) versus smaller reimbursement changes. We used linear probability models with individual-level random effects, adjusting for state and individual characteristics and annual time trends to assess the impact of a Medicaid vaccine administration reimbursement increase on annual influenza vaccination. RESULTS: Mean Medicaid reimbursements for vaccine administration doubled from 2011 to 2013 to 2014 (eg, from $11 to $22 for CPT 90460). States with smaller reimbursement changes had higher mean reimbursements and higher adjusted vaccination rates at baseline (2011) compared with states with larger temporary and extended reimbursement changes. The reimbursement change was not associated with increases in influenza vaccination rates. DISCUSSION: Influenza vaccination rates were low among adolescents with Medicaid throughout the study period, particularly in states with lower Medicaid reimbursement levels before the ACA. CONCLUSION: That reimbursement increases were not associated with higher vaccination rates suggests additional efforts are needed to improve influenza vaccination rates in this population.
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Gripe Humana , Vacunas , Estados Unidos , Adolescente , Humanos , Medicaid , Gripe Humana/prevención & control , Patient Protection and Affordable Care Act , Estudios Transversales , Vacunación , InmunizaciónRESUMEN
Importance: Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear. Objective: To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography. Design, Setting, and Participants: This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death. Exposure: Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing. Main Outcomes and Measures: Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity. Results: In this national sample of 14â¯305â¯819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals. Conclusions and Relevance: The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.
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Etnicidad , Pandemias , Anciano , Humanos , Estados Unidos , Estudios Transversales , Grupos Minoritarios , MedicareRESUMEN
OBJECTIVE: This study aimed to evaluate associations of Medicaid expansion with health care access for adults with obesity and to explore racial/ethnic differences in these changes in health care access. METHODS: Using 2011 to 2017 Behavioral Risk Factor Surveillance System data, the study compared health care access measures among adults who were aged ≥18 years and who had BMI ≥ 30 kg/m2 and household income ≤ 138% of the federal poverty line by state Medicaid expansion status using a difference-in-differences approach with logistic regression. The authors further stratified the main analysis by race/ethnicity. RESULTS: Medicaid expansion was associated with improvements in health care access, including lower proportions of those without a usual source of care (-3.6%, 95% confidence interval [CI]: -5.8% to -1.4%, p < 0.01) and cost as a barrier to medical care (-4.5%, 95% CI: -7.0% to -1.9%, p < 0.01). No significant changes were found in routine medical checkups in the last year (-1.8%, 95% CI: -4.4% to 0.8%, p = 0.12). However, across these measures, Medicaid expansion was consistently associated with better access among non-Hispanic White adults (-6.0% to -7.9%, p < 0.01) and not at all among non-Hispanic Black and Hispanic adults (p > 0.05). CONCLUSIONS: Medicaid expansion was associated with significant improvements in health care access among adults with obesity, but these improvements were variable across race and ethnicity.
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Accesibilidad a los Servicios de Salud , Medicaid , Adolescente , Adulto , Sistema de Vigilancia de Factor de Riesgo Conductual , Humanos , Cobertura del Seguro , Obesidad/epidemiología , Obesidad/terapia , Patient Protection and Affordable Care Act , Pobreza , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Driven in part by Medicare's Hospital Readmissions Reduction Program, hospitals are focusing on improving the transition from inpatient to outpatient care with particular emphasis on early follow-up with a primary care physician (PCP). OBJECTIVE: To assess whether the implementation of a scheduling assistance program changes rates of PCP follow-up or readmissions. DESIGN: Retrospective cohort study. SETTING: An urban tertiary care center PATIENTS: A total of 20,918 adult patients hospitalized and discharged home between September 2008 and October 2015. INTERVENTION: A postdischarge appointment service to facilitate early PCP follow-up. MAIN MEASURES: Primary outcomes were rates of follow-up visits with a PCP within seven days of discharge and hospital readmission within 30 days of discharge. Our first analysis assessed differences in outcomes among patients with and without the use of the service. In a second analysis, we exploited the fact that the service was not available on weekends and conducted an instrumental variable analysis that used the interaction between the intervention and day of the week of admission. RESULTS: In our multivariable analysis, use of the appointment service was associated with much higher rates of PCP follow-up (+31.9 percentage points, 95% CI: 30.2, 33.6; P < .01) and a decrease in readmission (-3.8 percentage points, 95% CI: -5.2, -2.4; P < .01). In the instrumental variable analysis, use of the service also increased the likelihood of a PCP follow-up visit (33.4 percentage points, 95% CI: 7.9, 58.9; P = .01) but had no significant impact on readmissions (-2.5 percentage points, 95% CI: -22.0, 17.0; P = .80). CONCLUSIONS: The postdischarge appointment service resulted in a substantial increase in timely PCP followup, but its impact on the readmission rate was less clear.