Patient and Visit Characteristics Associated With Use of Direct Scheduling in Primary Care Practices.

Importance: Medical practices increasingly allow patients to schedule their own visits through online patient portals, yet little is known about who adopts direct scheduling or how this service is used. Objective: To determine patient and visit characteristics associated with direct scheduling, visit patterns, and potential implications for access and continuity in the primary care setting. Design, Setting, and Participants: This cross-sectional study used electronic health record (EHR) data from 17 adult primary care practices in a large academic medical center in the Boston, Massachusetts, area. Participants included patients 18 years or older who were attributed in the EHR to an active primary care physician at 1 of the included primary care practices, were enrolled in the patient portal, and had at least 1 visit to 1 of these practices between March 1, 2018, and March 1, 2019, the period of analysis. Data were analyzed from October 25, 2019, to April 14, 2020. Main Outcomes and Measures: Adoption of direct scheduling, defined as at least 1 use during the study period. Usual scheduling was defined as scheduling with clinic staff by telephone or in person. Results: We examined 134 225 completed visits by 62 080 patients (mean [SD] age, 51.1 [16.4] years, 37 793 [60.9%] women) attributed to 140 primary care physicians at 17 primary care practices. A total of 5020 patients (8.1% [95% CI, 7.9%-8.3%]) adopted direct scheduling, with an age range of 18 to 95 years. Compared with nonadopters in the same practices, adopters were younger (adjusted odds ratio [AOR] per additional year, 0.98 [95% CI, 0.98-0.99]) and were more likely to be White (AOR, 1.09 [95% CI, 1.01-1.17]) and commercially insured (AOR vs uninsured, 1.40 [95% CI, 1.11-1.76]) and to have more comorbidities (AOR per additional comorbidity, 1.07 [95% CI, 1.04-1.11]). Compared with usually scheduled visits, directly scheduled visits were more likely to be for general medical examinations (1979 visits [36.7%] vs 26 519 visits [21.9%]; P < .001) and with one's own primary care physician (5267 visits [95.2%] vs 94 634 visits [73.5%]; P < .001). Conclusions and Relevance: These findings suggest that direct scheduling was associated with greater primary care continuity. Early adopters were more likely to be young, White, and commercially insured, and to the extent these differences persist as direct scheduling is used more widely, this service may widen socioeconomic disparities in primary care access.

Hospital Factors Associated With Interhospital Transfer Destination for Stroke in the Northeast United States.

Background We aimed to determine if there is an association between hospital quality and the likelihood of a given hospital being a preferred transfer destination for stroke patients. Methods and Results Data from Medicare claims identified acute ischemic stroke transferred between 394 northeast US hospitals from 2007 to 2011. Hospitals were categorized as transferring (n=136), retaining (n=241), or receiving (n=17) hospitals based on the proportion of acute ischemic stroke encounters transferred or received. We identified all 6409 potential dyads of sending and receiving hospitals, and categorized dyads as connected if ≥5 patients were transferred between the hospitals annually (n=82). We used logistic regression to identify hospital characteristics associated with establishing a connected dyad, exploring the effect of adjusting for different quality measures and outcomes. We also adjusted for driving distance between hospitals, receiving hospital stroke volume, and the number of hospitals in the receiving hospital referral region. The odds of establishing a transfer connection increased when rate of alteplase administration increased at the receiving hospital or decreased at the sending hospital, however this finding did not hold after applying a potential strategy to adjust for clustering. Receiving hospital performance on 90-day home time was not associated with likelihood of transfer connection. Conclusions Among northeast US hospitals, we found that differences in hospital quality, specifically higher levels of alteplase administration, may be associated with increased likelihood of being a transfer destination. Further research is needed to better understand acute ischemic stroke transfer patterns to optimize stroke transfer systems.

An Examination of Medical Malpractice Claims Involving Physician Trainees.

PURPOSE: To identify patient-, provider-, and claim-related factors of medical malpractice claims in which physician trainees were directly involved in the harm events. METHOD: The authors performed a case-control study using medical malpractice claims closed between 2012-2016 and contributed to the Comparative Benchmarking System database by teaching hospitals. Using the service extender flag, they classified claims as cases if physician trainees were directly involved in the harm events. They classified claims as controls if they were from the same facilities, but trainees were not directly involved in the harm events. They performed multivariable regression with predictor variables being patient and provider characteristics. The outcome was physician trainee involvement in harm events. RESULTS: From the original pool of 30,973 claims, there were 581 cases and 2,610 controls. The majority of cases involved residents (471, 81%). Cases had a statistically significant higher rate of having a trainee named as defendants than controls (184, 32% vs 233, 9%; P < .001). The most common final diagnosis for cases was puncture or laceration during surgery (62, 11%). Inadequate supervision was a contributing factor in 140 (24%) cases overall, with the majority (104, 74%) of these claims being procedure related. Multivariable regression analysis revealed that trainees were most likely to be involved in harm events in specialties such as oral surgery/dentistry and obstetrics-gynecology (OR = 7.99, 95% CI 2.93, 21.83 and OR = 1.85, 95% CI 1.24, 2.66, respectively), when performing procedures (OR = 1.58, 95% CI 1.27, 1.96), or when delivering care in the emergency room (OR = 1.65, 95% CI 1.43, 1.91). CONCLUSIONS: Among claims involving physician trainees, procedures were common and often associated with inadequate supervision. Training directors of surgical specialties can use this information to improve resident supervision policies. The goal is to reduce the likelihood of future harm events.

The importance of health insurance claims data in creating learning health systems: evaluating care for high-need high-cost patients using the National Patient-Centered Clinical Research Network (PCORNet).

OBJECTIVE: Case management programs for high-need high-cost patients are spreading rapidly among health systems. PCORNet has substantial potential to support learning health systems in rapidly evaluating these programs, but access to complete patient data on health care utilization is limited as PCORNet is based on electronic health records not health insurance claims data. Because matching cases to comparison patients on baseline utilization is often a critical component of high-quality observational comparative effectiveness research for high-need high-cost patients, limited access to claims may negatively affect the quality of the matching process. We sought to determine whether the evaluation of programs for high-need high-cost patients required claims data to match cases to comparison patients. MATERIALS AND METHODS: A retrospective cohort study design with multiple measures of before-and-after health care utilization for 1935 case management patients and 3833 matched comparison patients aged 18 years and older from 2011 to 2015. EHR and claims data were extracted from 3 health systems participating in PCORNet. RESULTS: Without matching on claims-based health care utilization, the case management programs at 2 of 3 health systems were associated with fewer hospital admissions and emergency visits over the subsequent 12 months. With matching on claims-based health care utilization, case management was no longer associated with admissions and emergency visits at those 2 programs. DISCUSSION: The results of a PCORNet-facilitated evaluation of 3 programs for high-need high-cost patients differed substantially depending on whether claims data were available for matching cases to comparison patients. CONCLUSIONS: Partnering with learning health systems to rapidly evaluate programs for high-need high-cost patients will require that PCORNet facilitates comprehensive and timely access to both electronic health records and health insurance claims data.

Medical Malpractice Involving Pulmonary/Critical Care Physicians.

BACKGROUND: Medical malpractice data can be leveraged to understand specialty-specific risk. METHODS: Malpractice claims were examined from the Comparative Benchmarking System (2007-2016), a national database containing > 30% of claims data in the United States. Claims were identified with either internal medicine or pulmonary/critical care (PCC) physicians as the primary provider involved in the harm. Claim characteristics were compared according to specialty and care setting (inpatient vs outpatient), and multiple regression analysis was performed to predict claim payment. RESULTS: Claims involving PCC physicians differed from those involving internal medicine physicians in terms of harm severity, allegation, final diagnosis, procedure involvement, payment rate, and contributing factors. The majority of claims involving PCC physicians resulted from inpatient care (63%), of which only 26% occurred delivering intensive care. Eighty-one percent were from harm events that resulted in death/permanent injury. The most common diagnosis was laceration during a procedure for inpatient claims (6%) and lung cancer for outpatient claims (28%). Thirty-one percent of claims overall involved procedures. Although only 26% were paid, the median indemnity per paid claim of $285,769 ranked PCC as the twelfth highest of 69 specialties. The two variables associated with indemnity payment were outpatient care (OR, 1.70; 95% CI, 1.01-2.86) and temporary harm (OR, 0.36; 95% CI, 0.15-0.87). CONCLUSIONS: Malpractice claims involving PCC physicians were distinct from claims involving internal medicine physicians. Although only one-quarter of claims was paid, the indemnity per claim was high among specialties. Specialty-specific prevention strategies must be developed to mitigate both patient harm and provider malpractice risk.

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients.

Background: Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective: To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 academic medical centers in the United States. Patients: 822 adults readmitted to a general medicine service. Measurements: For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results: Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation: Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion: Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source: Association of American Medical Colleges.

Living Alone and Discharge to Skilled Nursing Facility Care after Hospitalization in Older Adults.

BACKGROUND/OBJECTIVES: Community-based older adults are increasingly living alone. When they become ill, they might need greater support from the healthcare system than would those who live with others. There also has been a growing concern about the high use of postacute care such as skilled nursing facility (SNF) care and the level of variation in this use between hospitals and regions. Our objective was to examine whether living alone contributed to the risk of being discharged to a SNF. DESIGN: Retrospective cohort study. SETTING: Massachusetts General Hospital. PARTICIPANTS: Community-dwelling individuals aged 50 and older admitted to the medical service and discharged alive between July 2014 and August 2015 (N = 7,029). MEASUREMENTS: We extracted demographic, clinical, and functional data from the electronic medical record and used multivariable logistic regression to determine whether living alone at the time of hospitalization was associated with subsequent discharge to a SNF. RESULTS: Of eligible individuals, 24.8% reported living alone before admission. Those living alone were more likely to be female, older, and more independent before admission than those living with others. Of all participants, 10.9% were discharged to a SNF. After adjustment, participants living alone had more than twice the odds of being discharged to a SNF (odds ratio = 2.23, 95% confidence interval = 1.85-2.69, P < .001). DISCUSSION: People living alone are more likely to be discharged to SNFs, even when compared to other individuals with similar levels of clinical complexity and functional status. To the extent that this variation is due to a lack of home support, it could be possible to reduce SNF use through additional home services after hospital discharge.

Personal and Professional Characteristics of U.S. Dual-Boarded Critical Care Cardiologists in 2015.

OBJECTIVES: Evaluate the characteristics of U.S. physicians who are board certified in cardiology and critical care medicine ("dual-boarded cardiologists"). DESIGN: Retrospective cross-sectional study using a comprehensive database of licensed U.S. physicians linked to Medicare claims. SETTING: The United States. SUBJECTS: Dual-boarded cardiologists. MEASUREMENTS AND MAIN RESULTS: We used a comprehensive physician database to identify all physicians who were board certified in cardiology and critical care medicine before July 2015. We assessed physicians' characteristics and compared dual-boarded cardiologists with and without active board certification in critical care medicine and estimated the maximum proportion of 2014 Medicare Cardiac ICU admissions treated by dual-boarded cardiologists. Among 473 dual-boarded cardiologists, 16 (3.4%) were women; 468 (99%) and 85 (18%) maintained active board certification in cardiology and critical care medicine, respectively. Overall, 98 dual-boarded cardiologists (21%) submitted 1,215 total claims for critical care services in 2014. Compared to dual-boarded cardiologists without active board certification in critical care medicine, those with active certification had more publications (median publications: 6.5 vs 3.0; p = 0.002), were more likely to be professors (22.3% vs 9.5%; p = 0.003), and were more likely to bill Medicare for critical care services (29% vs 17.8%; p = 0.002). We estimated that no more than 0.47% of all 2014 Medicare Cardiac ICU admissions were treated by a dual-boarded cardiologist. CONCLUSIONS: Dual-boarded cardiologists appear to deliver a small proportion of all Cardiac ICU services received by Medicare beneficiaries. Optimizing the modern Cardiac ICU workforce will require greater efforts to promote and support the training of dual-boarded cardiologists.

Short, frequent, 5-days-per-week, in-center hemodialysis versus 3-days-per week treatment: a randomized crossover pilot trial through the Midwest Pediatric Nephrology Consortium.

BACKGROUND: No controlled trials in children with end-stage kidney disease have assessed the benefits of more frequently administered hemodialysis (HD). METHODS: We conducted a multicenter, crossover pilot trial to determine if short, more frequent (5 days per week) in-center HD was feasible and associated with improvements in blood pressure compared with three conventional HD treatments per week. Because adult studies have not controlled for the weekly duration of dialysis, we fixed the total treatment time at 12 h a week of dialysis during two 3-month study periods; only frequency varied from 5 to 3 days per week between study periods. RESULTS: Eight children (median age 16.7 years) consented at three children's hospitals. The prespecified primary composite outcome was a sustained 10% decrease in systolic blood pressure and/or a decrease in antihypertensive medications relative to each study period's baseline. Among the six patients completing both study periods, five (83.3%) experienced the primary outcome during HD performed 5 days per week but not 3 days per week; one of the six (16.7%) achieved that outcome during 3-day but not 5-day (p = 0.22) per week HD. During 5-day HD, all patients had significantly more treatments during which their pre-HD systolic (p = 0.01) or diastolic (p = 0.01) blood pressure was 10% lower than baseline. CONCLUSIONS: We observed that more frequent HD sessions per week was feasible and associated with improved blood pressure control, but barriers to changing thrice-weekly standard of care include financial reimbursement and the time demands associated with more frequent treatments.

A behavioral economics intervention to increase pertussis vaccination among infant caregivers: A randomized feasibility trial.

OBJECTIVES: The incidence of pertussis has tripled in the past five years. Infants can be protected by "cocooning," or vaccinating household contacts with the Tdap vaccine. However, Tdap coverage for adult caregivers of infants is low. This study evaluated the feasibility and impact of interventions informed by behavioral economics (retail pharmacy vouchers for Tdap vaccines and a celebrity public service announcement) to increase Tdap vaccination among caregivers of young infants. METHODS: We conducted a randomized controlled feasibility trial among adults attending newborn well-child visits at an urban Philadelphia pediatric primary care clinic who were not previously vaccinated with Tdap. Participants were randomized to one of four conditions: ($5-off Tdap voucher vs. free voucher)×(watching a 1min video public service announcement (PSA) about Tdap vaccination vs. no PSA). Tdap vaccination was assessed by tracking voucher redemption and following up with participants by phone. RESULTS: Ninety-five adult caregivers of 74 infants were enrolled in the study (mean age 29.3 years; 61% male; relationship to newborn: 54% father, 33% mother, 13% grandparent or other; caregiver insurance status: 35% Medicaid, 34% private insurance, 32% uninsured). Only 1 subject redeemed the retail pharmacy Tdap voucher. Follow-up interviews suggest that, even with the voucher, significant barriers to vaccination remained including: delaying planned vaccination, perceived inconvenient pharmacy locations, and beliefs about pertussis risk and severity. CONCLUSIONS: Despite leveraging existing infrastructure for adult vaccination, results suggest that retail pharmacy vouchers delivered during a newborn visit are not an effective strategy for promoting Tdap. Alternate approaches are needed that prioritize convenience and provide an immediate opportunity to vaccinate when motivation is high.

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression.

BACKGROUND: The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. METHODS: We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥ 2 HIV medical visits separated by ≥ 90 days in the year. Persons not retained completed ≥ 1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤ 200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. RESULTS: Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). CONCLUSIONS: Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

Comparative Effectiveness of Beta-lactam Versus Macrolide Monotherapy in Children with Pneumonia Diagnosed in the Outpatient Setting.

BACKGROUND: Most children diagnosed with community-acquired pneumonia (CAP) are treated in the outpatient setting. The objective of this study was to determine the comparative clinical effectiveness of beta-lactam monotherapy and macrolide monotherapy in this population. STUDY DESIGN: Children, 1-18 years old, with a clinical diagnosis of CAP at an outpatient practice affiliated (n = 71) with Geisinger Health System during January 1, 2008 to January 31, 2010 were eligible. The primary exposure was receipt of beta-lactam or macrolide monotherapy. The primary outcome was treatment failure defined as change in antibiotic prescription within 14 days of the initial pneumonia diagnosis. Propensity scores were used to determine the likelihood of receiving macrolide monotherapy. Treatment groups were matched 1:1, based on propensity score, age group and asthma status. Multivariable conditional logistic regression models estimated the association between macrolide monotherapy and treatment failures. RESULTS: Of 1999 children with CAP, 1164 were matched. In the matched cohorts, 24% of children had asthma. Patients who received macrolide monotherapy had no statistical difference in treatment failure regardless of age when compared with patients who received beta-lactam monotherapy. CONCLUSION: Our findings suggest that children diagnosed with CAP in the outpatient setting and treated with beta-lactam or macrolide monotherapy have the same likelihood to fail treatment regardless of age.

Patient ratings of case managers in a medical home: associations with patient satisfaction and health care utilization.

BACKGROUND: Case managers are employed in medical homes to coordinate care for clinically complex patients. OBJECTIVE: To measure the association of patient perceptions of case manager performance with overall satisfaction and subsequent health care utilization. DESIGN: Retrospective cohort study. SETTING: Integrated health system in Pennsylvania. PATIENTS: Members of the health system-owned health plan who 1) received primary care in the health system's clinics, 2) were exposed to clinic-embedded case managers, and 3) completed a survey of satisfaction with care. MEASUREMENTS: Survey assessment of case manager performance and overall satisfaction with care and claims-based assessment of case manager performance and subsequent hospitalizations or emergency department visits. Survey measures were dichotomized into very good versus less than very good. RESULTS: A total of 1755 patients (44%) completed the survey and 1415 met study criteria. Survey respondents who reported very good ratings of case manager performance across all items had a higher probability of reporting very good overall satisfaction with care (92.2% vs. 62.5%; P < 0.001) and had a lower incidence of subsequent emergency department visits (incidence rate ratio, 0.79 [95% CI, 0.64 to 0.98]; P = 0.029) but not hospitalizations (incidence rate ratio, 0.92 [CI, 0.75 to 1.11]; P = 0.37) up to 2 years after the survey compared with survey respondents who reported less-than-very good case manager performance on 1 or more questions on the survey. LIMITATIONS: Satisfaction data demonstrated substantial ceiling effects. Survey nonresponse may have introduced bias in the results. CONCLUSION: Patients' favorable perceptions of case managers are associated with higher overall satisfaction with care and may lower risk for future acute care use. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs.

Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts.

OBJECTIVES: Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention. METHODS: We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result). RESULTS: Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01-1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52-0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04-1.62). Patients with heterosexual (1.78, 1.20-2.65) and IDU (1.58, 1.06-2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01-1.04) and inpatient (1.09, 1.01-1.19) visits were at greatest risk of unnecessary HCV testing. CONCLUSIONS: Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.

Health insurance coverage for persons in HIV care, 2006-2012.

We examined trends in health insurance coverage among 36,999 HIV-infected adults in care at 11 US HIV clinics between 2006 and 2012. Aggregate health insurance coverage was stable during this time. The proportions of patient-years with private, Medicaid, Medicare, and no insurance during this period were 15.9%, 35.7%, 20.1%, and 28.4%, respectively. Medicaid coverage was more prevalent among women than men, blacks, and Hispanics than whites, and individuals with injection drug use risk compared with other transmission risk factors. Hispanics and younger age groups were more likely to be uninsured than other racial/ethnic and older age groups, respectively.

Factors associated with antimicrobial drug use in medicaid programs.

Using US Medicaid data, we found that 52% of adult Medicaid patients with acute respiratory tract infections filled prescriptions for antimicrobial drugs in 2007. Factors associated with lower likelihood of use were higher county-level availability of primary care physicians and state-level participation in a campaign for appropriate antimicrobial drug use.

Variations in ambulance use in the United States: the role of health insurance.

OBJECTIVES: The purpose of this study was to describe the associations between individual health insurance and ambulance utilization using a national sample of patients who receive emergency department (ED) care. METHODS: The data source was the National Hospital Ambulatory Medical Care Survey, years 2004 through 2006. Noninstitutionalized patients between ages 18 and 65 years were included. The primary dependent variable was ambulance use. Multivariable logistic regression methods were used to assess the associations between health insurance status and ambulance use and to adjust for confounders. RESULTS: A total of 61,013 ED visits were included, representing a national sample of approximately 70 million annual ED visits over 3 years. Ambulance transport was used in 11% of private insurance visits, 16% of Medicaid visits, and 13% of uninsured visits. In the adjusted model, visits by patients with Medicaid (adjusted odds ratio [aOR] = 1.60, 99% confidence interval (CI) = 1.37 to 1.86) and the uninsured (aOR = 1.43, 99% CI = 1.23 to 1.66) were more likely to arrive by ambulance than visits by patients with private insurance. Ambulance use among the uninsured was most pronounced in metropolitan areas. CONCLUSIONS: Ambulance use varies by health insurance status. Medicaid coverage and lack of insurance are each independently associated with increased odds of ambulance use, suggesting a disproportionate role for emergency medical services (EMS) in the care of patients with limited financial resources.

Healthcare utilization and cost of pneumococcal disease in the United States.

BACKGROUND: Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown. METHODS: We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars. RESULTS: We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65. CONCLUSIONS: Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.