Can Nonurgent Emergency Department Care Costs be Reduced? Empirical Evidence from a U.S. Nationally Representative Sample.

BACKGROUND: A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. OBJECTIVE: This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. METHODS: This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. RESULTS: Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million-$358 million), $58.5 million for public plans (95% CI $33.9 million-$83.1 million), and an overall of $379 million (95% CI $229 million-$529 million) nationally. CONCLUSIONS: These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs.

Disparities by race and insurance-status in declines in pediatric ED utilization during the COVID19 pandemic.

Pediatric Emergency Department (ED) utilization in the U.S. saw large declines during the COVID19 pandemic. What is relatively unexplored is whether the extent of declines differed by race and insurance status. An observational study was conducted using electronic medical record (EMR) data from the largest pediatric ED in Alabama for 2020 and 2019. The four subgroups of interest were African-American (AA), Non-Hispanic White (NHW), privately insured (PRIVATE), and publicly insured or self-insured (PUBLIC-SELF). Percentage changes in the 7-day moving average between dates in 2020 and 2019 were computed for total and high-severity ED visits by subgroup. Trends in percentage changes were plotted. T-tests were used to compare mean changes between subgroups. Large percentage declines in total ED visits and somewhat smaller percentage declines in high-severity visits were observed from March 2020. Declines were consistently larger for AA than NHW and for PUBLIC-SELF than PRIVATE. T-test results indicated mean date-specific percentage declines were significantly larger for AA than NHW for total visits (-38.92% [95% CI: -41.1, -36.8] versus -29.11% [95% CI: -30.8, -27.4]; p<0.001) and high-severity visits (-24.31% [95% CI: -26.2, -22.4] versus -19.49% [95% CI:-21.2, -17.8]; p<0.001), and larger for PUBLIC-SELF than PRIVATE for total visits (-36.32% [95% CI:-38.4, -34.3] versus 27.63% [95% CI:-29.2, -26.0]; p<0.001) and high-severity visits (-21.72% [95% CI: -23.5, -19.9] versus -20.01% [95% CI: -21.7, -18.3]; p = 0.04). In conclusion, significant differences by race and insurance status were observed in the decline in ED visits during the COVID19 pandemic, including high-severity visits. Minority-race and publicly insured or self-insured children often depend on the ED for health needs, lacking a usual source of care. Thus, these findings have worrisome implications regarding unmet healthcare needs and future exacerbations in health disparities.

Disparities in Telehealth Utilization in a Population of Publicly Insured Children During the COVID-19 Pandemic.

Telehealth became a crucial vehicle for health care delivery in the United States during the COVID-19 pandemic. However, little research exists on inequities in telehealth utilization among the pediatric population. This study examines disparities in telehealth utilization in a population of publicly insured children. This observational, retrospective study used administrative data from Alabama's stand-alone Children's Health Insurance Program, ALL Kids. Rates of any telehealth use for March to December 2020 were examined. In addition-to capture lack of health care utilization-rates of having no medical claims were examined and compared with March to December 2019 and 2018. Multinomial logit models were estimated to investigate how telehealth use and having no medical claims (reference category: having medical claims but no telehealth) were associated with race/ethnicity, rural-urban residence, and family income. Of the 106,478 enrollees over March to December 2020, 13.4% had any telehealth use and 24.7% had no medical claims. The latter was greater than no medical claims in 2019 (19.5%) and 2018 (20.7%). Black and Hispanic children had lower odds of any telehealth use (odds ratio [OR]: 0.81, P < 0.01; OR: 0.68, P < 0.01) and higher odds of no medical claims (OR: 1.11, P < 0.05; OR: 1.73, P < 0.05) than non-Hispanic White children. Rural residents had lower odds of telehealth use than urban residents. Those in the highest family income-based fee group had higher odds of telehealth use than the lowest family income-based fee group. As telehealth will likely continue to play an important role in health care delivery, additional efforts/investments are required to ensure telehealth does not further exacerbate inequities in pediatric health care access.

Promoting Physical Activity Through Policy at a Single Safety-Net Clinic: A Pilot Study.

BACKGROUND: Physical inactivity is a major issue for African Americans that contributes to increased risk for chronic conditions including obesity, heart disease, diabetes, and cognitive decline. The purpose of this single-clinic pilot study aimed to determine if a physical activity policy would increase primary-care provider discussions of physical activity during clinic visits using the Exercise is Medicine initiative as a guide. METHODS: The study design involved data collection at three time points. Participants were recruited from a single clinic providing high quality healthcare without regard to ability to pay. Participants included 109 African American patients between the ages of 24 and 81 (39 pre-intervention, 40 at 6 weeks post-intervention, and 30 at 12-months post-intervention). The primary outcome measure was participants' answers related to whether a physical activity discussion occurred with their primary-care provider. RESULTS: At baseline, 13% of participants reported a physical activity discussion with their provider, this increased to 33% at 6 weeks post-intervention. However, at 12-months post-intervention, the percentage of participants who reported a physical activity discussion decreased to 23%. CONCLUSION: Exercise is an underused evidence-based strategy that should be prescribed as a medicine to prevent and manage many chronic health conditions. This pilot study demonstrated the feasibility of improving provider-patient communications related to the importance of daily physical activity behaviors. Further research is needed to determine how to employ and sustain a clinic level policy that will encourage physical activity discussions at every visit.

Vertical Integration Into Skilled Nursing Facilities and Hospital Readmission Rates.

Following the Affordable Care Act (ACA), more hospitals vertically integrated into skilled nursing facilities (SNFs). Hospitals are now being penalized for avoidable readmissions, creating a greater demand for better coordination of care between hospitals and SNF. We created a longitudinal panel data set by merging data from the American Hospital Association's Annual Survey, CMS' Hospital Compare, and the Rural Urban Commuting Area data. Hospital and year fixed-effects models were used to examine the relationship between hospital vertical integration into SNF and 30-day pneumonia and heart failure (HF) readmission rates between 2008 and 2011. Our primary analyses modeled the impact of hospital vertical integration into SNF on 30-day readmissions for both pneumonia and HF using hospital and year fixed effects. Our secondary analyses examined whether hospital vertical integration into SNF was associated with a change in readmissions rates among different types of hospitals. Our results indicate that hospitals that vertically integrated into SNF were associated with a reduction in hospital 30-day pneumonia readmission rates (ß = -0.233, p = .039). Vertical integration into SNF was not significantly associated with 30-day HF readmissions. Our secondary analyses found variation in the impact of vertical integration on readmission rates among different hospital organizational types.

Is Access to and Use of Primary Care Practices that Patients Perceive as Having Essential Qualities of a Patient-Centered Medical Home Associated With Positive Patient Experience? Empirical Evidence From a U.S. Nationally Representative Sample.

OBJECTIVE: The patient-centered medical home (PCMH) has emerged as an innovative healthcare delivery model that holds the conceptual promise to improve healthcare quality and patient experience. This study examined how patient perceived PCMH is related to patient satisfaction and experience nationwide. This study advances academic discussion in that it is among the first to examine empirical evidence using a U.S. nationally representative sample. METHODS: This retrospective cohort study used data from the 2010 to 2011 Medical Expenditure Panel Survey. This study focused on insured individuals aged 18 and older. We measured and identified cohorts for a "full PCMH," a "partial PCMH" (i.e., with a usual source of care but not a PCMH), and an "unknown PCMH," with the reference group being the "no regular provider" group and the partial PCMH group, respectively. Using logit models, we assessed patient experiences of the PCMH use controlling for covariates in 2010. Given the nature of the complex survey design, the weights and variance were adjusted using the survey procedures to yield nationally representative results. RESULTS: The final study sample consisted of 7,743 individuals, representing 191 million individuals in the weighted population. After controlling for covariates in 2010, the full PCMH group was consistently observed to have higher odds of positive patient experience than individuals with no usual source of care: odds ratio (OR) = 1.89 (p = .003) for providers "listened carefully to you"; OR = 1.81 (p = .001) for providers "spent enough time with you"; OR = 1.85 (p = .007) for providers "showed respect for what you had to say"; and OR = 1.89 (p < .001) for the composite patient experience. Similarly, compared with the partial PCMH group, consistently higher odds of patient satisfaction among all patient experience measures were observed for the full medical home group: OR = 1.45 (p = .070, significant at α = 0.1 level) for providers "explained things so you understood"; OR = 1.69 (p = .002) for providers "listened carefully to you"; OR = 1.57 (p = .003) for providers "spent enough time with you"; OR = 1.48 (p = .039) for providers "showed respect for what you had to say"; and OR = 1.56 (p = .001) for the composite patient experience. CONCLUSIONS: Overall, the PCMH model was associated with improved patient satisfaction nationwide. Findings from this study have shed light on strategies of innovative healthcare delivery models in improving patient experience, which in turn, may translate to patients' compliance to treatment regimen and improved health outcomes.