Ambulatory Care Fragmentation and Total Health Care Costs.

BACKGROUND: The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. OBJECTIVE: To determine the association between ambulatory care fragmentation and total health care costs. RESEARCH DESIGN: Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 13,680 Medicare beneficiaries who are 65 years and older. MEASURES: We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. RESULTS: The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. CONCLUSIONS: Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.

Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs.

OBJECTIVE: Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN). STUDY DESIGN: We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17. A "gap" in CC occurs if the adult proxy reported dissatisfaction with communication between providers or difficulty getting the help needed to coordinate care for the child. Using logistic regression models adjusting for age and sex, we measured the association between a gap in CC and 1 or more ED visits during the past 12 months overall and stratified by any special needs. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated. RESULTS: Between 2018 and 2019, 15% of respondents reported a gap in CC and 19.4% of children had at least one ED visit. Among non-CSHCN, these rates were 11% and 17%. In this population, a gap in CC was independently associated with an increased odds of ED use (AOR: 2.14; 95% CI 1.82, 2.52). CONCLUSIONS FOR PRACTICE: Self-reported gaps in ambulatory CC were associated with increased odds of ED visits even among non-CSHCN children with minor illnesses, suggesting that providers need to be aware of potential pitfalls in CC for all children, and ensure that pertinent information is available where needed.

Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S.

BACKGROUND: It is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit. Whether any such association varies with race is unknown. OBJECTIVE: We sought to determine whether highly fragmented ambulatory care increases the risk of an ED visit, overall and by race. DESIGN AND PARTICIPANTS: We analyzed data for 14,361 participants ≥ 65 years old from the nationwide prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, linked to Medicare claims (2003-2016). MAIN MEASURES: We defined high fragmentation as a reversed Bice-Boxerman Index ≥ 0.85 (≥ 75th percentile). We used Poisson models to determine the association between fragmentation (as a time-varying exposure) and ED visits, overall and stratified by race, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiologic variables. KEY RESULTS: The average participant was 70.5 years old; 53% were female, and 33% were Black individuals. Participants with high fragmentation had a median of 9 visits to 6 providers, with 29% of visits by the most frequently seen provider; participants with low fragmentation had a median of 7 visits to 3 providers, with 50% of visits by the most frequently seen provider. Overall, high fragmentation was associated with more ED visits than low fragmentation (adjusted risk ratio [aRR] 1.31, 95% confidence interval [CI] 1.29, 1.34). The magnitude of this association was larger among Black (aRR 1.48, 95% CI 1.44, 1.53) than White participants (aRR 1.23, 95% CI 1.20, 1.25). CONCLUSIONS: Highly fragmented ambulatory care was an independent predictor of ED visits, especially among Black individuals.

Diabetes and cancer co-management: patient-reported challenges, needs, and priorities.

INTRODUCTION: Twenty percent of breast cancer survivors have co-occurring diabetes and face a 50% greater risk of 10-year mortality compared to survivors without diabetes. Individuals with cancer are often overwhelmed during cancer treatment and have less time for their diabetes, contributing to worse outcomes. We elicited perspectives of breast cancer survivors with diabetes regarding their specific needs for diabetes and cancer co-management. METHODS: We conducted semi-structured interviews with women with breast cancer aged 40 + years at three New York City hospitals from May 2021 to March 2022. Eligible participants had type 2 diabetes or pre-diabetes. Interviews were audio-recorded, professionally transcribed, and coded by two independent reviewers. RESULTS: We conducted interviews with 15 females with breast cancer of mean age 61.5 years (SD 7.2); 70% were Black, Hispanic, or Asian/Pacific Islander, and 20% had only a high school education. Most (73%) patients were insured by Medicaid or Medicare, and 73% underwent chemotherapy as part of their cancer care. Of the 15 participants, 60% reported that their glucose levels were of control during cancer treatment and nearly 50% reported glucose levels > 200 mg/dL. We identified distinct themes that reflect patient-reported challenges (worse glucose control after initiation of cancer treatment, lack of information on co-managing diabetes, negative psychosocial effects, burden of diabetes management during cancer care) and needs/priorities (designated provider to help, educational resources specific to diabetes and cancer, and individualized care plans). CONCLUSIONS: Patients co-managing diabetes and cancer face challenges and have unmet needs that should be addressed to improve diabetes control during cancer treatment. Our findings can directly inform interventions aimed at improving glucose control in this population.

Predicting Fragmented Care: Beneficiary, Physician, Practice, and Market Characteristics.

BACKGROUND: Understanding what drives fragmented ambulatory care (care spread across multiple providers without a dominant provider) can inform the design of future interventions to reduce unnecessary fragmentation. OBJECTIVES: To identify the characteristics of beneficiaries, primary care physicians, primary care practice sites, and geographic markets that predict highly fragmented ambulatory care in the United States. RESEARCH DESIGN: Cross-sectional analysis of Medicare claims data for beneficiaries attributed to primary care physicians and practices in 2018. We used hierarchical linear models with random intercepts and an extensive list of explanatory variables to predict the likelihood of high fragmentation. SUBJECTS: A total of 3,540,310 Medicare fee-for-service beneficiaries met the inclusion criteria, attributed to 26,344 primary care physicians in 9300 practice sites, and 788 geographic markets. MEASURES: We defined high care fragmentation as a reversed Bice-Boxerman Index score above 0.85. RESULTS: Explanatory variables explained only 6% of the variation in highly fragmented care. Unobserved differences between primary care physicians, between practice sites, and between markets together accounted for 4%. Instead, 90% of the variation in high fragmentation was unobserved residual variance. We identified the characteristics of beneficiaries (age, reason for original Medicare entitlement, and dually eligible for Medicaid insurance), physicians (comprehensiveness of care), and practices (size, being part of a system/hospital) that had small associations with high fragmentation. CONCLUSIONS: Variation in fragmentation was not explained by observed beneficiary, primary care provider, practice site, or market characteristics. Instead, the aggregate behavior of diverse health care providers beyond primary care, along with unmeasured patient preferences and behaviors, seem to be important predictors.

Communication Gaps Persist Between Primary Care and Specialist Physicians.

A survey conducted with data from 2008 found that physicians often do not communicate with each other at the time of referral or after consultation. Communication between physicians might have improved since then, with the dissemination of electronic health records (EHRs), but this is not known. We used 2019 survey data to measure primary care physicians' perceptions of communication at the time of referral and after consultation. We found that large gaps in communication persist. The similarity between these survey results suggests that despite the dissemination of EHRs, physicians still do not consistently communicate with each other about the patients they share.

Managing diabetes during treatment for breast cancer: oncology and primary care providers' views on barriers and facilitators.

PURPOSE: Diabetes is a prevalent comorbid condition among many women with breast cancer. The roles and responsibilities of managing diabetes during cancer care are unclear, as oncologists lack interest and clinical expertise and many patients stop seeing their primary care providers (PCPs). Uncertainty around who should manage diabetes for cancer patients can result in gaps in care for survivors. We sought to elicit the perspectives of providers about a novel diabetes care delivery intervention for women undergoing chemotherapy for breast cancer. METHODS: We conducted nominal group sessions with PCPs and breast oncologists across the USA. We introduced a novel care delivery model, which involved a nurse practitioner (NP) specifically trained in diabetes to work within the oncology team to manage diabetes for women during chemotherapy. PCPs and oncologists were asked to identify potential barriers and facilitators to the intervention's success and then vote on the top three most important barriers and facilitators, separately. Votes were aggregated across sessions and presented as frequencies and weighted percentages. RESULTS: From November to December 2020, two 60-min sessions with PCPs and two 60-min sessions with breast oncologists were held virtually. In total, 29 providers participated, with 16 PCPs and 13 breast oncologists. At the health system level, financial support for the NP-led intervention was identified as the most important barrier across both provider types. Clearly defined roles for each care team member were identified as the most important facilitator at the care team level. At the patient level, lack of cancer-specific diabetes education was identified as an important barrier. CONCLUSION: Our findings underscore the need to engage various stakeholders including policy makers, institutional leadership, care team members, and patients to improve diabetes care for patients undergoing chemotherapy for breast cancer. As such, multi-disciplinary interventions are warranted to increase awareness, engagement, and self-management practices among breast cancer patients with diabetes.

Frailty, gaps in care coordination, and preventable adverse events.

BACKGROUND: Older US adults often receive care from multiple ambulatory providers. Seeing multiple providers may be clinically appropriate but creates challenges for communication. Whether frailty is a risk factor for gaps in communication among older adults and subsequent preventable adverse events is unknown. METHODS: We conducted a cross-sectional analysis of community-dwelling US adults ≥ 65 years of age in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who attended an in-home study examination in 2013-2016 and completed a survey on experiences with healthcare in 2017-2018 (n = 5,024). Using 5 frailty indicators (low body mass index, exhaustion, slow walk, weakness, and history of falls), we characterized participants into 3 mutually exclusive groups: not frail (0 indicators), intermediate-frail (1-2 indicators), and frail (3-5 indicators). We used survey data on self-reported gaps in care coordination and self-reported adverse events that participants attributed to poor communication among providers (a drug-drug interaction, repeat testing, an emergency department visit, or a hospital admission). RESULTS: Overall, 2,398 (47.7%) participants were not frail, 2,436 (48.5%) were intermediate-frail, and 190 (3.8%) were frail. The prevalence of any gap in care coordination was 37.0%, 40.8%, and 51.1% among participants who were not frail, intermediate-frail and frail, respectively. The adjusted prevalence ratio (PR) for any gap in care coordination among intermediate-frail and frail versus not frail participants was 1.09 (95% confidence interval [95%CI] 1.02-1.18) and 1.34 (95%CI 1.15-1.56), respectively. The prevalence of any preventable adverse event was 7.0%, 11.3% and 20.0% among participants who were not frail, intermediate-frail and frail, respectively. The adjusted PR for any preventable adverse event among those who were intermediate-frail and frail versus not frail was 1.47 (95%CI 1.22-1.77) and 2.24 (95%CI 1.60-3.14), respectively. CONCLUSION: Among older adults, frailty is associated with an increased prevalence for self-reported gaps in care coordination and preventable adverse events. Targeted interventions to address patient-reported concerns regarding care coordination among intermediate-frail and frail older adults may be warranted.

Eliciting the educational priorities of home care workers caring for adults with heart failure.

BACKGROUND: Although home care workers (HCWs) are increasingly caring for adults with heart failure (HF), many feel unprepared and lack HF training. To serve as the foundation for a future educational intervention, we aimed to elicit HCWs' HF educational needs. METHODS: We partnered with the largest healthcare union in the US to recruit 41 HCWs employed by 17 home care agencies. Using the nominal group technique, we asked HCWs to respond to three questions: When caring for an HF patient: (1) What information do you want? (2) What symptoms worry you? (3) What situations do you struggle with? Participants ranked their responses by priority. Data were consolidated by question. RESULTS: For question 1, participants ranked HF signs and symptoms most highly, followed by HF treatment and medications. For question 2, chest pain was most worrisome, followed by neurologic changes and shortness of breath. For question 3, participants struggled with encouraging patients to follow a heart-specific diet. CONCLUSIONS: HCWs expressed a need to learn more about signs and symptoms of HF and ways to assist patients with HF self-care. These findings can inform the development of an HF training program for HCWs that specifically addresses their expressed needs.

Racial Disparities in Preventable Adverse Events Attributed to Poor Care Coordination Reported in a National Study of Older US Adults.

BACKGROUND: Previous work found that Black patients experience worse care coordination than White patients. OBJECTIVE: The aim was to determine if there are racial disparities in self-reported adverse events that could have been prevented with better communication. RESEARCH DESIGN: We used data from a cross-sectional survey that was administered to participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study in 2017-2018. SUBJECTS: REGARDS participants aged 65+ years of age who reported >1 ambulatory visits and >1 provider in the prior 12 months (thus at risk for gaps in care coordination). MEASURES: Our primary outcome was any repeat test, drug-drug interaction, or emergency department visit or hospitalization that respondents thought could have been prevented with better communication. We used Poisson models with robust standard error to determine if there were differences in preventable events by race. RESULTS: Among 7568 REGARDS respondents, the mean age was 77 years (SD: 6.7), 55.4% were female, and 33.6% were Black. Black participants were significantly more likely to report any preventable adverse events compared with Whites [adjusted risk ratio (aRR): 1.64; 95% confidence interval (CI): 1.42-1.89]. Specifically, Blacks were more likely than Whites to report a repeat test (aRR: 1.77; 95% CI: 1.38-2.29), a drug-drug interaction (aRR: 1.76; 95% CI: 1.46-2.12), and an emergency department visit or hospitalization (aRR: 1.45; 95% CI: 1.01-2.08). CONCLUSIONS: Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination than White participants, independent of demographic and clinical characteristics.

Ambulatory Care Fragmentation and Subsequent Hospitalization: Evidence From the REGARDS Study.

BACKGROUND: Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders. OBJECTIVE: The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables. DESIGN: Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year. MEASURES: We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period. RESULTS: The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24). CONCLUSION: Highly fragmented ambulatory care is an independent risk factor for hospitalization.

Healthcare Fragmentation and Incident Acute Coronary Heart Disease Events: a Cohort Study.

BACKGROUND: Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear. OBJECTIVE: To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health. DESIGN AND PARTICIPANTS: We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003-2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556). MAIN MEASURES: We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period. KEY RESULTS: The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health. CONCLUSION: High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.

Eliciting primary care and oncology provider perspectives on diabetes management during active cancer treatment.

PURPOSE: We sought to elicit the perspectives of primary care providers (PCPs) and oncologists regarding their expectations on who should be responsible for diabetes management, as well as communication mode and frequency about diabetes care during cancer treatment. METHODS: In-depth interviews were conducted with PCPs (physicians and nurse practitioners) and oncologists who treat cancer patients with type 2 diabetes. Interviews were audio-recorded and professionally transcribed. A grounded theory approach was used to analyze the qualitative data and identify key themes. RESULTS: Ten PCPs and ten oncologists were interviewed between March and July 2019. Two broad themes emerged from our interviews with PCPs: (1) cancer patients pausing primary care during cancer treatments, and (2) patients with poorer prognoses and advanced cancer. The following theme emerged from our interviews with oncologists: (3) challenges in caring for cancer patients with uncontrolled diabetes. Three common themes emerged from our interviews with both PCPs and oncologists: (4) discomfort with providing care outside of respective specialty, (5) the need to individualize care plans, and (6) lack of communication across primary and oncology care. CONCLUSIONS: Our findings suggest that substantial barriers to optimal diabetes management during cancer care exist at the provider level. Interventions prioritizing effective communication and educational resources among PCPs, oncologists, and additional members of the patients' care team should be prioritized to achieve optimal outcomes.

Differences in ambulatory care fragmentation by race.

BACKGROUND: More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care. METHODS: We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist). RESULTS: The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (<$35,000) and 41% had a high school education or less. Overall, participants had a median of 10 ambulatory visits to 4 providers in the 12 months following their baseline study visit. Participants in the highest quintile of fragmentation scores had a median of 11 visits to 7 providers. Black race was associated with an absolute adjusted 3% lower fragmentation score compared to white race (95% confidence interval (2% lower to 4% lower; p < 0.001). This difference was explained by blacks seeing fewer specialists than whites. Income and education were not independent predictors of fragmentation scores. CONCLUSIONS: Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.

Differences in ambulatory care fragmentation between cancer survivors and noncancer controls.

BACKGROUND: Patients with chronic conditions are treated by many providers, which can increase the risk of communication gaps across providers and potential harm to patients. However, to the authors' knowledge, the extent of fragmented care among this population is unknown. In the current study, the authors sought to determine whether cancer survivors have more fragmented care than noncancer controls and to quantify the extent of fragmentation. METHODS: Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study linked to Medicare claims were used. The authors included beneficiaries with continuous Part A and B coverage for 12 months at the time of their baseline REGARDS survey. The primary outcome of the current study was claims-based fragmentation over 12 months, which was calculated using the reversed Bice-Boxerman Index so a higher score reflected greater fragmentation. Unadjusted differences in fragmentation were compared between cancer survivors and controls. Beta regression models were used to estimate associations between cancer status and fragmentation, adjusting for potential confounders. RESULTS: The authors included 4922 participants aged ≥65 years at baseline. Of these patients, approximately 21% were cancer survivors. Survivors had a median of 11 visits (interquartile range, 7-15 visits) with 5 providers compared with controls, who had a median of 9 visits (interquartile range, 6-14 visits) with 4 providers (P < .0001). Cancer survivors had significantly more fragmented care compared with controls (median reversed Bice-Boxerman Index, 0.80 vs 0.76; P < .0001). After adjusting for confounders, cancer survivors had an increased odds of having fragmented care (odds ratio, 1.08; 95% CI, 1.02-1.14). CONCLUSIONS: Care fragmentation is more prevalent among cancer survivors compared with those without a history of cancer. Future studies should examine whether fragmentation puts survivors at risk of worse outcomes.

Diabetes care management patterns before and after a cancer diagnosis: A SEER-Medicare matched cohort study.

BACKGROUND: Diabetes places patients with cancer at an increased risk of infections, hospitalizations, and mortality. The objective of the current study was to characterize diabetes care management patterns among patients with cancer in the year before and, separately, after cancer diagnosis. The authors hypothesized that diabetes care declines after a diagnosis of cancer. METHODS: The Surveillance, Epidemiology, and End Results (SEER) cancer registry linked to Medicare claims data was used. The authors included diabetic beneficiaries aged ≥65 years who were diagnosed with incident, nonmetastatic breast, prostate, or colorectal cancer between 2008 and 2013. Controls were diabetic Medicare beneficiaries in SEER regions who did not have cancer. Cases were matched to controls based on age, sex, Charlson Comorbidity Index, and diabetes severity. Primary outcomes were diabetes care received over 12 months: 1) hemoglobin A1c testing; 2) eye examination; and 3) low-density lipoprotein testing. Using a difference-in-difference (DID) approach, the authors examined use differences 12 months before to after diagnosis for patients with cancer and controls. To avoid capturing testing related to diagnosis and not diabetes management, the authors implemented a 90-day washout period (45 days before and/or after diagnosis). RESULTS: A total of 32,728 diabetic patients with cancer and 32,728 matched noncancer controls were included. After diagnosis, patients with cancer were found to have modest, but significantly lower, rates of diabetes care use compared with controls. Patients with cancer had greater declines in hemoglobin A1c testing (DID, 2.4%; 95% CI, 1.7%-3.0%), low-density lipoprotein testing (DID, 4.3%; 95% CI, 3.6%-5.0%), and receipt of all diabetes indicators (DID, 2.7%; 95% CI, 1.8%-3.5%) 12 months before to after diagnosis. CONCLUSIONS: Compared with controls, less diabetes care use was observed among patients with cancer in the year after diagnosis. Understanding and addressing the reasons for this may improve outcomes in this population.

Association Between Patients' Self-Reported Gaps in Care Coordination and Preventable Adverse Outcomes: a Cross-Sectional Survey.

BACKGROUND: Whether patients' reports of gaps in care coordination reflect clinically significant problems is unclear. OBJECTIVE: To determine any association between patient-reported gaps in care coordination and patient-reported preventable adverse outcomes. DESIGN AND PARTICIPANTS: We administered a cross-sectional survey on experiences with healthcare to participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were ≥ 65 years old. Of the 15,817 participants in REGARDS at the time of our survey (August 2017-November 2018), 11,138 completed the survey. We restricted the sample to participants who reported ≥ 2 ambulatory visits and ≥ 2 ambulatory providers in the past year (N = 7568). MAIN MEASURES: We considered 7 gaps in ambulatory care coordination, elicited with previously validated questions. We considered 4 outcomes: (1) a test that was repeated because the doctor did not have the result of the first test, (2) a drug-drug interaction that occurred due to multiple prescribers, (3) an emergency department visit that could have been prevented by better communication among providers, and (4) a hospital admission that could have been prevented by better communication among providers. We used logistic regression to determine the association between ≥ 1 gap in care coordination and ≥ 1 preventable outcome, adjusting for potential confounders. KEY RESULTS: The average age of the sample was 77.0 years; 55% were female, and 34% were African-American. More than one-third of participants (38.1%) reported ≥ 1 gap in care coordination and nearly one-tenth (9.8%) reported ≥ 1 preventable outcome. Having ≥ 1 gap in care coordination was associated with an increased odds of ≥ 1 preventable outcome (adjusted odds ratio 1.55; 95% confidence interval 1.33, 1.81). CONCLUSIONS: Participants' reports of gaps in care coordination were associated with an increased odds of preventable adverse outcomes. Future interventions should leverage patients' observations to detect and resolve gaps in care coordination.

Understanding the Workflow of Home Health Care for Patients with Heart Failure: Challenges and Opportunities.

BACKGROUND: Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal. OBJECTIVE: We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist. DESIGN AND PARTICIPANTS: In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018. APPROACH: Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image. KEY RESULTS: Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step. CONCLUSIONS: Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

Internal medicine residents identify gaps in medical education on outpatient referrals.

BACKGROUND: Relevant clinical information is often missing when a patient sees a specialist after being referred by another physician in the ambulatory setting. This can result in missed or delayed diagnoses, delayed treatment, unnecessary testing, and drug interactions. Residents' attitudes toward providing clinical information at the time of referral and their perspectives toward training on referral skills are not clear. We sought to assess internal medicine residents' attitudes toward and experiences with outpatient referrals. METHODS: We conducted a cross-sectional survey in October-December 2018 of all internal medicine interns and residents affiliated with a large, urban internal medicine residency program in New York, NY. We used a novel survey instrument that included 13 questions about attitudes toward and experiences with outpatient referrals. We used descriptive statistics to characterize the results. RESULTS: Overall, 122 of 132 residents participated (92% response rate). Respondents were approximately equally distributed across post-graduate years 1-3. Although 83% of residents reported that it is "always" important to provide the clinical reason for a referral, only 11% stated that they "always" provide a sufficient amount of clinical information for the consulting provider when making a referral. Only 9% of residents "strongly agree" that residency provides sufficient training in knowing when to refer patients, and only 8% "strongly agree" that residency provides sufficient training in what information to provide the consulting physician. CONCLUSIONS: These results suggest a substantial discrepancy between the amount of information residents believe they should provide at the time of a referral and the amount they actually provide. Many residents report not receiving adequate training during residency on when to refer patients and what clinical information to provide at the time of referral. Improvements to medical education regarding outpatient referrals are urgently needed.

Patients' and Providers' Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study.

BACKGROUND: Patients with chronic conditions routinely see multiple outpatient providers, who may or may not communicate with each other. Gaps in information across providers caring for the same patient can lead to harm for patients. However, the exact causes and consequences of healthcare fragmentation are not understood well enough to design interventions to address them. OBJECTIVE: We sought to elicit patients' and providers' views on the causes and consequences of healthcare fragmentation. DESIGN AND PARTICIPANTS: We conducted a qualitative study with focus groups of patients and, separately, of providers (attending physicians and nurse practitioners) at an academic hospital-based primary care practice in New York City in June-August 2017. Patient participants were English-speaking adults with ≥ 2 chronic conditions. APPROACH: Each focus group lasted 1 h and asked the same two questions: "Why do you think some patients receive care from many different providers and others do not?" and "What do you think happens as a result of patients receiving care from many different providers?" Data collection continued until a point of data saturation was reached. Thematic analysis was used to identify themes and subthemes. KEY RESULTS: We conducted 6 focus groups with a total of 46 participants (25 patients and 21 providers). Study participants identified 41 unique causes of fragmentation, which originate from 4 different levels of the healthcare system (patient, provider, healthcare organization, and healthcare environment); most causes were not related to medical need. Participants also identified 24 unique consequences of fragmentation, of which 3 were desirable and 21 were undesirable. CONCLUSIONS: The results of this study offer a granular roadmap for how to decrease healthcare fragmentation. The large number and severity of negative consequences (including medical errors, misdiagnosis, increased cost, and provider burnout) underscore the urgent need for interventions to address this problem directly.