Disparities in telemedicine use among Native Hawaiian and Pacific Islander individuals insured through Medicaid.

States have implemented policy changes to increase access to telemedicine services for individuals receiving Medicaid benefits. Native Hawaiian and Pacific Islander (NHPI) individuals experienced disproportionate harms from COVID-19 and have long experienced disparities in health care access compared with other racial and ethnic groups, making the issue of telemedicine access particularly salient for NHPI individuals on Medicaid. Utilizing 100% 2020-2021 Medicaid claims, we compared trends in telemedicine use between NHPI and non-Hispanic White individuals on Medicaid in Washington State and conducted a decomposition analysis to identify drivers of underlying disparities. In both years, NHPI individuals were 38%-39% less likely to use any telemedicine than White individuals after adjusting for patient- and area-level characteristics. Decomposition analysis revealed that most of this difference was due to differential effects of characteristics, rather than group differences in characteristics. Namely, several characteristics that were associated with increased telemedicine use had more muted associations for NHPI vs White individuals, such as English as the primary spoken language and female sex. These findings suggest the presence of limited acceptability of or group-specific barriers to telemedicine for NHPI individuals, including potential discrimination in being offered telemedicine visits. These issues should be understood and mitigated through close collaboration between health care leaders and NHPI communities.

Evaluating Cognitive Impairment in a Large Health Care System: The Cognition in Primary Care Program.

Background: The prevalence of Alzheimer's disease and related disorders (ADRD) is rising. Primary care providers (PCPs) will increasingly be required to play a role in its detection but lack the training to do so. Objective: To develop a model for cognitive evaluation which is feasible in primary care and evaluate its implementation in a large health system. Methods: The Cognition in Primary Care Program consists of web-based training together with integrated tools built into the electronic record. We implemented the program among PCPs at 14 clinics in a large health system. We (1) surveyed PCPs to assess the impact of training on their confidence to evaluate cognition, (2) measured the number of cognitive assessments they performed, and (3) tracked the number of patients diagnosed with mild cognitive impairment (MCI). Results: Thirty-nine PCPs completed the training which covered how to evaluate cognition. Survey response rate from those PCPs was 74%. Six months after the end of the training, they reported confidence in assessing cognition (mean 4.6 on 5-point scale). Cognitive assessments documented in the health record increased from 0.8 per month before the training to 2.5 in the six months after the training. Patients who were newly diagnosed with MCI increased from 4.2 per month before the training to 6.0 per month in the six months after the training. Conclusions: This model for cognitive evaluation in a large health system was shown to increase cognitive testing and increase diagnoses of MCI. Such improvements are essential for the timely detection of ADRD.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations.

BACKGROUND: Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. OBJECTIVE: Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). DESIGN: Cross-sectional study using ordinary least squares regression controlling for patient and community factors. PARTICIPANTS: Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. MAIN MEASURES: Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022. KEY RESULTS: Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). CONCLUSIONS: Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review.

Importance: Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models. Objective: To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost. Evidence Review: A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023. Findings: This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending. Conclusions and Relevance: The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.

Association of Electronic Self-Scheduling and Screening Mammogram Completion.

INTRODUCTION: The purpose of this study was to evaluate if an electronic health record (EHR) self-scheduling function was associated with changes in mammogram completion for primary care patients who were eligible for a screening mammogram using U.S. Preventive Service Task Force recommendations. METHODS: This was a retrospective cohort study (September 1, 2014-August 31, 2019, analyses completed in 2022) using a difference-in-differences design to examine mammogram completion before versus after the implementation of self-scheduling. The difference-in-differences estimate was the interaction between time (pre-versus post-implementation) and group (active EHR patient portal versus inactive EHR patient portal). The primary outcome was mammogram completion among all eligible patients, with completion defined as receiving a mammogram within 6 months post-visit. The secondary outcome was mammogram completion among patients who received a clinician order during their visit. RESULTS: The primary analysis included 35,257 patient visits. The overall mammogram completion rate in the pre-period was 22.2% and 49.7% in the post-period. EHR self-scheduling was significantly associated with increased mammogram completion among those with an active EHR portal, relative to patients with an inactive portal (adjusted difference 13.2 percentage points [95% CI 10.6-15.8]). For patients who received a clinician mammogram order at their eligible visit, self-scheduling was significantly associated with increased mammogram completion among patients with an active EHR portal account (adjusted difference 14.7 percentage points, [95% CI 10.9-18.5]). CONCLUSIONS: EHR-based self-scheduling was associated with a significant increase in mammogram completion among primary care patients. Self-scheduling can be a low-cost, scalable function for increasing preventive cancer screenings.

Use of New Audio-Only Telemedicine Claim Modifiers.

Importance: Policymakers at both the state and federal levels face decisions about coverage of audio-only telemedicine amid a dearth of reliable data due to changes and variation in billing practices. Objective: To describe early trends in the use of new audio-only telemedicine claims modifiers 93 and FQ in Washington State, which were introduced to improve the designation and identification of audio-only telemedicine claims. Design, Setting, and Participants: This retrospective cohort study analyzed claims data from the Washington All-Payer Claims Database from January to November 2022. Participants included 4.3 million children and adults insured for at least 6 months in 2021 through public or private insurance plans. Exposures: Use of audio-only telemedicine was compared by age, race, ethnicity, insurance type, rurality, and Social Vulnerability Index. Main Outcomes and Measures: Audio-only telemedicine services were identified by claims appended by Current Procedural Terminology (CPT) code modifiers 93 or FQ or that included telephone-only CPT codes. Modifiers 93 and FQ denote audio-only telemedicine services for any reason and for behavioral health concerns, respectively. Results: In 2022, there were a total of 917 589 audio-only telemedicine services, of which 345 941 (38%) were appended with modifier FQ and 55 352 (6%) with modifier 93. Audio-only telemedicine services with these modifiers were most frequent for behavioral health diagnoses or routine prenatal and postpartum care. Individuals who used telemedicine exclusively via audio-only modality were more likely to be older (mean [SD] age, 46.0 [22.5] vs 42.0 [21.4] years) and insured by Medicare (41 758 of 196 225 [21%] vs 95 962 of 707 626 [14%]) than those who used at least 1 audiovisual service. Conclusions and Relevance: In this cohort study of a statewide all-payer claims database, modifiers 93 and FQ offered the important capability to identify audio-only telemedicine services beyond telephone-only CPT codes, but their uptake remained low. Audio-only telemedicine appears to offer an important means for access to behavioral health and perinatal care access, but further work is needed to study outcomes and quality of care.

Association Between Capitated Payments and Preventive Care Among U.S. Adults.

Introduction: There is increasing interest in using capitation rather than fee for service to promote primary care and population health. The goal of this study was to examine the association between practice reimbursement mix (majority fee for service versus majority capitation versus other) and receipt of common preventive screening examinations and health counseling from 2012 to 2018. Methods: Using the National Ambulatory Medical Care Survey, a retrospective cross-sectional study of 24,864 visits with primary care clinicians among patients aged 18-75 years without a cancer diagnosis was conducted. The main dependent measures were age- and sex-appropriate receipt of breast cancer screening, osteoporosis screening, cervical cancer screening, chlamydia testing, colon cancer screening, diabetes screening, and hyperlipidemia screening as well as 3 health counseling items. Multivariable logistic regression was performed to assess the association between reimbursement mix and receipt of preventive care, adjusted for patient, visit, and practice characteristics. Results: Majority capitation reimbursement was associated with a greater likelihood of receiving breast cancer screening (AOR=2.11, 95% CI=1.16, 3.84, p=0.014) and osteoporosis screening (AOR=4.34, 95% CI=1.74, 10.8, p=0.0017) than majority fee-for-service or other reimbursement mixes. Reimbursement mix was not associated with the likelihood of receiving 9 other preventive care or health counseling services. Conclusions: Larger amounts of capitation reimbursement may improve some but not all aspects of preventive care compared with fee for service.

Hospital Performance Under Alternative Readmission Measures Incorporating Observation Stays.

OBJECTIVE: To determine the extent to which counting observation stays changes hospital performance on 30-day readmission measures. METHODS: This was a retrospective study of inpatient admissions and observation stays among fee-for-service Medicare enrollees in 2017. We generated 3 specifications of 30-day risk-standardized readmissions measures: the hospital-wide readmission (HWR) measure utilized by the Centers for Medicare and Medicaid Services, which captures inpatient readmissions within 30 days of inpatient discharge; an expanded HWR measure, which captures any unplanned hospitalization (inpatient admission or observation stay) within 30 days of inpatient discharge; an all-hospitalization readmission (AHR) measure, which captures any unplanned hospitalization following any hospital discharge (observation stays are included in both the numerator and denominator of the measure). Estimated excess readmissions for hospitals were compared across the 3 measures. High performers were defined as those with a lower-than-expected number of readmissions whereas low performers had higher-than-expected or excess readmissions. Multivariable logistic regression identified hospital characteristics associated with worse performance under the measures that included observation stays. RESULTS: Our sample had 2586 hospitals with 5,749,779 hospitalizations. Observation stays ranged from 0% to 41.7% of total hospitalizations. Mean (SD) readmission rates were 16.6% (5.4) for the HWR, 18.5% (5.7) for the expanded HWR, and 17.9% (5.7) in the all-hospitalization readmission measure. Approximately 1 in 7 hospitals (14.9%) would switch from being classified as a high performer to a low performer or vice-versa if observation stays were fully included in the calculation of readmission rates. Safety-net hospitals and those with a higher propensity to use observation would perform significantly worse. CONCLUSIONS: Fully incorporating observation stays in readmission measures would substantially change performance in value-based programs for safety-net hospitals and hospitals with high rates of observation stays.

Strategies for Mitigating Consequences of Federal Breast Density Notifications.

This Viewpoint describes new federal updates to screening mammography rules and recommends strategies for mitigating potential consequences of the rules.

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries.

Importance: Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality. Objective: To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery. Design, Setting, and Participants: Cross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022. Exposures: Physician practice participation in the bundled payment program. Main Outcomes and Measures: The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions). Results: The final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]). Conclusions and Relevance: In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

How Physician Self-Perceptions Affect the Impact of Peer Comparison Feedback on Opioid Prescribing.

Peer comparison feedback is a promising strategy for reducing opioid prescribing and opioid-related harms. Such comparisons may be particularly impactful among underestimating clinicians who do not perceive themselves as high prescribers relative to their peers. But peer comparisons could also unintentionally increase prescribing among overestimating clinicians who do not perceive themselves as lower prescribers than peers. The objective of this study was to assess if the impact of peer comparisons varied by clinicians' preexisting opioid prescribing self-perceptions. Subgroup analysis of a randomized trial of peer comparison interventions among emergency department and urgent care clinicians was used. Generalized mixed-effects models were used to assess whether the impact of peer comparisons, alone or combined with individual feedback, varied by underestimating or overestimating prescriber status. Underestimating and overestimating prescribers were defined as those who self-reported relative prescribing amounts that were lower and higher, respectively, than actual relative baseline amounts. The primary outcome was pills per opioid prescription. Among 438 clinicians, 54% (n = 236) provided baseline prescribing self-perceptions and were included in this analysis. Overall, 17% (n = 40) were underestimating prescribers whereas 5% (n = 11) were overestimating prescribers. Underestimating prescribers exhibited a differentially greater decrease in pills per prescription compared to nonunderestimating clinicians when receiving peer comparison feedback (1.7 pills, 95% CI, -3.2 to -0.2 pills) or combined peer and individual feedback (2.8 pills, 95% CI, -4.8 to -0.8 pills). In contrast, there were no differential changes in pills per prescription for overestimating versus nonoverestimating prescribers after receiving peer comparison (1.5 pills, 95% CI, -0.9 to 3.9 pills) or combined peer and individual feedback (3.0 pills, 95% CI, -0.3 to 6.2 pills). Peer comparisons were more impactful among clinicians who underestimated their prescribing compared to peers. By correcting inaccurate self-perceptions, peer comparison feedback can be an effective strategy for influencing opioid prescribing.

Development and Feasibility Testing of a Decision Aid for Acute Appendicitis.

INTRODUCTION: Patients with acute uncomplicated appendicitis will be increasingly asked to choose between surgery and antibiotic management. We developed a novel decision aid for patients in the emergency department (ED) with acute appendicitis who are facing this choice. We describe the development of the decision aid and an initial feasibility study of its implementation in a busy tertiary care ED. MATERIALS AND METHODS: We conducted a prepost survey analysis comparing patients before and after standardized implementation of the decision aid. Patients were surveyed about their experience making treatment decisions after discharge from the hospital. The primary outcome measure was the total score on the decisional conflict scale (; 0-100; lower scores better). RESULTS: The study included 24 participants (12 in the predecision aid period; 12 in the post period). Only 33% of participants in each group knew antibiotics were a treatment option prior to arriving at the ED. Prior to implementing the use of decision aid, only 75% of patients reported being told antibiotics were a treatment option, while this increased to 100% after implementation of the decision aid. The mean total decisional conflict scalescores were similar in the pre and post periods (mean difference = 0.13, 95% CI: -13 - 13, P > 0.9). CONCLUSIONS: This novel appendicitis decision aid was effectively integrated into clinical practice and helped toinform patients about multiple treatment options. These data support further large-scale testing of the decision aid as part of standardized pathways for the management of patients with acute appendicitis.

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions.

OBJECTIVES: Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS: The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS: Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS: Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.

Association between Risk Communication Format and Perceived Risk of Adverse Events after COVID-19 Vaccination among US Adults.

The format used to communicate probability-verbal versus numerical descriptors-can impact risk perceptions and behaviors. This issue is salient for the Coronavirus disease 2019 (COVID-19), where concerns about vaccine-related risks may reduce uptake and verbal descriptors have been widely used by public health, news organizations and on social media, to convey risk. Because the effect of risk-communication format on perceived COVID-19 vaccine-related risks remains unknown, we conducted an online randomized survey among 939 US adults. Participants were given risk information, using verbal or numerical descriptors and were asked to report their perceived risk of experiencing headache, fever, fatigue or myocarditis from COVID-19 vaccine. Associations between risk communication format and perceived risk were assessed using multivariable regression. Compared to numerical estimates, verbal descriptors were associated with higher perceived risk of headache (ß = 5.0 percentage points, 95% CI = 2.0-8.1), fever (ß = 27 percentage points, 95% CI = 23-30), fatigue (ß = 4.9 percentage points, 95% = CI 1.8-8.0) and myocarditis (ß = 4.6 percentage points, 95% CI = 2.1-7.2), as well as greater variability in risk perceptions. Social media influence was associated with differences in risk perceptions for myocarditis, but not side effects. Verbal descriptors may lead to greater, more inaccurate and variable vaccine-related risk perceptions compared to numerical descriptors.