Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.

RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES: To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS: Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS: From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS: Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

Impact of Service-Based Student Loan Repayment Program on the Primary Care Workforce.

PURPOSE: As the average level of medical education indebtedness rises, physicians look to programs such as Public Service Loan Forgiveness (PSLF) and National Health Service Corps (NHSC) to manage debt burden. Both represent service-dependent loan repayment programs, but the requirements and program outcomes diverge, and assessing the relative uptake of each program may help to inform health workforce policy decisions. We sought to describe variation in the composition of repayment program participant groups and measure relative impact on patient access to care. METHODS: In this bivariate analysis, we analyzed data from 10,677 respondents to the American Board of Family Medicine's National Graduate Survey to study differences in loan repayment program uptake as well as the unique participant demographics, scope of practice, and likelihood of practicing with a medically underserved or rural population in each program cohort. RESULTS: The rate of PSLF uptake tripled between 2016 and 2020, from 7% to 22% of early career family physicians, while NHSC uptake remained static at 4% to 5%. Family physicians reporting NHSC assistance were more likely than those reporting PSLF assistance to come from underrepresented groups, demonstrated a broader scope of practice, and were more likely to practice in rural areas (23.3% vs 10.8%) or whole-county Health Professional Shortage Areas (12.5% vs 3.7%) and with medically underserved populations (82.2% vs 24.2%). CONCLUSIONS: Although PSLF supports family physicians intending to work in public service, their peers who choose NHSC are much more likely to work in underserved settings. Our findings may prompt a review of the goals of service loan forgiveness programs with potential to better serve health workforce needs.

Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals.

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities.

Research interests of family physicians applying for research training.

BACKGROUND: There is an ongoing need for research to support the practice of high quality family medicine. The Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation (FMD RapSDI) program is designed to build capacity for family medicine scientific discovery and innovation in the United States. Our objective was to describe the applicants and research questions submitted to the RapSDI program in 2019 and 2020. METHODS: Descriptive analysis for applicant characteristics and rapid qualitative analysis using principles of grounded theory and content analysis to examine the research questions and associated themes. We examined differences by year of application submission and the applicant's career stage. RESULTS: Sixty-five family physicians submitted 70 applications to the RapSDI program; 45 in 2019 and 25 in 2020. 41% of applicants were in practice for five years or less (n = 27), 18% (n = 12) were in in practice 6-10 years, and 40% (n = 26) were ≥ 11 years in practice. With significant diversity in questions, the most common themes were studies of new innovations (n = 20, 28%), interventions to reduce cost (n = 20, 28%), improving screening or diagnosis (n = 19, 27%), ways to address mental or behavioral health (n = 18, 26%), and improving care for vulnerable populations (n = 18, 26%). CONCLUSION: Applicants proposed a range of research questions and described why family medicine is optimally suited to address the questions. Applicants had a desire to develop knowledge to help other family physicians, their patients, and their communities. Findings from this study can help inform other family medicine research capacity building initiatives.

Family Practices in Transforming Clinical Practice Initiative Showed No Changes in Medicare Costs or Utilization.

BACKGROUND: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019. OBJECTIVE: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative. STUDY DESIGN: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample. SUBJECTS: A total of 761 PTN practices and 3451 non-PTN practices. MEASURES: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics. RESULTS: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541). CONCLUSIONS: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.

Physicians' Choice of Board Certification Activity Is Unaffected by Baseline Quality of Care: The TRADEMaRQ Study.

PURPOSE: Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities. METHODS: We conducted a cluster-randomized controlled trial-the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)-with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population). RESULTS: Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82). CONCLUSIONS: Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals.

Racial and ethnic disparities in access to primary care during COVID-19.

Context: Early evidence suggests that many patients chose to forgo or delay necessary medical care during the COVID-19 pandemic. Existing and well-documented racial and ethnic disparities in access to care were exacerbated by the pandemic for many reasons, potentially including the additional barriers involved in a rapid shift to telehealth for certain groups of patients. Objectives: 1) Examine changes in primary care visit volume and telehealth during the COVID-19 pandemic. 2) Test for racial and ethnic differences in primary care in-person and telehealth visits during the pandemic relative to pre-pandemic levels. Study design: Longitudinal. Datasets: EHR data including patient visits, procedures, and demographics captured in the American Board of Family Medicine's PRIME Registry. Population studied: 2,966,859 patients seeing 1,477 primary care clinicians enrolled in the PRIME Registry. Outcome measures: 7-day average of weekly visits per clinician, both in-person and telehealth, tracking trends in the volume of care provided before and during the pandemic by patient race/ethnicity. We defined telehealth conversion ratio (TCR) as the number of telehealth visits during the pandemic divided by the total number of pre-pandemic visits. We calculated TCR and visit volume changes from March 15 through the end of 2020 relative to the same period in 2019. Results: During the pandemic we observed decreases of 12% and 22% in the average number of total and in-person visits, respectively, as well as a 10% TCR. Total visits reached a nadir in April 2020 with a 29% decrease from the same point in 2019. Telehealth visits peaked the following week with 23% of that week's total visits, and 139 times more than 2019. Total visits decreased and telehealth visits increased for patients of all races/ethnicities. The magnitude of these changes differed, with Black (5% decline, 15% in-person decline, 10% TCR) and Hispanic (9%, 24%, 15%) patients seeing less of a decrease in total visits than White (12%, 21%, 9%) and Asian (16%, 30%, 14%) patients. Conclusion: Declines in primary care visits during the pandemic were partially offset by an increase in telehealth use. Utilization in our sample suggests less decline in Black and Hispanic patient primary care utilization during the pandemic than expected, in contrast to Asian patients, who demonstrated the largest declines. This metric and these results are novel and foundational for ongoing & further study using other data sources.

Microwave Antenna System for Muscle Rupture Imaging with a Lossy Gel to Reduce Multipath Interference.

Injuries to the hamstring muscles are an increasing problem in sports. Imaging plays a key role in diagnosing and managing athletes with muscle injuries, but there are several problems with conventional imaging modalities with respect to cost and availability. We hypothesized that microwave imaging could provide improved availability and lower costs and lead to improved and more accurate diagnostics. In this paper, a semicircular microwave imaging array with eight antennae was investigated. A key component in this system is the novel antenna design, which is based on a monopole antenna and a lossy gel. The purpose of the gel is to reduce the effects of multipath signals and improve the imaging quality. Several different gels have been manufactured and evaluated in imaging experiments. For comparison, corresponding simulations were performed. The results showed that the gels can effectively reduce the multipath signals and the imaging experiments resulted in significantly more stable and repeatable reconstructions when a lossy gel was used compared to when an almost non-lossy gel was used.

Clinical Quality Measure Exchange is Not Easy.

PURPOSE: The Trial of Aggregate Data Exchange for Maintenance of Certification and Raising Quality was a randomized controlled trial which first had to test whether quality reporting could be a by-product of clinical care. We report on the initial descriptive study of the capacity for and quality of exchange of whole-panel, standardized quality measures from health systems. METHODS: Family physicians were recruited from 4 health systems with mature quality measurement programs and agreed to submit standardized, physician-level quality measures for consenting physicians. Identified measure or transfer errors were captured and evaluated for root-cause problems. RESULTS: The health systems varied considerably by patient demographics and payer mix. From the 4 systems, 256 family physicians elected to participate. Of 19 measures negotiated for use, 5 were used by all systems. There were more than 15 types of identified errors including breaks in data delivery, changes in measures, and nonsensical measure results. Only 1 system had no identified errors. CONCLUSIONS: The secure transfer of standardized, physician-level quality measures from 4 health systems with mature measure processes proved difficult. There were many errors that required human intervention and manual repair, precluding full automation. This study reconfirms an important problem, namely, that despite widespread health information technology adoption and federal meaningful use policies, we remain far from goals to make clinical quality reporting a reliable by-product of care.

Harmonized Outcome Measures for Use in Depression Patient Registries and Clinical Practice.

Major depressive disorder is a common mental health condition that affects an estimated 16.2 million adults and 3.1 million adolescents in the United States. Yet, a lack of uniformity remains in measurements and monitoring for depression both in clinical practice and in research settings. This project aimed to develop a minimum set of standardized outcome measures relevant to both patients and clinicians that can be collected in depression registries and clinical practice. Twenty-nine depression registries and related data collection efforts were identified and invited to submit outcome measures. Additional measures were identified through literature searches and reviews of quality measures. A multistakeholder panel representing clinicians; payers; government agencies; industry; and medical specialty, health care quality, and patient advocacy organizations categorized the 27 identified measures using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework. The panel identified 10 broadly relevant measures and harmonized definitions for these measures through in-person and virtual meetings. The harmonized measures represent a minimum set of outcomes that are relevant to clinicians and patients and appropriate for use in depression research and clinical practice. Routine and consistent collection of these measures in registries and other systems would support creation of a national research infrastructure to efficiently address new questions, improve patient management and outcomes, and facilitate care coordination.

Characteristics of Family Medicine Residency Graduates, 1994-2017: An Update.

PURPOSE: The purpose of this study was to characterize graduates of family medicine (FM) residencies from 1994 to 2017 and determine whether they continue to practice family medicine after residency. METHOD: We sampled physicians who completed FM residency training from 1994-2017 using 2017 American Medical Association (AMA) Physician Masterfile linked with administrative files of the American Board of Family Medicine (ABFM). The main outcomes measured were characteristics of FM residency graduates, including medical degree type (Doctor of Medicine, MD vs Doctor of Osteopathic Medicine, DO), international medical school graduates (IMGs) vs US graduates, sex, ABFM certification status, and self-designated primary specialty. Family medicine residency graduates were grouped into 4-year cohorts by year of residency completion. RESULTS: From 1994 to 2017, 66,778 residents completed training in an ACGME accredited FM residency, averaging 2,782 graduates per year. The number of FM residency graduates peaked in 1998-2001, averaging 3,053 each year. The composition of FM residents diversified with large increases in DOs, IMGs, and female graduates over the past 24 years. Of all the FM residency graduates, 91.9% claimed FM as their primary specialty and 81% were certified with ABFM in 2017. FM/sport medicine (2.1%), FM/geriatric medicine (0.9%), internal medicine/geriatrics (0.8%), and emergency medicine (0.7%) were the most common non-FM primary specialties reported. CONCLUSIONS: DOs, IMGs, and female family medicine residency graduates increased from 1994 to 2017. With 9 in 10 graduates of family medicine residencies designating FM as their primary specialty, FM residency programs not only train but supply family physicians who are likely to remain in the primary care workforce.

General Practitioners in US Medical Practice Compared With Family Physicians.

PURPOSE: General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs. METHODS: Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics. RESULTS: Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals. CONCLUSIONS: GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting.

Maternity Care and Buprenorphine Prescribing in New Family Physicians.

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work.

Practice Patterns of Family Physicians With and Without Sports Medicine Certification.

OBJECTIVE: To update information regarding practice patterns of family physicians with a certificate of added qualifications (CAQ) in Sports Medicine (SM), because it has been over 10 years since the last comprehensive study. DESIGN: Cross-sectional analysis of 2017 and 2018 American Board of Family Medicine (ABFM) Family Medicine Certification and SM CAQ examination registration practice demographic questionnaire data. SETTING: N/A. PARTICIPANTS: Family physicians with a CAQ in SM [sports medicine family physicians (SM-FPs)] and family physicians without a CAQ registering for the ABFM Family Medicine Certification or SM CAQ examinations. INTERVENTION: N/A. MAIN OUTCOMES: Self-reported time spent practicing SM, activities in SM, scope of practice, and practice setting. RESULTS: Sports medicine family physicians are predominately men (78.7%) and below 49 years (65.8%). Most SM-FPs spend 60% of their time or less practicing SM and the scope of practice of SM-FPs is only slightly narrower than that of their family physician counterparts without a CAQ. In addition, 92.8% of SM-FPs are practicing in an urban setting. CONCLUSIONS: The similarity of scope of practice for SM-FPs and family physicians without a CAQ and the time spent practicing SM by SM-FPs suggests that most SM-FPs are spending a significant amount of time continuing to practice their primary specialty. Sports medicine family physicians are largely attracted to urban practice settings, most likely because of the higher likelihood of employment opportunities. Finally, factors that may be dissuading women from entering the field of SM deserve further investigation.

"That Was Pretty Powerful": a Qualitative Study of What Physicians Learn When Preparing for Their Maintenance-of-Certification Exams.

BACKGROUND: A key component of Maintenance of Certification (MOC) for family and internal medicine physicians is the requirement to pass a periodic examination of medical knowledge. Little is known about the effects of preparing for MOC exams on knowledge and practice. OBJECTIVE: To understand how MOC exam preparation can affect knowledge and practice. DESIGN: Qualitative, semi-structured interviews, 45-60 min each, conducted by telephone at participants' convenience. PARTICIPANTS: A total of 80 primary care physicians from the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM) who had recently taken an MOC exam; the sample purposefully selected to represent diversity of experiences with MOC exams and range of opinions about MOC, as well as diversity of participant backgrounds-gender, practice type, etc. APPROACH: Close analysis of physicians' accounts of what they learned when preparing for an MOC exam and how this knowledge affected their practice. RESULTS: Sixty-seven of 80 physicians stated they gained knowledge relevant to their practice. Sixty-three gave concrete examples of how this affected their practice, including direct changes to patient care (e.g., improved diagnosis or prescribing and reduced unnecessary testing) or less direct changes (e.g., improved ability to co-manage with other providers or communicate with patients). Physicians also described sharing what they learned with others, including peers and trainees. LIMITATIONS: Interviews could have been affected by recall and/or social desirability bias, as well as researchers' role as board staff. Although we followed a recruitment protocol designed to mitigate recruitment acceptance bias, our findings may not be generalizable to wider groups of physicians. CONCLUSIONS: Most physicians from two primary care specialties interviewed reported ways in which studying for an MOC exam resulted in acquiring knowledge that was both relevant and beneficial to their patient care.

Associations Between Burnout and Practice Organization in Family Physicians.

PURPOSE: Burnout has been reported to be as high as 63% among family physicians and has negative effects on physicians, patients, and the medical system. There are likely structural causes of burnout, but little is known about the relationship between practice organization and burnout. Our objective was to study this association in family physicians. METHODS: This cross-sectional study uses secondary data supplied by practicing physicians from the 2017 American Board of Family Medicine (ABFM) Family Medicine Certification examination registration questionnaire, a mandatory component of registration, yielding a 100% response rate. Burnout was measured as a positive response to either of 2 validated questions measuring emotional exhaustion and depersonalization. Practice environment was measured with questions on work stressors and teamwork. Logistic regression determined independent associations between burnout and individual and practice characteristics. RESULTS: Of the 1,437 physicians included, the burnout rate was 43.7%; 33.7% worked in hospital-owned practices and 65.5% reported no ownership stake in their practice. Controlling for personal characteristics and practice organization, being in a hospital-owned practice (odds ratio (OR) = 1.68; 95% CI, 1.14-2.46) and being a partial owner (OR =1.67; 95% CI, 1.13-2.46) were positively associated with burnout. When also controlling for practice environment, no practice organization variable remained associated with burnout. CONCLUSION: Burnout in family physicians should not be attributed solely to practice organization. No single practice type or ownership status was independently associated with burnout, which indicates that any practice can attempt to mitigate burnout.

A qualitative study of trainee experiences in Family Medicine-Obstetrics fellowships.

BACKGROUND: Family Medicine-Obstetrics fellowships provide family physicians with advanced obstetrics training. No accreditation system exists for these fellowships, which leads to variable training. Variation of fellows' experiences is not well understood. Our objective is to understand the motivations, training, and overall experiences of fellows in Family Medicine-Obstetrics fellowships, which may inform opportunities for improvement in fellowship design and suggest how Family Medicine-Obstetrics fellowship-trained physicians are prepared to practice among other obstetrics providers postgraduation. METHODS: We conducted semistructured interviews with current and past Family Medicine-Obstetrics fellows between Spring 2014 and Winter 2015. We used a snowball sampling approach. Interviews were recorded, transcribed, and coded following an inductive approach to content analysis. RESULTS: We contacted 47 and interviewed 21 current and past Family Medicine-Obstetrics fellows from 15 programs from across the country. Fellowships varied in cohort size, length, co-occurring presence of obstetrics and gynecology training programs, and structure and curriculum. Interviewees were motivated to complete a fellowship because of inadequate obstetrics training in residency, or because of an interest in rural or urban underserved practice. Fellowship experiences were shaped by fellowship leadership, program structure and curriculum, and relationships with obstetricians. Some felt prepared to forge collaborative professional relationships with obstetricians. CONCLUSIONS: The diversity of fellows' experiences suggests possible avenues of improvement for Family Medicine-Obstetrics fellowships. These fellowships can prepare physicians to provide obstetric services in a variety of settings, including working in multispecialty integrated maternity care systems.

Buprenorphine Provision by Early Career Family Physicians.

Buprenorphine can be used in primary care to treat opioid use disorder, but many family physicians feel unprepared to care for patients with opioid addiction. We sought to describe preparedness to provide and current provision of buprenorphine treatment by early career family physicians using data from the 2016 National Family Medicine Graduate Survey. Of 1,979 respondents, 10.0% reported preparedness to provide buprenorphine treatment, and 7.0% reported current buprenorphine provision. Residency preparation to provide buprenorphine treatment was most highly associated with current provision (odds ratio = 13.50; 95% CI, 7.59-24.03). Efforts to increase buprenorphine training may alleviate the workforce shortage to treat opioid use disorder.

Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations.

PURPOSE: Continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality. However, we lack provider-level measures of primary care continuity amenable to value-based payment, including the Medicare Quality Payment Program (QPP). We created 4 physician-level, claims-based continuity measures and tested their associations with health care expenditures and hospitalizations. METHODS: We used Medicare claims data for 1,448,952 beneficiaries obtaining care from a nationally representative sample of 6,551 primary care physicians to calculate continuity scores by 4 established methods. Patient-level continuity scores attributed to a single physician were averaged to create physician-level scores. We used beneficiary multilevel models, including beneficiary controls, physician characteristics, and practice rurality to estimate associations with total Medicare Part A & B expenditures (allowed charges, logged), and any hospitalization. RESULTS: Our continuity measures were highly correlated (correlation coefficients ranged from 0.86 to 0.99), with greater continuity associated with similar outcomes for each. Adjusted expenditures for beneficiaries cared for by physicians in the highest Bice-Boxerman continuity score quintile were 14.1% lower than for those in the lowest quintile ($8,092 vs $6,958; ß = -0.151; 95% CI, -0.186 to -0.116), and the odds of hospitalization were 16.1% lower between the highest and lowest continuity quintiles (OR = 0.839; 95% CI, 0.787 to 0.893). CONCLUSIONS: All 4 continuity scores tested were significantly associated with lower total expenditures and hospitalization rates. Such indices are potentially useful as QPP measures, and may also serve as proxy resource-use measures, given the strength of association with lower costs and utilization.