A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

What AHRQ Learned While Working to Transform Primary Care.

Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.

Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices.

BACKGROUND: Broad consensus exists about the value and principles of primary care; however, little is known about the workforce configurations required to deliver it. OBJECTIVE: The aim of this study was to explore the team configurations and associated costs required to deliver high-quality, comprehensive primary care. METHODS: We used a mixed-method and consensus-building process to develop staffing models based on data from 73 exemplary practices, findings from 8 site visits, and input from an expert panel. We first defined high-quality, comprehensive primary care and explicated the specific functions needed to deliver it. We translated the functions into full-time-equivalent staffing requirements for a practice serving a panel of 10,000 adults and then revised the models to reflect the divergent needs of practices serving older adults, patients with higher social needs, and a rural community. Finally, we estimated the labor and overhead costs associated with each model. RESULTS: A primary care practice needs a mix of 37 team members, including 8 primary care providers (PCPs), at a cost of $45 per patient per month (PPPM), to provide comprehensive primary care to a panel of 10,000 actively managed adults. A practice requires a team of 52 staff (including 12 PCPs) at $64 PPPM to care for a panel of 10,000 adults with a high proportion of older patients, and 50 staff (with 10 PCPs) at $56 PPPM for a panel of 10,000 with high social needs. In rural areas, a practice needs 22 team members (with 4 PCPs) at $46 PPPM to serve a panel of 5000 adults. CONCLUSIONS: Our estimates provide health care decision-makers with needed guideposts for considering primary care staffing and financing and inform broader discussions on primary care innovations and the necessary resources to provide high-quality, comprehensive primary care in the USA.

EvidenceNOW: Balancing Primary Care Implementation and Implementation Research.

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to generate knowledge about how America's health care delivery system can provide high-quality care, and to ensure that health care professionals and systems understand and use this evidence. In 2015 AHRQ invested in the largest primary care research project in its history. EvidenceNOW is a $112 million effort to disseminate and implement patient-centered outcomes research evidence in more than 1,500 primary care practices and to study how quality-improvement support can build the capacity of primary care practices to understand and apply evidence.EvidenceNOW comprises 7 implementation research grants, each funded to provide external quality-improvement support to primary care practices to implement evidence-based cardiovascular care and to conduct rigorous internal evaluations of their work. An independent, external evaluator was funded to conduct an overarching evaluation using harmonized outcome measures and pooled data. The design of EvidenceNOW required resolving tensions between implementation and implementation research goals.EvidenceNOW is poised to develop a blueprint for how stakeholders can invest in strengthening the primary care delivery system and to offer a variety of resources and tools to improve the capacity of primary care to deliver evidence-based care. Federal agencies must maximize the value of research investments to show improvements in the lives and health of Americans and the timeliness of research results. Understanding the process and decisions of a federal agency in designing a large clinical practice transformation initiative may provide researchers, policy makers, and clinicians with insights into future implementation research, as well as improve responsiveness to funding announcements and the implementation of evidence in routine clinical care.

Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value.

BACKGROUND AND OBJECTIVE: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. RESEARCH DESIGN: CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. RESULTS: ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. CONCLUSIONS: The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

Cardiac device implantation in the United States from 1997 through 2004: a population-based analysis.

OBJECTIVE: Use of cardiac devices has been increasing rapidly along with concerns over their safety and effectiveness. This study used hospital administrative data to assess cardiac device implantations in the United States, selected perioperative outcomes, and associated patient and hospital characteristics. METHODS: We screened hospital discharge abstracts from the 1997-2004 Healthcare Cost and Utilization Project Nationwide Inpatient Samples. Patients who underwent implantation of pacemaker (PM), automatic cardioverter/defibrillator (AICD), or cardiac resynchronization therapy pacemaker (CRT-P) or defibrillator (CRT-D) were identified using ICD-9-CM procedure codes. Outcomes ascertainable from these data and associated hospital and patient characteristics were analyzed. MEASUREMENTS AND MAIN RESULTS: Approximately 67,000 AICDs and 178,000 PMs were implanted in 2004 in the United States, increasing 60% and 19%, respectively, since 1997. After FDA approval in 2001, CRT-D and CRT-P reached 33,000 and 7,000 units per year in the United States in 2004. About 70% of the patients were aged 65 years or older, and more than 75% of the patients had 1 or more comorbid diseases. There were substantial decreases in length of stay, but marked increases in charges, for example, the length of stay of AICD implantations halved (from 9.9 days in 1997 to 5.2 days in 2004), whereas charges nearly doubled (from $66,000 in 1997 to $117,000 in 2004). Rates of in-hospital mortality and complications fluctuated slightly during the period. Overall, adverse outcomes were associated with advanced age, comorbid conditions, and emergency admissions, and there was no consistent volume-outcome relationship across different outcome measures and patient groups. CONCLUSIONS: The numbers of cardiac device implantations in the United States steadily increased from 1997 to 2004, with substantial reductions in length of stay and increases in charges. Rates of in-hospital mortality and complications changed slightly over the years and were associated primarily with patient frailty.

How useful are voluntary medication error reports? The case of warfarin-related medication errors.

BACKGROUND: A study was conducted to explore the value and limitations of voluntary medical error reports and to learn about common errors in warfarin use. METHODS: Voluntary reports of 8,837 inpatient errors and 820 outpatient errors in warfarin use submitted by 445 hospitals and 192 outpatient facilities participating in MEDMARX, a voluntary medication error reporting system, from 2002 to 2004, were gathered. RESULTS: Overall, errors occurred most often during transcription/documentation (35%) and administration (30%) in hospitals, and during prescribing (31%) and dispensing (39%) in outpatient settings. Dosing errors were the most common type. In hospitals, more than 50% of reported errors were initiated by nurses, and 50% were intercepted by nurses, whereas in outpatient settings, about 50% of reported errors occurred in pharmacies and 50% were intercepted by pharmacists. About 17% of inpatient and 13% of outpatient warfarin errors resulted in changes in patient care, and 42% of inpatient and 62% of outpatient errors resulted in procedural changes. Cascade analysis and textual descriptions further located specific, correctible safety lapses. DISCUSSION: Voluntary medical error reporting systems can, to some extent, provide meaningful and actionable information to guide patient safety improvement, but their usefulness is limited because of a lack of details, incomplete reporting, underreporting, and various reporting biases.

How Do Innovative Primary Care Practices Achieve the Quadruple Aim?

The Patient-Centered Medical Home (PCMH) now defines excellent primary care. Recent literature has begun to elucidate the components of PCMHs that improve care and reduce costs, but there is little empiric evidence that helps practices, payers, or policy makers understand how high-performing practices have improved outcomes. We report the findings from 38 such practices that fill this gap. We describe how they execute 8 functions that collectively meet patient needs. They include managing populations, providing self-management support coaching, providing integrated behavioral health care, and managing referrals. The functions provide a more actionable perspective on the work of primary care.

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services.

As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system-level efforts are needed to increase the use of preventive services.

Incidence and short-term outcomes of primary and revision hip replacement in the United States.

BACKGROUND: The purpose of this study was to use 2003 nationwide United States data to determine the incidences of primary total hip replacement, partial hip replacement, and revision hip replacement and to assess the short-term patient outcomes and factors associated with the outcomes. METHODS: We screened more than eight million hospital discharge abstracts from the 2003 Healthcare Cost and Utilization Project Nationwide Inpatient Sample and approximately nine million discharge abstracts from five state inpatient databases. Patients who had undergone total, partial, or revision hip replacement were identified with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. In-hospital mortality, perioperative complications, readmissions, and the association between these outcomes and certain patient and hospital variables were analyzed. RESULTS: Approximately 200,000 total hip replacements, 100,000 partial hip replacements, and 36,000 revision hip replacements were performed in the United States in 2003. Approximately 60% of the patients were sixty-five years of age or older and at least 75% had one or more comorbid diseases. The in-hospital mortality rates associated with these three procedures were 0.33%, 3.04%, and 0.84%, respectively. The perioperative complication rates associated with the three procedures were 0.68%, 1.36%, and 1.08%, respectively, for deep vein thrombosis or pulmonary embolism; 0.28%, 1.88%, and 1.27% for decubitus ulcer; and 0.05%, 0.06%, and 0.25% for postoperative infection. The rates of readmission, for any cause, within thirty days were 4.91%, 12.15%, and 8.48%, respectively, and the rates of readmissions, within thirty days, that resulted in a surgical procedure on the affected hip were 0.79%, 0.91%, and 1.53%. The rates of readmission, for any cause, within ninety days were 8.94%, 21.14%, and 15.72%, and the rates of readmissions, within ninety days, that resulted in a surgical procedure on the affected hip were 2.15%, 1.61%, and 3.99%. Advanced age and comorbid diseases were associated with worse outcomes, while private insurance coverage and planned admissions were associated with better outcomes. No consistent association between outcomes and hospital characteristics, such as hip procedure volume, was identified. CONCLUSIONS: Total hip replacement, partial hip replacement, and revision hip replacement are associated with different rates of postoperative complications and readmissions. Advanced age, comorbidities, and nonelective admissions are associated with inferior outcomes.

The validity of ICD-9-CM codes in identifying postoperative deep vein thrombosis and pulmonary embolism.

BACKGROUND: Deep vein thrombosis and pulmonary embolism (DVT/PE) are common complications after surgery and are associated with substantial excess mortality and length of stay. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes recorded in hospital claims have been used to identify and study DVT/PE, but the validity of this method is not well studied. METHODS: Identification of postoperative DVT/PE events were compared using ICD-9-CM codes and medical record abstraction in random samples of hospital discharges of Medicare beneficiaries in 2002-2004. RESULTS: Among 20,868 eligible surgical hospitalizations, 232 DVT cases and 95 PE cases were identified by ICD-9-CM codes; 108 DVT cases and 31 PE cases by medical record abstraction; 72 DVT cases and 23 PE cases by both methods. The resulting estimates of PPV of ICD9-CM coding were 31% (72/232 cases) for DVT, 24% (23/95) for PE, and 29% (90/308) for DVT/PE combined. The resulting sensitivity estimates were 67% (72/108 cases) for DVT, 74% (23/31) for PE, and 68% (90/133) for DVT/PE combined. DISCUSSION: ICD-9-CM codes in Medicare claims are sensitive but have limited predictive validity in identifying postoperative DVT/PE. Improvements in the validity are needed before the indicator can be used for safety performance assessment.

Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database.

PURPOSE: The potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied. METHODS: A national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed. RESULTS: Facilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, mis-communication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors. CONCLUSION: A national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.

Racial and ethnic differences in patient assessments of interactions with providers: disparities or measurement biases?

Patient assessment surveys have established a primary role in health care quality measurement as evidence has shown that information from patients can affect quality improvement for practitioners and lead to positive marketwide changes. This article presents findings from the recently released National Healthcare Disparities Report revealing that although most clinical quality and access indicators show superior health care for non-Hispanic whites compared with blacks and Hispanics, blacks and Hispanics assess their interactions with providers more positively than non-Hispanic whites do. The article explores possible explanations for these racial/ethnic differences, including potential pitfalls in survey design that draw biased responses by race/ethnicity. The article then suggests strategies for refining future research on racial/ethnic disparities based on patient assessment of health care.

Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations.

OBJECTIVES: To assess the prevalence and correlates of potentially harmful drug-drug combinations and drug-disease combinations prescribed for elderly patients at outpatient settings. DESIGN: Retrospective analysis of the 1995-2000 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). SETTING: Physician offices and hospital outpatient departments. PARTICIPANTS: Outpatient visits by patients aged 65 and older in the NAMCS and NHAMCS (n=70,203). MEASUREMENTS: Incidences of six drug-drug combinations and 50 drug-disease combinations that can place elderly patients at risk for adverse events according to expert consensus panels. RESULTS: Overall, 0.74% (95% confidence interval (CI)=0.65-0.83) of visits with two or more prescriptions had at least one inappropriate drug-drug combination, and 2.58% (95% CI=2.44-2.72) of visits with at least one prescription had one or more inappropriate drug-disease combinations. Of visits with a prescription of warfarin, 6.60% (95% CI=5.46-7.74) were prescribed a drug with potentially harmful interaction. Of patients with benign prostatic hypertrophy, 4.06% (95% CI=3.06-5.06) had at least one of six drugs that should be avoided. The number of drugs prescribed is most predictive of inappropriate drug-drug and drug-disease combinations. CONCLUSION: Potentially harmful drug-drug and drug-disease combinations occur in various degrees in outpatient care in the elderly population. Targeting combinations such as those involving warfarin that are high in prevalence and potential harm offers a practical approach to improving prescribing and patient safety.

Burden of illness for children and where we stand in measuring the quality of this health care.

CONTEXT: Measures of health care quality for children are not as well developed as those for adults. It is also unclear the extent to which the current pool of measures address common causes of illness and health care utilization for children. OBJECTIVE: The goal of this study was to create lists of high-priority conditions for children based on different vantage points for defining burden relative to both inpatient and outpatient care for children. These high-priority conditions were then cross-tabulated with all known existing quality measures for pediatric health care. DATA: High-prevalence conditions for children were identified by using the 2000 National Ambulatory Medical Care Survey, 2000 National Hospital Ambulatory Medical Care Survey, 1999 Medical Expenditure Panel Survey, 2000 Healthcare Cost and Utilization Project's State Inpatient Databases, and 2000 Healthcare Cost and Utilization Project's State Ambulatory Surgery Databases. Burden assessments were done using frequencies of visits, charges, in-hospital deaths. Existing quality measures for children were identified from a recent compendium of such measures and a search of the National Quality Measures Clearinghouse. RESULTS: There are numerous and large gaps in existing quality-of-care measures for children relative to high-burden conditions in both the inpatient and outpatient setting. With the ever increasing efforts to measure and even publicly report on health care, efforts for children need to include focus on building a representative repertoire of quality measures for the high-burden conditions children experience.

Ambulatory care visits for treating adverse drug effects in the United States, 1995-2001.

BACKGROUND: Adverse d[rug events (ADEs) are a well-recognized patient safety 4concern, but their magnitude is unknown. Ambulatory viisits for treating adverse drug effects (VADEs) as recordeed in national surveys offer an alternative way to estimatte the national prevalence of ADEs because each VA]DE indicates that an ADE occurred and was seriousenough to require care. METHODS: A nationallyrepresentative sample of visits to physician offices, hospital outpatient departments, and emergency departments was analyzed. VADEs were identified as tthe first-listed cause of injury. RESULTS: In 2001, there Awere 4.3 million VADEs in the United States, averaging 15 visits per 1,000 population. VADE rates at physicianoffices, hospital outpatient departments, and hospittal emergency departments were at 3.7, 3.4, and 7.3 lper 1,000 visits, respectively. There was an upward tr'end in the total number of VADEs from 1995 to 2001 ((p < .05), but the increases in VADEs per 1000 visits an.d per 1,000 population were not statistically significant. VADEs were lower in children younger than 15 and higher in the elderly aged 65-74 than in adults aged 225-44 (p < .01) and were more frequent in females than irn males (p < .05). DISCUSSION: Although methodologically conservative, the study suggests that ADEs are a significant threat to patient safety in the United States.

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

This study examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores and the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to 1999 were matched with institutional IQI/PSI performance from 24 states in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation with no significant relationship between them. Principal component analysis found 1 factor each of the IQIs/PSIs that explained the majority of variance on the IQIs/PSIs. Worse performance on the PSI factor was associated with worse performance on JCAHO scores (P=.02). No significant relationships existed between JCAHO categorical accreditation decisions and IQI/PSI performance. Few relationships exist between JCAHO scores and IQI/PSI performance. There is a need to continuously reevaluate all measurement tools to ensure they are providing the public with reliable, consistent information about health care quality and safety.

Health care use and costs for children with attention-deficit/hyperactivity disorder: national estimates from the medical expenditure panel survey.

CONTEXT: Although attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent chronic condition of childhood, little is known about patterns of health care use and associated expenditures. OBJECTIVE: To compare health care use and costs among children with ADHD, children with asthma, and the general pediatric population. DESIGN AND SETTING: The 1996 Medical Expenditure Panel Survey, a nationally representative household survey. PARTICIPANTS: All 5439 children aged 5 to 20 years from the 1996 Medical Expenditure Panel Survey were included in this analysis. Children who had ADHD, asthma, or neither (general population) were identified from International Classification of Diseases, Ninth Revision, Clinical Modification codes and prescription records. MAIN OUTCOME MEASURES: Mean health care use (outpatient visits, emergency department visits, hospital stays, home health visit days, and prescriptions) and associated expenditures. RESULTS: We identified 165 children with ADHD, 322 with asthma, and 4952 with neither diagnosis. Children with ADHD had significantly higher mean total health care costs ($1151) compared with children with asthma ($1091; P<.05) and the general population ($712; P<.001). After adjusting for age, sex, race, household income, access to care, parent education, and marital status, excess total costs were $479 for children with ADHD (P<.001) and $437 for children with asthma (P<.01). CONCLUSIONS: Overall costs of care for children with ADHD are comparable to costs for children with asthma and significantly greater than for the general pediatric population. Specific types of health care use and the sources of expenditures differ between children with ADHD and children with asthma. Because much ADHD-related care occurs within school and mental health settings, these figures likely underestimate the true costs of caring for children with this condition.

Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of U.S. hospitals, 1990-1996.

OBJECTIVE: To examine the impact of nurse staffing on selected adverse events hypothesized to be sensitive to nursing care between 1990 and 1996, after controlling for hospital characteristics. DATA SOURCES/STUDY SETTING: The yearly cross-sectional samples of hospital discharges for states participating in the National Inpatient Sample (NIS) from 1990-1996 were combined to form the analytic sample. Six states were included for 1990-1992, four states were added for the period 1993-1994, and three additional states were added in 1995-1996. STUDY DESIGN: The study design was cross-sectional descriptive. DATA COLLECTION/EXTRACTION METHODS: Data for patients aged 18 years and older who were discharged between 1990 and 1996 were used to create hospital-level adverse event indicators. Hospital-level adverse event data were defined by quality indicators developed by the Health Care Utilization Project (HCUP). These data were matched to American Hospital Association (AHA) data on community hospital characteristics, including registered nurse (RN) and licensed practical/vocational nurse (LPN) staffing hours, to examine the relationship between nurse staffing and four postsurgical adverse events: venous thrombosis/pulmonary embolism, pulmonary compromise after surgery, urinary tract infection, and pneumonia. Multivariate modeling using Poisson regression techniques was used. PRINCIPAL FINDINGS: An inverse relationship was found between RN hours per adjusted inpatient day and pneumonia (p < .05) for routine and emergency patient admissions. CONCLUSIONS: The inverse relationship between pneumonia and nurse staffing are consistent with previous findings in the literature. The results provide additional evidence for health policy makers to consider when making decisions about required staffing levels to minimize adverse events.

The effects of HMO penetration on preventable hospitalizations.

OBJECTIVE: To examine the effects of health maintenance organization (HMO) penetration on preventable hospitalizations. DATA SOURCE: Hospital inpatient discharge abstracts for 932 urban counties in 22 states from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), hospital data from American Hospital Association (AHA) annual survey, and population characteristics and health care capacity data from Health Resources and Services Administration (HRSA) Area Resource File (ARF) for 1998. METHODS: Preventable hospitalizations due to 14 ambulatory care sensitive conditions were identified using the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators. Multiple regressions were used to determine the association between preventable hospitalizations and HMO penetration while controlling for demographic and socioeconomic characteristics and health care capacity of the counties. PRINCIPAL FINDINGS: A 10 percent increase in HMO penetration was associated with a 3.8 percent decrease in preventable hospitalizations (95 percent confidence interval, 2.0 percent-5.6 percent). Advanced age, female gender, poor health, poverty, more hospital beds, and fewer primary care physicians per capita were significantly associated with more preventable hospitalizations. CONCLUSIONS: Our study suggests that HMO penetration has significant effects in reducing preventable hospitalizations due to some ambulatory care sensitive conditions.