Background: Physicians’ time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length. Objective: To measure how much time primary care physicians spend with their patients, during each visit. Research Design: We used a national source of EHR data for primary care practices, from a large health information technology company. We calculated exam length and schedule deviations based on timestamps recorded by the EHR, after implementing sequential data refinements to account for non–real-time EHR use and clinical multitasking. Observational analyses calculated and plotted the mean, median, and interquartile range of exam length and exam length relative to scheduled visit length. Subjects: A total of 21,010,780 primary care visits in 2017. Measures: We identified primary care visits based on physician specialty. For these visits, we extracted timestamps for EHR activity during the exam. We also extracted scheduled visit length from the EHR’s practice management functionality. Results: After data refinements, the average primary care exam was 18.0 minutes long (SD=13.5 min). On average, exams ran later than their scheduled duration by 1.2 minutes (SD=13.5 min). Visits scheduled for 10 or 15 minutes were more likely to exceed their allotted time than visits scheduled for 20 or 30 minutes. Conclusions: Time-stamped EHR data offer researchers and health systems an opportunity to measure exam length and other objects of interest related to time.
Despite the Affordable Care Act's push to improve the coordination of care for patients with multiple chronic conditions, most measures of coordination quality focus on a specific moment in the care process (e.g., medication errors or transfer between facilities), rather than patient outcomes. One possible supplementary way of measuring the care coordination quality of a facility would be to identify the patients needing the most coordination, and to look at outcomes for that group. This paper lays the groundwork for a new measure of care coordination quality by outlining a conceptual framework that considers the interaction between a patient's interdisciplinarity, biological susceptibility, and procedural intensity. Interdisciplinarity captures the degree of specialized medical expertise needed for a patient's care and will be an important measure to estimate the number of specialists a patient might see. We then develop a preliminary measure of interdisciplinarity and run tests linking interdisciplinarity to medical mistakes, as defined by Agency for Healthcare Research and Quality's Patient Safety Indicators. Finally, we use our preliminary measure to verify that interdisciplinarity is likely to be statistically different from existing measures of comorbidity, like the Charlson score. Future research will need to build upon our findings by developing a more statistically validated measure of interdisciplinarity.
Objective To describe physicians’ variation in de‐adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence. Data Sources We analyzed 2007‐2015 claims data from OptumLabs® Data Warehouse, a longitudinal, real‐world data asset with de‐identified administrative claims and electronic health record data. Study Design We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty. Data Extraction We identified patient‐year‐quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients’ diabetes care based on evaluation and management visits and prescriptions of glucose‐lowering drugs. Principal Findings Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, −0.18 to −0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, −0.06 to −0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians’ characteristics did not explain their variation (pseudo R2 = 0.000). Conclusion On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de‐adoption settings.
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