Objective. To develop and characterize utilization‐based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. Data Source/Study Setting. The 1996–1997 Part B and 1996 Outpatient File primary care claims for fee‐for‐service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). Study Design. A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. Data Collection/Extraction Methods. Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. Principal Findings. The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005–1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. Conclusions. Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.

Objective To examine whether perceived discrimination based on multiple personal characteristics is associated with physical, emotional, and cognitive health concurrently, prospectively, and with change in health over time among older adults. Design : Longitudinal Setting Health and Retirement Study (HRS) Participants Participants (N=7,622) who completed the Leave-Behind Questionnaire as part of the 2006 HRS assessment (mean age 67); participants (n=6,450) completed the same health measures again in 2010. Measurements Participants rated their everyday experience with discrimination and attributed those experiences to eight personal characteristics: race, ancestry, sex, age, weight, physical disability, appearance, and/or sexual orientation. At both the 2006 and 2010 assessments, participants completed measures of physical health (subjective health, disease burden), emotional health (life satisfaction, loneliness), and cognitive health (memory, mental status). Results Discrimination based on age, weight, physical disability, and appearance was associated with poor subjective health, greater disease burden, lower life satisfaction and greater loneliness at both assessments and with declines in health across the four years. Discrimination based on race, ancestry, sex, and sexual orientation was associated with greater loneliness at both time points, but not with change over time. Discrimination was mostly unrelated to cognitive health. Conclusions The detrimental effect of discrimination on physical and emotional health is not limited to young adulthood but continues to contribute to health and well-being in old age. These effects were driven primarily by discrimination based on personal characteristics that change over time (e.g., age, weight) rather than discrimination based on more stable characteristics (e.g., race, sex).

Objective: To examine care system choices for Veterans dually-eligible for VA and Medicare FFS following changes in VA eligibility policy, which expanded availability of VA health care services. Conclusions:Veterans newly eligible for VA healthcare services, particularly those with the highest risk scores, had higher odds of dual system use compared to earlier eligibles. Providers should ensure coordination of care for Veterans who may be receiving care from multiple sources. Provisions of the Patient Protection and Affordable Care Act may help to ensure care coordination for persons receiving care from multiple systems.

Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.

BackgroundOlder patients with multiple chronic conditions are often faced with increased health care needs and subsequent higher medical costs, posing significant financial burden to patients, their caregivers, and the health care system. The increasing adoption of electronic health record systems and the proliferation of clinical data offer new opportunities for prevalence studies and for population health assessment. The last few years have witnessed an increasing number of clinical research networks focused on building large collections of clinical data from electronic health records and claims to make it easier and less costly to conduct clinical research.ObjectiveThe aim of this study was to compare the prevalence of common chronic conditions and multiple chronic conditions in older adults between Florida and the United States using data from the OneFlorida Clinical Research Consortium and the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS).MethodsWe first analyzed the basic demographic characteristics of the older adults in 3 datasets—the 2013 OneFlorida data, the 2013 HCUP NIS data, and the combined 2012 to 2016 OneFlorida data. Then we analyzed the prevalence of each of the 25 chronic conditions in each of the 3 datasets. We stratified the analysis of older adults with hypertension, the most prevalent condition. Additionally, we examined trends (ie, overall trends and then by age, race, and gender) in the prevalence of discharge records representing multiple chronic conditions over time for the OneFlorida (2012-2016) and HCUP NIS cohorts (2003-2013).ResultsThe rankings of the top 10 prevalent conditions are the same across the OneFlorida and HCUP NIS datasets. The most prevalent multiple chronic conditions of 2 conditions among the 3 datasets were—hyperlipidemia and hypertension; hypertension and ischemic heart disease; diabetes and hypertension; chronic kidney disease and hypertension; anemia and hypertension; and hyperlipidemia and ischemic heart disease. We observed increasing trends in multiple chronic conditions in both data sources.ConclusionsThe results showed that chronic conditions and multiple chronic conditions are prevalent in older adults across Florida and the United States. Even though slight differences were observed, the similar estimates of prevalence of chronic conditions and multiple chronic conditions across OneFlorida and HCUP NIS suggested that clinical research data networks such as OneFlorida, built from heterogeneous data sources, can provide rich data resources for conducting large-scale secondary data analyses.

We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.

No abstract

OBJECTIVE: Identifying racial and ethnic differences in perceived need for treatment among families of children with autism spectrum disorder (ASD) will improve understanding of disparities in care seeking. We described racial and ethnic differences in perceived need for services that children with ASD and their families frequently use. METHODS:We conducted bivariate analyses of racial and ethnic categories and perceived need for 6 common services used by children with ASD as found in the 2005 to 2006 (n = 2123) and the 2009 to 2010 (n = 3055) National Survey of Children With Special Health Care Needs data sets. Multivariate logistic regressions within concatenated data sets were conducted to examine associations between racial and ethnic category and perceived service needs while controlling for predisposing, enabling, and child factors. RESULTS:Compared with caregivers of white non-Hispanic children with ASD, caregivers of Hispanic children reported less need for prescription medications in adjusted multivariate analyses. Caregivers of black non-Hispanic children with ASD reported less need for prescription medications and for child and family mental health services than caregivers of white non-Hispanic children. Both English-speaking Hispanic caregivers and black nonHispanic caregivers reported greater need for occupational, speech, and physical therapy than white non-Hispanic caregivers. No racial or ethnic differences were found in perceived need for specialty medical care or respite care. CONCLUSIONS:Caregivers of children with ASD from different racial and ethnic backgrounds may differentially perceive need for different types of care. Their perceptions may in turn affect how they prioritize and seek care, independent of their child's specific needs. Dr Benevides conceptualized and designed the study, analyzed the data, and drafted the initial manuscript; Dr Carretta contributed to the study design, data management, data analysis, and interpretation of the fi ndings and critically reviewed and revised the manuscript; Dr Mandell contributed to the study design and interpretation of the fi ndings and critically reviewed and revised the manuscript; and all authors approved the fi nal manuscript as submitted. [2][3][4] However, caregivers of children with ASD have reported that obtaining appropriate and timely care is often difficult and costly, 5 and many are dissatisfied with the process of obtaining care. 6,7 Caregivers of children with ASD report more unmet needs for a variety of services than caregivers of children with other emotional, developmental, or behavioral difficulties. 8,9 Caregivers of children with ASD who are from racial or ethnic minority groups experience even greater difficulty than nonminority caregivers obtaining care. [10][11][12][13][14] Authors of these studies finding racial or ethnic differences in type and quality of care suggest that these differences may not result solely from health care system or provider factors (eg, availability of providers, sensitivity of provide...