Characterizing Physician Practice in Nursing Homes Using Claims-Based Measures: Correlation With Nursing Home Administrators’ Perceptions

Abstract

Heterogeneity in physician practice within nursing homes (NHs) may explain variations in quality. However, data on physician practice organization in NHs are hard to obtain. We characterized NH physician practice using two claims-based measures: (a) concentration of NH care among physicians (measured by Herfindahl–Hirschman index of visits); and (b) physician NH practice specialization (measured by the proportion of a physician’s visits to NHs). We examined the relationship between the measures and NH administrator perceptions of physician practice reported in the Shaping Long-Term Care in America (SLTCA) Survey. All 2011 Part B claims from 13,718 physicians who treated Medicare fee-for-service patients in 2,095 NHs in the SLTCA survey were analyzed. The median Herfindahl–Hirschman index was 0.44 (interquartile range [IQR] 0.28-0.70), and the median specialization was 38.1% (IQR 19.9% to 60.9%). NHs with higher physician specialization reported more frequent physician participation in care coordination activities. Claims-based measures could inform the study of NH physician practice.

Clinicians who primarily practice in nursing homes and outcomes among residents with urinary tract infection or pneumonia

“…There is a growing body of evidence on the impact of "specialization" in NH care on resident outcomes, including potentially avoidable hospitalizations, healthcare costs, clinical quality measures, and potentially harmful medication prescribing. [13][14][15][16][17][18][19][20][21][22][23] However, information related to antibiotic prescribing and infection-related outcomes is limited. Currently, no set of standardized criteria exists to define clinicians who primarily practice in NHs.…”

“…Prior literature has examined relationships between clinicians who primarily practice in NHs and potentially avoidable hospitalizations, healthcare costs, clinical quality measures, and potentially harmful medication prescribing, although the impact on infection-related outcomes is understudied. 6,[13][14][15][16][17][18][19][20][21][22][23] If differences in antibiotic prescribing patterns and clinical outcomes differ for residents treated by clinicians who do versus do not primarily practice in NHs, then it could be beneficial for antibiotic stewardship programs to strategically adapt interventions and target them to clinicians based on clinician effort in NHs to improve infection-related outcomes. 24 The objective of this study was to examine the association between clinicians who primarily practiced in NHs and infectionrelated outcomes among U.S. NH residents who were treated with antibiotics for urinary tract infection (UTI) or pneumonia.…”

US Generalist Physicians and Groups That Focused Practice in a Single Care Setting

“…In contrast, setting-based specialization by generalists may better align their expertise with the increasing medical complexity of the aging patient population. For instance, physicians who focus their practice in nursing homes may be more experienced in treating patients with cognitive impairment and communicating with caregivers 14 and may have the ability to organize their practice around the ebb and flow of clinical demands specific to nursing homes 15. In contrast, generalists who limit their practice to a single setting may be less well-equipped to coordinate care and facilitate smooth patient transitions between settings, experience a loss of professional autonomy,16 and miss personal satisfaction from maintaining longitudinal relationships with patients 17…”

Medication safety in nursing home patients

“…Residents may also have difficulty advocating for themselves whether or not they suffer from cognitive impairment. At the same time though, nursing home patients often have multiple comorbidities and have elevated risk of medication adverse effects, and they may see physicians relatively infrequently, as clinical staffing models vary widely between facilities 11 12…”