The Intersection of Patient Complexity, Prescriber Continuity and Acute Care Utilization

Maciejewski, Matthew L.; Powers, Benjamin; Sanders, Linda; Farley, Joel F.; Hansen, Richard A.; Sleath, Betsy; Voils, Corrine I.

doi:10.1007/s11606-013-2746-0

Cited by 37 publications

(59 citation statements)

References 23 publications

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“…Yunyongying and Gove for their interest in our article on prescriber continuity and health care utilization. 1 We agree with the authors that one should not infer that having more prescribers of cardiometabolic medications causes increased emergency room visits and hospital admissions. We were careful to use the term "association" throughout the paper and specifically noted in the limitations that the "observational study design used in our study introduces the possibility of unobserved confounding, which precludes causal inference…"…”

supporting

confidence: 58%

Patient Complexity, Prescriber Continuity and Acute Care

Maciejewski

Voils

2014

J GEN INTERN MED

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A uthor's Reply-We thank Drs. Yunyongying and Gove for their interest in our article on prescriber continuity and health care utilization. 1 We agree with the authors that one should not infer that having more prescribers of cardiometabolic medications causes increased emergency room visits and hospital admissions. We were careful to use the term "association" throughout the paper and specifically noted in the limitations that the "observational study design used in our study introduces the possibility of unobserved confounding, which precludes causal inference…"We also agree that not all providers and not all visits are equal because some have a greater impact on patient health than others. In future work, we intend to refine this claimsbased measure of Continuity of Medication Management (via counts of cardiometabolic prescribers) to try to account for this fact.Although we agree with the authors on these points, we disagree that disease complexity was not addressed. We adjusted for patient-level disease complexity via a validated set of chronic condition indicators from the Gagne score 2 and the number of cardiometabolic medications. We also examined cardiometabolic-specific utilization in addition to all-cause utilization, because these outcomes might more plausibly be related to coordination of care among cardiometabolic prescribers.Finally, the criticism that we failed to examine potentially more predictive provider-level factors, such as extent of care coordination between providers, is unreasonable for claims-based analyses, because there are no validated measures of this construct. We agree that this construct may be critical to understand the quality of care coordination interventions, but its measurement may require qualitative assessment or survey measurement. Construction of a claims-based measure of care coordination is not currently feasible.It is important to determine how to provide optimal care to patients, particularly those with multiple chronic conditions. Our manuscript represents the start of this challenging research agenda by presenting a "proof of concept" analysis, which suggested that having multiple prescribers is associated with risk for avoidable health care utilization. We aim to conduct additional research to determine how best to measure the construct of continuity of medication management, to understand its comparative utility over traditional continuity of care measures, and to further validate these initial findings.

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supporting

confidence: 58%

Patient Complexity, Prescriber Continuity and Acute Care

Maciejewski

Voils

2014

J GEN INTERN MED

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“…In contrast to findings from studies conducted elsewhere [4,[25][26][27], we found that patients who consulted multiple prescribers did not have an increased risk of drug-related visits. In Malaysia, the major provider of healthcare is the Ministry of Health, which has a network of hospitals and health clinics, with the second major provider being the private sector.…”

Section: Discussioncontrasting

confidence: 99%

Factors Associated with Drug-Related Emergency Department Visits at a Teaching Hospital in Malaysia

2017

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Introduction Adverse drug events (ADEs) are a significant health problem globally, with the emergency department (ED) being an important environment for the detection of ADEs. Data regarding drug-related visits to the ED in Malaysia are currently limited.Objectives The aim of this study was to determine factors associated with prescription drug-related ED visits at a teaching hospital. Methods A case-control study was conducted on patients who visited the ED of Hospital Universiti Sains Malaysia over a 7-week period between December 2014 and January 2015. A visit to the ED was considered drug-related if the chief presenting complaint was related to prescription drug use. Data were collected by interviewing patients, and also from the patient's medical record. Multiple logistic regression was applied to determine the risk factors. Results Overall, 144 physician-identified patients with drug-related ED visits were considered as cases and 288 patients with non-drug-related complaints were selected as controls. Independent risk factors identified for drug-related ED visits were female sex (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.03-2.71), currently taking regular medication (OR 3.4, 95% CI 1.87-6.05), concurrent comorbidity (OR 2.3, 95% CI 1.28-4.10), a history of drug allergy (OR 5.36, 95% CI 2.30-12.48), and recent hospital admission (OR 2.85, 95% CI 1.23-4.10). Independent risk factors were also associated with the following health problems: diabetes mellitus (OR 6.83, 95% CI 3.30-14.12), central nervous system disorders (OR 9.42, 95% CI 3.08-14.12), and cardiovascular disorders (OR 2.5, 95% CI 1.25-4.79).Conclusions The determinants of a drug-related ED visit at a teaching hospital are multifactorial. Interventions to prevent future occurrences should focus on those patients at risk. Key PointsFemale sex, receiving regular medication, having a history of drug allergy, and recent hospital admission are risk factors for prescription drug-related emergency department (ED) visits.Patients with health problems such as diabetes, central nervous system disorders, and cardiovascular disorders also have a higher risk of ED visits related to drug use.The most common drug classes involved with drugrelated ED visits were antidiabetic agents, antihypertensives, antibiotics, anti-asthmatics, and diuretics.

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“…22 Therefore, many patients with multiple chronic conditions seek care from multiple providers, which can introduce disruptions in care continuity and result in adverse health outcomes and reduced quality of care. 23 Nevertheless, because the medical home model emphasizes care management and care coordination, it may also be a successful model for providing guideline-concordant diabetes care among individuals with diabetes and co-occurring chronic health and mental health conditions. 23 …”

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“…23 Nevertheless, because the medical home model emphasizes care management and care coordination, it may also be a successful model for providing guideline-concordant diabetes care among individuals with diabetes and co-occurring chronic health and mental health conditions. 23 …”

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confidence: 99%

Do Medical Homes Offer Improved Diabetes Care for Medicaid Enrollees with Co-occurring Schizophrenia?

Olesiuk¹,

Farley²,

Domino³

et al. 2017

Journal of Health Care for the Poor and Underserved

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Purpose To determine whether Medicaid recipients with co-occurring diabetes and schizophrenia that are medical-home-enrolled are more likely to receive guideline-concordant diabetes care than those who are not medical-home-enrolled, controlling for confounders. Methods We used administrative data on adult, non-dually eligible North Carolina Medicaid beneficiaries with diagnoses of both diabetes and schizophrenia (N=3,897) for fiscal years 2008–2010. We evaluated the relationship between medical-home-enrollment and receipt of recommended diabetes care reimbursed by Medicaid (lipid profiles, HbA1c tests, medical attention for nephropathy, and eye exams for those over 30), using fixed-effects regression models on person-month level data. Results There was a statistically significant, positive effect of medical home enrollment on receipt of Medicaid-funded eye exams, HbA1c tests, and medical attention for nephropathy, but not receipt of lipid profiles. Conclusions For Medicaid enrollees with diabetes and schizophrenia, medical home enrollment is generally associated with greater likelihood of receiving guideline-concordant diabetes care.

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The Intersection of Patient Complexity, Prescriber Continuity and Acute Care Utilization

Abstract: Having more prescribers was associated with greater healthcare utilization for complex patients, despite adjustment for the number of conditions and medications. The number of prescribers may be an appropriate target for reducing acute care utilization by complex patients.

Cited by 37 publications

References 23 publications

Patient Complexity, Prescriber Continuity and Acute Care

Patient Complexity, Prescriber Continuity and Acute Care

Factors Associated with Drug-Related Emergency Department Visits at a Teaching Hospital in Malaysia

Do Medical Homes Offer Improved Diabetes Care for Medicaid Enrollees with Co-occurring Schizophrenia?

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