Article Figures & Data
Figures
- Figure 1.
Unweighted frequencies and weighted percentages of the study populations of physicians (left) and Medicare beneficiaries (right), based on the Center for Studying Health System Change Physician Survey linked with Medicare claims, 2007 to 2009. ACSC, ambulatory care–sensitive condition; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; E&M, evaluation and management visit; HSC, Center for Studying Health System Change; NPI, National Provider Identifier.
Tables
- Table 1. Prevalence of Practice Supports Among Usual Primary Care Physician Respondents Caring for the Study Sample of Patients With One or More of Four Chronic Conditions, 2008*
Practice Support Beneficiaries Whose PCP Had the Practice Support (%) PCP communication with patients and other specialists about specialist care received (% that said “Always” or “Most of the Time”) 1. How often do you know about all visits that your patients make to other physicians? 50.9 2. When you refer a patient to a specialist, how often do you send the specialist notification of patient's history and reason for consultation? 68.9 3. How often do you receive useful information about your referred patients from specialists? 66.5 4. After your patient has seen a specialist, how often do you talk with the patient or family members about the results of the visits(s) with the specialist? 61.8 Health information technology (extent of use) 1. Physician's main practice uses an electronic health record Yes 44.2 No 55.8 2. Clinical information technology function is available in practice and used personally by respondent occasionally or routinely: a. To email patients 14.9 b. To provide reminders to clinicians of preventive services 35.2 c. To provide reminders to clinicians on follow-up 32.3 d. To generate reminders to patients about preventive services 35.2 e. To access patient notes, medication lists, or problem lists 48.4 f. To order lab or other diagnostic tests 49.8 g. To view test results 73.5 h. To access practice guidelines 80.4 i. For clinical decision support 65.1 j. To obtain information on formularies 42.3 k. To obtain information on potential drug interactions, allergies 67.4 l. To write prescriptions 38.4 m. To transmit prescriptions to pharmacy 36.4 Nurse and patient educator care management (% yes) 1. Nurse care managers monitor and coordinate the care of patients with: Asthma 10.8 Diabetes 21.9 Congestive heart failure 15.7 2. Nonphysician staff educate patients in managing that condition Asthma 23.0 Diabetes 43.6 Congestive heart failure 21.4 Quality and performance measurement for your own patients (% yes) 1. Receives reports on preventive care quality from practice/organization or health plan 59.5 2. Receives reports on quality of chronic care from practice/organization or health plan 65.0 3. How large of an effect do written practice guidelines have on your practice of medicine (% large or very large) 29.0 4. Participates in quality reporting programs sponsored by outside organizations like CMS 25.8 Registry Receives reports or patient lists of your own patients from your practice or health plan registry (% yes) 37.5 Data source: Medicare claims from years 2007 to 2009 and linked Center for Studying Health System Change (HSC) nationally representative Physician Survey (2008).
↵* Analytic sample is the 123,760 (unweighted frequency; weighted count, N = 1,359,053) Medicare fee-for-service beneficiaries with any one or more of 4 chronic conditions (asthma, diabetes, congestive heart failure) whose usual primary care physician (PCP) was a respondent to the HSC nationally representative physician survey (2008).
CMS, Centers for Medicare & Medicaid Services; PCP, primary care physician.
- Table 2. Characteristics of Study Sample of Medicare Beneficiaries with One or More of Four Key Chronic Conditions
Beneficiary Characteristics Beneficiaries in Sample* Age (years) 65–74 51.0 75–84 33.7 ≥85 15.3 Female sex 57.9 Median income in ZIP code area ($) 0–43,541 33.2 43,541–58,773 33.1 ≥58,773 33.7 Medicaid dual eligibles 11.4 Patients with chronic condition of interest Asthma/COPD 56.6 Diabetes 54.6 Congestive heart failure 21.8 Prior ambulatory care–sensitive hospitalization in 2007† 2.0 HCC score‡ Mean 1.18 Median 0.89 Mode 0.30 Range 0.29–13.59 Data are percentages unless otherwise indicated.
Data sources: Medicare claims from years 2007 to 2009 for 123,760 beneficiaries whose usual physician was a respondent to the Center for Studying Health System Change Physician Survey 2008 and whose specialty could plausibly be a “medical home,” that is, family medicine, general internal medicine, geriatrics, medicine/pediatrics.
↵* These 123,760 beneficiaries represent a weighted sample of 1,359,053 Medicare beneficiaries.
↵† Ambulatory care–sensitive conditions of interest for this analysis were diabetes, chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure.
↵‡ HCC is the hierarchical coexisting conditions score (for the analytic sample, which is sicker than the general Medicare population) based on community-dwelling Medicare beneficiaries. A higher score indicates more severe comorbidity.
- Table 3. Ambulatory Care–Sensitive Condition Hospitalizations for Medicare Beneficiaries With Chronic Conditions, According to Practice Supports and Patient and Practice Characteristics (Main Effects Model)
ACSC Hospitalization, 2008–2009 Primary care practice supports (extent of use) PCP communicates with patient and with other specialists about specialist care received Lower tercile (reference) 1 Middle tercile 0.88 (0.80, 0.96)* Upper tercile 0.81 (0.74, 0.89)† Extent of HIT use Lower tercile (reference) 1 Middle tercile 1.08 (0.99, 1.18) Upper Tercile 1.07 (0.98, 1.18) Registry or patient list (vs none) 1.00 (0.92, 1.09) Nurse and patient educator care management Lower tercile (reference) 1 Middle tercile 1.03 (0.94, 1.13) Upper tercile 1.02 (0.93, 1.12) Quality and performance measurement Lower tercile (reference) 1 Middle tercile 0.98 (0.83, 1.16) Upper tercile 1.00 (0.83, 1.22) Patient characteristics HCC score (already adjusted for age, sex, and dual Medicaid eligibility) Lower tercile (reference) 1 Middle tercile 2.18 (1.89, 2.51)† Upper tercile 5.30 (4.66, 6.04)† ACSC hospitalization in prior year (vs none)‡ 5.78 (5.05, 6.62)† Income (median) in ZIP code Lower tercile 1.28 (1.16, 1.40)* Middle tercile 1.11 (1.02, 1.22)§ Upper tercile (reference) 1 Patient race/ethnicity White 1 Black 1.13 (0.97, 1.30) Hispanic 1.09 (0.85, 1.41) Other 0.87 (0.65, 1.16) Practice characteristics Revenue from Medicare (%) 0–30 (reference) 1 31–50 1.16 (1.05, 1.27)* 51–100 1.17 (1.07, 1.29)† Practice size (no. of physicians) 1–2 1 3–10 1.04 (0.95, 1.14) 11–49 1.04 (0.93, 1.17) ≥50 0.97 (0.85, 1.11) Practice type Independent practice (physician owned) 1 Community health center 0.74 (0.50, 1.08) Hospital-based outpatient practice/clinic† 0.96 (0.77, 1.19) Data are odds ratio (95% confidence limits). All estimates are adjusted for all the other variables listed in the first column as well as for the urban influence codes (large metro, small metro, micropolitan, rural). All analyses were conducted in SUDAAN and accounted for clustering of patients within physicians.
Data Source: Linked data from the nationally representative Center for Studying Health System Change (HSC) Physician Survey (2008) and Medicare fee-for-service claims for the years 2007 to 2009 for all beneficiaries for whom a physician from the HSC national survey was their usual source of care. Usual source of care was determined by the plurality algorithm for evaluation and management visits.
↵* P < .01 vs reference group, two-sided test.
↵† P < .001 vs reference group, two-sided test.
↵‡ Ambulatory care–sensitive conditions (ACSCs) examined included congestive heart failure, chronic obstructive pulmonary disease, asthma and diabetes. ACSC hospitalizations for any one or more of these conditions (combined rate) were calculated using claims for 2008 and 2009 (the numerator). The denominator for all analyses is 123,760 patients with one or more of these chronic conditions (identified in 2007–2008 claims).
↵§ P < .05 vs reference group, two-sided test.
HCC, hierarchical condition category score; HIT, health information technology; PCP, primary care physician.
- Table 4. Ambulatory Care–Sensitive Condition Hospitalizations for Medicare Beneficiaries With Chronic Conditions, Stratified by Usual Primary Care Physician's Level of Health Information Technology Use According to Practice Supports and Patient and Practice Characteristics
ACSC Hospitalizations, 2008 to 2009 Low HIT Medium HIT High HIT OR (95% CL) OR (95% CL) OR (95% CL) Primary care Practice Supports (extent of use) PCP communicates with patient and with other specialists about specialist care received Lower tercile (reference) 1 1 1 Middle tercile 0.92 (0.79, 1.07) 0.98 (0.84, 1.14) 0.79 (0.67, 0.92)* Upper tercile 1.00 (0.85, 1.18) 0.75 (0.65, 0.88)† 0.70 (0.59, 0.82)† Registry or patient list (vs none) 0.91 (0.77, 1.07) 1.00 (0.87, 1.16) 1.08 (0.94, 1.25) Nurse and patient educator care management Lower tercile (reference) 1 1 1 Middle tercile 0.94 (0.80, 1.10) 0.83 (0.71, 0.98)‡ 1.40 (1.18, 1.67)* Upper tercile 1.06 (0.90, 1.24) 0.97 (0.81, 1.16) 1.11 (0.93, 1.32) Quality and performance measurement Lower tercile (reference) 1 1 1 Middle tercile 0.98 (0.83, 1.16) 0.97 (0.83, 1.12) 0.90 (0.76, 1.07) Upper tercile 1.00 (0.83, 1.22) 1.01 (0.84, 1.23) 0.88 (0.74, 1.05) Patient characteristics HCC score (already adjusted for age, sex, and dual Medicaid eligibility) Lower tercile (reference) 1 1 1 Middle tercile 2.16 (1.65, 2.81)† 2.08 (1.64, 2.63)† 2.33 (1.84, 2.95)† Upper tercile 5.30 (4.12, 6.83)† 5.07 (4.12, 6.22)† 5.44 (4.38, 6.77)† ACSC hospitalization in prior year (vs none)§ 5.35 (4.17, 6.87)† 5.55 (4.45, 6.92)† 6.52 (5.12, 8.28)† Income (median) in zip code Lower tercile 1.26 (1.06, 1.47)* 1.24 (1.06, 1.45)* 1.21 (1.02, 1.43)‡ Middle tercile 1.16 (1.00, 1.38) 1.03 (0.89, 1.19) 1.04 (0.89, 1.23) Upper tercile (ref) 1 1 1 Patient race/ethnicity White 1 1 1 Black 1.16 (0.90, 1.47) 1.18 (0.93, 1.52) 1.04 (0.80, 1.36) Hispanic 1.03 (0.65, 1.61) 1.23 (0.79, 1.90) 1.09 (0.71, 1.65) Other 0.79 (0.44, 1.40) 1.12 (0.75, 1.65) 0.70 (0.46, 1.06) Practice characteristics Revenue from Medicare (%) 0–30 (reference) 1 1 1 31–50 1.12 (0.94, 1.33) 1.58 (1.28, 1.94)† 1.04 (0.89, 1.22) 51–100 1.25 (1.06, 1.47)* 1.25 (1.06, 1.48)* 1.18 (0.98, 1.40) Practice size (no. physicians) 1–2 1 1 1 3–10 1.01 (0.87, 1.16) 1.29 (1.09, 1.53) 0.98 (0.83, 1.16) 11–49 1.11 (0.88, 1.39) 1.17 (0.94, 1.46) 0.90 (0.74, 1.09) ≥50 1.28 (0.96, 1.72) 0.96 (0.73, 1.24) 0.83 (0.67, 1.03) Practice type Independent practice (physician owned) 1 1 1 Community health center 0.62 (0.30, 1.27) 1.22 (0.67, 2.21) 0.66 (0.29, 1.50) Hospital-based outpatient practice/clinic† 0.71 (0.46, 1.08) 1.06 (0.69, 1.63) 1.17 (0.90, 1.51) Data are odds ratio (95% confidence limits). The first data column is the subgroup of beneficiaries whose usual physician has low HIT use, the middle column has medium HIT use, and the right-hand column has high HIT use. All estimates are adjusted for all the other variables listed in the first column as well as for the urban influence codes (large metro, small metro, micropolitan, rural). All analyses were conducted in SUDAAN and accounted for clustering of patients within physicians.
Data source: Linked data from the nationally representative Center for Studying Health System Change (HSC) Physician Survey (2008) and Medicare fee-for-service claims for the years 2007 to 2009 for all beneficiaries for whom a physician from the HSC national survey was their usual source of care. Usual source of care was determined by the plurality algorithm for evaluation and management visits.
↵* P < .01, vs reference group, two-sided test.
↵† P < .001, vs reference group, two-sided test.
↵‡ P < .05, vs reference group, two-sided test.
↵§ Ambulatory care–sensitive conditions (ACSCs) examined included congestive heart failure, chronic obstructive pulmonary disease, asthma and diabetes. ACSC hospitalizations for any one or more of these conditions (combined rate) were calculated using claims for 2008 and 2009 (the numerator). The denominator for all analyses is the 123,760 patients with one or more of these chronic conditions (identified in 2007–2008 claims).
CL, confidence limit; HCC, hierarchical condition category; HIT, health information technology; OR, odds ratio; PCP, primary care physician.
- Table A1. International Classification of Diseases, Ninth Revision, Clinical Modification, Diagnosis Codes Used in Search
Diabetes (short- and long-term complications and uncontrolled diabetes) 25010–25013, 25020–25023, 25030–25033 25040–25043, 25050–25053, 25060–25063, 25070–25073, 25080–25083, 25090–25093 8410–8419 25000–25003, 25010–25013, 25020–25023, 25030–25033, 25040–25043, 25050–25053, 25060–25063, 25070–25073, 25080–25083, 25090–25093 Chronic obstructive pulmonary disease/adult asthma 490* 4660* 4910 4911 49120 49121 4918 4919 4920 4928 494 4940 4941 496 49300–49302, 49310–48312, 49320–49322, 49381–49382, 49390–49392 Congestive heart failure 39891, 40201, 40211, 40291, 40401, 40403, 40411, 40413, 40491, 40493, 4280, 4281, 42820, 42821–42823, 42830–42833, 42840–42843, 4289 ↵* Qualifies only if accompanied by secondary diagnosis of any other code on this list.
- Table A2. Interaction Between Interspecialty Communication and Ambulatory Care–Sensitive Hospitalizations for Patients With Chronic Conditions, Stratified by Personal Primary Care Physician's Level of Health Information Technology Use (Unadjusted Percentages)
PQI Hospitalizations in 2008 or 2009 (%) Low HIT Medium HIT High HIT PCP communicates with patient and with other specialists about specialist care received Lower tercile (reference) 2.47 2.82 2.78 Middle tercile 2.09 2.50 2.45 Upper tercile 2.50 2.04 1.90 P value <.0001 <.0001 <.0001 The first column is the subgroup of beneficiaries in practices whose usual physician has low health information technology (HIT) use, the middle column has medium HIT use and the far right column has high HIT use.
Data source: Linked data from the nationally representative Center for Studying Health System Change (HSC) Physician Survey (2008) and Medicare fee-for-service claims for the years 2007 to 2009 for all beneficiaries for whom a physician from the HSC national survey was their usual source of care. Usual source of care was determined by the plurality algorithm for evaluation and management visits.
Ambulatory care–sensitive conditions (ACSCs) examined included congestive heart failure, chronic obstructive pulmonary disease, asthma, and diabetes. ACSC hospitalizations for any one or more of these conditions (combined rate) were calculated using claims for 2008 and 2009 (the numerator). The denominator for all analyses is the 123,760 patients with one or more of these chronic conditions (identified in 2007–2008 claims).
PCP, primary care physician; PQI, prevention quality indicators.
