ABSTRACT
Goals: Sufferers with complicated persistent circumstances have various multidisciplinary care wants and utilization patterns, which restrict the effectiveness of initiatives designed to enhance continuity of care (COC) and cut back utilization. Our goal was to categorize sufferers with complicated persistent circumstances into distinct teams by sample of outpatient care use and COC to tailor interventions.
Examine Design: Observational cohort examine from 2014 to 2015.
Strategies: We recognized sufferers whose 1-year hospitalization danger was in at the least the ninetieth percentile in 2014 who had a persistent gastrointestinal illness (cirrhosis, inflammatory bowel illness, persistent pancreatitis) as case examples of complicated persistent illness. We described frequency of workplace visits, variety of outpatient suppliers, and a pair of COC measures (ordinary supplier of care, Bice-Boxerman COC indices) over 12 months. We used latent profile evaluation, a statistical technique for figuring out distinct subgroups, to categorize sufferers based mostly on total, main care, gastroenterology, and psychological well being continuity patterns.
Outcomes: The 26,751 veterans within the cohort had a imply (SD) of 13.3 (8.6) workplace visits and seven.2 (3.8) suppliers in 2014. Sufferers have been categorised into 5 subgroups: (1) excessive gastroenterology-specific COC with psychological well being use; (2) excessive gastroenterology-specific COC with out psychological well being use; (3) excessive total utilization with psychological well being use; (4) low total COC with psychological well being use; and (5) low total COC with out psychological well being use. These teams different of their sociodemographic traits and danger for hospitalization, emergency division use, and mortality.
Conclusions: Sufferers at excessive danger for well being care utilization with specialty care wants will be grouped by various propensity for well being care continuity patterns.
Am J Manag Care. 2023;29(3):In Press
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Takeaway Factors
- Sufferers with complicated persistent illness have various multidisciplinary care wants and utilization patterns, which restrict the effectiveness of initiatives designed to enhance continuity of care and cut back utilization.
- Sufferers with cirrhosis, persistent pancreatitis, and inflammatory bowel illness (as case examples of complicated persistent illness) will be grouped by various propensity for well being care continuity patterns.
- These various patterns may very well be harnessed to personalize care coordination interventions to optimize well being care utilization.
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Well being care is tormented by fragmentation, excessive prices, and low-value care each in the USA and globally.1 The US patient-centered medical dwelling (PCMH) mannequin was designed to enhance the person expertise of care, inhabitants well being, and per capita value of care by means of promotion of continuity of care (COC) with a main care supplier (PCP), who helps to coordinate different points of care. Continuity with a single PCP has been related to decrease well being care prices and lowered care utilization within the common inhabitants.2 Nonetheless, the PCMH mannequin, and measures designed to evaluate its advantages (equivalent to measures of COC), are largely tailor-made to common main care populations.
Complicated persistent illnesses are circumstances with excessive morbidity that require care by a number of suppliers, equivalent to diabetes difficult by kidney illness and peripheral neuropathy.3 Sufferers with complicated persistent circumstances that require persistent specialty care are liable to fragmentation, which is commonly related to poor health-related outcomes.4,5 These sufferers typically require care by a crew composed of PCPs and specialists (together with psychological well being suppliers), with a specialist typically serving as central coordinator. Within the setting of team-based care by a number of suppliers in a number of disciplines, COC measured throughout all suppliers declines, and claims-based care measures will inevitably seem extra fragmented.6-8 These sufferers have various multidisciplinary care wants and utilization patterns, and it’s unclear how typical interventions and continuity measures needs to be utilized to them.9,10
To higher inform and tailor interventions to enhance COC for sufferers with complicated persistent circumstances that require persistent specialty care and to scale back the implications of fragmentation—together with well being care overutilization, data loss, and discordant plans of care—we aimed to grasp the totally different patterns of outpatient care use and COC on this inhabitants, utilizing 3 complicated persistent circumstances as case examples. Our overarching goal is to leverage these 3 circumstances as a proof of idea, which may very well be extrapolated to different complicated persistent circumstances in future work. We hypothesized that we’d discover a number of totally different patterns of outpatient care and COC throughout outpatient main, specialty, and psychological well being care.
METHODS
Examine Inhabitants
The US Division of Veterans Affairs (VA) Veterans Well being Administration is a nationwide built-in well being system that has made substantial investments in enhancing the standard of well being care and monitoring and enhancing COC on a inhabitants well being stage. We carried out a cross-sectional evaluation of continuity patterns in VA sufferers with excessive ranges of well being care utilization utilizing knowledge from 2014 and 2015. The cohort for this evaluation was drawn from an ongoing examine of care continuity and fragmentation,11 the inhabitants for which included VA sufferers at excessive danger for hospitalization (1-year hospitalization danger better than or equal to ninetieth percentile in 2014, based mostly on the VA’s Care Evaluation Wants rating) and who have been alive on the finish of fiscal 12 months 2014.
Cirrhosis, persistent pancreatitis, and inflammatory bowel illness (IBD) are prototypical examples of complicated persistent circumstances. They’ve excessive morbidity and propensity for well being care overuse, necessitate high-intensity self-management by sufferers, and require multidisciplinary administration by each main care and gastroenterology suppliers. They’re additionally not supported inside current medical dwelling packages. Our analyses targeted on sufferers with 1 of those 3 persistent gastrointestinal (GI) circumstances. We chosen these GI circumstances to attenuate heterogeneity in COC amongst totally different specialty care disciplines. Sufferers with IBD, cirrhosis, and persistent pancreatitis have been recognized utilizing beforehand validated algorithms (eAppendix Determine 1 [eAppendix available at ajmc.com]).12-16
Sufferers have been required to have at the least 1 VA workplace go to in 2014 and have a minimal of 4 complete workplace visits that have been both within the VA or locally however lined by the VA. A minimal of 4 workplace visits is required to calculate the standard supplier of care index (UPC) and Bice-Boxerman COC index (COCI) with a fascinating stage of variation.17 This threshold of a minimal of 4 visits is normal in earlier research and addresses the bias towards reporting minimal variation in care fragmentation patterns when sufferers have low-volume care, whereas representing sufferers with a excessive burden of care.6,17-19
Variables of Curiosity
Outpatient VA visits and VA-covered group visits with physicians, nurse practitioners, doctor assistants, residents, psychologists, and licensed scientific social employees with a nationwide supplier identifier have been collected.20 PCPs included common follow, household follow, inner drugs, pediatric drugs, geriatric drugs, and preventive drugs suppliers. Psychological well being suppliers included specialists in psychiatry/neuropsychiatry, dependancy drugs, psychology, and scientific social work.
Well being care continuity patterns have been characterised utilizing a number of distinct measures: the frequency of workplace visits, the overall variety of outpatient suppliers, and a pair of claims-based COC measures. The two COC measures have been (1) the UPC and (2) the COCI (eAppendix Desk 1). The UPC is a measure of care density and captures the proportion of all visits which can be attributed to a affected person’s most ceaselessly visited supplier, whereas the COCI measures the extent to which a given particular person’s complete variety of visits for an episode of sickness or a selected time interval are with a single supplier.21 The indices vary from 0 to 1, the place 0 represents a situation by which every go to is made to a special supplier and 1 represents a situation by which all visits are made to a single supplier. We developed variants of every of the continuity measures as utilized to outpatient care total, in addition to PCP-specific, gastroenterology-specific, and psychological well being–particular outpatient care. Supplier-specific UPC and COCI measures have been thought of for sufferers with at the least 2 visits with a PCP, psychological well being supplier, or gastroenterologist in order that our findings can be generalizable to sufferers who noticed a selected supplier sort twice yearly, which is comparatively widespread.
We reported patient-level covariates together with age, gender, race, ethnicity, rural-urban commuting space designation, marital standing, and homelessness standing. These classifications are all laid out in VA Company Information Warehouse information. We recognized the variety of persistent circumstances and Charlson Comorbidity Index rating for every affected person utilizing Worldwide Classification of Illnesses, Ninth Revision, Scientific Modification codes.22-24 We additionally examined final result measures in fiscal 12 months 2015, which included hospitalization or loss of life, emergency division (ED) visits, and variety of outpatient visits.
Statistical Evaluation
We used latent profile evaluation, which is a model-based technique of clustering. Latent profile evaluation is a technique used to establish unobserved subgroups in a inhabitants, utilizing a specified set of variables from noticed knowledge and assuming inhabitants heterogeneity.25 We match a latent profile mannequin utilizing the gsem command in Stata (StataCorp) for a prespecified mixture of noticed steady and depend variables. We estimated the anticipated proportions of the inhabitants in every group. These lessons, or subgroups, have been then labeled with the marginal means of every noticed variables based mostly on subgroup. To look at goodness of match, we evaluated fashions with 3 to 10 subgroups, utilizing the Akaike data criterion (AIC) and Bayesian data criterion (BIC).26 The mannequin with the smallest values for AIC and BIC was thought of the mannequin with the most effective match. The anticipated chances of preselected affected person traits and well being care utilization values have been reported by class membership.
Sensitivity Analyses
The frequency of PCP-, psychological well being–, and gastroenterology-specific visits is total low, and subsequently there was concern that sufferers with good provider-specific continuity could bias the derivation and interpretation of the UPC and COCI measurements. Subsequently, we carried out a sensitivity evaluation, redefining the PCP-, psychological well being–, and gastroenterology-specific COC measures as a dichotomous variable, the place a provider-specific UPC and COCI of 1 was labeled as “single supplier.” In a second sensitivity evaluation we prolonged the earlier evaluation to incorporate an indicator variable to establish whether or not a PCP or psychological well being or gastroenterology supplier was the standard supplier of care. Associations amongst affected person traits, well being care utilization, and subgroup membership have been analyzed utilizing a χ2 take a look at and one-way evaluation of variance for categorical and steady variables, respectively. All analyses have been carried out in Stata/MP model 15 (StataCorp). This examine was authorized by the Palo Alto VA (affiliated with Stanford College) and Ann Arbor VA Institutional Overview Boards.
RESULTS
Cohort Description
We recognized 26,751 sufferers with persistent gastroenterology illness with a hospitalization danger rating within the high 10% and a minimal of 4 VA or VA-covered workplace visits in fiscal 12 months 2014 (eAppendix Determine 2). Amongst these sufferers, 4450 (16.7%) carried a prognosis of IBD, 17,568 (65.7%) had cirrhosis, and 5536 (20.7%) had persistent pancreatitis. A majority have been White (72.1%) and male (95.3%), and so they had a imply (SD) age of 62 (9.35) years and a imply (SD) Charlson Comorbidity Index rating of 4.5 (3.02). Total, 28.5% (n = 7623) of sufferers resided in rural areas, and 13.1% had a historical past of homelessness. Comorbid circumstances have been widespread on this cohort, with greater than half (56.3%) having 8 or extra persistent circumstances—amongst them, psychological well being circumstances, most cancers, weight problems, and alcohol use dysfunction have been widespread (Desk 1). Baseline well being care utilization in 2014 was excessive, with a imply (SD) of 1.3 (1.85) hospitalizations and a pair of.6 (3.47) ED visits per individual.
A excessive quantity of care was widespread typically with a number of suppliers, with an total imply (SD) of 13.3 (8.63) workplace visits and seven.2 (3.83) suppliers per affected person (Desk 2). The general imply (SD) UPC was 0.36 (0.16), indicating that 36% of visits have been with probably the most ceaselessly seen supplier, and the general imply (SD) COCI was 0.17 (0.14) on a scale from 0 to 1. PCP-specific care had greater continuity, with a imply (SD) PCP-specific UPC of 0.81 (0.23) and COCI of 0.67 (0.38). The imply (SD) gastroenterology-specific UPC and COCI have been 0.72 (0.26) and 0.52 (0.42), respectively. The imply (SD) psychological well being–particular UPC and COCI have been 0.72 (0.24) and 0.56 (0.37), respectively.
Latent Profile Evaluation
A 5-class mannequin was chosen as the ultimate mannequin based mostly on area usefulness and goodness of match (eAppendix Desk 2), and in order that no class had lower than 5% of the cohort. Every of those 5 subgroups are described by particular well being care utilization (based mostly on frequency of workplace visits and variety of suppliers) and COC (based mostly on the UPC and COCI measurements) patterns (Desk 3). Among the many 5 subgroups, 2 of those teams may very well be categorised by excessive gastroenterology-specific COC (subgroup 1, subgroup 2) however distinguished by the presence or absence of psychological well being use. Two teams may very well be categorised by low total COC (subgroup 4 and subgroup 5), though one group includes psychological well being utilization whereas the opposite doesn’t. Three of the teams may very well be categorised by the presence of psychological well being visits (subgroup 1, subgroup 3, and subgroup 4), though these teams may very well be differentiated by diploma of total well being care utilization. PCP-specific COC was excessive throughout teams, though GI- and psychological well being–particular COC different by group.
Subgroup Traits
Demographic traits different by subgroup (Desk 4). Sufferers within the 2 subgroups with low COC (subgroup 3 and subgroup 4) and people in 1 subgroup with excessive outpatient care utilization (subgroup 2) have been extra more likely to be non-White, have been extra more likely to reside in a rural space, and tended to have fewer persistent circumstances. Sufferers within the 2 subgroups characterised by low COC (subgroup 3 and subgroup 4) additionally tended to have the next baseline proportion of hospitalization and ED utilization. Sufferers categorised by the presence of considerable psychological well being care use (subgroup 1, subgroup 2, and subgroup 3) tended to be youthful and have been extra more likely to be feminine and married. They have been additionally much less more likely to have a historical past of homelessness. The subgroups with psychological well being use (subgroup 1, subgroup 2, and subgroup 3) additionally had the very best proportions of sufferers with persistent pancreatitis.
Within the subsequent 12 months (fiscal 12 months 2015), sufferers had a imply (SD) of 11.8 (9.05) workplace visits, and 11,259 (42.1%) had a hospitalization, 16,167 (60.4%) had an ED go to, and 1719 (6.4%) died. Fiscal 12 months 2015 well being care utilization different throughout subgroups, with the next proportion of subsequent hospitalizations and ED visits amongst 3 subgroups—the group with excessive outpatient care utilization and psychological well being care use (subgroup 2) and the two teams with low total COC (subgroup 3 and subgroup 4) (Desk 5).
Sensitivity Analyses
In a sensitivity evaluation with dichotomized gastroenterology-, PCP-, and psychological well being–particular UPC and COCI variables (based mostly on whether or not all care occurred with a single supplier), 39.2%, 34.7%, and 52.7% of sufferers had a single PCP, psychological well being supplier, and gastroenterologist, respectively. Utilizing these dichotomized variables, we have been in a position to classify sufferers into related phenotypes (eAppendix Desk 3). In a second sensitivity evaluation, we analyzed the supplier sort for the UPC measure and located that the standard supplier of care was a PCP for 51.4% of sufferers, whereas psychological well being suppliers and gastroenterology suppliers have been the standard suppliers for 19.9% and 13.7% of sufferers, respectively. With addition of those indicator variables, sufferers have been categorised into related subgroups (eAppendix Desk 3).
DISCUSSION
Sufferers with persistent GI circumstances who’re in danger for prime utilization have various well being care continuity patterns that may be described past a single COC index. We have been in a position to classify these people into 1 of 5 subgroups based mostly on PCP-specific, gastroenterology-specific, psychological well being–particular, and total frequency of workplace visits; variety of suppliers; and UPC and COCI measurements. These have been (1) excessive gastroenterology-specific COC with psychological well being use; (2) excessive gastroenterology-specific COC with out psychological well being use; (3) excessive total utilization with psychological well being use; (4) low total COC with psychological well being use; and (5) low total COC with out psychological well being use. These classifications replicate subpopulations with various traits and danger for subsequent well being care utilization.
Total COC as decided by the UPC and COCI was low however different by subgroup, much like different illness states and findings of research of COC in different well being care programs.5,6,27,28 Sufferers categorised as having the bottom total COC or highest outpatient care utilization additionally had extra subsequent hospitalizations and ED visits. That is much like prior findings.2,6,29 A current systematic assessment inspecting hospitalizations for ambulatory care–delicate circumstances demonstrated a major enhance in probability of hospitalizations amongst sufferers with low COC, with odds ratios starting from 1.34 to eight.69.30 This must be thought of within the context of illness severity, as sicker sufferers could also be extra more likely to be seen by a better variety of suppliers. Nonetheless, we chosen for sufferers who have been at excessive danger for hospitalization based mostly on a longtime danger rating.
Use of psychological well being care providers additionally performed an vital position in classifying sufferers, with psychological well being utilization and fragmentation characterizing sure subgroup phenotypes, but a definite absence of psychological well being care occurred amongst different subgroups with each excessive and low COC. Though psychological well being care use patterns performed a considerable position in classifying sufferers, they didn’t align with excessive or low subsequent well being care utilization. This has implications for psychological well being care.
Though current PCMH fashions in the USA aren’t tailor-made to sufferers with high-intensity specialty care wants, classifying high-risk sufferers could help in additional personalizing care coordination methods for effectiveness and sustainability. For instance, sufferers with a necessity for frequent psychological well being providers could profit from a collaborative care mannequin centered round psychological well being suppliers.31,32 It might even be useful to incorporate participation of psychological well being suppliers in interventions designed to enhance COC or coordination, equivalent to multidisciplinary conferences or the addition of care supervisor roles. Sufferers with complicated persistent circumstances that require extra specialised care, equivalent to people with superior coronary heart failure or persistent obstructive pulmonary illness, may additionally profit extra from interprofessional case conferences or structured communication about specialist-recommended care plans.33 As well as, figuring out subpopulations with various danger for subsequent well being care utilization may also help prioritize targets for enchancment. Tailor-made interventions must be additional evaluated as a part of future efforts to optimize well being care utilization and COC.
This examine provides vital perception into the usage of claims-based COC measurements in understanding patterns of care. Measures such because the UPC and COCI present us with a quantitative technique of describing the focus and dispersion of care. Nonetheless, these measures are influenced by the frequency of workplace visits, variety of suppliers, and variety of visits with every supplier from which these indices are derived. If sufferers solely have a few visits in a specialty care clinic, this limits the attainable values for the continuity measures, and the restricted variation could have implications for population-based research. As well as, these measures will be skewed if sufferers are inclined to have most of their care with one supplier, as occurred on this examine, by which most sufferers acquired all their care from a single PCP, psychological well being supplier, or gastroenterologist.
Claims-based COC measures present restricted perception into informational continuity, or causes for fragmentation patterns, such because the power of the patient-provider relationship, provider-provider comanagement relationships, entry to care, incomplete evaluations, and affected person engagement. Total COC, though generally used, is difficult to interpret within the context of various illness severity, which can require totally different numbers of suppliers for optimum care. For instance, a affected person with delicate IBD may have solely a PCP and gastroenterologist, whereas a extra severely unwell affected person with IBD may additionally require care by a surgeon, but the latter affected person will seem to have decrease COC by the measure. Lastly, it is very important be aware that the unique COCI recognized continuity with a single supplier or group of referred suppliers. Subsequent operationalizations of this measure have ignored referral patterns amongst suppliers on condition that these are troublesome to determine in claims knowledge. Nonetheless, because of this, current measures can not measure the continuity of a multispecialty group of physicians caring for a affected person with a posh illness. It might be that to completely perceive patterns of well being care use, we should develop measures of the COC with a multispecialty care crew.
Strengths and Limitations
The strengths of this examine embrace a big pattern dimension and nationwide knowledge set. The examine additionally has its limitations, together with restricted descriptors of cirrhosis or IBD severity or associated medicine use, though as a gaggle of excessive utilizers the affect of illness severity on utilization is much less related. The examine findings don’t signify sufferers with fewer than 4 visits per 12 months, though any potential interventions that may very well be derived utilizing the examine findings are targeted on sufferers with excessive baseline utilization. Future analysis might think about whether or not measuring fragmentation over an extended interval would possibly yield totally different findings attributable to an elevated variety of visits per specialty. Supplier-specific UPC and COCI measures have been thought of for sufferers with at the least 2 visits with a PCP, psychological well being supplier, or gastroenterologist in order that our findings can be generalizable to sufferers who noticed a selected supplier sort twice yearly, which is comparatively widespread. The restrictions of this system must be thought of, as good continuity with a supplier could skew the UPC and COCI on this context. Subsequently, we carried out analyses by which provider-specific UPC and COCI have been handled as steady variables and one other by which these variables have been dichotomized and outlined by the presence or absence of good continuity with a single supplier to seize whether or not this may affect our examine findings. Any care that veterans acquired outdoors the VA that was not a VA-covered service was not thought of. We additionally want to think about the restricted generalizability of those knowledge to a nonveteran inhabitants. We plan to handle this limitation by externally validating our findings in different populations in future work. We additionally want to think about potential restricted generalizability to different complicated persistent circumstances managed by different specialties. We plan to increase these strategies to different circumstances and specialties in future work. Lastly, given the restrictions of the info, disease-specific traits and outcomes (eg, IBD severity or length) weren’t examined.
CONCLUSIONS
Sufferers with high-intensity GI care wants and a excessive danger for well being care utilization will be grouped by various propensity for well being care continuity patterns. These findings are related as a proof of idea for complicated persistent circumstances that require administration with a specialist. In addition they extra particularly inform efforts throughout the PCMH setting to enhance COC for sufferers with persistent GI circumstances and to scale back the implications of fragmentation for these sufferers. Future research ought to lengthen this evaluation to different nationwide well being programs and different circumstances with complicated specialty care wants and examine these findings with these of a common inhabitants of sufferers in danger for elevated utilization. An in-depth qualitative analysis of sufferers in every classification would additionally assist to higher perceive these patterns of care and related influences, together with the position of informational and interpersonal continuity amongst suppliers. These various patterns may very well be harnessed to personalize care coordination interventions to optimize well being care utilization.
Acknowledgments
The authors thank Cindie Slightam and Camila Chaudhary for his or her help in challenge administration and Wealthy Evans for his or her steerage in knowledge evaluation. This work was supported utilizing assets and services on the VA Informatics and Computing Infrastructure, VA HSR RES 13-457.
Creator Affiliations: Middle for Scientific Administration Analysis, VA Ann Arbor Well being Care System (SC-M, AKW, TPH, SDS), Ann Arbor, MI; Division of Gastroenterology and Hepatology (AKW), Division of Inside Medication (SC-M, JB, TPH, SDS), College of Michigan, Ann Arbor, MI; VA Palo Alto Well being Care System (LG, DMZ), Menlo Park, CA; Stanford College Faculty of Medication (LG, DMZ), Stanford, CA.
Supply of Funding: Dr Cohen-Mekelburg was funded by grant KL2TR002241 by means of the Michigan Institute for Scientific and Well being Analysis from the Nationwide Institutes of Well being. Dr Zulman is funded by a Division of Veterans Affairs Well being Providers Analysis and Improvement Service grant (IIR 15-316, COR 20-199, PEI 18-205), the Gordon and Betty Moore Basis (6382), and Stanford College (RISE COVID-19 Disaster Response Seed Grant).
Creator Disclosures: The authors report no relationship or monetary curiosity with any entity that might pose a battle of curiosity with the subject material of this text.
Authorship Info: Idea and design (SC-M, DMZ); acquisition of knowledge (LG, DMZ); evaluation and interpretation of knowledge (SC-M, JB, AKW, TPH, SDS, DMZ); drafting of the manuscript (SC-M, JB, AKW, TPH, SDS, DMZ); essential revision of the manuscript for vital mental content material (SC-M, LG, JB, AKW, TPH, SDS, DMZ); statistical evaluation (SC-M, LG); provision of sufferers or examine supplies (LG); acquiring funding (DMZ); administrative, technical, or logistic help (LG); and supervision (SC-M, DMZ).
Handle Correspondence to: Shirley Cohen-Mekelburg, MD, MS, College of Michigan, 1500 E Medical Middle Dr, 3912 Taubman Middle, Ann Arbor, MI 48105. E mail: shcohen@umich.edu.
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