The Intersection of Patient Complexity, Prescriber Continuity and Acute Care Utilization
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Care continuity is considered a critical characteristic of high-performing health systems. Few studies have examined the continuity of medication management of complex patients, who often have multiple providers and complex medication regimens.
The purpose of this study was to characterize patient factors associated with having more prescribers and the association between number of prescribers and acute care utilization.
DESIGN AND SUBJECTS
A retrospective cohort study was conducted of 7,933 Veterans with one to four cardiometabolic conditions (diabetes, hypertension, hyperlipidemia or congestive heart failure) and prescribed medications for these conditions in 2008.
The association between number of cardiometabolic conditions and prescribers was modeled using Poisson regression. The number of cardiometabolic conditions and number of prescribers were modeled to predict probability of inpatient admission, probability of emergency room (ER) visits, and number of ER visits among ER users. Demographic characteristics, number of cardiometabolic medications and comorbidities were included as covariates in all models.
Patients had more prescribers if they had more cardiometabolic conditions (p < 0.001). The adjusted odds of an ER visit increased with the number of prescribers (two prescribers, Odds Ratio (OR) = 1.16; three prescribers, OR = 1.21; 4+ prescribers, OR = 1.39), but not with the number of conditions. Among ER users, the number of ER visits was neither associated with the number of prescribers nor the number of conditions. The adjusted odds of an inpatient admission increased with the number of prescribers (two prescribers, OR = 1.27; three prescribers, OR = 1.30; 4+ prescribers, OR = 1.34), but not with the number of conditions.
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.
- Wong ND, Lopez V, Tang S, Williams GR. Prevalence, treatment, and control of combined hypertension and hypercholesterolemia in the United States. Am J Cardiol. 2006;98(2):204–208. CrossRef
- Kerr EA, Heisler M, Krein SL, et al. Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? J Gen Intern Med. 2007;22(12):1635–1640. CrossRef
- Bayliss EA, Ellis JL, Steiner JF. Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities. Ann Fam Med. 2007;5(5):395–402. CrossRef
- Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med. 2005;3(3):215–222. CrossRef
- Anderson G. Chronic conditions: making the case for ongoing care. 2010; http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583. Accessed December 10, 2013.
- Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269–2276. CrossRef
- Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71–e87.
- Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356(11):1130–1139. CrossRef
- Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150(4):841–845. CrossRef
- Tamblyn RM, McLeod PJ, Abrahamowicz M, Laprise R. Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations. CMAJ. 1996;154(8):1177–1184.
- Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc. 2005;53(9):1518–1523. CrossRef
- Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother. 2007;5(1):31–39. CrossRef
- Fortney JC, Steffick DE, Burgess JF Jr, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health Serv Res. 2005;40(5 Pt 1):1422–1442. CrossRef
- Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107(3):524–529. CrossRef
- Services CfMaM. Chronic Conditions among Medicare Beneficiaries, Chart Book. Baltimore, MD2011.
- Sacks FM, Obarzanek E, Windhauser MM, et al. Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH). A multicenter controlled-feeding study of dietary patterns to lower blood pressure. Ann Epidemiol. 1995;5(2):108–118. CrossRef
- Gagne JJ, Glynn RJ, Avorn J, Levin R, Schneeweiss S. A combined comorbidity score predicted mortality in elderly patients better than existing scores. J Clin Epidemiol. 2011;64(7):749–759. CrossRef
- Maciejewski ML, Liu CF, Fihn SD. Performance of comorbidity, risk adjustment, and functional status measures in expenditure prediction for patients with diabetes. Diabetes Care. 2009;32(1):75–80. CrossRef
- Maciejewski ML, Liu CF, Kavee AL, Olsen MK. How price responsive is the demand for specialty care? Health Econ. 2012;21(8):902–912. CrossRef
- Maciejewski ML, Livingston EH, Smith VA, Kahwati LC, Henderson WG, Arterburn DE. Health expenditures among high-risk patients after gastric bypass and matched controls. JAMA Surg. 2012;147(7):633–640.
- Liu CF, Manning WG, Burgess JF Jr, et al. Reliance on veterans affairs outpatient care by medicare-eligible veterans. Med Care. 2011;49(10):911–917. CrossRef
- Farley JF, Wang CC, Hansen RA, Voils CI, Maciejewski ML. Continuity of antipsychotic medication management for Medicaid patients with schizophrenia. Psychiatr Serv. 2011;62(7):747–752. CrossRef
- Hansen RA, Powers BJ, Sanders L, et al. Prescriber Continuity and Medication Adherence for Complex Patients. Annals of Pharmacotherapy. in press.
- Brookhart MA, Patrick AR, Schneeweiss S, et al. Physician follow-up and provider continuity are associated with long-term medication adherence: a study of the dynamics of statin use. Arch Intern Med. 2007;167(8):847–852. CrossRef
- Tinetti ME, Studenski SA. Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med. 2011;364(26):2478–2481. CrossRef
- Adler-Milstein J, Jha AK. Sharing clinical data electronically: a critical challenge for fixing the health care system. JAMA. 2012;307(16):1695–1696. CrossRef
- The Intersection of Patient Complexity, Prescriber Continuity and Acute Care Utilization
Journal of General Internal Medicine
Volume 29, Issue 4 , pp 594-601
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- complex patient
- emergency room
- Industry Sectors
- Author Affiliations
- 1. Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA
- 2. Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, 27705, USA
- 3. Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
- 4. Department of Pharmacy Care Systems, Harrison School of Pharmacy, Auburn University, Auburn, AL, USA