Journal of General Internal Medicine

, Volume 34, Issue 8, pp 1645–1652 | Cite as

Association of Patient Social, Cognitive, and Functional Risk Factors with Preventable Hospitalizations: Implications for Physician Value-Based Payment

  • Kenton J. JohnstonEmail author
  • Hefei Wen
  • Mario Schootman
  • Karen E. Joynt Maddox
Health Policy



Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians’ performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization.


To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers’ performance.


Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers’ performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data.


Safety-net and non-safety-net clinics.


Community-dwelling Medicare beneficiaries contributing 38,616 person-years from 2006 to 2013.


Acute and chronic ACSC hospitalizations.


After adjusting for clinical comorbidities, Alzheimer’s/dementia (IRR 1.30, 95% CI 1.02–1.65), difficulty with 3–6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05–1.94), difficulty with 1–2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26–1.90), and 3–6 IADLs (IRR 1.90, 95% CI 1.49–2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03–1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04–1.69), being unmarried (IRR 1.18, 95% CI 1.01–1.36), difficulty with 1–2 IADLs (IRR 1.30, 95% CI 1.05–1.60), and 3–6 IADLs (IRR 1.44, 95% CI 1.16–1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers’ performance gap (p < .05) on ACSC hospitalization rates relative to non-safety-net providers.


Social, cognitive, and functional risk factors are independently associated with ACSC hospitalizations. Failure to account for them may penalize outpatient safety-net providers for factors that are beyond their control.


physician value-based payment Medicare safety-net providers 



We thank Julia Clarke of Saint Louis University for providing assistance on the literature review.


Saint Louis University purchased and provided access to the data used in this study. Dr. Joynt Maddox is supported by K23-HL109177-03 from the National Heart, Lung, and Blood Institute (NHLBI).

Author Contributions

Dr. Johnston had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: all authors.

Acquisition, analysis, or interpretation of data: all authors.

Drafting of the manuscript: all authors.

Critical revision of the manuscript for important intellectual content: all authors.

Statistical analysis: Johnston.

Obtained funding: Johnston.

Administrative, technical, or material support: Johnston.

Study supervision: all authors.

Compliance with Ethical Standards

This study was approved by the Saint Louis University Institutional Review Board.

Conflict of Interest

Dr. Joynt Maddox does work under contract with the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. All remaining authors declare that they do not have a conflict of interest.

Role of the Sponsor

Neither Saint Louis University nor the NHLBI had any role in the design and conduct of the study; analysis or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Supplementary material

11606_2019_5009_MOESM1_ESM.docx (128 kb)
ESM 1 (DOCX 127 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Kenton J. Johnston
    • 1
    Email author
  • Hefei Wen
    • 2
  • Mario Schootman
    • 3
  • Karen E. Joynt Maddox
    • 4
  1. 1.Department of Health Management and Policy and Center for Outcomes ResearchCollege for Public Health and Social Justice, Saint Louis UniversitySt. LouisUSA
  2. 2.Department of Health Management and PolicyUniversity of KentuckyLexingtonUSA
  3. 3.Department of Clinical Analytics and InsightsCenter for Clinical Excellence, SSM HealthSt. LouisUSA
  4. 4.Cardiovascular DivisionWashington University School of MedicineSt. LouisUSA

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