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J Gen Intern Med. 2019 Aug;34(8):1645-1652. doi: 10.1007/s11606-019-05009-3. Epub 2019 Apr 25.

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

Author information

1
Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA. johnstonkj@slu.edu.
2
Department of Health Management and Policy, University of Kentucky, Lexington, KY, USA.
3
Department of Clinical Analytics and Insights, Center for Clinical Excellence, SSM Health, St. Louis, MO, USA.
4
Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA.

Abstract

BACKGROUND:

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.

OBJECTIVE:

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.

DESIGN:

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.

SETTING:

Safety-net and non-safety-net clinics.

PARTICIPANTS:

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

MEASUREMENTS:

Acute and chronic ACSC hospitalizations.

RESULTS:

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.

CONCLUSIONS:

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.

KEYWORDS:

Medicare; physician value-based payment; safety-net providers

PMID:
31025305
PMCID:
PMC6667509
[Available on 2020-08-01]
DOI:
10.1007/s11606-019-05009-3

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