BACKGROUND: More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care. METHODS: We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist). RESULTS: The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (<$35,000) and 41% had a high school education or less. Overall, participants had a median of 10 ambulatory visits to 4 providers in the 12 months following their baseline study visit. Participants in the highest quintile of fragmentation scores had a median of 11 visits to 7 providers. Black race was associated with an absolute adjusted 3% lower fragmentation score compared to white race (95% confidence interval (2% lower to 4% lower; p < 0.001). This difference was explained by blacks seeing fewer specialists than whites. Income and education were not independent predictors of fragmentation scores. CONCLUSIONS: Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.
BACKGROUND: More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care. METHODS: We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist). RESULTS: The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (<$35,000) and 41% had a high school education or less. Overall, participants had a median of 10 ambulatory visits to 4 providers in the 12 months following their baseline study visit. Participants in the highest quintile of fragmentation scores had a median of 11 visits to 7 providers. Black race was associated with an absolute adjusted 3% lower fragmentation score compared to white race (95% confidence interval (2% lower to 4% lower; p < 0.001). This difference was explained by blacks seeing fewer specialists than whites. Income and education were not independent predictors of fragmentation scores. CONCLUSIONS: Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.
Authors: Peter S Hussey; Eric C Schneider; Robert S Rudin; D Steven Fox; Julie Lai; Craig Evan Pollack Journal: JAMA Intern Med Date: 2014-05 Impact factor: 21.873
Authors: Fenglong Xie; Lisandro D Colantonio; Jeffrey R Curtis; Monika M Safford; Emily B Levitan; George Howard; Paul Muntner Journal: Am J Epidemiol Date: 2016-09-19 Impact factor: 4.897
Authors: Virginia J Howard; Dawn O Kleindorfer; Suzanne E Judd; Leslie A McClure; Monika M Safford; J David Rhodes; Mary Cushman; Claudia S Moy; Elsayed Z Soliman; Brett M Kissela; George Howard Journal: Ann Neurol Date: 2011-03-17 Impact factor: 10.422
Authors: David J Nyweide; Denise L Anthony; Julie P W Bynum; Robert L Strawderman; William B Weeks; Lawrence P Casalino; Elliott S Fisher Journal: JAMA Intern Med Date: 2013-11-11 Impact factor: 21.873
Authors: Nynikka R A Palmer; Ann M Geiger; Tisha M Felder; Lingyi Lu; L Douglas Case; Kathryn E Weaver Journal: Am J Public Health Date: 2013-05-16 Impact factor: 9.308
Authors: Monika M Safford; Todd M Brown; Paul M Muntner; Raegan W Durant; Stephen Glasser; Jewell H Halanych; James M Shikany; Ronald J Prineas; Tandaw Samdarshi; Vera A Bittner; Cora E Lewis; Christopher Gamboa; Mary Cushman; Virginia Howard; George Howard Journal: JAMA Date: 2012-11-07 Impact factor: 56.272
Authors: Craig E Pollack; Peter S Hussey; Robert S Rudin; D Steven Fox; Julie Lai; Eric C Schneider Journal: Med Care Date: 2016-05 Impact factor: 2.983
Authors: Calvin L Colvin; Monika M Safford; Paul Muntner; Lisandro D Colantonio; Lisa M Kern Journal: Am J Manag Care Date: 2022-03 Impact factor: 3.247