Trends in utilization of preventive services in
medically under-served communities among
small urban practices that have already
adopted health IT
Samantha De Leon, PhD; Sarah Shih, MPH
June, 2010
Primary Care Information Project
NYC D
Department
t
t off H
Health
lth & M
Mental
t lH
Hygiene
i
Primary Care Information Project
Rates of Childhood Immunizations
90
80
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ast Modified 9/9/2009 1:49:30 PM
70
60
50
40
30
Commercial
20
Medicaid
10
0
2003
2004
2005
2006
2007
2008
Year
Source: State of Health Care Quality, 2009, NCQA
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% recieved
d immun
nizations
s
100
Paper to Electronic Health Records (EHR)
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Primary Care Information Project | 2
Small practices enrolled in Primary Care Information Project (PCIP)
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Study Population
Hospital outpatient
facilities, large & small
practices
# Practices on the
EHR
402
Small Practices 307
Successful EHR implementation
across all practices
Successful transmission of
claims data to NYCDOH within
1st year
Successful transmission of
claims data for at least
9months
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Small Practices (transmit
at least 9 months)
99
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ast Modified 9/9/2009 1:49:30 PM
# Practices PCIP
implementation
pipeline
521
Methods
For each small practice
- transmitted ambulatory services claims data /
tabulated monthly preventive services utilization trends
practice/provider demographics
Data aggregation:
- categorized
g
p
preventive services /
Statistical Analysis:
- longitudinal mixed models
- separate growth curves for each practice adjusting for
autocorrelation between observations
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based on procedure (CPT) codes used in Healthcare
Effectiveness Data & Information Set (HEDIS) measures
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- practice self- reported questionnaire /
Provider specialty within primary care at small practices in NYC
45.0
35.0
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30.0
25.0
20.0
15.0
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(%) Pro
oviders Sellf-Report
40.0
10.0
50
5.0
0.0
Internal
Medicine
Pediatrics
Family
Medicine
Obstetrics &
Gynecology
Other
Missing
* Total number of providers at small practices in PCIP = 776 as of May 2010
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Provider Staffing levels at small practices in NYC
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* Total number of small practices in PCIP = 307 as of May 2010
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# Administrative Support Staff/ Physician FTE at small practices in NYC
40.0
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30.0
25.0
20.0
15.0
10.0
5.0
0.0
0
0.1 - 1.0
1.1 - 2.0
2.1 - 6.0
# Administrative S
Support S
Staff
ff / FTE
*T
Total
t l number
b off smallll practices
ti
iin PCIP = 307 as off May
M 2010
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(%) pra
actices self reported
35.0
# Medical Support Staff (RNs, PAs)/ Physician FTE at small practices in NYC
90
70
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60
50
40
30
20
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(%) prac
ctices self-rreported
80
10
0
0
0.1 - 1.0
> 1.0
# Medical Support Staff per FTE
*T
Total
t l number
b off smallll practices
ti
iin PCIP = 307 as off May
M 2010
Primary Care Information Project | 9
Preventive services utilization categories from HEDIS measures
Considered # procedures per day per FTE for:
- pneumoccocal & influenza vaccinations; childhood
immunizations
- lead; breast cancer; cervical cancer; colon cancer; glaucoma; A1c;
nephropathy; eye exam; blood pressure; LDL/ cholesterol
Access/ Availability of Care
- adult & pediatric ambulatory preventive visits;
ambulatory domiciliary visit; adult ambulatory ophthalmology visit
Utilization
U
ili i off M
Mentall H
Health
lhS
Services
i
- follow-up outpatient visit with a mental health professional
p
after hospitalization
- follow-up outpatient visit (without a mental health professional) after
hospitalization
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- adult ambulatory home visit; adult ambulatory nursing visit; adult
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Preventive Services – Screenings
Preventive services utilization – Access/ Availability of Care
Type of Preventive Service
1.1
72.6%
2.3
73.0%
1.3
72.0%
17
1.7
40 4%
40.4%
1.7
34.9%
(CPT= 99385-99387,
99385 99387 99395-99397,
99395 99397 99401-99404,
99401 99404 99411-99412,
99411 99412 99420,
99420 99429)
Pediatric ambulatory preventive visit
(CPT= 99381-99385, 99391-99395,99401-99404, 99411-99412, 99420, 99429)
Pediatric ambulatory adolescent visit
(CPT= 99383-99385, 99393-99395)
Pediatric well
well-child
child visit (2
(2-6
6 years)
(CPT= 99382, 99383, 99392, 99393)
Pediatric well-child visit (15 months)
(CPT= 99381, 99382, 99391, 99392, 99432)
* E&M Outpatient visits (new,
(new established and consultations)
consultations)= 10.9
10 9 procedures per day per FTE (2
(2.0%
0% missing)
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(%)
reporting
practices
(n= 307)
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ast Modified 9/9/2009 1:49:30 PM
Adult ambulatory preventive visit
Avg #
procedures
per day
per FTE
Preventive services utilization – Screenings & Mental Health
Type of Preventive Service
0.1
71.0%
1.3
68.4%
0.8
56.0%
Chl
Chlamydia
di screening
i
05
0.5
44 0%
44.0%
Follow-up outpatient visit with mental health
professional after hospitalization
0.9
41.0%
Pneumococcal vaccinations
(CPT= 90732, G0009)
Childhood Immunizations
((i.e.,, Diptheria,
p
, tetanus,, pertussis,
p
, MMR,, hepatitis,
p
, IPV,, VZV))
Influenza vaccinations
(CPT= 90658, G0008)
(CPT= 99221-99223, 99231-99233, 99238-99239, 99251-99255, 99261-99263)
* E&M O
Outpatient
t ti t visits
i it (new,
(
established
t bli h d and
d consultations)=
lt ti
) 10.9
10 9 procedures
d
per d
day per FTE (2.0%
(2 0% missing)
i i )
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(%)
reporting
practices
(n= 307)
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Avg #
procedures
per day
per FTE
Preliminary Results (n=307 practices)
For each preventive service category
- tabulated monthly # preventive services per day per FTE
- compared over time for each practice
- regardless of completeness of the data
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Analysis of all practices contributing data within the 1st year of
implementing the EHR
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For each preventive service category considered:
- no significant associations
- greater variability in the data
* may have decreased signal to noise
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Access/ Availability of Care (n= 99 practices at least 9 months data)
Estimated # procedures per FTE per month for a typical small practice
60
p-value= 0.08
50
40
30
p-value= 0.05
20
0
0
1
2
3
4
5
6
7
8
9
10
11
12
Month
Adult
Preventive
Pediatric
Preventive
Adolescent
Preventive
Child (2-6yrs)
(2 6yrs)
Preventive
Child (15mo)
Preventive
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10
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Averrage # proc
cedures per month per FTE
70
Screenings & Mental Health (n= 99 practices at least 9 months data)
Estimated # procedures per FTE per month for a typical small practice
25
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20
15
10
5
p-value= 0.04
0
0
1
2
3
4
5
6
7
8
9
10
11
12
Month
Pneumonia
vaccination
i ti
Childhood
iimmunizations
i ti
Influenza
i ti
vaccination
Chlamydia
screening
Follow-up
Mental Health
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Ave
erage # proc
cedures perr month per FTE
30
Discussion
Results suggest some categories of preventive services can be
reliably tracked through practice management claims data
Preventive services not reliably tracked in practice claims data
Results suggest within 1st year of implementing the EHR
- 1.3% increase per month Ambulatory Preventive Adult visits
- 2.2%
2 2% increase per month Ambulatory Preventive Pediatric visits
- 2.0% increase per month Pneumococcal vaccinations
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- Cancer
C
screening,
i
LDL and
d bl
blood
d pressure screening
i
- Ambulatory home or nursing visits
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- Ambulatory
A b l t
P
Preventive
ti Vi
Visits
it ((adult
d lt and
d pediatric)
di t i )
- Pneumococcal & influenza vaccinations; Chlamydia screening;
childhood immunizations
- Follow-up
F ll
outpatient
t ti t (mental
(
t l health)
h lth) visits
i it