• J Gen Intern Med · Mar 2023

    Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S.

    • Lisa M Kern, Joanna B Ringel, Mangala Rajan, Lawrence P Casalino, Lisandro D Colantonio, Laura C Pinheiro, Calvin L Colvin, and Monika M Safford.
    • Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA. lmk2003@med.cornell.edu.
    • J Gen Intern Med. 2023 Mar 1; 38 (4): 873880873-880.

    BackgroundIt is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit. Whether any such association varies with race is unknown.ObjectiveWe sought to determine whether highly fragmented ambulatory care increases the risk of an ED visit, overall and by race.Design And ParticipantsWe analyzed data for 14,361 participants ≥ 65 years old from the nationwide prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, linked to Medicare claims (2003-2016).Main MeasuresWe defined high fragmentation as a reversed Bice-Boxerman Index ≥ 0.85 (≥ 75th percentile). We used Poisson models to determine the association between fragmentation (as a time-varying exposure) and ED visits, overall and stratified by race, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiologic variables.Key ResultsThe average participant was 70.5 years old; 53% were female, and 33% were Black individuals. Participants with high fragmentation had a median of 9 visits to 6 providers, with 29% of visits by the most frequently seen provider; participants with low fragmentation had a median of 7 visits to 3 providers, with 50% of visits by the most frequently seen provider. Overall, high fragmentation was associated with more ED visits than low fragmentation (adjusted risk ratio [aRR] 1.31, 95% confidence interval [CI] 1.29, 1.34). The magnitude of this association was larger among Black (aRR 1.48, 95% CI 1.44, 1.53) than White participants (aRR 1.23, 95% CI 1.20, 1.25).ConclusionsHighly fragmented ambulatory care was an independent predictor of ED visits, especially among Black individuals.© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.

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