Evaluating preventative care and post hospitalization primary car

Evaluating Preventative Care and Post-Hospitalization Primary Care Follow-Up in Adults with Intellectual and/or Developmental Disabilities by Jason Robert Xenakis M., New York Medical College, 2017 M., New York Medical College, 2015 B., Marist College, 2010 A Doctoral Dissertation in Health Policy and Management, School of Health Sciences and Practice, Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Public Health at New York Medical College 2019 Acknowledgments This work, the last academic assignment I complete as a student, is the culmination of nearly a decade of studying here at New York Medical College. The friendships I have forged, the guidance I have received, and the skills I have enhanced will be with me for the rest of my life. For these reasons, I will always remember and forever be indebted to this great institution of higher education. I would like to specifically thank my dissertation committee members—Dr.

Adam Block, Dr. Patricia Patrick, and Dr. Kenneth Knapp—for their guidance and support throughout this project. I would also like to thank the research assistants that helped in data collection–Andrew Flatley and Peace Orji.

In addition to this, I would like to acknowledge Dr. David O’Hara, Dr. Susan Fox, Dr. AnneBeth Litt, and Marilyn Klein for their unrelenting work at the Westchester Institute for Human Development.

These individuals have spent their careers caring for complex and vulnerable populations of individuals, which is something they should be deeply proud of. i Table of Contents List of Tables. v List of Figures. ix Study Abstracts.

x Preventative Care Abstract. x Post-Hospitalization Primary Care Follow-Up Abstract .xii Chapter 1: Introduction. 1 Chapter 2: Literature Review. 5 Definition of Intellectual and/or Developmental Disability (IDD).

5 Prevalence and IDD-Specific Medical Challenges. 8 Post-Hospitalization Primary Care Follow-Up. 23 Chapter 3: Research Methods. 38 Study #1 Methodology – Characteristics Associated with Preventative Care Utilization in Adults with Intellectual and/or Developmental Disabilities.

38 ii Study Design. 39 Institutional Review Board and Ethical Considerations. 40 Confidentiality and Privacy. 40 Data Source and Collection.

47 Data Analysis Plan. 58 Study #2 Methodology – Characteristics Associated with Primary Care Follow-Up and Discharge Summary Receipt Post-Hospitalization in Adults with Intellectual and/or Developmental Disabilities. 59 Institutional Review Board and Ethical Considerations. 60 iii Confidentiality and Privacy.

60 Data Source and Collection. 64 Data Analysis Plan. 77 Study #1 Results – Characteristics Associated with Preventative Care Utilization in Adults with Intellectual and/or Developmental Disabilities. 83 Study #2 Results - Characteristics Associated with Primary Care Follow-Up and Discharge Summary Receipt Post-Hospitalization in Adults with Intellectual and/or Developmental Disabilities.

107 Preventative Care Study Findings. 108 Post-Hospitalization Primary Care Follow-Up Study Findings. 114 Policy and Practice Implications and Future Research. 126 v List of Tables Table 1.

Preventative Care Study Hypotheses……………………………………. Hospitalization Study Hypotheses…………………………………. United States Preventative Service Task Force (UPSTF) and Center for Disease Control Preventative Care Recommendations………………………………. Select Preventative Care Studies in Adults with Intellectual and/or Developmental Disabilities…………………………………………………………….

Select Hospitalization Studies in Adults with Intellectual and/or Developmental Disabilities………………………………………………………………………. Microsoft Excel Spreadsheet Subject Log Example (Preventative Care Study)……………………………………………………………………………………. List of Original Variables (Preventative Care Study)………………. Electronic Medical Record (CureMD) Manual Data Collection Standardized Location Key (Preventative Care Study)………………………………………….

Preventative Service Variable Guidelines……………………………. Stata Independent Variable Value Coding (Preventative Care Study)…. Stata Dependent Variable Value Coding (Preventative Care Study)………. Microsoft Excel Spreadsheet Subject Log Example (Hospitalization Study)…………………………………………………………………………………….

List of Original Variables (Hospitalization Study)………………………. Electronic Medical Record (CureMD) Manual Data Collection Standardized Location Key (Hospitalization Study)………………………………………………. Stata Independent and Dependent Variable Value Coding (Hospitalization Study)……………………………………………………………………………………. Example of the Agency for Healthcare Research and Quality (AHRQ) ICD-9- CM Clinical Classification Software (CCS) Grouping…………………………….

Demographic Characteristics of the Study Sample (Preventative Care Study)……………………………………………………………………………………. County Distribution of the Study Sample (Preventative Care Study)…………. Clinical and Utilization Characteristics of the Study Sample (Preventative Care Study)……………………………………………………………………………. Bivariate Logistic Regression of Preventative Service Utilization (Preventative Care Study)……………………………………………………………………….

Multivariate Logistic Regression of Preventative Service Utilization (Preventative Care Study)………………………………………………………………. Demographic Characteristics and Level of Intellectual Disability of the Study Sample (Hospitalization Study)………………………………………………………. Frequency of Year of Admission, Length of Stay Strata, and Hospital for all Encounters (Hospitalization Study)………………………………………………………90 Table 4. Admission Count by Unique Patient (Hospitalization Study)…………………91 Table 4.

Top Five Hospitals Mean Length of Stay (Hospitalization Study)……………. Frequency of Principal Diagnosis of Hospitalization Using Level 1 and 2 CCS Grouping (Hospitalization Study)………………………………………………. Frequency of Discharge Status from Hospital (Hospitalization Study)…. Time Strata of Primary Care Follow-Up and Hospital Discharge Summary Receipt (Hospitalization Study)……………………………………………………….

Bivariate Logistic Regression of Top Five Most Frequent Admitting Hospitals and Primary Care Follow-Up and Hospital Discharge Summary Receipt Within 30 Days (Hospitalization Study)…………………………………………………………………. Bivariate Logistic Regression of Primary Care Follow-Up and Hospital Discharge Summary Receipt Within 7 and 14 Days (Hospitalization Study)……………. Multivariate Logistic Regression of Primary Care Follow-Up and Hospital Discharge Summary Receipt within 7 and 14 Days (Hospitalization Study)……………100 viii Table 4. Multivariate Logistic Regression of Primary Care Follow-Up and Hospital Discharge Summary Receipt within 7 and 14 Days with Hospital Variable (Hospitalization Study)………………………………………………………………………………….

Multivariate Logistic Regression of Primary Care Follow-Up and Hospital Discharge Summary Receipt Within 7 and 14 Days with Level 1 CCS Grouper Diagnosis Variable (Hospitalization Study)……………………………………………………. Multivariate Logistic Regression of Primary Care Follow-Up and Hospital Discharge Summary Receipt Within 7 and 14 Days with Hospital and Level 1 CCS Grouper Diagnosis Variable (Hospitalization Study)…………………………………. Preventative Care Studies in Adults with Intellectual and/or Developmental Disabilities that Report Adjusted Odds Ratios which Compare Living Situation and Preventative Service Utilization……………………………………………………….112 ix List of Figures Figure 2. Rate of 30-day All-Cause Readmissions by Expected Payer, 2010-2016….

Medication Distribution of the Study Sample………………………………. Preventative Service Utilization of Eligible Study Sample ……………. Preventative Service Utilization Stratified by Living Situation with Bivariate Odds Ratios (Group Home vs Non-Group Home)………………………………………. Primary Care Follow-Up Within 7 and 14 Days Stratified by Living Situation (Hospitalization Study)……………………………………………………………….

Discharge Summary Receipt Within 7 and 14 Days Stratified by Living Situation (Hospitalization Study)……………………………………………………….97 x Study Abstracts Preventative Care Abstract Title: Characteristics that are associated with preventative care utilization in adults with intellectual and/or developmental disabilities (IDD). Background: Individuals with IDD are less likely than the general population to receive preventative services as recommended by the United States Preventative Service Task Force (USPSTF) and Centers for Disease Control and Prevention (CDC). What remains unclear are the risk factors that contribute to this healthcare disparity. Objective: To explore the demographic, socioeconomic, and clinical variables that are associated with whether an adult with IDD will receive appropriate preventive services from their primary care provider.

Methods: A cross-sectional study reviewed 2017 medical records from an IDD-specific multi-specialty outpatient facility for demographic, socioeconomic, and clinical characteristics, as well as preventative service utilization data. Results: A total of 1,162 adult patient records were reviewed. The level of intellectual disability of the sample was found to be mild (54. Most patients reported living in a group home (81.1%) versus non-group home settings (17.

Preventative service utilization by eligible patients was distributed as follows: influenza vaccination (67.6%), pneumococcal xi vaccination (80.2%), colorectal cancer screening (62.1%), breast cancer screening (68.8%), and cervical cancer screening (71. Multivariate regression analysis discovered that clinical characteristics of patients (i., level of intellectual disability, communication ability, and number of medications) were not significantly associated with preventative service utilization. Multivariate regression analysis variables that were found to be associated with influenza vaccination included age over 40 (aOR: 2.5), living in a group home (aOR: 3.1), Medicaid only insurance (aOR: 1.2), and having had an annual health assessment (aOR: 3. Colorectal cancer screening was also associated with having had an annual health assessment (aOR: 2.

Cervical cancer screening was associated with living in a group home (aOR: 3. Conclusion: Demographic and socioeconomic characteristics were associated with some preventative service utilization, whereas clinical characteristics, such as level of intellectual disability, communication ability, and number of medications, were not. Primary care providers should target patients who live at home for preventative service utilization, address any barriers or concerns families of patients with IDD have, and stress the importance of seeing a physician for an annual heath assessment. Further research should continue to evaluate the success group homes have had in assuring preventative service utilization, as well as the broader implications of regulatory oversite at the state level.

xii Post-Hospitalization Primary Care Follow-Up Abstract Title: Characteristics that are associated with primary care follow-up and discharge summary receipt post-hospitalization in adults with intellectual and/or developmental disabilities. Background: Transition from an inpatient to an outpatient setting is a high risk time for patients. Studies in the general population find that poor post-hospitalization primary care follow-up results in higher rates of readmissions – a widely used indicator of healthcare quality. There is no research that evaluates post-hospitalization primary care follow-up or discharge summary receipt in the IDD population.

Objective: To explore the demographic, socioeconomic, and clinical characteristics that are associated with whether an adult with IDD will achieve timely post-hospitalization primary care follow-up. Methods: A cross-sectional study evaluating 788 hospitalizations of adults with IDD from January 1, 2012 to December 31, 2016 and their primary care follow-up at an IDD- specific multi-specialty outpatient facility. Applicable inpatient admissions were identified using Medicare Quality and Resource Use Reports and linked to the outpatient facilities’ electronic medical records in order to capture demographic, socioeconomic, clinical, and follow-up variables on each subject. Results: A total of 788 hospital admissions completed by 341 unique individuals were identified.

This population had a high rate of primary care follow-up (94.8%), and xiii hospitalization discharge summary receipt (83. Multivariate regression analysis, which controlled for demographics, living situation, level of intellectual disability, hospital, and principal hospital diagnosis, identified that living in non-group home settings was associated with a lower likelihood of timely primary care follow-up and discharge summary receipt when compared to adults with IDD who live in group homes. This analysis also detected that age over 40 was associated with a lower likelihood or primary care follow-up within 7 days (aOR: 0.8) and non- Caucasian race to be associated with a higher likelihood of primary care follow-up within 14 days (aOR: 2. Conclusion: The major variable that predicted timely primary care follow-up and discharge summary receipt was living in a group home.

This is most likely due to state- mandated audits of group home policies and procedures. Nevertheless, primary care follow-up for the population evaluated in this study was much better than the general Medicare population. Primary care providers and hospital discharge teams should be cognizant of the challenges and barriers that adults with IDD who live in non-group home settings face. Further research should continue to evaluate the success that group homes have had in post-hospitalization primary care follow-up and communicate their success to other state regulatory groups.

1 Chapter 1: Introduction Background Adults with intellectual and/or developmental disability (IDD) represent 7% of the United States’ population (Zablotsky et al., 2017; Krahn & Fox, 2014; Maulik et al. There is substantial evidence that this group of adults suffer from a range of healthcare disparities when compared to the general population (U. Department of Health and Human Services, 2002; Lunsky et al. These disparities result in inferior health outcomes and higher healthcare expenditures per capita ( Fujiura, Li & Magana, 2018).

Although there is evidence that healthcare disparities exist, there is a scarcity of research evaluating what is driving these disparities within the population of adults with IDD. Research in the general population has identified that age and gender appropriate preventative services (e., biannual breast cancer screening, yearly influenza vaccination, etc.), as well as timely post-hospitalization primary care follow-up reduce morbidity and mortality of patients, as well as decrease per capita healthcare costs (Winawer et al., 1993; Centers for Disease Control and Prevention [CDC], 2019a). These two distinct, but important healthcare processes, have been important targets for healthcare quality improvement at the organizational and policy levels. However, there is limited research into both of these processes as they pertain to adults with IDD.