Physician Subspecialization and the Health and Health Care of Older Americans

医生亚专业化与美国老年人的健康和保健

• 批准号: 10584875
• 负责人: Michael Lawrence Barnett
• 金额: $ 67.18万
• 依托单位: HARVARD SCHOOL OF PUBLIC HEALTH
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-30 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10584875
• 关键词: Address; Algorithms; American; Area; Atrial Fibrillation; Awareness; Blood Vessels; Cardiac Electrophysiologic Techniques; Cardiac ablation; Cardiology; Caring; Characteristics; Chronic; Classification; Clinical; Communities; Data; Databases; Defibrillators; Detection; Development; Diagnosis; Directories; Discipline; Drug Prescriptions; Elderly; Gatekeeping; Geographic Factor; Geography; Growth; Health; Health Policy; Health Services Accessibility; Health system; Healthcare; Heart failure; Individual; Infrastructure; Insurance; Insurance Carriers; Intervention; Lead; Measures; Medicaid; Medical Oncology; Medical Technology; Medicare; Medicare claim; Methods; Mission; Modeling; National Institute on Aging; Office Visits; Oncologist; Operative Surgical Procedures; Outcome; Patients; Pattern; Personal Satisfaction; Pharmacotherapy; Physician' s Practice Patterns; Physicians; Policies; Population; Primary Care Physician; Primary Health Care; Quasi-experiment; Science; Services; Specialist; Specialty Boards; Surgical Oncology; Surgical Specialties; Technology; Telemedicine; Time; Tracer; Work; aging population; aortic valve replacement; base; beneficiary; care fragmentation; chemotherapy; comorbidity; design; detection method; graduate medical education; improved; improved outcome; malignant breast neoplasm; medical specialties; member; novel; overtreatment; socioeconomics; tool

PROJECT SUMMARY Over the past 40 years, specialist physicians have supplanted primary care as the most frequently seen clinicians for older adults in the US. This shift towards specialty care is driven by advancing medical technology and increased “subspecialization,” whereby specialist physicians focus on narrower and narrower clinical areas. Subspecialization has grown markedly: in 1980, the American Board of Medical Specialties had 28 specialty boards, with an additional 28 certified subspecialties. By 2020, 40 specialty boards encompassed 147 separate subspecialties. While subspecialists bring greater clinical expertise, too much subspecialization could lead to inequitable access, overtreatment, overdiagnosis or fragmentation of care. There is little empirical evidence on the implications of growing subspecialization for the health of older Americans. A major obstacle to filling these evidence gaps is the lack of meaningful measures of subspecialization at the physician level. Existing physician directories, like the one used by Medicare, contain in-depth specialty data, but are also highly inaccurate. For example, Medicare data identify only 17% of board-certified advanced heart failure specialists in the US. Other specialties have similar data gaps. To understand how access to subspecialists influences access to specific advanced treatments and clinical outcomes, it is necessary to better define the hundreds of types of subspecialty care being provided to patients. We propose to characterize subspecialization in the US and assess its implications for the health and health care of older adults. Using comprehensive data from Medicare, we will develop novel methods to classify physician subspecialists by their observed practice patterns, focusing on 3 key specialties in the care of older adults (cardiology, medical oncology and general surgery) as “tracer” disciplines to fill evidence gaps in subspecialty care that can inform policy. Specifically, we will: 1) Use community detection algorithms, a common tool in network science, to identify subspecialists based on their practice patterns (as measured by services provided, drug treatments, and patient diagnoses). 2) Identify patient, health system and geographic factors associated with subspecialty supply and access. 3) Using quasi-experimental methods, measure the impact of access to subspecialist care on health outcomes and utilization in the three key specialties. These Aims will provide novel evidence to guide health policy, including improved methods to accurately measure subspecialist supply, guide health insurers and policymakers for applications such as determining adequacy of specialist coverage in insurance design (e.g., Medicare Advantage), identify populations with shortages in subspecialist access, and guide telemedicine development. Without this evidence, clinical advances may not reach older adults who could benefit the most.

项目摘要 在过去的40年中，专业医生已经取代了最常见的初级保健 美国老年人的临床医生。 并增加了“亚科化”，是一个较狭窄的临床 领域的次数显着增长：1980年，美国医学专业委员会有28个 专业委员会，到2020年，额外有28个认证的委员会。 单独的亚专业人士。 导致无法获得，过度锻炼，过度诊断或护理破裂。 证据表明，不断增长的亚专业对美国人健康的影响。 填补这些证据差距的主要障碍是缺乏有意义的副作用 在医师级别。 数据，但也很不准确。 美国心力衰竭专家。 专科医生影响获得特定的高级治疗和临床结果的访问，有必要 更好地定义为患者提供的数百种类型的专科护理。 我们建议在美国表征亚科，评估是对健康的影响和 使用Medicare的综合数据，我们将开发出新的方法 通过观察到的练习模式对医师专科医生进行分类，重点关注三个关键专业 老年人（心脏病学，医学肿瘤学和一般手术）作为“示踪剂”学科，以填补证据空白 可以为政策提供信息的专业护理。 1）使用社区检测算法是网络科学中的常见工具，以基于 他们的实践模式（通过提供，药物治疗和患者诊断的服务来衡量）。 2）确定患者，卫生系统和地理因素与专业咨询和进入相关。 3）使用准实验方法，衡量获得专科护理对健康结果的影响 和三个主要专业的利用。 这些目标将为指导健康政策提供EVIDEL证据 准确衡量专科供应，指导健康保险公司和政策制定者，例如 确定保险设计中专业覆盖范围的充分性（例如Medicare Advantage），确定 非专业访问的人群，并指导远程医疗的发展 证据，临床进步可能无法吸引最大受益的老年人。