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.

项目概要 过去 40 年来，专科医生已取代初级保健成为最常见的医疗服务 美国老年人的追随者这种向专业护理的转变是由先进的医疗技术推动的。 并增加“亚专业化”，即专科医生专注于越来越窄的临床 亚专业化显着增长：1980 年，美国医学专业委员会有 28 个。 专业委员会，另有 28 个经过认证的子专业，到 2020 年，将有 40 个专业委员会，涵盖 147 个专业委员会。 虽然亚专科医生带来了更多的临床专业知识，但过多的亚专业化可能会带来负面影响。 导致不公平的获取、过度治疗、过度诊断或护理分散。 经验很少。 有关日益细分的专业化对美国老年人健康影响的证据。 填补这些证据空白的一个主要障碍是缺乏有意义的亚专业化措施 现有的医生目录（例如 Medicare 使用的目录）包含深入的专业知识。 数据，但也非常不准确，例如，医疗保险数据仅识别出 17% 的经董事会认证的高级患者。 美国其他专业的心力衰竭专家也存在类似的数据差距。 亚专科医生会影响获得特定先进治疗和临床结果的机会，因此有必要 更好地定义为患者提供的数百种亚专科护理类型。 我们建议描述美国的亚专业化特征，并评估其对健康和健康的影响。 利用医疗保险的综合数据，我们将开发新的方法来实现老年人的医疗保健。 根据观察到的实践模式对医师亚专科进行分类，重点关注护理领域的 3 个关键专业 老年人（心脏病学、肿瘤内科和普通外科）作为“追踪”学科，以填补证据空白 具体而言，我们将： 1）使用社区检测算法（网络科学中的常用工具）来识别亚专家 他们的实践模式（通过提供的服务、药物治疗和患者诊断来衡量）。 2) 确定与专科供应和获取相关的患者、卫生系统和地理因素。 3) 使用准实验方法，衡量获得亚专科护理对健康结果的影响 并在三个重点专业中运用。 这些目标将为指导卫生政策提供新的证据，包括改进方法 准确衡量亚专科供应情况，指导医疗保险公司和政策制定者的应用，例如 确定保险设计中专业承保范围的充分性（例如 Medicare Advantage），确定 缺乏专科服务的人群，并指导远程医疗的发展。 证据表明，临床进展可能无法惠及最能受益的老年人。