Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021
Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021
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DOI：
10.1001/jama.2021.24294
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发表时间：
2022-01-18
影响因子：
120.7
通讯作者：
Kahn, Katherine L.
中科院分区：
文献类型：
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作者：
Mafi, John N.;Craff, Melody;Kahn, Katherine L.
重要性随着美国门诊护理在大流行早期的减少，目前尚不清楚在不同的保险类型和服务中，护理是否一致地恢复到预期的比率。目的评估具有医疗补助或医疗保险-医疗补助双重资格的患者是否比具有商业、医疗保险优势或医疗保险按服务收费保险的患者使用门诊护理的比率显著低于预期的回报。在这项回顾性队列研究中，研究了2019年1月1日至2021年2月28日的门诊护理服务模式，使用Milliman MedInsight研究数据库合并了来自多个美国付款人的索赔数据。采用差异中差异的设计，估计了大流行病期间的利用率与大流行病未发生时的预期利用率之间的差异程度。2020年1月至2月及其后疫情期间各2个月的使用率变动与去年同期的变动进行比较。每月使用计数的年龄和性别调整泊松回归模型，抵消总患者月和分层的服务和保险type.EXPOSURES与医疗补助或医疗保险-医疗补助双重资格的患者相比，与商业，医疗保险优势，或医疗保险收费服务保险的患者，分别.主要结果和措施每100人的利用率为6服务：急诊科，办公室和紧急护理，行为健康，筛查结肠镜检查，筛查乳房X光检查，避孕咨询或HIV筛查。结果超过1450万美国成年人被纳入（平均年龄52.7岁，54.9%为女性）。在2020年3月至4月的时间范围内，6种门诊服务的综合使用率下降至预期率的67.0%（95%CI，66.9%-67.1%），但在2020年11月至12月的时间范围内恢复至预期率的96.7%（95%CI，96.6%-96.8%）。在2021年1月至2月的第二波COVID-19疫情期间，总体使用率再次下降至预期率的86. 2%（95% CI，86. 1%-86. 3%），结肠镜检查仍为预期率的65. 0%（95% CI，64. 1%-65. 9%），乳腺X光检查为预期率的79. 2%（95% CI，78. 5%-79. 8%）。到2021年1月至2月的时间框架，总体利用率恢复到预期水平，如下所示：医疗补助患者为78.4%（95% CI）。78.2%-78.7%），医疗保险-医疗补助双重资格为73.3%（95%CI。72.8%-73.8%）。市售90.7%（95% CI. 90.5%-90.9%），Medicare Advantage为83.2%（95% CI。81.7%-82.2%），医疗保险按服务收费为82.0%（95% CI，81.7%~ 82.2%; P < .001;分别比较具有医疗补助和医疗保险-医疗补助双重资格的患者与其他每种保险类型的预期利用率回报）。结论和相关性在2020年3月至2021年2月期间，在COVID-19疫情爆发后使用率下降后，6项日间护理服务的总使用量有所增加。然而，对于具有医疗补助或医疗保险-医疗补助双重资格的参与者，使用这些门诊护理服务的增长率显著低于商业，医疗保险优势或医疗保险收费服务的参与者。
IMPORTANCE Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services.OBJECTIVE To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance.DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman Medlnsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type.EXPOSURES Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively.MAIN OUTCOMES AND MEASURES Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening.RESULTS More than 14.5 million US adults were induded (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI. 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI. 72.8%-73.8%). commercial at 90.7% (95% CI. 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI. 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types).CONCLUSIONS AND RELEVANCE Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.