Physician Subspecialization and the Health and Health Care of Older Americans

项目总结 在过去的40年里，专科医生已经取代了初级保健成为最常见的 美国老年人的临床医生。这种向专科护理的转变是由先进的医疗技术推动的 以及增加“亚专科”，即专科医生专注于越来越狭隘的临床 区域。子专科显著增长：1980年，美国医学专科委员会有28个 专业板，还有另外28个认证的子专业。到2020年，40个专业委员会包括147个 不同的子专业。虽然次级专家带来更多的临床专业知识，但太多的次级专业化可能会 导致获得不公平、过度治疗、过度诊断或护理支离破碎。几乎没有经验性的 越来越多的亚专业化对美国老年人健康的影响的证据。 填补这些证据空白的一个主要障碍是缺乏有意义的次级专业化措施。 在医生层面上。现有的医生名录，如Medicare使用的名录，包含深入的专业知识 数据，但也非常不准确。例如，联邦医疗保险数据仅识别了17%的董事会认证的高级 美国的心力衰竭专家。其他专业也有类似的数据差距。要了解如何访问 专科医生影响获得特定的高级治疗和临床结果，因此有必要 更好地定义为患者提供的数百种专科护理类型。 我们建议在美国描述亚专业化的特征，并评估其对健康和 老年人的医疗保健。使用来自联邦医疗保险的全面数据，我们将开发新的方法来 根据观察到的执业模式对内科专家进行分类，重点关注护理中的3个关键专业 将老年人(心脏病学、内科肿瘤学和普通外科)作为“示踪剂”学科来填补证据空白 可以为政策提供信息的专科护理。具体来说，我们会： 1)使用社区检测算法，这是网络科学中的一种常见工具，根据以下情况确定子专家 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，衡量获得专科护理对健康结果的影响 并在三个重点专业中加以利用。 这些目标将为指导卫生政策提供新的证据，包括改进方法以 准确衡量专科医生的供应，指导健康保险公司和政策制定者的应用，如 确定保险设计中专家覆盖的充分性(例如，Medicare Advantage)，确定 为缺乏专科服务的人群提供医疗服务，并指导远程医疗的发展。如果没有这个 有证据表明，临床进步可能不会惠及老年人，他们可能受益最大。

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.