title: The intersection of patient complexity, prescriber continuity and acute care utilization.
abstract: BACKGROUND
  Care continuity is considered a critical characteristic of high-performing health systems. Few studies have examined the continuity of medication management of complex patients, who often have multiple providers and complex medication regimens.
  
  
  OBJECTIVE
  The purpose of this study was to characterize patient factors associated with having more prescribers and the association between number of prescribers and acute care utilization.
  
  
  METHODS
  A retrospective cohort study was conducted of 7,933 Veterans with one to four cardiometabolic conditions (diabetes, hypertension, hyperlipidemia or congestive heart failure) and prescribed medications for these conditions in 2008.
  
  
  METHODS
  The association between number of cardiometabolic conditions and prescribers was modeled using Poisson regression. The number of cardiometabolic conditions and number of prescribers were modeled to predict probability of inpatient admission, probability of emergency room (ER) visits, and number of ER visits among ER users. Demographic characteristics, number of cardiometabolic medications and comorbidities were included as covariates in all models.
  
  
  RESULTS
  Patients had more prescribers if they had more cardiometabolic conditions (p < 0.001). The adjusted odds of an ER visit increased with the number of prescribers (two prescribers, Odds Ratio (OR) = 1.16; three prescribers, OR = 1.21; 4+ prescribers, OR = 1.39), but not with the number of conditions. Among ER users, the number of ER visits was neither associated with the number of prescribers nor the number of conditions. The adjusted odds of an inpatient admission increased with the number of prescribers (two prescribers, OR = 1.27; three prescribers, OR = 1.30; 4+ prescribers, OR = 1.34), but not with the number of conditions.
  
  
  CONCLUSIONS
  Having more prescribers was associated with greater healthcare utilization for complex patients, despite adjustment for the number of conditions and medications. The number of prescribers may be an appropriate target for reducing acute care utilization by complex patients.
authors.affiliation: Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, USA, Mlm34@duke.edu.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Maciejewski
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Powers
authors.forename: Linda L
authors.initials: LL
authors.lastname: Sanders
authors.forename: Joel F
authors.initials: JF
authors.lastname: Farley
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hansen
authors.forename: Betsy
authors.initials: B
authors.lastname: Sleath
authors.forename: Corrine I
authors.initials: CI
authors.lastname: Voils
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003266:Continuity of Patient Care / Q000639:trends; D011307:Drug Prescriptions; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D014728:Veterans