Proton Beam Therapy and Treatment for Localized Prostate Cancer: If You Build It, They Will Come

ED use made 17 759 visits over the study period, while the 1928 patients with frequent ED use made 12 289 visits. Ap- proximately half (49.8%) of all ED visits occurred on week- days, while BMC primary care practices were open. Most ED visits were for low-severity conditions. Comment. Emergency department use by primary care patients at an urban safety-net hospital was high, though most visits were of low severity. One possible reason for this is lack of access to primary care, 4 with few available appointments to see a PCP. While data on time to third next available appointment, a standard measure of pri- mary care access, 5 are not available for the primary care practices during the study period, other practice met- rics suggest that access may have been a problem. For example, missed primary care appointment rates were high, averaging 24.5%. High missed appointment rates are often correlated with long wait times to schedule ap- pointments. 6 In addition, monthly telephone call statis- tics show that only between 72.4% and 88.1% of patient telephone calls were answered by the primary care call center over the study period. It is possible that patients called the practices with an urgent problem, did not have their telephone call answered promptly, and decided to seek care in the ED instead. Indeed, 13% of telephone calls were abandoned by patients over the study period (patients called and subsequently hung up while they were kept on hold). The fact that nearly half of all ED visits took place during the hours of primary care clinic op- eration further suggests that appointment availability may have been an issue. In addition, a sizable minority, roughly one-fifth, of primary care is provided by residents, 7 who have limited availability when they are not in clinic. It is also possible that Massachusetts health reform has af- fected access to primary care. As newly insured patients have entered primary care in large numbers, it is pos- sible that access to primary care has worsened for other patients. Massachusetts has been a bellwether for the imple- mentation of health reform and will be a bellwether for the transformation of primary care, with the move away from fee-for-service payments and the introduction of global payments for health care. Overall ED volume has continued to increase in Massachusetts after health re- form. 8 It is unclear if changes in primary care practice and payment will be sufficient to reduce high levels of ED use among patients at an urban safety-net hospital. Karen E. Lasser, MD, MPH Andrea C. Kronman, MD, MSc Howard Cabral, PhD, MPH Jeffrey H. Samet, MD, MA, MPH Author Affiliations: Section of General Internal Medi- cine, Department of Medicine, Boston Medical Center and Boston University School of Medicine (Drs Lasser, Kronman, and Samet), and Departments of Community Health Sciences (Drs Lasser and Samet), Biostatistics (Drs Cabral), and Epidemiology (Dr Samet), Boston Univer- sity School of Public Health, Boston, Massachusetts. Correspondence: Dr Lasser, Health/Care Disparities Re- search Program, 801 Massachusetts Ave, Boston Medi- cal Center, Section of General Internal Medicine, Room #2091, Boston, MA 02118 (karen.lasser@bmc.org). Author Contributions: Dr Lasser, the primary author, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accu- racy of the data analysis. Study concept and design: Lasser, Kronman, and Samet. Acquisition of data: Lasser. Analy- sis and interpretation of data: Lasser, Kronman, Cabral, and Samet. Drafting of the manuscript: Lasser, Cabral, and Samet. Critical revision of the manuscript for important in- tellectual content: Lasser, Kronman, Cabral, and Samet. Statistical analysis: Lasser, Kronman, and Cabral. Ob- tained funding: Lasser and Samet. Administrative, techni- cal, and material support: Lasser. Study supervision: Lasser and Samet. Financial Disclosure: Dr Lasser was a consultant to Rise Health (June-November 2011). Funding/Support: This study was supported by the De- partment of Medicine at Boston Medical Center/Boston University School of Medicine. Previous Presentation: This work was presented at the Society of General Internal Medicine Annual Meeting; May 7, 2011; Phoenix, Arizona. Additional Contributions: Meredith Manze D’Amore, PhD (Section of General Internal Medicine, Boston Medi- cal Center/Boston University School of Medicine), as- sisted in manuscript preparation; Linda C. Rosen, BSEE (Boston University Office of Clinical Research), per- formed data extraction; and Maxim D Shrayer, PhD (De- partment of Slavic and Eastern Languages and Litera- tures, Boston College), and William Fernandez, MD (Department of Emergency Medicine, Boston Medical Center/Boston University School of Medicine), pro- vided comments on an earlier draft of the manuscript. 1. Billings J, Parikh N, Mijanovich T. Emergency department use: the New York Story. Issue Brief (Commonw Fund). 2000;(434):1-12. 2. Ballard DW, Price M, Fung V, et al. Validation of an algorithm for categoriz- ing the severity of hospital emergency department visits. Med Care. 2010; 3. Wharam JF, Landon BE, Galbraith AA, Kleinman KP, Soumerai SB, Ross- Degnan D. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA. 2007;297(10):1093-1102. 4. Smulowitz P, Landon BE, Burke L, Baugh C, Gunn H, Lipton R. Emergency department use by the uninsured after health care reform in Massachusetts. Intern Emerg Med. 2009;4(6):501-506. 5. Murray M, Berwick DM. Advanced access: reducing waiting and delays in pri- mary care. JAMA. 2003;289(8):1035-1040. 6. Lasser KE, Mintzer IL, Lambert A, Cabral H, Bor DH. Missed appointment rates in primary care: the importance of site of care. J Health Care Poor Underserved. 2005;16(3):475-486. 7. Zallman L, Ma J, Xiao L, Lasser KE. Quality of US primary care delivered by resident and staff physicians. J Gen Intern Med. 2010;25(11):1193-1197. 8. Smulowitz PB, Lipton R, Wharam JF, et al. Emergency department utiliza- tion after the implementation of Massachusetts health reform. Ann Emerg Med. 2011;58(3):225-234.e1. Proton Beam Therapy and Treatment for Localized Prostate Cancer: If You Build It, They Will Come T he number of treatment options for localized prostate cancer continues to expand, amidst growing concern regarding overdiagnosis and overtreatment of low-risk disease. 1-3 Treatment pat- terns, however, may be driven by availability of novel tech- ARCH INTERN MED/ VOL 172 (NO. 3), FEB 13, 2012 WWW.ARCHINTERNMED.COM ©2012 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by a UCSF LIBRARY User on 07/06/2016