Assessing Association Between Team Structure and Health Outcome and Cost by Social Network Analysis

J Am Geriatr Soc. 2020 Dec 1;10.1111/jgs.16962. doi: 10.1111/jgs.16962. Online ahead of print.


Background/objective: To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care.

Design: Cross-sectional study.

Setting: Data from 20% randomly selected primary care service areas in the 2015 Medicare claims were used to identify primary care practices.

Participants: 449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices.

Measurements: Social network analysis measures, including edge density, degree centralization, and betweenness centralization for each practice.

Results: When compared with practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs had only lower degree of centralization and higher MD-to-MD connectedness. Within the primary care practices comprising MDs, NPs, or/and PAs, the nonphysician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared with the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-0.99), emergency department (ER) admission (OR = 0.80, 95% CI = 0.70-0.92), and total spending (cost ratio (CR) = 0.86, standard error of the mean (SE) = 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR = 1.15, 95% CI = 1.03-1.28), ER admission (OR = 1.23, 95% CI = 1.08-1.40), and total spending (CR = 1.14, SE = 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR = 0.90, 95% CI = 0.81-0.99). Team leadership by an NP versus an MD was similar in the rate of ER admissions, hospitalizations, or total spending.

Conclusion: Our findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.

Keywords: Medicare; nurse practitioners; primary care; social network analysis.