Dangerous Prescribing and Care Fragmentation

The quality of care that patients receive may depend on how effectively their clinicians coordinate and learn from one-another. In this study, we consider whether fragmented care leads to dangerous or low-value prescribing. When care is fragmented, no clinician has primary responsibility for the full scope of a patient’s many prescriptions. For example, taking an opioid pain reliever alongside a benzodiazepine anti-anxiety drug puts a patient at greatly increased risk of overdose and death, and a patient receiving fragmented care across multiple providers could easily find herself with escalating prescriptions for both drugs without any single provider aware of the dangerous combination.

We seek to quantify the association between care fragmentation and prescribing quantity and quality, purged of patient selection. To this end, we exploit “mover” patients (c.f. Finkelstein et al. 2016, Agha et al. 2017) who move across regions with varying levels of care fragmentation. We track how patients’ prescription drug use evolves when they move from, for example, a low fragmentation to a high fragmentation area. We also apply this research design to analyses at the provider group level by studying how care changes when patients change provider groups (c.f. Agha et al. 2018). In preliminary, cross-sectional results, we find that areas with fragmented care delivery tend to have fewer prescriptions, and fewer low-risk prescriptions. However, such findings may be the result of patient selection, highlighting the importance of research designs like the mover approach that are robust to non-random allocation of patients to areas.