Published Online: August 5, 2019. doi:10.1001/jamainternmed.2019.3107
Author Contributions: Dr Growdon had full access to all of the data in the study
and takes responsibility for the integrity of the data and the accuracy of the data
Study concept and design: Growdon, Sacks, Avorn.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Growdon.
Critical revision of the manuscript for important intellectual content:
Sacks, Kesselheim, Avorn.
Statistical analysis: Growdon, Avorn.
Obtained funding: Kesselheim, Avorn.
Administrative, technical, or material support: Avorn.
Study supervision: Kesselheim, Avorn.
Conflict of Interest Disclosures: None reported.
Funding/Support: Work at PORTAL is supported by Arnold Ventures, with
additional support from the Engelberg Foundation and Harvard-MIT Center for
Regulatory Science. Dr Sacks also receives support from the Carney Family
Role of the Funder/Sponsor: Arnold Ventures, the Engelberg Foundation, the
Harvard-MIT Center for Regulatory Science, and the Carney Family Foundation
had no roles in the design and conduct of the study; collection, management,
analysis, and interpretation of the data; preparation, review, or approval of the
manuscript; and decision to submit the manuscript for publication.
1. Kesselheim AS, Avorn J, Sarpatwari A. The high cost of prescription drugs in
the United States origins and prospects for reform. JAMA. 2016;316(8):858-871.
2. Johansen ME, Richardson C. Estimation of potential savings through
therapeutic substitution. JAMA Intern Med. 2016;176(6):769-775. doi:10.1001/
3. Centers for Medicare and Medicaid Services. Medicare Part D Drug Spending
Dashboard and Data. https://www.cms.gov/Research-Statistics-Data-and-
MedicarePartD.html. Published March 14, 2019. Accessed March 20, 2019.
4. Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/
APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection,
evaluation, and management of high blood pressure in adults. Hypertension.
5. Vanderholm T, Klepser D, Adams AJ. State approaches to therapeutic
interchange in community pharmacy settings: legislative and regulatory
authority. J Manag Care Spec Pharm. 2018;24(12):1260-1263.
6. Sacks CA, Lee CC, Kesselheim AS, Avorn J. Medicare spending on
brand-name combination medications vs their generic constituents. JAMA.
Trends in Hospitalization vs Observation Stay
for Ambulatory Care–Sensitive Conditions
Hospitalizations related to ambulatory care–sensitive condi-
tions (ACSCs) are widely considered a key measure of access
to high-quality primary care.1 The Agency for Healthcare Re-
search and Quality defines ACSCs as conditions, such as uri-
nary tract infection and dehydration, forSearch All AHRQ Sites
Provide Feedback | Submit a Case
Ambulatory Care Safety
September 7, 2019
Despite the fact that the vast majority of health care takes place in the outpatient, or
ambulatory care, setting, e�orts to improve safety have mostly focused on the inpatient
setting. However, a body of research dedicated to patient safety in ambulatory care has
emerged over the past few years. These e�orts have identi�ed and characterized factors
that in�uence safety in o�ce practice, the types of errors commonly encountered in
ambulatory care, and potential strategies for improving ambulatory safety.
Factors In�uencing Safety in Ambulatory Care
Ensuring patient safety outside of the hospital setting poses unique challenges for
both providers and patients. A recent article proposed a model for patient safety in
chronic disease management, modi�ed from the original Chronic Care Model . This
model broadly encompasses three concepts that in�uence safety in ambulatory care:
The role of patient and caregiver behaviors
The role of provider–patient interactions
The role of the community and health system
Speci�c types of errors can be linked to each of these three concepts.
Types of Safety Events in Ambulatory Care
Since face-to-face interactions between providers and patients in the ambulatory setting
are limited and occur weeks to months apart, patients must assume a much greater role
in and responsibility for managing their own health. This elevates the importance of
including the patient as a partner and ensuring that patients understand their illnesses
and treatments. The need for outpatients to self-manage their own chronic diseases
requires that they monitor their symptoms and, in some cases, adjust their own lifestyle
or medications. For example, a patient with diabetes must measure her own blood
sugars and perhaps adjust her insulin dose based on blood sugar values and dietary
intake. A patient’s inability or failure to perform such activities may compromise safety
in the short term and clinical outcomes in the long term. Patients must also understand
how and when to contact their caregivers outside of routine appointments, and they
must often play
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