Access to specialized health care services among older Canadians

Background

Canada is experiencing rapid population aging, which has a wide range of implications, including an increased need for health care services. However, very few studies have examined use of specialized health care services (e.g., visits to medical specialists, non-emergency tests, and surgeries) among older Canadians.

Data and methods

Data from the Canadian Health Survey on Seniors - 2019/2020 were used to examine specialized health care service use among older Canadians. Latent class analysis was calibrated using a nationally representative sample of 39,047 Canadians aged 65 years or older to identify distinct patterns of need factors related to health care service use. Multivariable logistic regression, stratified by gender, was used to examine the association of predisposing characteristics, enabling resources, and need factors with specialized health care service use.

Results

In 2019/2020, an estimated 2.6 million older Canadians (43.4%) visited medical specialists, 1.4 million (23.2%) got non-emergency tests, and 0.6 million (10.4%) had non-emergency surgeries. Among those, 15.6% reported experiencing difficulties accessing services. Women were less likely than men to have visited medical specialists and have received non-emergency tests. Lower education was consistently associated with lower odds of specialized health care service use. Individuals in the multimorbidity, high stress-multimorbidity-disability, and poor physical and mental health classes were more likely than those in the comparatively healthy class to use specialized health care services and to experience difficulties accessing them.

Interpretation

Findings of this study highlight gender differences and the importance of considering multidimensional need factors - ranging from physical health to mental health to psychosocial factors - in examining use of specialized health care services.

Antibiotic use for airway infections in Norwegian children-A national register-based study

AIM

Respiratory tract infections (RTIs) are major contributors to childhood antibiotic use. We aimed to investigate geographical and temporal trends in the prescription of antibiotics and consultations for RTIs in children <18 years living in Norway from 2010 to 2017.

METHODS

In a nationwide observational study, we analysed antibiotic prescriptions from the Norwegian Prescription Database and reimbursed contacts from primary care physicians. We limited the study to airway antibiotics and diagnostic codes indicating RTIs.

RESULTS

Antibiotic prescriptions due to an RTI varied from 75 to 134 per 1000 consultation due to RTI across counties in Norway (relative risk 1.79, 95% CI 1.68-1.90 for highest compared to lowest). The use of health care varied from 414 to 585 consultations for RTI per 1000 inhabitant/year (relative risk 1.43, 95% CI 1.41-1.44 for highest compared to lowest). From 2010 to 2017, we observed a 21% reduction in antibiotic prescriptions per RTI consultation and of 6% for the number of consultations for an RTI. At the county level, the use of health care was positively associated with the proportion of RTIs that resulted in antibiotic prescription.

CONCLUSION

We found a reduction in doctors' antibiotic prescription and the use of health care for RTIs, and a variation across counties.

The Australian Genetic Heart Disease Registry: Protocol for a Data Linkage Study

BACKGROUND

Genetic heart diseases such as hypertrophic cardiomyopathy can cause significant morbidity and mortality, ranging from syncope, chest pain, and palpitations to heart failure and sudden cardiac death. These diseases are inherited in an autosomal dominant fashion, meaning family members of affected individuals have a 1 in 2 chance of also inheriting the disease ("at-risk relatives"). The health care use patterns of individuals with a genetic heart disease, including emergency department presentations and hospital admissions, are poorly understood. By linking genetic heart disease registry data to routinely collected health data, we aim to provide a more comprehensive clinical data set to examine the burden of disease on individuals, families, and health care systems.

OBJECTIVE

The objective of this study is to link the Australian Genetic Heart Disease (AGHD) Registry with routinely collected whole-population health data sets to investigate the health care use of individuals with a genetic heart disease and their at-risk relatives. This linked data set will allow for the investigation of differences in outcomes and health care use due to disease, sex, socioeconomic status, and other factors.

METHODS

The AGHD Registry is a nationwide data set that began in 2007 and aims to recruit individuals with a genetic heart disease and their family members. In this study, demographic, clinical, and genetic data (available from 2007 to 2019) for AGHD Registry participants and at-risk relatives residing in New South Wales (NSW), Australia, were linked to routinely collected health data. These data included NSW-based data sets covering hospitalizations (2001-2019), emergency department presentations (2005-2019), and both state-wide and national mortality registries (2007-2019). The linkage was performed by the Centre for Health Record Linkage. Investigations stratifying by diagnosis, age, sex, socioeconomic status, and gene status will be undertaken and reported using descriptive statistics.

RESULTS

NSW AGHD Registry participants were linked to routinely collected health data sets using probabilistic matching (November 2019). Of 1720 AGHD Registry participants, 1384 had linkages with 11,610 hospital records, 7032 emergency department records, and 60 death records. Data assessment and harmonization were performed, and descriptive data analysis is underway.

CONCLUSIONS

We intend to provide insights into the health care use patterns of individuals with a genetic heart disease and their at-risk relatives, including frequency of hospital admissions and differences due to factors such as disease, sex, and socioeconomic status. Identifying disparities and potential barriers to care may highlight specific health care needs (eg, between sexes) and factors impacting health care access and use.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48636.

Predictors and Consequences of Homelessness: Protocol for a Cohort Study Design Using Linked Routine Data

BACKGROUND

Homelessness is a global burden, estimated to impact more than 100 million people worldwide. Individuals and families experiencing homelessness are more likely to have poorer physical and mental health than the general population. Administrative data is being increasingly used in homelessness research.

OBJECTIVE

The objective of this study is to combine administrative health care data and social housing data to better understand the consequences and predictors associated with being homeless.

METHODS

We will be linking health and social care administrative databases from Northern Ireland, United Kingdom. We will conduct descriptive analyses to examine trends in homelessness and investigate risk factors for key outcomes.

RESULTS

The results of our analyses will be shared with stakeholders, reported at conferences and in academic journals, and summarized in policy briefing notes for policymakers.

CONCLUSIONS

This study will aim to identify predictors and consequences of homelessness in Northern Ireland using linked housing, health, and social care data. The findings of this study will examine trends and outcomes in this vulnerable population using routinely collected health and social care administrative data.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42404.

Syndromic Surveillance of Health Effects Due to Summer Sun Overexposure: Construction of an Indicator Based on Drug Sales in Pharmacies-Preliminary Study within the PRISME Project

INTRODUCTION

Solar radiation is classified as a known human carcinogen. In France, people frequently ask local pharmacies to dispense products for sunburns. In the PRISME project, studying this use can be a specific and sensitive way to assess these overexposures.

OBJECTIVE

This study aims to construct an indicator for monitoring healthcare consumption in pharmacies after overexposure to solar UV.

METHODS

The study, conducted between July and August 2019, covered a sample of pharmacies located in coastal communities of southern France. A list of products for sunburn was defined. When one of the products on this list was sold, the customer was asked to fill out a questionnaire to determine whether the purchase was related to UV overexposure. A positive predictive value (PPV) per active ingredient was calculated.

RESULTS

Overall, nine pharmacies participated in the study, and 288 questionnaires were collected. The majority of products purchased were for women (60.7%), for people aged 15 and over (78.1%), and for people not living in the department (68.9%). The most frequently purchased products were our trolamine-containing products which accounted for 53% of sales. With the exception of three products, all PPVs were greater than 0.8.

CONCLUSION

The high PPV confirms the suitability of the product selection as an indicator for monitoring healthcare consumption related to solar UV overexposure. Two indicators (one sensitive and one specific) were selected to maximise the chances of identifying UV-related remedies.

Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators

PURPOSE

Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years.

METHODS

We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis.

RESULTS

The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation.

CONCLUSIONS

The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.

The impact of a point-of-care visual clinical decision support tool on admissions for cellulitis in the University of Maryland medical system

Introduction

Cellulitis is commonly diagnosed in emergency departments (EDs), yet roughly one third of ED patients admitted for presumed cellulitis have another, usually benign, condition instead (eg, stasis dermatitis). This suggests there is an opportunity to reduce health care resource use through improved diagnosis at the point of care. This study seeks to test whether a clinical decision support (CDS) tool interoperable with the electronic medical record (EMR) can reduce inappropriate hospital admissions and drive more appropriate and accurate care.

Methods

This study was a trial of an EMR-interoperable, image-based CDS tool for evaluation of ED patients with suspected cellulitis. At the point of assigning a provisional diagnosis of cellulitis in the EMR, the clinician was randomly prompted to use the CDS. Based on the patient features entered into the CDS by the clinician, the CDS provided the clinician a list of likely diagnoses. The following were recorded: patient demographics, disposition and final diagnosis of patients, and whether antibiotics were prescribed. Logistic regression methods were used to determine the impact of CDS engagement on our primary outcome of admission for cellulitis, adjusted for patient factors. Antibiotic use was a secondary end point.

Results

From September 2019 to February 2020 (or 7 months), the CDS tool was deployed in the EMR at 4 major hospitals in the University of Maryland Medical System. There were 1269 encounters for cellulitis during the study period. The engagement with the CDS was low (24.1%, 95/394), but engagement was associated with an absolute reduction in admissions (7.1%, p = 0.03). After adjusting for age greater than 65 years, female sex, non-White race, and private insurance, CDS engagement was associated with a significant reduction of admissions (adjusted OR = 0.62, 95% confidence interval (CI): 0.40-0.97, p = 0.04) and antibiotic use (Adjusted OR = 0.63, 95% CI: 0.40-0.99, p = 0.04).

Conclusions

CDS engagement was associated with decreased admissions for cellulitis and decreased antibiotic use in this study, despite low levels of CDS engagement. Further research should examine the impact of CDS engagement in other practice environments and measure longer-term outcomes in patients discharged from the ED.

Fintech and medical expenses: What social workers should know

Individuals who cannot afford out of pocket medical expenses may reduce health care use, resulting in poorer health outcomes. To ease the situation, employers turn to financial technology ("fintech") health care credit applications. We examine whether an employer-sponsored credit fintech application (MedPut) helps employees manage medical expenses. Results of the analysis of variance (ANOVA) and probit regression models reveal MedPut users did worse financially and delayed health care due to cost more often than employees who did not use MedPut. Results may inform social work policy and direct practice perspectives on fin-tech and medical expenses.

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Greek Version of the Cardiac Rehabilitation Barriers Scale (CRBS-GR): What Are the Barriers in South-East Europe?

Cardiac Rehabilitation (CR) is a secondary prevention intervention proven to improve quality of life, yet with low participation. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess multi-level barriers to participation. This study aimed at the translation, and cross-cultural adaptation of the CRBS into the Greek language (CRBS-GR), followed by psychometric validation. Some 110 post-angioplasty patients with coronary artery disease (88.2% men, age 65.3 ± 10.2 years) answered the CRBS-GR. Factor analysis was performed to obtain the CRBS-GR subscales/factors. The internal consistency and 3-week test-retest reliability was evaluated using Cronbach's alpha (α) and intraclass correlation coefficient (ICC), respectively. Construct validity was tested via convergent and divergent validity. Concurrent validity was assessed with the Hospital Anxiety and Depression Scale (HADS). Translation and adaptation resulted in 21 items similar to the original version. Face validity and acceptability were supported. Construct validity assessment revealed four subscales/factors, with acceptable overall reliability (α = 0.70) and subscale internal consistency for all but one factor (α range = 0.56-0.74). The 3-week test-retest reliability was 0.96. Concurrent validity assessment demonstrated a small to moderate correlation of the CRBS-GR with the HADS. The greatest barriers were the distance from the rehabilitation center, the costs, the lack of information about CR, and already exercising at home. The CRBS-GR is a reliable and valid tool for identifying CR barriers among Greek-speaking patients.

Perceptions of prognosis and end-of-life care outcomes in patients with advanced lung and gastrointestinal cancer

BACKGROUND

Many patients with advanced cancer have misperceptions of their prognosis, which may impact end-of-life decision-making. Data regarding associations between prognostic perceptions over time and end-of-life care outcomes are lacking.

AIM

To describe patients' perceptions of their prognosis with advanced cancer and examine associations between these perceptions and end-of-life care outcomes.

DESIGN

Secondary analysis of longitudinal data from a randomized controlled trial of a palliative care intervention for patients with newly diagnosed incurable cancer.

SETTING/PARTICIPANTS

Conducted at an outpatient cancer center in the northeastern United States and patients were within 8 weeks of a diagnosis with incurable lung or non-colorectal gastrointestinal cancer.

RESULTS

We enrolled 350 patients in the parent trial, of which 80.5% (281/350) died during the study period. Overall, 59.4% (164/276) of patients reported they were terminally ill, and 66.1% (154/233) reported that their cancer was likely curable at the assessment closest to death. Patient acknowledgment of terminal illness was only associated with lower risk of hospitalizations in the last 30 days of life (OR = 0.52, p = 0.025). Patients who reported their cancer as likely curable were less likely to utilize hospice (OR = 0.25, p = 0.002) or die at home (OR = 0.56, p = 0.043), and they were more likely to be hospitalized in the last 30 days of life (OR = 2.28, p = 0.011).

CONCLUSIONS

Patients' perceptions of their prognosis are associated with important end-of-life care outcomes. Interventions are needed to enhance patients' perceptions of their prognosis and optimize their end-of-life care.

Single-Use Ureteroscopes Are Associated with Decreased Risk of Urinary Tract Infection After Ureteroscopy for Urolithiasis Compared to Reusable Ureteroscopes

Objective: Urinary tract infection (UTI) is a common complication after ureteroscopy. Despite sterilization, there is evidence that reusable ureteroscopes can still harbor bacteria. Whether this property is associated with increased risk of UTI is unknown. The objective of this study was to compare rates of postoperative UTI after ureteroscopy for urolithiasis performed with single-use ureteroscopes vs reusable ureteroscopes. Materials and Methods: This was a single-center, retrospective cohort study of all patients who underwent ureteroscopy for urolithiasis between June 2012 and March 2021. Outcomes were compared between those who underwent stone removal with single-use and reusable ureteroscopes. The primary endpoint was postoperative UTI. The secondary endpoints were intra-operative and postoperative outcomes, and health service utilization after surgery. Results: Of 991 patients identified, 500 (50.4%) underwent ureteroscopy with a single-use ureteroscope. Rates of postoperative UTI were lower in those undergoing ureteroscopic stone removal with a single-use ureteroscope compared to a reusable ureteroscope (6.5% vs 11.9%, p = 0.018). In multivariable analysis, use of a single-use ureteroscope was associated with lower odds of postoperative UTI compared to a reusable ureteroscope when adjusting for risk (odds ratio 0.37, p = 0.015). Use of a single-use ureteroscope was associated with a higher stone clearance rate compared to a reusable ureteroscope (90.0% vs 83.9%, p = 0.005). There was no difference in operative time, overall complication rate, readmission, or emergency department visits between two groups. Conclusion: Single-use ureteroscopes are associated with a twofold decreased risk of UTI and increased stone clearance rate after ureteroscopy for urolithiasis compared to reusable ureteroscopes.

Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis

BACKGROUND

Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use.

OBJECTIVE

The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit.

METHODS

This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use.

RESULTS

Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups.

CONCLUSIONS

Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.

Student loans, physical and mental health, and health care use and delay in college

Objective: Determine relationships between college students' student loan presence and self-rated physical and mental health, major medical problems, mental health conditions, physical, dental, and mental health care visits and delays, and medication use and reductions. Participants: A total of 3,248 undergraduates at two regional public U.S. universities, surveyed Spring 2017. Methods: OLS and Logistic regression. Results: Loan presence was related to significantly worse self-rated physical and mental health and more major medical problems, but not to mental health conditions, or physical or mental health medication use. Respondents with loans were less likely to visit the dentist and more likely to report delaying medical, dental, and mental health care, and reducing medication use to save money. Conclusions: Results provide evidence of health and health care use divides among college students by loan presence.

Association Between Neuroticism and Dementia on Healthcare Use: A Multi-Level Analysis Across 27 Countries from The Survey of Health, Ageing and Retirement in Europe (SHARE)

BACKGROUND

People with high levels of neuroticism are greater users of health services. Similarly, people with dementia have a higher risk of hospitalization and medical visits. As a result, dementia and a high level of neuroticism increase healthcare use (HCU). However, how these joint factors impact the HCU at the population level is unknown. Similarly, no previous study has assessed the degree of generalization of such impacts, considering relevant variables including age, gender, socioeconomic, and country-level variability.

OBJECTIVE

To examine how neuroticism and dementia interact in the HCU.

METHODS

A cross-sectional study was performed on a sample of 76,561 people (2.4% with dementia) from 27 European countries and Israel. Data were analyzed with six steps multilevel non-binomial regression modeling, a statistical method that accounts for correlation in the data taken within the same participant.

RESULTS

Both dementia (Incidence Rate Ratio (IRR): 1.537; α= 0.000) and neuroticism (IRR: 1.122; α= 0.000) increased the HCU. The effect of having dementia and the level of neuroticism increased the HCU: around 53.67% for the case of having dementia, and 12.05% for each increment in the level of neuroticism. Conversely, high levels of neuroticism in dementia decreased HCU (IRR: 0.962; α= 0.073). These results remained robust when controlling for age, gender, socioeconomic, and country-levels effects.

CONCLUSION

Contrary to previous findings, neuroticism trait in people with dementia decreases the HCU across sociodemographic, socioeconomic, and country heterogeneity. These results, which take into account this personality trait among people with dementia, are relevant for the planning of health and social services.

Testing for Hepatitis C Virus Infection Among Adults Aged ≥18 in the United States, 2013-2017

OBJECTIVE

Approximately 2.4 million people in the United States are living with hepatitis C virus (HCV) infection. The objective of our study was to describe demographic and socioeconomic characteristics, liver disease-related risk factors, and modifiable health behaviors associated with self-reported testing for HCV infection among adults.

METHODS

Using data on adult respondents aged ≥18 from the 2013-2017 National Health Interview Survey, we summarized descriptive data on sociodemographic characteristics and liver disease-related risk factors and stratified data by educational attainment. We used weighted logistic regression to examine predictors of HCV testing.

RESULTS

During the study period, 11.7% (95% CI, 11.5%-12.0%) of adults reported ever being tested for HCV infection. Testing was higher in 2017 than in 2013 (adjusted odds ratio [aOR] = 1.27; 95% CI, 1.18-1.36). Adults with ≥some college were significantly more likely to report being tested (aOR = 1.60; 95% CI, 1.52-1.69) than adults with ≤high school education. Among adults with ≤high school education (but not adults with ≥some college), those who did not have health insurance were less likely than those with private health insurance (aOR = 0.78; 95% CI, 0.68-0.89) to get tested, and non-US-born adults were less likely than US-born adults to get tested (aOR = 0.77; 95% CI, 0.68-0.87).

CONCLUSIONS

Rates of self-reported HCV testing increased from 2013 to 2017, but testing rates remained low. Demographic characteristics, health behaviors, and liver disease-related risk factors may affect HCV testing rates among adults. HCV testing must increase to achieve hepatitis C elimination targets.

Climate Change and Health: Consequences of High Temperatures among Vulnerable Groups in Finland

In this article, we examine the effects of high temperatures on hospital visits and mortality in Finland. This provides new information of the topic in a context of predominantly cool temperatures. Unique, individual-level data are used to examine the relationship at the municipality-month level over a span of 20 years. Linear regression methods alongside high-dimensional fixed effects are used to minimize confounding variation. Analysis is conducted with special emphasis on the elderly population, as well as on specific elderly risk groups identified in previous literature. We show that for an additional day per month above 25°C, monthly all-cause mortality increases by 1.5 percent (95% CI: 0.4%-2.6%) and acute hospital visits increase by 1.1 percent (95% CI: 0.7%-1.6%). We also find some evidence that these effects are elevated in selected population subgroups, the low-income elderly, and people with dementia. Hospital visits also increase among younger age groups, illustrating the importance of using multiple health indicators. Such detailed evidence is important for identifying vulnerable groups as extreme heat waves are expected to become more frequent and intense in northern countries.

Impact of the COVID-19 pandemic on mental health in parents of infants with colic and on health care use

AIM

To examine the impact of the COVID-19 pandemic on the mental health of parents of infants with colic and on health care use.

METHODS

Retrospective cohort study. Data of 64 parents of infants with colic pre-pandemic and 43 parents of infants with colic during the pandemic were analyzed using validated questionnaires on parental stress, depression, and anxiety. Additionally, we evaluated the number of outpatient clinic visits and admission rates pre- and during the pandemic by collecting data on the diagnosis treatment combination 'excessive crying' from electronic patient files in three secondary hospitals in the Netherlands.

RESULTS

Mothers in the pandemic group reported significantly higher levels of depression than mothers in the pre-pandemic group (12.3 ± 7.0 and 8.8 ± 5.2) (p=0.04). Moreover, mothers showed a trend toward higher stress levels during the pandemic (29.6 ± 9.6 and 25.2 ± 8.1; p=0.06). During the pandemic, admission numbers of infants with colic compared to pre-pandemic data increased with 34% (146 vs. 196).

CONCLUSION

Mothers of infants with colic reported significantly more feelings of depression during the COVID-19 pandemic. Furthermore, the pandemic was associated with increased healthcare use amongst infants with colic. With the continuing pandemic, we recommend active perinatal support for this vulnerable population.

Effect of Medicare Advantage on health care use and care dissatisfaction in mental illness

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on health care use and dissatisfaction with care received among Medicare beneficiaries with mental illness.

DATA SOURCES

I identified traditional Medicare (TM) and MA beneficiaries with mental illness using the Medicare Current Beneficiary Survey for 2012-2016.

STUDY DESIGN

I included two types of outcomes: four measures of health care use and 10 measures of care dissatisfaction. My primary independent variable was enrollment in TM versus MA. To address selective enrollment into MA, I used an instrumental variable (IV) approach. Following prior research, I decomposed the MA benchmark into exogenous and endogenous components and then used the exogenous component as my instrument.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

PRINCIPAL FINDINGS

IV analyses showed that compared with TM enrollment, MA enrollment significantly decreased outpatient hospital visits and medical provider visits by 6.73 (95% CI: -12.10 to -1.36) and 36.48 (95% CI: -52.67 to -20.28). However, there were no significant changes in inpatient hospital admissions and prescription drug purchases. Compared with TM enrollment, MA enrollment significantly increased dissatisfaction with out-of-pocket expenses by 25.51 percentage points (95% CI: 0.43 to 50.60). However, there were no significant changes in other measures of care dissatisfaction in terms of access to care, quality of care, and prescription medication.

CONCLUSIONS

These findings suggest that MA enrollment may lead to low health care use among those with mental illness, indicating efficient care delivery. Also, MA enrollment may not preclude those with mental illness from accessing needed care. However, high dissatisfaction with out-of-pocket expenses among MA beneficiaries may imply the use of out-of-network providers. Further research is warranted to investigate whether high dissatisfaction with out-of-pocket expenses may be attributable to MA's narrow networks for mental services.

Acute Pancreatitis Is Associated with Increased Risk of In-Hospital Mortality and Health Care Utilization Among Pediatric Patients with Hematopoietic Stem Cell Transplantation

OBJECTIVE

To analyze the impact of acute pancreatitis on mortality and hospital outcomes among the pediatric population following hematopoietic stem cell transplantation (HSCT).

STUDY DESIGN

We analyzed nationally representative, nonoverlapping years of the National Inpatient Sample and Kids Inpatient Database between 2003 and 2016, including all pediatric patients who had HSCT. Patients were divided into those with and without a diagnosis of acute pancreatitis and compared for demographics, clinical characteristics, comorbid conditions related to both HSCT and acute pancreatitis, and outcome measures such as in-hospital mortality and health care resource use (length of hospital stay and total hospitalization charges).

RESULTS

We analyzed a total of 128 772 hospitalizations of children and adolescents with HSCT. The overall incidence rate of acute pancreatitis was approximately 1%, with an overall increasing trend between 2003 and 2016, P < .001. The overall mortality rate was significantly greater among patients with acute pancreatitis (14.9% vs 3.6%, P < .001). Multivariate regression analysis showed that acute pancreatitis was independently associated with 3.4 times (95% CI 2.86-4.02, P < .001) increased risk of in-hospital mortality. Patients with acute pancreatitis who underwent HSCT had a greater incidence of end-organ damage and thrombotic events. Pediatric acute pancreatitis was associated with 24.3 additional days of hospitalization (95% CI 22.9-25.7, P < .001) and incurred additional $213 496 in hospitalization charges (95% CI 193 768-233 063, P < .001).

CONCLUSIONS

Pediatric recipients of HSCT who develop acute pancreatitis have adverse outcomes with increased in-hospital mortality, end-organ damage, prolonged hospital stay, and greater hospitalization charges.

Shared Decision-Making Among Adolescent and Young Adult Cancer Survivors and Noncancer Adults: Associated Medical Expenditures and Health Care Utilization

Purpose: Engagement of patients in their care can lead to better health outcomes, especially for adolescent and young adult (AYA) cancer survivors who experience mental and physical illnesses more often than noncancer adults. We examined how patient engagement in care influences health care expenses and use. Methods: AYA cancer survivors (n = 1162) and a comparison group of matched adults with no history of cancer (n = 2954) were identified from the 2011 to 2016 Medical Expenditure Panel Survey (MEPS) data. Medical expenditures and health care utilization associated with shared decision-making (SDM) measured by a self-administered questionnaire adapted from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CAHPS-CG) survey were evaluated using multivariable regression models. Results: AYA cancer survivors were more likely to report poor SDM compared with adults with no history of cancer (odds ratio = 1.31, 95% confidence interval [CI]): 1.06 to 1.62). AYA cancer survivors with poor SDM were more likely to report poor mental and physical health compared with AYAs with good SDM. AYA cancer survivors with poor SDM had $3037 (CI: $110 to $7032) in additional annual medical expenses and 4.86 (CI: 2.00 to 8.52) in additional office visits compared with AYA cancer survivors with optimal SDM, even after adjusting for chronic conditions and psychological distress. Conclusion: Our results highlight the substantial economic burden associated with poor SDM in AYA cancer survivors. Our research suggests that interventions to improve SDM in AYA cancer survivors may contribute to patients' positive perception of their health and result in AYAs seeking fewer medical services resulting in lower medical expenses.

Factors Affecting Korean Medicine Health Care Use for Functional Dyspepsia: Analysis of the Korea Health Panel Survey 2017

Functional dyspepsia (FD) significantly reduces quality of life, and Korean medicine treatment, including herbal medicine, is frequently used in the clinical setting. We aimed to analyze the factors affecting Korean medicine health care (KMHC) use for FD. Data from the Korea Health Panel Survey 2017 were analyzed. Individuals aged > 19 years who were diagnosed with FD and used outpatient care were included. Multiple logistic regression analyses were performed to investigate the association of predisposing, enabling, and need factors with KMHC use for FD, based on Andersen’s behavioral model. The best subsets of factors affecting KMHC use for FD were selected using a stepwise procedure. Participants aged 65 years or older were less likely to use KMHC to treat FD than those aged 19 to 34 years (odds ratio (OR), 0.14; 95% confidence interval (CI), 0.02−0.93). Residents of Busan, Daegu, Ulsan, or Gyeongsang tended to use more KMHC to treat FD than those of Seoul, Gyeonggi, or Incheon (OR, 2.45; 95% CI, 1.02−5.88). Participants with private health insurance were more likely to use KMHC to treat FD than those without private health insurance (OR, 3.41; 95% CI, 1.02−11.42). The prediction model of KMHC use for FD selected sex, age, private health insurance, and stress as the best subset of factors (AUC, 0.709; 95% CI, 0.637−0.781). The results of this study will aid in the decision making of clinicians, researchers, and policymakers.

Projecting future health and service use among older people in Ireland: an overview of a dynamic microsimulation model in The Irish Longitudinal Study on Ageing (TILDA)

Background: Demographic ageing is a population health success story but poses unprecedented policy challenges in the 21st century. Policymakers must prepare health systems, economies and societies for these challenges. Policy choices can be usefully informed by models that evaluate outcomes and trade-offs in advance under different scenarios. Methods: We developed a dynamic demographic-economic microsimulation model for the population aged 50 and over in Ireland: the Irish Future Older Adults Model (IFOAM).  Our principal dataset was The Irish Longitudinal Study on Ageing (TILDA). We employed first-order Markovian competing risks models to estimate transition probabilities of TILDA participants to different outcomes: diagnosis of serious diseases, functional limitations, risk-modifying behaviours, health care use and mortality. We combined transition probabilities with the characteristics of the stock population to estimate biennial changes in outcome state.   Results: IFOAM projections estimated large annual increases in total deaths, in the number of people living and dying with serious illness and functional impairment, and in demand for hospital care between 2018 and 2040.  The most important driver of these increases is the rising absolute number of older people in Ireland as the population ages. The increasing proportion of older old and oldest old citizens is projected to increase the average prevalence of chronic conditions and functional limitations. We deemed internal validity to be good but lacked external benchmarks for validation and corroboration of most outcomes. Conclusion: We have developed and validated a microsimulation model that projects health and related outcomes among older people in Ireland.  Future research should address identified policy questions. The model enhances the capacity of researchers and policymakers to quantitatively forecast health and economic dynamics among older people in Ireland, to evaluate ex ante policy responses to these dynamics, and to collaborate internationally on global challenges associated with demographic ageing.

The burden and health care use of patients with migraine and tension-type headache in post-conflict area of Serbia

PURPOSE

The aim of the present study was to assess the burden and health care use of adult patients with migraine and tension type headache in a post-conflict area of Serbia.

METHODS

This cross-sectional study was conducted on a representative sample of adults, living in predominantly Serb communities on the Kosovo and Metohija territory. The required data was obtained through a survey, utilizing a culturally-adapted questionnaire. The study sample comprised of 1,062 adults.

RESULTS

In the year preceding the study, 49.7% of included subjects suffering from migraines and 27.5% of those experiencing tension type headache sought medical assistance for their condition. The majority (88.5%) of the respondents utilized non steroid antiinfammatory drugs as analgesic, while 14.2% used prophylactic treatment. Migraine sufferers reported losing on average 11.1 days in a 3-month period, while those experiencing tension type headache lost 4.7 days (p < 0.001) due to headaches, preventing them from partaking in professional, family and social activities. On headache-free days, 24.5% of the respondents were anxious or tense in anticipation of a headache onset, while 30% did not feel that the headache had completely resolved. Moreover, 11.5% of the sample reported never or rarely feeling in control of the headache, while 20% of the respondents were of view that their headaches were not taken seriously by their employer and co-workers and rarely discuss them. Adverse effect of headaches on education is more frequently noted by migraine sufferers than those experiencing tension type headache (p = 0.001), and this disparity persists in relation to career (p < 0.001) and family planning (p = 0.001).

CONCLUSIONS

In Kosovo and Metohija, primary headaches exert a profound influence on the affected individuals and their community, and thus require recognition as one of the priorities of social initiatives aimed at the enhancement of public health.

Psychological distress and associated additional medical expenditures in adolescent and young adult cancer survivors

BACKGROUND

Adolescent and young adult (AYA) cancer survivors experience psychological distress often because of cancer and its treatment. However, no prior studies have evaluated the additional medical expenditures and health care utilization associated with psychological distress in AYA cancer survivors.

METHODS

AYA cancer survivors and a comparison matched group of adults with no history of cancer were identified from 2011-2016 Medical Expenditure Panel Survey data. Medical expenditures and health care utilization were evaluated with multivariable regression models.

RESULTS

AYA cancer survivors were more likely to have psychological distress (11.5% of 1757) than adults with no history of cancer (5.8% of 5227). The prevalence of psychological distress was found to be high many years after the diagnosis, with 11.2% reporting distress ≥20 years after their cancer diagnosis. AYA cancer survivors with psychological distress were more likely to smoke and have chronic conditions and were less likely to exercise regularly in comparison with AYAs with no history of psychological distress. AYA cancer survivors with psychological distress had additional annual medical expenses ($4415; 95% CI, $993-$9690), office visits (2.80; 95% CI, 0.23-6.15), and use of prescription medications/medication renewals (11.58; 95% CI, 5.70-19.47) in comparison with AYA cancer survivors without psychological distress. Additional annual medical expenses of psychological distress were $2600 higher in AYA cancer survivors than adults without a history of cancer ($1802; 95% CI, $440-$3791).

CONCLUSIONS

These results highlight the substantial economic burden associated with psychological distress in AYA cancer survivors. This research could inform survivorship care plans and interventions addressing the psychological needs of AYA cancer survivors.

Dental care use and other population characteristics of older Americans with self-reported chronic conditions in the health and retirement study

OBJECTIVES

To analyze relative differences in oral health care utilization, oral health, and other population characteristics of older Americans with respect to self-reported chronic conditions in the health and retirement study.

METHODS

Differences in estimated percentages of those with specific chronic conditions by selected attributes were tested for statistical significance with standardized normal Z tests and logistic regressions. All estimates were based on weighted data from 1992 to 2016 Early Release RAND HRS Longitudinal file. SE estimates for the percentages accounted for the complex sample design of the survey.

RESULTS

We establish that the strength of the associations between regular use of dental care and the absence of a chronic condition is similar in magnitude to having a college education, living in a high-income family, never smoking, not having certain functional limitations, and being under 65 years of age.

DISCUSSION

These cross-sectional findings establish the relative strength of relationships between dental care use, oral health status, and other population characteristics and eight diagnosed conditions. Further work beyond the scope of this paper is needed to confirm these results as either attributes of those with the disease or causal risk factors for the onset of the condition.

Combined impact of ADHD and insomnia symptoms on quality of life, productivity, and health care use in the general population

BACKGROUND

Both attention-deficit/hyperactivity disorder (ADHD) and insomnia have been independently related to poorer quality of life (QoL), productivity loss, and increased health care use, although most previous studies did not take the many possible comorbidities into account. Moreover, ADHD and insomnia often co-occur. Symptoms of ADHD and insomnia together may have even stronger negative effects than they do separately. We investigated the combined effects of symptoms of ADHD and insomnia, in addition to their independent effects, on QoL, productivity, and health care use, thereby controlling for a wide range of possible comorbidities and confounders.

METHODS

Data from the third wave of the Netherlands Mental Health Survey and Incidence Study-2 were used, involving N = 4618 from the general population. Both the inattention and the hyperactivity ADHD symptom dimensions were studied, assessed by the ASRS Screener.

RESULTS

Mental functioning and productivity were negatively associated with the co-occurrence of ADHD and insomnia symptoms, even after adjusting for comorbidity and confounders. The results show no indication of differences between inattention and hyperactivity. Poorer physical functioning and health care use were not directly influenced by the interaction between ADHD and insomnia.

CONCLUSIONS

People with both ADHD and sleep problems have increased risk for poorer mental functioning and productivity loss. These results underscore the importance of screening for sleep problems when ADHD symptoms are present, and vice versa, and to target both disorders during treatment.

Prior health care utilization among adolescents treated for a suicide attempt at a rural ED

PURPOSE

To characterize prior contact with a rural academic health system among young people treated for a suicide attempt in the system's emergency departments (EDs).

METHODS

We retrospectively examined electronic medical records from a health system serving 29 medically underserved rural counties in the Southeastern United States. Patients ages 10-25 years were included in the study if they were admitted to the ED for a suicide attempt in 2015-2018. Patients were stratified according to whether they had any encounter in the same health system in the 12 months prior to the attempt.

FINDINGS

Of 236 patients meeting inclusion criteria, only 10% had contact with the health system in the 12 months prior to ED treatment for a suicide attempt. Patients who lived farther than 25 km from the flagship hospital were less likely to have had prior contact (odds ratio [OR]: 0.10, 95% confidence interval [CI]: 0.02-0.34). Young adults ages 19-25 years were also less likely to have prior contact than adolescents (OR: 0.27, 95% CI: 0.08-0.76).

CONCLUSIONS

Few adolescents and young adults in this rural region received prior health care from the same health system where they were treated for a suicide attempt. Hospitals operating in rural areas need to partner with community health care providers to ensure adequate reach of screening and treatment programs to prevent youth suicide and reduce care fragmentation.

Social Determinants of Health Needs and Pediatric Health Care Use

OBJECTIVE

To examine the associations between family-reported social needs in primary care settings and pediatric health care use.

STUDY DESIGN

Data were obtained for a sample of 56 253 children and youths (age 0-21 years) who received primary care at a large hospital-based pediatric institution between June 2018 and October 2019 to estimate a propensity score for the probability of being seen in a primary care clinic. Inverse probability weighted regression specifications were used to examine the associations between reported social needs and health care use. Families were asked about 4 social needs: housing, utilities, transportation, and food. Outcomes included the number of Emergency Department (ED), inpatient, social work, and well-child visits (only for those aged 0-2 years) in the 6 months before and after needs screening.

RESULTS

Overall, 12.0% of the families reported a general social need, with 28% of those needs identified as urgent. Food and transportation needs were most common. Patients with needs were more likely to have an ED or inpatient visit at 6 months prescreening and 6 months postscreening compared with those without needs. Among children aged <2 years, those with a social need were less likely to have completed a well-child visit at 6 months postscreening compared with those without a need.

CONCLUSIONS

Social needs are linked to less preventive care use and greater reliance on emergency care services. Understanding how to better assist families in need requires greater attention.

Insurance coverage and health care use among children with diabetes

BACKGROUND

Health insurance coverage may be associated with pediatric diabetes mellitus (DM) management. However, it is unknown how continuity of insurance coverage is associated with health care use outcomes in pediatric DM.

METHODS

We used the nationally representative 2016-2019 National Survey of Children's Health to examine how interruption of health insurance coverage may affect health care use among children with DM. Children ages 0-17 years with DM were included in the analysis. Outcomes included emergency department visits, specialist visits, and unmet health care needs in the last 12 months. Insurance coverage was classified as continuous private, continuous public, or discontinuous (including gaps in coverage and year-round lack of coverage).

RESULTS

Based on a sample of 548 children, 56% percent had continuous private insurance coverage, as compared to 32% with continuous public insurance, and 12% with discontinuous coverage. Thirty-five percent of children had visited the ED in the past 12 months, and only 47% had visited any specialist in the past 12 months, including but not limited to a pediatric endocrinologist. An estimated 19% of children had unmet health care needs over the past 12 months. On multivariable analysis, children with coverage gaps were significantly less likely than children with continuous private coverage to have a visited a specialist in the past 12 months (adjusted odds ratio: 0.27; 95% CI: 0.08, 0.88; p = 0.030).

CONCLUSIONS

This study points to a need to establish and maintain specialist follow-up for children with DM, especially those from socioeconomically disadvantaged backgrounds.

Does health insurance contribute to improved utilization of health care services for the elderly in rural Tanzania? A cross-sectional study

Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries. Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania. Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use. Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured. Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received.

Outcomes of in-hospital cardiopulmonary resuscitation for cardiac arrest in adult patients with metastatic solid cancers: A Nationwide Inpatient Sample database analysis from 2012 to 2014

BACKGROUND

Cardiopulmonary arrest is known to have a poor prognosis, further worsened by preexisting comorbidities. With improved treatment, the prevalence of metastatic cancers is rapidly increasing; however, the outcomes of in-hospital cardiopulmonary resuscitation (ICPR) remain to be well described. This study examines the epidemiology, associations, and outcomes of ICPR in these patients.

METHODS

This is a retrospective cohort analysis of the Nationwide Inpatient Sample database (2012-2014) including patients aged ≥18 years with metastatic cancers. Primary outcome was inpatient mortality following ICPR. Factors associated with the primary outcome were analyzed using univariate/multivariate logistic regression analysis.

RESULTS

Among all admissions with metastatic cancers (n = 5,500,684), 0.47% (n = 26,070) received ICPR. Inpatient mortality was 81.77% (n = 8905) versus 68.90% among those without metastatic solid cancers and receiving ICPR. Inpatient palliative care encounter was documented in 18.95% of patients with metastatic cancer who received ICPR. On multivariate logistic regression, some of the notable factors associated with higher mortality included being of African American or Hispanic race and hospital admission over the weekend. Factors associated with lower mortality included female sex, elective admission, and head and neck as the primary site. Admissions with ICPR were associated with higher mean total charge of hospitalization (by $48,670) compared with admissions without ICPR. Of those who survived ICPR, 43.82% were transferred to another facility after discharge.

CONCLUSIONS

Among adult patients with metastatic solid cancers having ICPR, 81.8% died within the same hospital admission. Race and admission type predicted mortality. Despite known poor prognosis, only a minority had palliative care.

LAY SUMMARY

Cardiopulmonary resuscitation during hospitalization for patients who have metastatic cancer has a very poor outcome with a mortality rate of 81.77%. Inpatient cardiopulmonary resuscitation in these patients is also associated with a significantly higher cost of care, longer length of stay, and high rate of transfer to a different health care facility upon discharge. Knowledge of these outcomes is helpful in discussing the pros and cons of pursuing aggressive resuscitative interventions with patients and families.

Factors Associated with Dental Service Use Based on the Andersen Model: A Systematic Review

Background: A systematic review synthesizing studies examining the determinants of dental service use drawing on the (extended) Andersen model is lacking. Hence, our purpose was to fill this knowledge gap; Methods: Three established electronic databases (PubMed, PsycInfo, as well as CINAHL) were searched. Observational studies focusing on the determinants of dental service use drawing on the Andersen model were included; Results: In sum, 41 studies have been included (ten studies investigating children/adolescents and 31 studies investigating adults). Among children, particularly higher age (predisposing characteristic), higher income (enabling resource) and more oral health problems (need factor) were associated with increased dental service use. Among adults, findings are, in general, less consistent. However, it should be noted that one half of the studies found an association between increased education (predisposing characteristic) and increased dental service. In general, study quality was rather high. However, it should be noted that most studies did not report how they dealt with missing data; Conclusions: Our systematic review revealed that all components (i.e., predisposing characteristics, enabling resources and need factors) of the Andersen model tend to be associated with dental service use among children, whereas the findings are more mixed among adults. In conclusion, beyond need factors, dental service use also tend to be driven by other factors. This may indicate over—or, more likely—underuse of dental services and could enrich the inequality discussion in dental services research.

The Effects of Home Care Provider Mix on the Care Recipient: An International, Systematic Review of Articles from 2000 to 2020

In this systematic review, we examine the literature from 2000 to 2020 to ascertain whether we can make strong conclusions about the relative benefit of adding informal care or formal care providers to the care mix among individuals receiving care in the home, specifically focusing on care recipient outcomes. We evaluate how informal care and formal care affect (or are associated with) health care use of care recipients, health care costs of care recipients, and health outcomes of care recipients. The literature to date suggests that informal care, either alone or in concert with formal care, delivers improvements in the health and well-being of older adults receiving care. The conclusions one can draw about the effects of formal care are less clear.

Hospital Admissions for Respiratory Tract Infections in Children Aged 0-5 Years for 2017/2023

Aim: To compare hospital admissions across common respiratory tract infections (RTI) in 2017-21, and project possible hospital admissions for the RTIs among children aged 0-12 months and 1-5 years in 2022 and 2023. Methods: In 644 885 children aged 0-12 months and 1-5 years, we plotted the observed monthly number of RTI admissions [upper- and lower RTI, influenza, respiratory syncytial virus (RSV), and COVID-19] from January 1st, 2017 until October 31st, 2021. We also plotted the number of RTI admissions with a need for respiratory support. We used the observed data to project four different scenarios of RTI admissions for the rest of 2021 until 2023, with different impacts on hospital wards: (1) "Business as usual," (2) "Continuous lockdown," (3) "Children's immunity debt," and (4) "Maternal and child immunity debt." Results: By October 31st, 2021, the number of simultaneous RTI admissions had exceeded the numbers usually observed at the typical season peak in January, i.e., ~900. Based on our observed data and assuming that children and their mothers (who transfer antibodies to the very youngest) have not been exposed to RTI over the last one and a half years, our scenarios suggest that hospitals should be prepared to handle two to three times as many RTI admissions, and two to three times as many RTI admissions requiring respiratory support among 0-5-year-olds as normal, from November 2021 to April 2022. Conclusion: Scenarios with immunity debt suggest that pediatric hospital wards and policy makers should plan for extended capacity.

Perceptions of Health Care Use in Germany during the COVID-19 Pandemic

This paper examined the determinants of perceived access to health care use during the COVID-19 pandemic in Germany using data from two waves (8 and 16) of the COVID-19 Snapshot Monitoring (COSMO). Descriptive and regression analysis were used. In wave 8, we found that about 60% of the individuals rather disagreed about having had problems accessing medical care. Furthermore, 73% of the individuals rather disagreed to having experienced health deteriorations due to restrictions on the availability of medical care. Moreover, 85% of the individuals were rather optimistic about future access to healthcare services. Overall, slightly better past and future access to healthcare services has been reported in wave 16. Several determinants were identified in regression analysis. In conclusion, data suggest that perceived past and future access to healthcare services during the COVID-19 pandemic is reasonably good.

The Impact of Medical Financial Hardship on Children's Health

Objective. To determine whether living in a family with medical financial hardship decreases children's access to health care. Methods. We identified children aged 4 to 17 years from the 2013 to 2018 National Health Interview Surveys. Medical financial hardship was defined as living in a family where one or more family members had problems paying medical bills in the past 12 months. Results. Of 53 483 children in the analysis, 19% were exposed to medical financial hardship. This was adversely associated with children's health status and health care use, especially greater odds of delaying care (odds ratio [OR] = 5.28; 95% confidence interval [CI] = 4.51-6.19) and having unmet health care needs (OR = 4.43; 95% CI = 4.00-4.91). Conclusions. One fifth of children live in families experiencing medical financial hardship, and this exposure is adversely correlated with child health outcomes even controlling for established measures of socioeconomic status, such as family income, health insurance coverage, and need-based program participation.

Understanding the Barriers of Violence Victims' Health Care Use

Violence is a leading cause of death among U.S. adults under age 45. There are also 3.3 million living violence victims, most of whom forgo formal health care when injured. We developed and tested a framework to understand why. We argue that violence victims must consider their need for care and three situational factors of victimization that may serve as barriers for care seeking: the victim's relationship to the offender, their victimization history, and the offense committed (sexual vs. nonsexual). In analyses of 9,912 violent victimizations from 8,635 participants in the National Crime Victimization Survey from 1993 to 2017, we found that injury severity and situational factors of victimization independently and interactively predict formal health care use. Even when serious injury occurs, victimizations involving known offenders, repeat victimizations, and sexual violence are less likely than their counterparts to result in formal health care use. We discuss the implications of these findings for victims and health care providers.

Findings of a General Population Survey in Germany

(1) The aim of this study was to identify the association between post-materialism and health care use (in terms of the frequency of doctor visits and the reason for doctor visits). (2) Data were taken from the German General Social Survey (a representative sample of individuals aged 18 years and over, n = 3338). The Inglehart's post-materialist index was used to quantify post-materialism. The doctor visits (self-reported) in the past three months served as an outcome measure. The reasons for seeing a doctor served as an additional outcome measure (acute illness; chronic illness; feeling unwell; requesting advice; visit to the doctor's office without consulting the doctor (e.g., need to get a prescription); preventive medical check-up/vaccination). (3) After adjusting for several covariates, negative binomial regressions revealed that compared with materialism, post-materialism was associated with decreased doctor visits (total sample; women). Moreover, the likelihood of visiting the doctor for reasons of chronic illnesses was lower in post-materialistic women, whereas the likelihood of visiting the doctor for reasons of preventive medical check-up/vaccination was higher in post-materialistic women. (4) Study findings identify an unexplored link between post-materialism and doctor visits in women. One may conclude that in the long-term, the increased likelihood of preventive medical check-ups in post-materialistic women will be beneficial in decreasing the need for doctor visits for reasons of chronic illnesses. However, future research is required to elucidate the underlying mechanisms.

Associations of baseline patient-reported outcomes with treatment outcomes in advanced gastrointestinal cancer

BACKGROUND

Patient-reported outcomes (PROs) assessing quality of life (QOL) and symptom burden correlate with clinical outcomes in patients with cancer. However, to the authors' knowledge, data regarding associations between PROs and treatment response are lacking.

METHODS

The authors prospectively approached consecutive patients with advanced gastrointestinal cancer who were initiating a new treatment. Prior to treatment, patients reported their QOL (Functional Assessment of Cancer Therapy-General [FACT-G], 4 subscales: Functional, Physical, Emotional, Social; higher scores indicate better QOL) and symptom burden (Edmonton Symptom Assessment System [ESAS], Patient Health Questionnaire-4 [PHQ-4]; higher scores represent greater symptoms). Regression models were used to examine associations of baseline PROs with treatment response (clinical benefit or progressive disease [PD] at time of first scan), healthcare utilization, and survival.

RESULTS

From May 2019 to April 2020, a total of 112 patients with advanced gastrointestinal cancer were enrolled. For treatment response, 64.3% had CB and 35.7% had PD. Higher baseline ESAS-Physical (odds ratio, 1.04; P = .027) and lower FACT-G Functional (odds ratio, 0.92; P = .038) scores were associated with PD. Higher ESAS-Physical (hazard ratio [HR], 1.03; P = .044) and lower FACT-G Total (HR, 0.96; P = .005), FACT-G Physical (HR, 0.89; P < .001), and FACT-G Functional (HR, 0.87; P < .001) scores were associated with a greater hospitalization risk. Lower FACT-G Total (HR, 0.96; P = .009) and FACT-G Emotional (HR, 0.86; P = .012) scores as well as higher ESAS-Total (HR, 1.03; P = .014) and ESAS-Physical (HR, 1.04; P = .032) scores were associated with worse survival.

CONCLUSIONS

Baseline PROs are associated with treatment response in patients with advanced gastrointestinal cancer, namely physical symptoms and functional QOL, in addition to health care use and survival. The findings of the current study support the association between PROs and important clinical outcomes, including the novel finding of treatment response.

Potentially Preventable Hospitalizations Among Older Adults: 2010-2014

PURPOSE

We undertook a study to examine national trends in potentially preventable hospitalizations-those for ambulatory care-sensitive conditions that could have been avoided if patients had timely access to primary care-across 3,200 counties and various subpopulations of older adults in the United States.

METHODS

We used 2010-2014 Medicare claims data to examine trends in potentially preventable hospitalizations among beneficiaries aged 65 years and older and developed heat maps to examine county-level variation. We used a generalized estimating equation and adjusted the model for demographics, comorbidities, dual eligibility (Medicare and Medicaid), ZIP code-level income, and county-level number of primary care physicians and hospitals.

RESULTS

Across the 3,200 study counties, potentially preventable hospitalizations decreased in 327 counties, increased in 123 counties, and did not change in the rest. At the population level, the adjusted rate of potentially preventable hospitalizations declined by 3.45 percentage points from 19.42% (95% CI, 18.4%-20.5%) in 2010 to 15.97% (95% CI, 15.3%-16.6%) in 2014; it declined by 2.93, 2.87, and 3.33 percentage points among White, Black, and Hispanic patients to 14.96% (95% CI, 14.67%-15.24%), 17.92% (95% CI, 17.27%-18.58%), and 17.10% (95% CI, 16.25%-18.0%), respectively. Similarly, the rate for dually eligible patients fell by 3.71 percentage points from 21.62% (95% CI, 20.5%-22.8%) in 2010 to 17.91% (95% CI, 17.2%-18.7%) in 2014. (P <.001 for all).

CONCLUSIONS

During 2010-2014, rates of potentially preventable hospitalization did not change in the majority of counties. At the population level, although the rate declined among all subpopulations, dually eligible patients and Black and Hispanic patients continued to have substantially higher rates compared with non-dually eligible and White patients, respectively.

Personality, Health Care Use, and Costs: A Study Protocol for a Systematic Review

Recent empirical studies have shown that personality factors are associated with health care use (HCU). However, to date, a systematic review is lacking summarizing evidence regarding the link between personality factors and health care use or costs (i.e., monetarily valued health care use). Therefore, the objective of this systematic review is to provide an overview of evidence from observational studies investigating the link between personality characteristics and health care use or costs. Electronic databases (PubMed, PsycINFO, NHS EED) will be searched using predefined search terms. In an additional step, the reference lists of included studies will be searched (manually). No restrictions will be applied regarding the time of publication. Observational studies (both cross-sectional and longitudinal) assessing the link between personality characteristics and health care use/costs across all age categories will be included. Only studies using validated tools to quantify personality characteristics will be included. Among others, studies only focusing on mental HCU or studies only analyzing samples with a specific disorder (e.g., individuals with personality disorders) will be excluded. Mainly, data on methods (study design, measures, and statistical analysis), sample characteristics, and results regarding the link between personality and HCU/costs will be extracted. A quality assessment will be conducted. Two reviewers will perform the study selection, data extraction, and assessment of the study quality. If disagreements occur, they will be resolved through discussion to reach a consensus or by inclusion of a third party. Results will be presented narratively (text and tables). Depending on the number and heterogeneity of the studies included, a meta-analysis will be conducted. Results will be disseminated through publication in a peer-reviewed, scientific journal.

Changes in chronic medication adherence, costs, and health care use after a cancer diagnosis among low-income patients and the role of patient-centered medical homes

BACKGROUND

Approximately 40% of patients with cancer also have another chronic medical condition. Patient-centered medical homes (PCMHs) have improved outcomes among patients with multiple chronic comorbidities. The authors first evaluated the impact of a cancer diagnosis on chronic medication adherence among patients with Medicaid coverage and, second, whether PCMHs influenced outcomes among patients with cancer.

METHODS

Using linked 2004 to 2010 North Carolina cancer registry and claims data, the authors included Medicaid enrollees who were diagnosed with breast, colorectal, or lung cancer who had hyperlipidemia, hypertension, and/or diabetes mellitus. Using difference-in-difference methods, the authors examined adherence to chronic disease medications as measured by the change in the percentage of days covered over time among patients with and without cancer. The authors then further evaluated whether PCMH enrollment modified the observed differences between those patients with and without cancer using a differences-in-differences-in-differences approach. The authors examined changes in health care expenditures and use as secondary outcomes.

RESULTS

Patients newly diagnosed with cancer who had hyperlipidemia experienced a 7-percentage point to 11-percentage point decrease in the percentage of days covered compared with patients without cancer. Patients with cancer also experienced significant increases in medical expenditures and hospitalizations compared with noncancer controls. Changes in medication adherence over time between patients with and without cancer were not determined to be statistically significantly different by PCMH status. Some PCMH patients with cancer experienced smaller increases in expenditures (diabetes) and emergency department use (hyperlipidemia) but larger increases in their inpatient hospitalization rates (hypertension) compared with non-PCMH patients with cancer relative to patients without cancer.

CONCLUSIONS

PCMHs were not found to be associated with improvements in chronic disease medication adherence, but were associated with lower costs and emergency department visits among some low-income patients with cancer.

Malnutrition and Food Insecurity Might Pose a Double Burden for Older Adults

Although food insecurity has been associated with a disadvantageous socioeconomic status, especially in older adults, its association with comorbidities is less clear. The scope of the present cross-sectional study was to assess the prevalence of food insecurity among older adults and evaluate the association between food insecurity, malnutrition, chronic disease, multimorbidity and healthcare utilization. A total of 121 older adults (mean (standard deviation) age: 72.6 (8.1)) were recruited from a Primary Care Health Center from 10 August 2019 to 10 September 2019. Food insecurity and malnutrition status were assessed by the Household Food Insecurity Access Scale and Mini Nutritional Assessment tool, respectively. Recorded variables included financial, family data and comorbidities. The prevalence of food insecurity in the sample reached 50.4%, with men and older adults malnourished or at risk for malnutrition, exhibiting high risk for food insecurity. Multimorbidity, frequency of health care utilization and medication adherence were not associated with food insecurity, possibly due to the free health services and remunerated medications offered by the Greek government. However, male gender and malnutrition risk were significant predictors of food insecurity in the multiple logistic analyses. This study highlights the need for mainstreaming food insecurity assessment among older adults with comorbidities, especially those at risk for malnutrition.

Living conditions and health care usage of Haitian families in the Dominican Republic: A comparison of urban and rural/peri-urban households

Previous research has drawn attention to the health risks and poor living conditions that families of Haitian descent contend with in the Dominican Republic, particularly in rural, agricultural communities. Less clearly described is whether these problems persist as households transition to non-agricultural work and increasingly urban residence patterns. This study compares the use of health care services and access to water, sanitation, and food for Haitian and Dominico-Haitian families living in the city of Puerto Plata with households located on the rural-urban fringe. Data were collected during household surveys with 61 urban and 30 rural/peri-urban families. Households residing in the rural/peri-urban community had lower incomes, more unmet sanitation needs, and less stable access to water than urban families. Overall, households lacked adequate food, with 74.4% experiencing food insufficiency. Respondents reported using diverse types of health services and treatments, but households in the rural/peri-urban community had higher rates of health care use than urban families. These findings indicate urban families have better access to some resources that promote health than rural/peri-urban households. By identifying health issues and environmental conditions in rural/peri-urban and urban areas, this study aims to provide guidance for policy-makers, agencies, and organisations that serve Haitian migrant communities.

Eye Examination Recency among African American Older Adults with Chronic Medical Conditions

Background: Pervasive racial and economic inequalities have a disproportionate impact on health care utilization among African Americans. One area where we see such disparities is in the recency of eye examinations among the economically disadvantaged. However, our current understanding of the barriers and facilitators of eye examinations in underserved African-American older adults is limited. Aims: Building on Andersen’s model of health service use and using an exploratory approach; we tested various demographic, social, and health factors that were associated with eye examination among underserved middle-aged and older adults in South Los Angeles. We examined predisposing characteristics, enabling factors, and need-for-care characteristics. Methods: With a cross-sectional design, we conducted this survey on a convenience sample of (n = 740) non-institutionalized African-American older adults who were 55+ years old and residing in South Los Angeles, CA, USA. Data were collected on demographic factors, continuity of care, access to care, self-rated health, chronic medical conditions, and depressive symptoms. The outcome was recency of eye examination. Multivariate regression was used for data analysis. Results: 59% of the participants had received at least one eye examination during the last 12 months. A total of 17% had an eye examination within the last two years. Notably, 26% of diabetic participants did not have an eye examination within the last two years. One out of four participants indicated that, within the last two years, no provider ever recommended that they receive an eye examination. Age, education, continuity of medical care, accessibility of medical care, satisfaction with medical care, providers’ recommendation for eye examination, self-rated health, and a diagnosis of hypertension and diabetes mellitus were predictors of eye examination recency. Overall, our analysis indicates that these enabling factors accounted for most of the variance in the recency of eye examinations. Conclusion: A large proportion of underserved African-American middle-aged and older adults in South Los Angeles do not comply with the recommended annual eye examination. This is, in part, because about one-third of them have not received an eye exam recommendation from their health care providers. However, a wide range of factors such as age, education, continuity of care, satisfaction with access, self-rated health, and a diagnosis of hypertension and diabetes mellitus, also influence whether or not African-American middle-aged and older adults receive an eye examination. Programs should address a wide range of multi-level factors to tackle this health inequality.

Health care utilisation in infants and young children born to women with intellectual and developmental disabilities: A systematic review and meta-analysis

BACKGROUND

Mothers with intellectual and developmental disabilities (IDD) experience socio-economic and health disparities which could impact their offspring's health care utilisation. We systematically reviewed evidence on health care utilisation in infants and young children of women with and without IDD.

METHODS

MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from inception to October 2019 for studies examining preventive care, immunisations, emergency department visits, and hospitalisations. Data extraction and quality assessment were performed using standardised tools. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were generated using random effects models for outcomes with data available from ≥3 studies.

RESULTS

Four articles describing three cohort studies and one cross-sectional study met our criteria. Maternal IDD status was associated with increased neonatal intensive care unit admission rates (pooled OR 2.03; 95% CI 1.31, 3.13). There were no differences in immunisation rates or hospitalisations.

CONCLUSIONS

Few studies have examined the impact of maternal IDD status on health care utilisation in their infants and young children. More high-quality studies are needed.

3-year Outcome of Patients with Persistent Pain after Root Canal Treatment: The National Dental Practice-Based Research Network

INTRODUCTION

We measured the long-term outcomes of patients reporting persistent pain 6 months after root canal treatment (RCT) and assessed the characteristics differing patients with pain chronification from those with pain resolution.

METHODS

Forty-five patients previously found to have persistent pain 6 months post-RCT from the National Dental Practice-Based Research Network were approached for a 3-year follow-up, and 27 participated in the survey. The frequency of self-reported pain, its impact on the ability to perform daily activities, and health care use were measured. The differences between patients whose persistent pain continued and those whose pain resolved were assessed.

RESULTS

Five patients met criteria for pain at 3.4 years (range, 3.1-3.9 years) post-RCT, which was moderate in intensity, occurred for about 3 days in the preceding month, and kept 1 patient from usual activities. Additional health care was received by 4 of 5 patients whose pain continued compared with 7 of 22 patients whose pain resolved. A longer duration of preoperative pain and higher pain intensity and interference at 6 months were found among patients with pain chronification. Of 13 patients with specific diagnoses for the persistent pain derived at 65 ± 41 days (∼8 months) post-RCT, 10 improved regardless of the diagnosis or treatment, and 11 had a temporomandibular disorder and/or headache as comorbid diagnoses (6) or causes (6) of the persistent "tooth" pain.

CONCLUSIONS

Progression of persistent post-RCT pain occurred in 19% of patients. The majority (56%) of patients improved without additional interventions. Both the group that improved and the group that continued to experience pain had a mixture of odontogenic and nonodontogenic etiologies.