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PubMed2003

Racial/ethnic differences in the healthcare experience (coverage, utilization, and satisfaction) of US adults with diabetes.

OBJECTIVE: To examine racial/ethnic differences in healthcare coverage, utilization, and satisfaction, among US adults with diabetes. DESIGN AND SETTING: We conducted a cross-sectional analysis among 9443 adults with diabetes who participated in the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of the civilian non-institutionalized US population aged > or = 18 yrs. MAIN OUTCOME MEASURES: We compared healthcare coverage, utilization, and satisfaction across 4 race/ethnicity categories: non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), Hispanics (HSP), and others, and examined whether these factors were associated with self-rated health status. RESULTS: By self-report, more NHB (14.8%), HSP (20.7%), and members of other races (21.8%) were uninsured, compared to NHW (6.4%). Similarly, cost was a barrier to visiting a doctor for 23.9% of HSP, 19.5% of NHB, and 13.4% of members of other races; however, only 8.2% of non-Hispanic Whites reported cost as a barrier. More NHW (90.1%) and NHB (90.7) reported having had a check-up in the past year, compared to HSP (84.5%) or others (84.1%). All 3 variables exhibited significant differences by race or ethnicity (all P<.01). After adjustment for age, sex, income, education, and insulin use, the association with race/ethnicity persisted for health insurance coverage (P<.001), and for cost as a barrier (P<.003). Reporting cost as a barrier to visiting a doctor (P=.013), and rating one's overall health care as fair or poor (P=.001), were associated with poorer health status. CONCLUSIONS: These results suggest that ethnic minorities with diabetes report less healthcare coverage and more cost-related barriers to utilization, compared to non-Hispanic Whites. Persons with fair/poor health status were more likely to report cost barriers and poor satisfaction. Future research should focus on the reasons for such differences and on interventions to improve health care for minority populations.

Adult↗
PubMed2001

Opioid analgesics versus ketorolac in spine and joint procedures: impact on healthcare resources.

BACKGROUND: Ketorolac's efficacy as a postoperative analgesic has been shown to be comparable to that of narcotic analgesics, but with significantly fewer narcotic-related adverse events. OBJECTIVE: To assess whether the choice of postoperative analgesic, narcotic or ketorolac, has an impact on healthcare resource utilization and cost durng inpatients' recovery period. DESIGN: Retrospective, multicenter, controlled, parallel, cost-minimization analysis. SETTING: Six US teaching hospitals. PATIENTS: This study included 559 patients that underwent either a spine or joint procedure and received adequate doses of narcotic (n = 284 of either morphine or meperidine) or ketorolac (n = 275). MEASUREMENTS: Time to reach recovery milestones, average utilization of healthcare resources, and average per-case postoperative treatment cost. RESULTS: Several recovery milestones, including time to first bowel movement, first oral intake, and first unassisted ambulation, were reached sooner in the ketorolac group, with a resultant shorter mean length of postoperative stay (narcotic 3.78 d, ketorolac 2.80 d; p = 0.01). Total per-patient cost of treatment was 32% greater in the narcotic group, resulting primarily from higher costs associated with hospitalization. CONCLUSIONS: Despite the higher acquisition cost of medication, healthcare resource utilization and total per-patient cost of treatment were lower for patients in the ketorolac group compared with patients in the narcotic analgesic study group. The majority of patients in the ketorolac group were also given concurrent narcotic analgesics; therefore, the beneficial effects observed may be secondary to the combination of ketorolac and narcotic analgesics.

Analgesics, Opioid↗
PubMed1997

Genetic and environmental contributions to healthcare need and utilization: a twin analysis.

OBJECTIVE: An exploratory study to examine the genetic and environmental influences on healthcare-seeking behavior for four health conditions (high blood pressure, mental health problems, joint disorders, and hearing problems). DATA SOURCES: Data collected from 3,602 male-male twin pair members of the Vietnam Era Twin (VET) Registry. STUDY DESIGN: Varying models for the relationship between genetic and environmental influences on health condition liability and on treatment use were tested in an attempt to explain the relative contributions of additive genetic, common, and unique environmental effects to health condition and treatment use. DATA COLLECTION: A mail and telephone survey of general health status was administered in 1987 to VET Registry twins. PRINCIPAL FINDINGS: Variance component estimates under the best-fitting model for the genetic component ranged from 24 percent to 52 percent for the condition status and from 42 percent to 56 percent for treatment-seeking behavior. CONCLUSIONS: Utilization models that consider only environmental parameters will leave a large percentage of variability unexplained. Familial patterns have an impact not only on disease susceptibility but also on healthcare utilization, thereby having lifelong implications for social and fiscal constraints placed on the healthcare system. Thus, explanatory models for healthcare utilization behavior should consider the contribution of genetic factors in the decision to seek and use health services.

Adult↗
PubMed2005

Long-term medical care utilization and costs among traumatic brain injury survivors.

OBJECTIVE: To examine billing patterns and predictors of healthcare utilization and costs associated with traumatic brain injury. DESIGN: Retrospective cohort study of healthcare billings for 63 survivors of traumatic brain injury, over a 19-mo period, using a state-sponsored Medicaid program. The relationship of indicators of injury severity and disability to billings and payments was investigated. Mean age at time of injury was 33 yrs. Mean highest Glasgow Coma Scale rating immediately after brain injury was 8. RESULTS: A total of 795,635 US dollars was billed to Medicaid for 3,950 services and medications used. A total of 281,897 US dollars was paid for these billings out of the Medicaid account studied. Billings were used for statistical analyses, as they were considered the most stable indicator of cost. Motor deficits at discharge from inpatient rehabilitation (FIM motor score) showed inverse relationships to total billings (rho = -0.42, P < 0.001), subcategories of billings reflecting equipment and supplies (rho = -.26, P = 0.020), and outpatient billings (rho = -0.27, P = 0.015). Change in FIM motor scores during inpatient rehabilitation was inversely associated with billings (rho = -0.40). Change in FIM motor scores provided unique information in predicting utilization after accounting for demographic characteristics and severity of injury. CONCLUSIONS: Motor disability and improvement during inpatient rehabilitation were significant predictors of billings after traumatic brain injury. Initial severity of brain injury was not a significant factor in utilization.

Adolescent↗
PubMed1997

Perceived family criticism and primary care utilization: psychosocial and biomedical pathways.

We explored the relationship of perceived family criticism to subsequent healthcare utilization in patients attending a family medicine center. We examined: a) the relationship of perceived criticism to subsequent utilization for biomedical and psychosocial/somatic problems; b) the mediating effects of self-rated mental health and physical function; and c) the mediating effects of social support. The analyses were adjusted for age, sex, race, education, health insurance, and martial status. Higher perceived criticism predicted more psychosocial/somatic and biomedical visits. The relationship of perceived criticism with psychosocial/somatic visits was entirely mediated through self-rated mental health. The relationship of perceived criticism with biomedical visits was partly mediated through self-rated physical function and, in part, independent. Social support played no role in explaining these relationships. Further research is needed to determine whether lowering perceived family criticism lowers primary care utilization.

Family↗
PubMed1999

Cross-national comparison of capitation funding: the American, British and Dutch experience.

In this paper we review the performance of the capitation payment systems of three countries--the Adjusted Average Per Capita Cost (AAPCC) system used in the United States to reimburse Health Maintenance Organizations (HMOs) for insuring Medicare recipients, a somewhat similar system in the Netherlands which reimburses third-party payers for insuring the entire population and a weighted system utilized in Britain for regional funding. Our review revealed significant problems with the current version of the AAPCC formula as there is evidence of the biased selection of beneficiaries and actual losses to Medicare through its use. Furthermore, several studies show that the demographic adjusters utilized in the AAPCC formula are extremely poor predictors of future healthcare utilization relative to the potential of direct and indirect health status measures. The Dutch experience with capitated funding has been similar to that of the United States. While Dutch researchers have built on the work of their American counterparts they acknowledge that further work is needed before a fully functional system is implemented. Britain's weighted system has fulfilled its original mandate to redistribute healthcare resources based on population need but recent changes giving increased influence to age weighting could reverse some of these gains. A number of proposed improvements to these risk adjustment problems were reviewed including the development of diagnostic cost groups, the coexisting hierarchical conditions model and the use of community-rated high-risk pooling. The findings from this study can help others narrow the alternatives they need to consider when thinking of introducing capitation funding or refining already existing systems.

Capitation Fee↗
PubMed2006

Direct healthcare costs and predictors of costs in patients with primary Sjogren's syndrome.

OBJECTIVES: To analyse the healthcare usage, direct healthcare costs and predictors of cost in primary Sjögren's syndrome (PSS) in the UK and to compare the findings with the data from healthy control groups and rheumatoid arthritis (RA) patients. METHODS: A total of 129 patients with PSS (American-European criteria), 91 with RA and 92 controls, were included in the study. All groups were age-matched females and all completed questionnaires on health status (SF-36) and healthcare utilization (economic component of the Stanford Health Assessment Questionnaire). Annual direct healthcare costs were calculated (and expressed in 2004 UK pound sterling) and predictors of costs for each patient group were determined by regression analyses. Age, health status, disease duration and anti-Ro/La antibody positivity were used as potential predictor variables. RESULTS: Mean age was similar in the PSS (59.2 yrs, S.D. 11.6), RA (60.3 yrs, S.D. 10.5) and control groups (57.7 yrs, S.D. 12.5). The mean disease duration was 5.4 yrs (S.D. 4.8) in the PSS group and 13.4 yrs (S.D. 11.4) in the RA group. The mean annual total direct cost per patient [95% confidence interval (CI)] was 2188 pounds sterling (1831 and 2546 pounds sterling) in the PSS group, 2693 pounds sterling(2069 and 3428 pounds sterling) in the RA group and 949 pounds sterling (741 and 1156 pounds sterling) in the control group. The costs in the PSS group were greater than for the RA and control groups for visits to all healthcare professionals (total) as well as visits to the dentist, dental hospital and ophthalmologist. The costs in the PSS and RA groups were higher than in controls for diagnostic tests and visits to hospital and the accident and emergency (A&E) department. The PSS group also incurred higher costs than controls, but lower costs than the RA group, for visits to a rheumatologist, urine and blood tests, assistive devices and drug therapy. Regression analysis identified the SF-36 physical function subscale as the best predictor of costs in PSS patients as well as controls and the mental health subscale in RA patients. CONCLUSION: This is the first study to evaluate direct healthcare costs in patients with PSS. PSS has a significant impact on the healthcare system, similar to that of RA, by more than doubling costs compared with control patients.

Adult↗
PubMed2004

Effects of the balanced budget act on Medicare home health utilization.

This article examines the effects of the Balanced Budget Act of 1997 on Medicare home healthcare utilization by older adults in different income groups. Data are drawn from a sample of functionally limited Medicare-eligible elderly respondents (N=2,749) from the Medical Expenditures Panel Survey. Results from multivariate analyses revealed that, although policies succeeded in curbing home health expenditures for all income groups, the reduction was heavily concentrated among the poorest respondents. Between 1997 and 1998, Medicare home health expenditures decreased by 1,404 dollars in lower income respondents, four times as much as the reduction in expenditures in middle-income respondents (352 dollars) and more than twice the reduction in high-income respondents (567 dollars). These findings raise important questions about whether the decrease in expenditures will result in increased incidence of adverse effects or less satisfaction with care of vulnerable individuals.

Activities of Daily Living↗
PubMed2004

Health service use by children in rural Bihar.

Bihar is one of the most economically deprived states in India. Home to nearly 10 per cent of India's population, it consistently ranks poorly on a variety of development and health-related indicators. In order to improve child survival and decrease childhood mortality, it is important to understand the determinants of healthcare use so that appropriate policies may be developed to maximize health services utilization. This paper undertakes such as analysis. It uses the Andersen Behavioral Model to understand determinants of health services utilization for children suffering from diarrhea and respiratory illness in rural Bihar. Data were abstracted from the Second National Family Health Survey (NFHS-2). Out of 2703 children under 3 years of age in the dataset, 840 had an episode of diarrhea and/or respiratory illness in the preceding 2 weeks. A majority (69 per cent) had utilized healthcare services for their illness. The results indicate that controlling for other factors, sex of the child, household standard of living, service availability and need, are significant determinants of health service utilization. The analysis highlights the usefulness of the NFHS-2 data as a tool to conduct health services research and analyses at the state level, and in developing policies to safeguard and improve the health of vulnerable population groups in India.

Child Health Services↗
PubMed2005

Primary intensive care: pilot study of a primary care-based intervention for high-utilizing patients.

This pilot study was conducted to determine whether primary care patients with perceived inappropriate high healthcare utilization would require fewer emergency or inpatient services while enrolled in a weekly multidisciplinary clinic. Seventeen high-utilizing or difficult management patients of a primary care center were referred for the special intervention, Primary Intensive Care (PIC). Although not selected for the presence of psychopathology, 16 patients had comorbid psychiatric diagnoses. Patients followed in the PIC Clinic had significantly lower inpatient and emergency department use during their enrollment in the intervention when compared to the matched pre-enrollment time period, although the total hospital cost differences did not reach statistical significance. Patient and staff satisfaction was high, although the intervention was very difficult for the providers.

Adult↗
PubMed2003

Medical care utilization patterns in women with diagnosed domestic violence.

BACKGROUND: Information on women with domestic violence (DV) suggests increased healthcare utilization across all levels of care and many diagnoses. In the present ancillary study (1997-2002), derived from a large, group-randomized intervention trial we conducted in a staff-model health maintenance organization (HMO) (1995-1998), we examined total and incremental utilization rates, costs, and patterns for women aged >/=18 years with DV identified through the record reviews conducted for the trial. By the choice of comparison groups used, our present aim was to "bracket" any associated increase in utilization. METHODS: We compared visits and costs of medical-record confirmed cases of DV (n =62) to those for women without evidence of DV in the record (n =2287). These two groups were derived from women making visits for any one of four index reasons (injury, chronic pelvic pain, depression, or physical examination) associated with higher risk of DV or higher likelihood of its discussion. We constructed a second comparison group (n =6032) from the general population of enrolled women. We used the Chronic Disease Score to adjust for comorbidity. RESULTS: After adjusting for comorbidity, we found a 1.6-fold higher rate of all visits (95% confidence interval [CI]=1.4-1.9) and 1.6-fold higher estimated costs (95% CI=1.3-2.0) for abused women compared to non-DV women. The rates were 2.3-fold higher when compared to all enrolled women. CONCLUSIONS: Women with medical-record-documented DV demonstrate a pattern of increased utilization and costs across all levels of care and types of diagnoses. We conclude that being a DV case-patient is associated with between 1.6- and 2.3-fold increases in total utilization and costs.

Adult↗
PubMed2005

The effect of welfare reform on prenatal care and birth weight.

Welfare reform has resulted in a dramatic decline in welfare caseloads and some have claimed that a significant number of low-income women may be without health insurance as a result. The loss of insurance may reduce low-income, pregnant women's health care utilization, and this may adversely affect infant health. Welfare reform also may affect healthcare utilization and health of pregnant women and infants because of welfare-induced changes in family disposable income, time available for health investments, and levels of stress. In this paper we examine the effect of welfare reform on prenatal care utilization and birth weight of low-educated women and their infants. We find that a 50% reduction in the caseload, which is similar to that which occurred in the 1990s, is associated with a zero to seven percent decrease in first trimester prenatal care; a zero to five percent decrease in the number of prenatal care visits; and a zero to 10% increase in low birth weight. Since welfare reform was responsible for only part of the decline in the caseload, welfare reform per se had even smaller effects.

Adult↗
PubMed1997

Disease management interventions to improve outcomes in congestive heart failure.

This study is part of a planned 24-month, multicenter, longitudinal comparison of a comprehensive congestive heart failure (CHF) disease management program and was designed to determine effectiveness after 12 months of implementation. The impact of interventions such as telemonitoring of patients, post-hospitalization follow-up, and provider education on selected primary outcomes (hospital admission and readmission rates, length of stay, total hospital days, and emergency room utilization) in a managed care setting was evaluated. Subjects in the study included all participants in the managed care plan, as well as 149 selected program participants. The effects of the program were analyzed for pure CHF and CHF-related diagnoses, with outcomes for the third quarter of 1996 (postintervention follow-up) being compared with those for the third quarter of 1995 (preintervention baseline). Overall, the data demonstrated significantly reduced admission and readmission rates for patients with the pure CHF diagnosis. Among the entire CHF patient population, the third quarter admission rate declined 63% (P = 0.00002), and the 30-day and 90-day readmission rates declined 75% (P = 0.02) and 74% (P = 0.004), respectively. Among program participants with pure CHF diagnoses, the 30-day readmission rate was reduced to 0, and an 83% reduction occurred for both the third quarter admission (P = 0.008) and 90-day readmission (P = 0.06) rates. In addition, the average length of stay for patients with CHF-related diagnoses was significantly reduced among both plan participants (P = 0.03) and program participants (P = 0.001). Reductions were also seen in total hospital days and emergency room utilization. These data thus indicate that a comprehensive disease management program can reduce healthcare utilization not only among CHF patients in the program but also among the entire managed care plan population.

Disease Management↗
PubMed2004

Patterns of complementary and alternative medicine use in ED patients and its association with health care utilization.

This study characterizes the use of complementary and alternative medicines (CAM) among ED patients and demonstrates patterns of healthcare utilization among users and nonusers of CAM therapies. A cross-sectional observational study was performed by administering questionnaires to ED patients at a university teaching hospital. Of the 356 patients surveyed, more than half (55%) had tried at least one complementary and alternative therapy within the past 12 months and 17% had tried CAM for their presenting medical problem. The use of CAM interventions varied significantly among different demographic groups. The number of ED visits over the past year did not differ between the users and nonusers of CAM, but those using alternative therapies did have more visits to outpatient physicians over the past 12 months (7.8 vs. 5.2; 95% confidence interval [CI], 7-4.6; P <.01). After controlling for age, ethnicity, education level, religion, income, and self-report of overall health status, users of CAM had more frequent visits to outpatient physicians (odds ratio [OR], 1.06; 95% CI, 1.02-1.1; P <.01), had no difference in their rates of hospitalization, but trended toward spending fewer days in the hospital when they were admitted (OR,.96; 95% CI,.92-1.0; P =.06). Complementary and alternative medicines are being used by a majority of ED patients with a significant number having used CAM for their presenting complaint before visiting the ED. CAM users do not differ in their utilization of the ED when compared with nonusers, but do have a significantly increased frequency of outpatient physician visits.

Adolescent↗
PubMed2006

Patterns and utilization of isotretinoin for acne from 1984 to 2003: is there need for concern?

OBJECTIVES: To (1) describe the patterns and trends of isotretinoin utilization between 1984 and 2003, (2) describe the characteristics of isotretinoin users within that same time period, (3) identify and quantify predictors of isotretinoin use, and (4) describe the impact of guidelines on isotretinoin utilization between 1984 and 2003. METHODS: Using the Régie de l'Assurance Maladie du Québec (healthcare utilization, medications) and Med-Echo (hospitalizations) administrative databases, we conducted a descriptive study on a population-based sample of first-time isotretinoin users from 1984 to 2003. We determined the characteristics of these users, predictors of an isotretinoin treatment >or=20 weeks, and impact of guidelines on the number of new isotretinoin users. Guidelines included the implementation of the Pregnancy Prevention Program (PPP - 1988) and the Dear Healthcare Professional Letter regarding possible psychiatric risks issued to Canadian physicians (DHPL - 2001). RESULTS: Mean (SD) age was 23.9 (7.6) years; 50% males, 52% welfare recipients, 77% urban dwellers, and 55% of prescriptions were written by dermatologists. Sixty-four percent of patients did not receive any anti-acne medications in the 12 months prior to receiving isotretinoin. Thirty-five percent of patients had an isotretinoin treatment >or=20 weeks suggested by product guidelines. The odds ratio of having a treatment >or=20 weeks significantly increased after the implementation of the PPP and other guidelines. There was no statistically significant decrease in the number of new isotretinoin users following the implementation of the PPP and DHPL. CONCLUSION: These data suggest inappropriate isotretinoin utilization, even more so after guidelines were promulgated.

Acne Vulgaris↗
PubMed2004

Time since immigration and health services utilization of Korean-American older adults living in Los Angeles County.

The aim of this study was to characterize ambulatory healthcare utilization of older Korean Americans and its association with length of time since immigration. It was hypothesized that older Korean Americans who were recent immigrants would use outpatient physician visits less often than early immigrants. The data are from the 2000 Korean-American Health Survey, which assessed the health status and medical needs of Korean Americans living in Los Angeles County. The dependent variable was the number of visits to a physician for check-up or consultation. Multivariate regression modeling was used to assess the influence of length of time since immigration on the dependent variable controlling for predisposing, enabling, and need variables for a sample of 208 Koreans Americans aged 65 and older. Results indicated that high school education in Korea and health insurance status were significant predictors of number of visits to a physician during the previous year (P<.05). The main variable of interest, the number of years living in the United States, approached significance at P=.09. It was concluded that enabling variables such as education and health insurance significantly influenced use of healthcare services in the older Korean-American population. The lack of studies regarding older minority populations and their access to healthcare further highlight theneed not only to characterize the access of these often-vulnerable populations, but also to generate interest for further studies.

Aged↗
PubMed2004

Health services utilization and cost for at-risk drinkers: rural and urban comparisons.

OBJECTIVE: The purpose of this study was to examine differences between healthcare use and associated costs in rural and urban at-risk drinkers. METHOD: Primary healthcare utilization and cost data were collected from 1995 to 1998 on rural (n = 215) and urban (n = 228) cohorts of drinkers residing in six southeastern states who met criteria for at-risk drinking. Data were obtained through subject interview and from abstracts of medical and pharmacy records. RESULTS: Overall healthcare costs were not significantly different between the rural and urban cohorts. For subjects who incurred any hospital costs (including emergency room [ER] visits), however, costs were significantly greater (p < .01) for rural patients (median = dollars 2,561) than for urban patients (median = dollars 865). Hospital costs associated with patients' ER visits and any subsequent admissions were also greater (p < .01) for rural patients (median = dollars 1,004) than for urban patients (median = dollars 512). Use of healthcare services was significantly more likely to occur among women (p < .0001), individuals with lower overall self-reported physical health (p < .01) and individuals with health insurance (p < .0001). Among subjects who used healthcare services, greater costs were significantly associated with older age (p < .05), being female (p <.0001), having lower overall physical health (p < .0001) and having health insurance (p < .01). CONCLUSIONS: While overall healthcare costs are not significantly different between rural and urban residents in this sample of at-risk drinkers, there are some notable differences in the costs associated with inpatient and ER services.

Adult↗
PubMed2005

Risk of selected cardiovascular diseases and posttraumatic stress disorder among former World War II prisoners of war.

PURPOSE: American World War II (WWII) prisoners of war (POWs) suffered both mental and physical deprivation while interned. The long-term health consequences of the internment were studied for an increased risk of cardiovascular diseases and posttraumatic stress disorder (PTSD). METHODS: This study evaluated healthcare utilization data for 10 years (1991-2000) from Veterans Affairs (VA) and non-VA healthcare providers for 19,442 former WWII POWs and 9728 non-POW controls. The risk of diseases was approximated by odds ratios adjusted for race and age. RESULTS: Collectively, former POWs had statistically significant increased risk of PTSD, and those POWs with PTSD also had statistically significant increased risks of cardiovascular diseases including hypertension and chronic ischemic heart disease when compared to both non-POWs and POWs without PTSD. CONCLUSIONS: Among former WWII POWs, risk of cardiovascular disease is related to having PTSD.

Aged↗