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PubMed2005

Cost of heart failure in Swedish primary healthcare.

OBJECTIVES: To calculate the cost for patients with heart failure (HF) in a primary healthcare setting. DESIGN: Retrospective study of all available patient data during a period of one year. SETTING: Two healthcare centers in Linköping in the southeastern region of Sweden, covering a population of 19 400 inhabitants. SUBJECTS: A total of 115 patients with a diagnosis of HF. MAIN OUTCOME MEASURES: The healthcare costs for patients with HF and the healthcare utilization concerning hospital days and visits to doctors and nurses in hospital care and primary healthcare. RESULTS: The mean annual cost for a patient with HF was SEK 37 100. There were no significant differences in cost between gender, age, New York Heart Association functional class, and cardiac function. The distribution of cost was 47% for hospital care, 22% for primary healthcare, 18% for medication, 5% for nursing home, and 6% for examinations. CONCLUSION: Hospital care accounts for the largest cost but the cost in primary healthcare is larger than previously shown. The total annual cost for patients with HF in Sweden is in the range of SEK 5.0-6.7 billion according to this calculation, which is higher than previously known.

Aged↗
PubMed2004

Use of antidepressant medications: are there differences in psychiatric visits among patient treatments in the Veterans Administration?

BACKGROUND: Information on the effectiveness of newer antidepressants like serotonin-norepinephrine reuptake inhibitors in terms of healthcare utilization is limited. Treatment guidelines affect evaluation. Second-line medications are usually prescribed to patients with higher utilization. OBJECTIVES: The objective of this study was to compare antidepressants within the Veterans Affairs (VA) healthcare system on the basis of the number of outpatient psychiatric visits for each class of antidepressants. RESEARCH DESIGN AND SUBJECTS: We conducted a retrospective cohort design using precollected information from VA national databases from 1999 and 2000. The study identified 92,537 patients on serotonin specific reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or tricyclic antidepressants (TCAs). MEASURES: We stratified individual patients by the number of visits in the baseline year for each medication class. For each stratum, we created a dichotomized variable YK: Yk = 1 if there is a reduction of K visits or more and 0 if there is no reduction. We calculated the odds of reduction of psychiatric visits among the 3 classes of antidepressants. RESULTS: TCAs and SSRIs were associated with greater odds of reduction compared with SNRIs at the level of 1 through 10 or 11 visits, respectively. SNRIs were associated with greater odds of reduction in visits at the level of 14, 16, or more visits compared with SSRIs and TCAs, respectively (P <0.05). SSRIs were associated with greater odds of reduction compared with TCAs at the level of 1 to 11 visits (P <0.05); there were no significant differences between the 2 classes above 11 visits. CONCLUSION: Effectiveness research using databases should consider how medications are prescribed within systems. Treatment guidelines result in differences in severity and utilization among users of different medications.

Adolescent↗
PubMed2004

Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population.

BACKGROUND: Hispanic Americans are often treated as a monolithic ethnic group with a single pattern of healthcare utilization. However, there could be considerable differences within this population. We examine the association between use of healthcare services and Hispanic Americans'country of ancestry or origin, language of interview, and length of time lived in the United States. METHODS: Our data come from the Medical Expenditure Panel Survey, a nationally representative survey of healthcare use and expenditures. Descriptive statistics and logistic regression results are presented. RESULTS: Multivariate models show that Mexicans and Cubans are less likely, and Puerto Ricans more likely, to have any emergency department visits than non-Hispanic whites. Mexicans, Central American/Caribbeans, and South Americans are less likely to have any prescription medications. All Hispanics are less likely to have any ambulatory visits and prescription medications, whereas only those with a Spanish-language interview are less likely to have emergency department visits and inpatient admissions. More recent immigrants are less likely to have any ambulatory care or emergency department visits, whereas all Hispanics born outside the United States are less likely to have any prescription medications. CONCLUSIONS: The Hispanic population is composed of many different groups with diverse health needs and different barriers to accessing care. Misconceptions of Hispanics as a monolithic population lacking within-group diversity could function as a barrier to efforts aimed at providing appropriate care to Hispanic persons and could be 1 factor contributing to inequalities in the availability, use, and quality of healthcare services in this population.

Adolescent↗
PubMedDate not supplied

Darbepoetin alfa: a novel erythropoiesis-stimulating protein.

OBJECTIVE: To review the pharmacology, pharmacokinetics, clinical efficacy, and safety of darbepoetin alfa. DATA SOURCES: Pertinent references were identified by a MEDLINE search (1995-January 2001) of the medical literature, review of English-language literature and references of these articles, product information, and abstracts from professional meetings. STUDY SELECTION: Clinical efficacy data were gathered from all available trial data citing darbepoetin alfa. Additional information concerning pharmacology, pharmacokinetics, and safety was also reviewed. DATA SYNTHESIS: Darbepoetin alfa is a new erythropoiesis-stimulating protein with a threefold longer half-life than recombinant human erythropoietin (r-HuEPO). Darbepoetin alfa is approved for intravenous and subcutaneous administration in patients requiring and not requiring dialysis. Clinical studies in patients with chronic kidney disease (CKD) have shown darbepoetin alfa to be equivalent to r-HuEPO in terms of increases in hemoglobin concentration, percentage of patients obtaining target hemoglobin, and average time to reach target hemoglobin concentration. Trials are currently ongoing in patients receiving cancer chemotherapy. The adverse event profile appears to be similar between the 2 agents. CONCLUSIONS: The equivalent efficacy and safety profile, as well as the longer half-life, may make darbepoetin alfa an attractive alternative to r-HuEPO in patients with CKD. Since these patients need to receive r-HuEPO 1-3 times weekly at the expense of increased healthcare utilization to improve their hemoglobin, agents such as darbepoetin alfa, with longer durations of action, may reduce healthcare expenses. In addition, enhanced patient compliance may be realized with once-weekly or once every-other-week administration.

Adult↗
PubMed2005

Patterns of diagnoses in hospital admissions in a multistate cohort of HIV-positive adults in 2001.

BACKGROUND: Admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but it is unclear if the trends have continued in the current HAART era. An understanding of healthcare utilization patterns is important for optimization of care and resource allocation. We examined the diagnoses for hospitalizations of patients with HIV in 2001. METHODS: Demographic and healthcare data were collected for 8376 patients from 6 U.S. HIV care sites in 2001. We categorized diagnoses into 18 disease groups and used Poisson regression to analyze the number of admissions for each of the 4 most common groups. We also compared patients with admissions for AIDS-defining illnesses (ADI) with patients admitted for other diagnoses. RESULTS: Twenty-one percent of patients had at least 1 hospitalization. Among patients hospitalized at least once, 28% were hospitalized for an ADI. Comparing diagnosis categories, the most common hospitalizations were AIDS-defining illnesses (21.6%), gastrointestinal (GI) diseases (9.5%), mental illnesses (9.0%), and circulatory diseases (7.4%). In multivariate analysis, women had higher hospitalization rates than men for ADI (incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.25-1.79) and GI diseases (IRR, 1.52; 95% CI, 1.15-2.00). Compared with whites, blacks had higher admission rates for mental illnesses (IRR, 1.70; 95% CI, 1.22-2.36), but not for ADI. As expected, CD4 count and viral load were associated with ADI admission rates; CD4 counts were also related to hospitalizations for GI and circulatory conditions. CONCLUSIONS: Five years after the introduction of HAART, AIDS-defining illnesses continue to have the highest hospitalization rate among the diagnosis categories examined. This result emphasizes the importance of vaccination for pneumonia and influenza, as well as prophylaxis for Pneumocystis jiroveci pneumonia. The relatively large number of mental illness admissions highlights the need for comanagement of psychiatric disease, substance abuse, and HIV. Overall, the majority of patients were hospitalized for reasons other than ADI, illustrating the importance of managing comorbid conditions in this population. Data from this cohort of patients with HIV may help guide the allocation of healthcare resources by enhancing our understanding of factors associated with variation in inpatient utilization rates.

AIDS-Related Opportunistic Infections↗
PubMed2000

Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare?

OBJECTIVE: To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING: A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS: Residents (n = 700) living in the community between September 1995 and February 1996. METHODS: Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS: Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS: Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.

Aged↗
PubMed2006

Impact of statin copayments on adherence and medical care utilization and expenditures.

OBJECTIVE: To examine the effects of statin cost-sharing (ie, copayments, coinsurance) on adherence to statin medications and the impact of adherence on healthcare utilization and spending. STUDY DESIGN: Retrospective, observational study of statin users receiving health benefits or supplemental coverage from employer-sponsored health plans. METHODS: Medical and pharmacy claims were selected from the Medstat MarketScan database for patients who were continuously enrolled from 2000 through 2003. Two-stage residual inclusion models were estimated. The first stage modeled adherence to statins, which was derived from the medication possession ratio, and represented the percentage of days on therapy in an 18-month time frame, July 2001 through December 2002. In the second stage, generalized linear models were used to estimate 2003 utilization and expenditures. Separate estimates were produced for new statin users (n = 24 113) and continuing statin users (n = 93 253). RESULTS: Lower statin copayments were associated with higher levels of statin adherence. In percentage terms, when holding all other variables at their mean value, a $10 increase in copayment resulted in a 1.8 percentage point reduction in the probability of adherence for new users and a 3 percentage point reduction in the probability of adherence for continuing users. For continuing users adherent to statins, total costs did not change, but fewer negative events (emergency department visits, hospitalizations, and coronary heart disease-related hospitalizations) occurred. CONCLUSIONS: Policy makers and plan managers should consider interventions that improve adherence to statins, such as lower copayments.

Aged↗
PubMed2005

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.

BACKGROUND: Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. OBJECTIVE: The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV. DESIGN: Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. SETTING: This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. PATIENTS: In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. MAIN OUTCOME MEASURES: Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. RESULTS: Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002. CONCLUSION: Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

AIDS-Related Opportunistic Infections↗
PubMed2004

Changing healthcare professionals' behaviors to eliminate disparities in healthcare: What do we know? How might we proceed?

The patient-healthcare provider communication process--particularly the provider's cultural competency--is increasingly recognized as a key to reducing racial/ethnic disparities in health and healthcare utilization. A working group was formed by the Office of Minority Health, Department of Health and Human Services to identify strategies for improving healthcare providers' cultural competency. This expert panel, one of several working groups called together to explore methods of reducing healthcare disparities, was comprised of individuals from academic medical centers and health professional organizations who were nationally recognized as having expertise in healthcare communication as it relates to diverse populations. During the 2-day conference, the panel identified, from personal experience and knowledge of the literature, key points of intervention and interventions most likely to improve the cross-cultural competency of healthcare providers. Proposed interventions included introduction of cultural competence education before, during, and after clinical training; implementation of certification and accreditation requirements in cross-cultural competence for practicing healthcare providers; use of culturally diverse governing boards for clinical practices; and active promotion of workforce cross-cultural diversity by healthcare organization administrators. For each intervention, methods for implementation were specified. On-going monitoring and evaluation of processes of care using race/ethnicity data were recommended to ensure the programs were functioning.

Attitude of Health Personnel↗
PubMed2004

Service utilization among compensation-seeking veterans.

To examine the relationship between compensation-seeking status, symptom reporting, and health care utilization among combat veterans presenting for a Posttraumatic Stress disorder (PTSD) evaluation. Archival data for 68 veterans was drawn from electronic medical records for which compensation-seeking status was available. Consistent with previous findings, self-reports of distress and validity scale indices on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) were higher among compensation-seeking (CS) veterans than noncompensation-seeking (NCS) veterans despite a lack of difference in actual PTSD diagnoses. However, no significant differences emerged between these two groups on healthcare utilization indices. Although exploratory analyses did not yield significant group differences on various healthcare indices, there was a trend for CS veterans to use PTSD services more, suggesting the need to further explore utilization patterns among these groups.

Eligibility Determination↗
PubMedDate not supplied

Relationship of sexual assault history to somatic symptoms and health anxiety in women.

Prior reports have pointed to a link between traumatic experiences and health consequences in women. The objective of this study was to determine whether there is an association between sexual assault history and measures of somatic symptoms and illness attitudes in a sample of female Veterans Affairs primary care patients, a group in whom high rates of sexual trauma have been reported. We conducted a cross-sectional study of a representative sample of 219 women in a Veteran's Affairs primary care outpatient clinic. Sexual assault history, somatic symptoms and health anxiety were assessed by self-report questionnaire. Multivariate analyses were used to examine relationships between sexual assault exposure and these outcomes. Ninety-seven women (43.9%) reported experience(s) of sexual assault (i.e., rape, attempted rape or being made to perform any type of sexual act through force or threat of harm). Sexual assault was associated with a significant increase in somatization scores, physical complaints across multiple symptom domains and health anxiety. Sexual assault was also a significant statistical predictor of having multiple sick days in the prior 6 months and of being a high utilizer of primary care visits in the prior 6 months. These data confirm a strong association between sexual trauma exposure and somatic symptoms, illness attitudes and healthcare utilization in women. Causal mechanisms cannot be inferred from these data. Studies in other cohorts are warranted.

Adult↗
PubMed2005

Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization.

BACKGROUND: Dementia is a growing public health problem and a well-described risk factor for delirium. Yet little is known about delirium superimposed on dementia in community-dwelling populations. The purpose of this study was to examine the 3-year occurrence, healthcare utilization, and costs associated with delirium superimposed on dementia in community-dwelling persons. METHODS: We used a 3-year cross-sectional, retrospective design with an administrative database from a large managed care organization. Four individually matched samples of 699 individuals each were selected for comparison purposes: delirium superimposed on dementia (DSD), dementia alone, delirium alone, and a control group with neither delirium nor dementia. The occurrence rate of DSD was calculated by measuring those individuals with a dementia diagnosis that were also coded with an International Classification of Diseases, Ninth Edition Clinical Modification (ICD-9 CM) code for delirium or delirium with dementia. RESULTS: Of the total sample of 76,688 persons aged 65 years or older in the managed care organization, 7347 (10%) were coded as having dementia, and an additional 763 (1%) as having delirium alone. Among the 7347 with dementia, 976 (13%) had DSD, representing 1.3% of the total sample. After log transformation of total costs and adjustment for multiple covariates, the adjusted mean total health care costs remained significantly higher for the DSD group than for all other groups. CONCLUSIONS: This study is the first to report the occurrence rate of DSD in a community-dwelling population, and to demonstrate the substantial health care costs and utilization associated with DSD.

Aged↗
PubMed2005

Angiotensin receptor blockers: impact on costs of care.

Direct and indirect costs related to the treatment of hypertension are estimated at nearly $60 billion annually. Short- and long-term costs of healthcare utilization and treatment are, therefore, important considerations in selection of antihypertensive therapy. Studies of patients with hypertension and type 2 diabetes have shown that treatment with angiotensin receptor blockers (ARBs) can reduce healthcare costs as a result of a decreased incidence of end-stage renal disease and other clinical end points. ARBs also increase survival in these patients. Cost savings have also been reported in patients with heart failure as a result of reductions in office and emergency department visits, hospital admissions, and hospital stays.

Angiotensin Receptor Antagonists↗
PubMed2005

Disability as a "family affair": parental disability and childhood immunization.

BACKGROUND: There is a substantial body of research focusing on the health and healthcare utilization of individuals with a disability but less has been done to examine the impact of disability on nondisabled family members. OBJECTIVE: We sought to investigate the influence of parental disability on children's healthcare as measured by the timely receipt of childhood immunizations. RESEARCH DESIGN: Observations on 11,997 children between the ages 2 and 5 years were obtained from the 1994 and 1995 United States National Health Interview Surveys representing 27,534,841 children when weighted. Children are determined to be in compliance with the Centers for Disease Control immunization protocol at age 24 months if they have received 4 DTP, 3 polio, and 1 MMR vaccine dose. Disability is characterized using the activity and personal care scales from the National Health Interview Surveys. The data were analyzed using logistic regression controlling for factors identified in prior research to be related to timely receipt of immunization. RESULTS: Children living with a parent who is unable to provide his or her own personal care are 65% less likely (odds ratio = 0.35; 95% confidence interval = 0.17-0.70) to be immunized on time than children who live with parent(s) who do not have a disability. Children of parents who are limited in their personal care, and children of parents who have work limitations, are not less likely than children of nondisabled parents to receive immunizations on time. CONCLUSIONS: The impact of a parent's severe disability extends to the health care of dependent children. These findings argue for research to investigate the full scope of the effects of parental disability on children's health and for policies that address this impact.

Activities of Daily Living↗
PubMedDate not supplied

Costs and complications of hospitalizations for children with cerebral palsy.

BACKGROUND: Although many children with cerebral palsy (CP) develop secondary conditions requiring hospitalization, in-patient hospital utilization by this population has not been characterized. OBJECTIVE: To characterize hospitalizations in children with CP and to compare them with hospitalizations of those without CP using a large national data set. METHODS: Analysis of the Healthcare Utilization Project Kid Inpatient Database, a weighted survey of paediatric discharges from US hospitals in 1997. RESULTS: In 1997, 37,000 children with CP were hospitalized, generating charges approaching 600 million dollars. Children with CP demonstrated longer lengths of stay (6.3 vs 4.1 days, p < 0.001), higher total charges (16,024 vs 9952 dollars, p < 0.001), more diagnoses (5.6 vs 3.0, p < 0.001) and more procedures (1.7 vs 1.1, p < 0.001) per admission. Five major diagnostic categories accounted for 83.2% of the discharge diagnoses for children with CP (48.6% for those without CP, p < 0.001). Children with CP were more often transferred to other facilities (p < 0.001) or prescribed home health care (p < 0.001) upon discharge. CONCLUSIONS: Hospitalization of children with CP represents a major expenditure for health care systems. Studies to improve the management of conditions associated with CP could result in better outcomes for children and families and potentially decrease costs associated with hospitalization.

Adolescent↗
PubMed2006

Managing the burden of chronic kidney disease.

Patients with chronic kidney disease (CKD) have high rates of healthcare utilization, morbidity, and mortality. Increasing rates of obesity, diabetes, and hypertension suggest that the expected numbers of patients with CKD will rise. Managing the economic and clinical burden of CKD will be a significant challenge for the healthcare system. The burden of CKD can be considered in terms of both CKD-specific and CKD-related morbidity and mortality. CKD-specific complications include anemia and bone disease. CKD-related complications include obesity, diabetes and hypertension. CKD-specific complications tend to occur later in the course of disease and may be best treated by a nephrologist, while CKD-related complications may be most easily treated by primary care physicians. Coordinating patient care is essential to managing the burden of this growing disease.

Continuity of Patient Care↗
PubMed2004

Evaluation of asthma prescription measures and health system performance based on emergency department utilization.

BACKGROUND: Measures based on the use of either antiinflammatory and/or reliever medications have been used to evaluate clinical performance in asthma. OBJECTIVE: We compared the association between 2 asthma prescription measures (APMs) and subsequent risk of emergency department (ED) asthma visits. DESIGN: We conducted a cross-sectional analysis of automated pharmacy and healthcare utilization data from 3 large geographically diverse managed care organizations. PARTICIPANTS: We studied children, 3 to 15 years of age, with at least 1 encounter for asthma (hospitalization, ED, or ambulatory care), at least 1 dispensing of an asthma medication, and continuous enrollment between June 1996 and July 1997. MEASURES: Two performance measures were derived for patients with persistent asthma: 1) the proportion of individuals who have received controller therapy and 2) the ratio of dispensed controller to dispensed reliever medications. Children with persistent asthma were identified using the Health Employers Data Information System (HEDIS) criteria of the National Committee on Quality Assurance definition. Multivariate logistic regression was used to assess independent effects in models for ED visits. RESULTS: Among children with persistent asthma, the dispensing of a controller was associated with a significantly lower risk of an ED visit as compared with children not dispensed a controller (odds ratio, 0.3; 95% confidence interval, 0.2-0.4). An association between the ratio of controller to reliever dispensing and the risk of subsequent ED visit was also observed, however, the underlying level of reliever dispensing modified the relationship. Among children with persistent asthma, the ratio of controller to reliever dispensing was inversely associated with risk of ED visit among children dispensed <4 relievers/person-year but no significant relationship was seen among children dispensed > or =4 relievers/person-year. CONCLUSION: Among children with persistent asthma, the use of an asthma prescription measure (APM) can help stratify children based on their risk of future adverse events. The HEDIS measure, the dispensing of a controller medication among a population with persistent asthma, and the controller to reliever ratio are associated with the risk of subsequent ED visit. However, the association between the ratio measure and risk for ED visit is modified by the underlying level of reliever dispensing.

Adolescent↗
PubMed1999

Gender, psychosocial factors and the use of medical services: a longitudinal analysis.

Many researchers have reported gender differences in levels of reported symptoms, morbidity, mortality and medical care utilization, but the debate continues about the underlying causes of these differences. Some have argued that women use more medical services because they are more sensitive to symptoms and interested in health, while others believe that women's greater service utilization arises from the fact that women experience more morbidities than do men. To date, these questions have not been studied prospectively. Using data from a household interview survey carried out in 1970-1971 and linked to 22 years of health services utilization records, we explored the effects of gender, self-reported health status, mental and physical symptom levels, health knowledge, illness behaviors and health concerns and interest on the long-term use of health services. After controlling for the aforementioned factors, female gender remained an independent predictor of higher utilization over the 22-year period studied, and psychosocial and health factors measured at the initial interview predicted service use even 19-22 years later. Controlling for factors identified as likely causes of gender-related differences in healthcare utilization, gender remains an important predictor of medical care use before and after removing sex-specific utilization. In addition, the consistent predictive ability of attitudinal and behavioral factors, combined with the finding that health knowledge did not predict utilization, indicates that efforts to help patients assess their service needs should target the attitudinal and behavioral factors that vary with gender, rather than health-related knowledge alone.

Adolescent↗