Healthcare Utilization In Year Research Articles

Rapid Access From Primary Care to a Multidisciplinary Clinic at Tertiary Care Improves Clinical Outcomes for Patients With Diabetic Foot Ulcers: Results From Diabetic Foot in Primary and Tertiary (DEFINITE) Care's Lower Extremity Amputation Prevention Program (LEAPP) Clinic.

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional, multidisciplinary team (MDT) program for patients with diabetic foot ulcers (DFU) within a healthcare cluster in Singapore. This is one of our subgroup analyses within DEFINITE Care, assessing clinical outcomes of lower extremity amputation prevention program (LEAPP), a multidisciplinary diabetic foot clinic, and non-LEAPP patients within the program. From June 2020 to June 2022, 2798 patients within the DEFINITE cohort completed a minimum of 12-month follow up. Of these patients, 20.6% were managed by LEAPP, whereas 79.4% were non-LEAPP patients. Patients in the LEAPP cohort were older with co-existing metabolic conditions and complications of diabetes. Using non-LEAPP cohort as the reference group and after adjusting for age, gender, ethnicity, comorbidities, and medications, there was a significantly lower risk of death (odds ratio [OR] 0.60, P = .001) and composite major lower extremity amputation (LEA) or death (OR 0.66, P = .002) among LEAPP patients at 1 year with longer mean days from enrollment to minor LEA, major LEA, and death. The adjusted 1-year healthcare utilization outcomes for LEAPP patients demonstrated an increase in inpatient admissions, primary care polyclinic visits, hospital specialist outpatient clinic (SOC) visits and elective day surgery procedures. Despite the increased in inpatients admissions, cumulative hospital length of stay in LEAPP patients were lower. This subgroup analysis has demonstrated that the MDT approach to caring for patients with DFU in tertiary centers not only improves mortality by 40%, but also delayed the incidence of minor LEA, major LEA, and death.

Health Care Utilization and Death in Patients With Heart Failure During the COVID-19 Pandemic

ObjectiveTo compare the 1-year health care utilization and mortality in persons living with heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic. Patients and MethodsResidents of a 9-county area in southeastern Minnesota aged 18 years or older with a HF diagnosis on January 1, 2019; January 1, 2020; and January 1, 2021, were identified and followed up for 1-year for vital status, emergency department (ED) visits, and hospitalizations. ResultsWe identified 5631 patients with HF (mean age, 76 years; 53% men) on January 1, 2019, 5996 patients (mean age, 76 years; 52% men) on January 1, 2020, and 6162 patients (mean age, 75 years; 54% men) on January 1, 2021. After adjustment for comorbidities and risk factors, patients with HF in 2020 and patients with HF in 2021 experienced similar risks of mortality compared with those in 2019. After adjustment, patients with HF in 2020 and 2021 were less likely to experience all-cause hospitalizations (2020: rate ratio [RR], 0.88; 95% CI, 0.81-0.95; 2021: RR, 0.90; 95% CI, 0.83-0.97) compared with patients in 2019. Patients with HF in 2020 were also less likely to experience ED visits (RR, 0.85; 95% CI, 0.80-0.92). ConclusionIn this large population-based study in southeastern Minnesota, we observed an approximately 10% decrease in hospitalizations among patients with HF in 2020 and 2021 and a 15% decrease in ED visits in 2020 compared with those in 2019. Despite the change in health care utilization, we found no difference in the 1-year mortality between patients with HF in 2020 and those in 2021 compared with those in 2019. It is unknown whether any longer-term consequences will be observed.

Peripheral Artery Disease Screening in the Community and 1-Year Mortality, Cardiovascular Events, and Adverse Limb Events

This study aimed to examine all-cause mortality, 1- and 2-year major cardiovascular events, and major adverse limb events in individuals aged ≥65 years who received an in-home health visit with peripheral artery disease screening. In addition, we compared 1-year healthcare utilization before and after peripheral artery disease screening for those who screened positive. Medicare Advantage beneficiaries aged ≥65 years participating in the Optum HouseCalls program in the U.S. between April 1, 2017 and February 1, 2019 were included. The intervention consisted of a peripheral artery disease screening program using a plethysmography system. One-year all-cause mortality as a landmark analysis, 1- and 2-year major cardiovascular events, and major adverse limb events after screening were compared by peripheral artery disease screen status using claims data. We compared cardiovascular medications and revascularization procedures between the year before and after the peripheral artery disease screening event for those with peripheral artery disease. Of 192,500 beneficiaries, 27.7% screened positive. One-year all-cause mortality rates for those who screened positive for peripheral artery disease versus those who screened negative were higher (1.51% vs 0.89%; p<0.001; adjusted hazard ratio=1.21; 95% CI=1.08, 1.36) as well as 1-year major cardiovascular events (5.54% vs 3.60%; adjusted hazard ratio= 1.22; 95% CI=1.15, 1.30) and major adverse limb events (0.23% vs 0.04%; adjusted hazard ratio=3.15; 95% CI=2.10, 4.73). Similar risks were observed for 2-year results. Before and after peripheral artery disease screening, medications remained stable for those who screened positive (e.g., statin therapy=54.2% vs 56.6%); rates of peripheral vascular interventions remained stable (0.0% vs 0.1%). A national peripheral artery disease screening effort is feasible. Detecting previously undiagnosed peripheral artery disease is a way to risk stratify a population that would benefit from further cardiovascular risk management.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database

BackgroundEarly initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending.MethodsUsing the Truven MarketScan database, we identified nearly 980,000 US adults ages 18–64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05.ResultsAt 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40–0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47–0.51), emergency department visits (OR = 0.51, 95% CI = 0.49–0.54), advanced imaging (OR = 0.57, 95% CI = 0.56–0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66–0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65–0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4–25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to −$410; P < 0.001).ConclusionEarly PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state.Level of evidenceIV

Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles

Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.

1274-P: Impact of Type 1 Known Diabetes (T1D) Risk on Health-Care Utilization at Diagnosis

Despite increasing incidence of T1D worldwide, most newly-diagnosed individuals have no family history. Many experience delay in diagnosis, resulting in &amp;gt;30% of children with new-onset T1D presenting in diabetic ketoacidosis (DKA). Screening for T1D is currently restricted to the research setting. We sought to describe differences in health care utilization at T1D diagnosis in known at-risk patients identified through research studies compared to matched controls. Cases (n=39) were known islet autoantibody positive children (0-19 y) diagnosed with T1D between 2010-2017 at the Barbara Davis Center. Controls were matched 3:1 by dates of birth and diagnosis from community-diagnosed patients (n=117). The Colorado All Payer’s Claims Database was used to count diagnoses, procedures, and healthcare claims in the year before and following diagnosis. Continuous variables were compared using t-test or Wilcoxon rank sum test, categorical by chi-square. There was no difference between cases and controls for age of onset (9.6 +/- 3.6 vs. 9.6 +/- 3.5 y p=1.0) or gender (54 vs. 46% male, p=1.0); however, cases had higher rate of private insurance (72 vs. 49%, p=.01) and higher percentage of non-Hispanic whites (87 vs. 65%, p=.008). At diagnosis with T1D, cases had lower HbA1c (6.7 [6.1, 8.1]% vs. 12.1 [10.5, 14.1]%, p&amp;lt;.0001) and rate of DKA (5 vs. 57%, p&amp;lt;.0001). In the year prior to diagnosis, there were no differences in the number of claims, procedures, diagnoses, or medications. In contrast, in the year of diagnosis, cases had fewer emergency room claims (0 [0, 2] vs. 2 [0, 4], p&amp;lt;.0001), total claims (20 [9, 30] vs. 33 [19, 48], p&amp;lt;.0001), procedures (31 [16, 43] vs. 52 [28, 77] p&amp;lt;.0001) and unique diagnoses (7 [4, 10] vs. 12 [7, 19] p=.0003), while there was no difference in number of medications (8 [4, 10] vs10 [7, 13] p=.07). In conclusion, antibody-screened patients had lower healthcare utilization in year of diagnosis. Further study, including cost estimation, may lend insight into benefits of T1D screening programs. Disclosure B.I. Frohnert: None. K. Manseau: None. G.T. Alonso: None. Funding JDRF (5-ECR-2017-388-A-N)

Timing of physical therapy consultation on 1-year healthcare utilization and costs in patients seeking care for neck pain: a retrospective cohort

BackgroundPatients seek care from physical therapists for neck pain but it is unclear what the association of the timing of physical therapy (PT) consultation is on 1-year healthcare utilization and costs. The purpose of this study was to compare the 1-year healthcare utilization and costs between three PT timing groups: patients who consulted a physical therapist (PT) for neck pain within 14 days (early PT consultation), between 15 and 90 days (delayed PT consultation) or between 91 and 364 days (late PT consultation).MethodsA retrospective cohort of 308 patients (69.2% female, ages 48.7[±14.5] years) were categorized into PT timing groups. Descriptive statistics were calculated for each group. In adjusted regression models, 1-year healthcare utilization of injections, imaging, opioids and costs were compared between groups.ResultsCompared to early PT consultation, the odds of receiving an opioid prescription (aOR = 2.79, 95%CI: 1.35–5.79), spinal injection (aOR = 4.36, 95%CI:2.26–8.45), undergoing an MRI (aOR = 4.68, 95%CI:2.25–9.74), X-ray (aOR = 2.97, 95%CI:1.61–5.47) or CT scan (aOR = 3.36, 95%CI: 1.14–9.97) were increased in patients in the late PT consultation group. Similar increases in risk were found in the delayed group (except CT and Opioids). Compared to the early PT consultation group, mean costs were $2172 ($557, $3786) higher in the late PT contact group and $1063 (95%CI: $ 138 - $1988) higher in the delayed PT consultation group.DiscussionThere was an association with the timing of physical therapy consultation on healthcare utilization and costs, where later consultation was associated with increases costs and healthcare utilization. This study examined the association of timing of physical therapy consultation on costs and healthcare utilization, but not the association of increased access to physical therapy consultation. Therefore, the findings warrant further investigation to explore the effects of increased access to physical therapy consultation on healthcare utilization and costs in a prospective study.

Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain.

ObjectiveTo examine patients seeking care for neck pain to determine associations between the type of provider initially consulted and 1-year health care utilization.Patients and MethodsA retrospective cohort of 1702 patients (69.25% women, average age, 45.32±14.75 years) with a new episode of neck pain who consulted a primary care provider, physical therapist (PT), chiropractor (DC), or specialist from January 1, 2012, to June 30, 2013, was analyzed. Descriptive statistics were calculated for each group, and subsequent 1-year health care utilization of imaging, opioids, surgery, and injections was compared between groups.ResultsCompared with initial primary care provider consultation, patients consulting with a DC or PT had decreased odds of being prescribed opioids within 1 year from the index visit (DC: adjusted odds ratio [aOR], 0.54; 95% CI, 0.39-0.76; PT: aOR, 0.59; 95% CI, 0.44-0.78). Patients consulting with a DC additionally demonstrated decreased odds of advanced imaging (aOR, 0.43; 95% CI, 0.15-0.76) and injections (aOR, 0.34; 95% CI, 0.19-0.56). Initiating care with a specialist or PT increased the odds of advanced imaging (specialist: aOR, 2.96; 95% CI, 2.01-4.38; PT: aOR, 1.57; 95% CI, 1.01-2.46), but only initiating care with a specialist increased the odds of injections (aOR, 3.21; 95% CI, 2.31-4.47).ConclusionInitially consulting with a nonpharmacological provider may decrease opioid exposure (PT and DC) over the next year and also decrease advanced imaging and injections (DC only). These data provide an initial indication of how following recent practice guidelines may influence health care utilization in patients with a new episode of neck pain.

COMParative Early Treatment Effectiveness between physical therapy and usual care for low back pain (COMPETE): study protocol for a randomized controlled trial.

BackgroundLow back pain is among the leading causes of medical visits and lost duty days among members of the United States Armed Forces and represents the highest 5-year risk of permanent disability in the US Army. For certain elements of care, the timing may be just as important as the type of care. The purpose of this study is to assess the impact of the timing of access to a physical therapist by patients with low back pain, by looking at outcomes and low back pain-related healthcare utilization over a 1-year period.Methods/DesignThis trial will be a two-arm pragmatic randomized clinical trial occurring at two different clinical sites in the Military Health System. We will assess outcomes and related downstream costs for patients who access physical therapy at the primary care level compared to those that receive usual care only. There will be 220 consecutive patients randomized to receive care in either group (early physical therapy or usual care only) for the first 4 weeks, and these patients will then be allowed to receive any additional care dictated by their primary care provider for the following year. The primary outcome measure is the Oswestry Disability Index. Secondary outcome measures are the Global Rating of Change, Patient Satisfaction and 1-year healthcare utilization. Follow-ups will occur at 4 weeks, 3 months and 1 year.DiscussionThis trial takes a pragmatic approach to delivering care by enabling a usual care environment for managing low back pain, while also allowing immediate access to physical therapy. After the initial intervention, the patient’s primary provider can continue to manage the patient as he/she normally would in practice. The Military Health System Data Repository will capture all low back pain-related healthcare utilization that occurs in order to allow for a comparison between groups. Analysis from retrospective cohorts has shown improved outcomes and decreased costs for patients that received early versus late physical therapy, but this has yet to be shown in prospective trials.Trial registrationClinicalTrials.Gov NCT01556581 initially on 14 March 2012.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0959-8) contains supplementary material, which is available to authorized users.

One-year outcome of subacromial corticosteroid injection versus manual physical therapy for unilateral shoulder impingement syndrome: a pragmatic randomized clinical trial

Background: Corticosteroid injections (CSI) and physical therapy are often used to treat shoulder impingement syndrome, but their effectiveness has never been directly compared out to one year. Purpose:Theprimarypurposeof this studywas to directly compare the effectiveness of 2 common nonsurgical treatment approaches for shoulder impingement syndrome. The secondary purpose was to compare 1year healthcare utilization between the two groups. Methods: Patients referred to physical therapy received random assignment into 2 groups: 40mg triamcinalone acetonide subacromial CSI versus 6 sessions of manual physical therapy (MPT). Follow-up occurred at 1, 3, 6, and 12months. TheShoulder Pain andDisability Index (SPADI) served as the primary outcome. Secondary outcomes included the Global Rating of Change (GRC), the Numeric Pain Rating Scale (NPRS), and 1-year healthcare utilization based off electronic medical records review. Results:Over an 18-month period, 104 consecutive adults between 18 and 65 years of age with unilateral shoulder impingement were enrolled. Both groups demonstrated ∼50% improvement in SPADI at all 4 follow-ups maintained through 1 year, howevermean difference between groupswas not significant (1.5 [95% CI: 6.3, 9.4]). Both groups showed improvements in GRC and NPRS, but between group differences for the GRC (0 [95% CI: 2, +1]) and NPRS (0.4 [95% CI: 0.5, 1.2]) were not significant. During the 1-year followup, patients receiving CSI hadmore SIS-related visits to their primary care provider (60% vs. 37%), required additional steroid injections (38% vs. 20%), and 19% needed physical therapy (compared to 9% in the MPT group). Conclusion(s): Patients randomized to the MPT group experienced similar outcomes in terms of function, pain and patient perceived improvement as patients receiving CSI. However they utilized significantly less additional healthcare resources than the CSI patients for the following year after initial treatment. Implications: CSI and MPT are two common conservative treatment options offered to patients with shoulder impingement. Understanding their long-term impact and the comparative effectiveness of each can help guide best evidence care decisions. Disclaimer:The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army or Defense.

Burden of illness: direct and indirect costs among persons with hemophilia A in the United States

Objective:To examine the direct and indirect costs of hemophilia care among persons with hemophilia A in the US.Methods:Observational data were obtained from HUGS-Va, a multi-center study from six federally supported hemophilia treatment centers (HTCs). Eligible individuals completed a standardized initial questionnaire and were followed regularly for 2 years to obtain information on work or school absenteeism, time spent arranging hemophilia care, and unpaid hemophilia-related support from caregivers. Data from 1-year healthcare utilization records and 2-year clotting factor dispensing records measured direct medical costs. Indirect costs were imputed using the human capital approach, which uses wages as a proxy measure of work time output.Results:A total of 222 patients with complete data were included in the analysis. Two-thirds had severe hemophilia and the mean age was 21.1 years. The use of prophylaxis in severe hemophilia patients is associated with statistically significant reduction in the numbers of emergency department (ED) visits and bleeding episodes compared with those who were treated episodically. From the societal perspective, mild hemophilia costs $59,101 (median: $7519) annually per person, $84,363 (median: $61,837) for moderate hemophilia, $201,471 (median: $143,431) for severe hemophilia using episodic treatment, and $301,392 (median: $286,198) for severe hemophilia receiving prophylaxis. Clotting factor contributed from 54% of total costs in mild hemophilia to a maximum of 94% for patients with severe hemophilia receiving prophylaxis.Conclusion:Hemophilia is a costly disorder not only because of its high medical expenses, but also due to the high indirect costs incurred.

525 Esophageal Mucosal Mast Cell Infiltration As a Linker to Clinical Overlap of Irritable Bowel Syndrome in Subgroup With Esophageal Chest Pain

G A A b st ra ct s intervention program to help reduce IBS symptoms and resource utilization. Methods: We included twoKaiser Permanente centers. Cases were 50 adolescents from our center diagnosed with IBS and subsequently referred and attended our IBS management program. Controls were 25 adolescents from a nearby center whom were diagnosed with IBS, but had no access to the program. Cases and controls were well matched for age, sex, and baseline healthcare utilization. Our interventional IBS programwas a simple multi-disciplinary behavioral therapy that consists of two 90-minute sessions using education, reassurance, dietary intervention, exercise instruction, and guided imagery. Records were reviewed for GI-related visits and imaging, total visits, and all imaging from the year prior to diagnosis and for 4 years after diagnosis. Results: To determine the extent of healthcare utilization in the year following the diagnosis of IBS, a retrospective chart review was performed and was compared to the year prior to diagnosis. In the year after diagnosis the changes in GI-related visits were +2.05 ± 0.46 for controls vs. +0.75 ± 0.25 for cases (P,0.05) and overall visits were +8.95 ± 1.94 for controls vs. +3.61 ± 1.07 for cases (P ,0.05). Changes in overall imaging studies were +1.85 ± 1.23 for controls and -0.23 ± 0.34 for cases (P=0.06), and change in GIrelated imaging was +1.13 ± 0.79 for controls compared to -0.05 ± 0.25 for cases (P ,0.05). Four-year follow up for GI-related visits were 4.83 ± 0.57 for controls vs. 2.06 ± 0.53 for cases (P,0.05), total number of visits showed 39.38 ± 8.64 for controls compared to 22.07 ± 2.76 for cases (P=0.07). GI-related imaging was 4.23 ± 1.21 for controls vs. 1.03 ± 0.33 for cases (P,0.05) and overall imaging was 11.08 ± 4.03 for controls vs. 2.93 ± 0.57 for cases (P,0.05). Conclusion: The year following the diagnosis of IBS, adolescents visit doctors frequently and utilize significant healthcare resources. This costly year is a year. A simple multimodal behavioral program offered shortly after diagnosis of IBS significantly reduces the healthcare utilization and imaging studies in the crisis year and continues to be effective four years after the intervention.