Actual Health Care Utilization Research Articles

The socioeconomic inequity in healthcare utilization among individuals with cardiovascular diseases in India.

We assess the effects of socioeconomic inequity on healthcare utilization among individuals with cardiovascular diseases (CVDs) in India using the indirect standardization method with Erreygers' corrected concentration index. We analyze both horizontal and vertical inequities and linearly decompose the respective inequities to identify the major factors driving both kinds of inequities. Our findings show that actual healthcare utilization is highly concentrated among rich CVD individuals. After controlling for the confounding effects of health needs, horizontal inequity is found to be significantly pro-rich, and income and urban concentration are found to be the major factors driving this inequity. However, the direction and magnitude of vertical inequity vary, depending on the selection of the target group. When we use healthcare utilization of the richest 20 percent as the target, we find no significant vertical inequity among CVD individuals. However, when we take the richest 10 percent as the target, we observe a significant pro-rich differential effect of health needs on healthcare utilization between all individuals and the target group. Decomposition reveals an inappropriate differential effect of health needs and age in driving vertical inequity. Hence, the presence of vertical inequity may trigger further pro-rich socioeconomic inequity in healthcare utilization if not supported by any targeted healthcare coverage.

COST-EFFECTIVENESS ANALYSIS OF THE ACTIVE TREATMENT OR NO TREATMENT (ACT OR NOT) RANDOMIZED CONTROLLED TRIAL OF THE OPTIMAL MANAGEMENT OF PERSISTENT PREGNANCIES OF UNKNOWN LOCATION

Pregnancies of unknown location (PUL) account for ∼10% of all pregnancies and optimal, cost-conscious management of persistent PULs remains an area of continued controversy. We performed a planned, prospective, economic evaluation concurrent with the multicenter ACT or NOT trial of 255 women with abnormally trending human chorionic gonadotropin levels consistent with a nonviable gestation without ultrasonographic evidence of an intrauterine or extrauterine pregnancy, conducted from 7/25/2014 to 6/4/2019. Participants were randomized 1:1:1 to expectant management (EXP), uterine evacuation (UE) with methotrexate if indicated, or two doses of methotrexate (MTX), stratified by site. Analysis was performed based on actual treatment received given high rate of crossover. A within-trial analysis was performed from the healthcare sector perspective with a 6-week time horizon. Costs were estimated from actual healthcare utilization, in 2018 USD. Health care unit costs were assigned from national Medicare reimbursement rates or published prices. UE occurred primarily by manual vacuum aspiration in clinic; dilation and evacuation was assumed evenly performed in clinic and a surgical center. Salpingectomies were laparoscopic outpatient procedures. Effectiveness was measured in quality-adjusted life-year (QALY) and rate of salpingectomy. The primary outcome was incremental cost-effectiveness ratio (ICER) of cost/QALY gained; cost/1% reduction in salpingectomy was a secondary outcome. MTX had the lowest mean cost, of $875, followed by EXP $1085, and UE $1902 (p=0.001). EXP had the highest QALY of all treatment arms (0.0784) followed by UE (0.0769) and MTX (0.0725) (p=0.13). There was a higher rate of salpingectomy in the EXP arm compared to MTX (9.4% vs 1.2%; p=0.02). EXP was cost effective compared to MTX with an ICER of $35,610/QALY gained (95% CI, -$425,247.40 to $501,594.30). EXP dominated UE. Cost-effectiveness acceptability curve analysis demonstrated EXP was cost-effective 89% of the time compared to MTX at the generally accepted maximum willingness-to-pay threshold of $150,000/QALY gained. The incremental cost per 1% reduction in salpingectomy rate was $26 favoring MTX over EXP and $633 favoring UE over EXP. This study demonstrated management of PULs with EXP was cost-effective when compared to MTX and UE but had the highest rate of salpingectomy.

Healthcare utilization among children in foster care in the greater Houston area

Children in foster care have greater physical and mental health conditions than children not in foster care. However, little is known about their actual healthcare utilization. This study describes healthcare utilization from July 1, 2014 to June 30, 2016 among children in foster care in the greater Houston, Texas area who receive Medicaid coverage through a single Medicaid managed care organization for children in foster care. Enrollment and claims data were used to describe demographic characteristics; outpatient utilization, location and type of encounters; inpatient utilization; and timeliness of first visit. Overall, 11,073 children were enrolled for any portion of the study period and 88% utilized healthcare services. Children who accessed healthcare services were significantly younger (p < 0.001) and enrolled in the study period longer (p < 0.001) than those who did not access care. Overall, the mean number of outpatient encounters per person-year was 16.5 (SD 42.0) with a median of 6 encounters. The majority (58.8%) of outpatient services were provided in the home, but these were only accessed by 21.6% of the children. Among the 1,412 (12.8%) children who utilized inpatient services, the number of inpatient days per person-year ranged from 0.5 to 365.3 with a median of 2.9 inpatient days per person-year. With respect to timeliness of the first visit, 61% of children received healthcare services in their first 30 days in care, indicating 40% did not receive this initial encounter as recommended by the American Academy of Pediatrics and required by the Texas Department of Family and Protective Services. The high volume of home-based services for skilled nursing; occupational, physical, and speech therapy indicate a high level of need for a subset of this already vulnerable population.

Can healthcare choice be predicted using stated preference data?

Lack of evidence about the external validity of Discrete Choice Experiments (DCEs)-sourced preferences inhibits greater use of DCEs in healthcare decision-making. This study examines the external validity of such preferences, unravels its determinants, and provides evidence of whether healthcare choice is predictable. We focused on influenza vaccination and used a six-step approach: i) literature study, ii) expert interviews, iii) focus groups, iv) survey including a DCE, v) field data, and vi) in-depth interviews with respondents who showed discordance between stated choices and actual healthcare utilization. Respondents without missing values in the survey and the actual healthcare utilization (377/499 = 76%) were included in the analyses. Random-utility-maximization and random-regret-minimization models were used to analyze the DCE data, whereas the in-depth interviews combined five scientific theories to explain discordance. When models took into account both scale and preference heterogeneity, real-world choices to opt for influenza vaccination were correctly predicted by DCE at an aggregate level, and 91% of choices were correctly predicted at an individual level. There was 13% (49/377) discordance between stated choices and actual healthcare utilization. In-depth interviews showed that several dimensions played a role in clarifying this discordance: attitude, social support, action of planning, barriers, and intention. Evidence was found that our DCE yields accurate actual healthcare choice predictions if at least scale and preference heterogeneity are taken into account. Analysis of discordant subjects showed that we can even do better. The DCE measures an important part of preferences by focusing on attribute tradeoffs that people make in their decision to participate in a healthcare intervention. Inhibitors may be among these attributes, but it is more likely that inhibitors have to do with exogenous factors like goals, religion, and social norms. Con-ducting upfront work on constraints/inhibitors of the focal behavior, not just what promotes the behavior, might further improve predictive ability.

Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries.

BackgroundSome people have a lower threshold to seek care for certain symptoms than others. This study aims to investigate what factors are associated with patients’ propensity to seek care. In addition, this study explores whether patients’ propensity to seek care is associated with their actual health care utilization. We hypothesized that higher scores for propensity to seek care will lead to more general practitioners (GP) consultations, but to lower rates of avoidable hospitalization.MethodsPropensity to seek care and GP utilization were measured by the Patient Experience Questionnaire of the QUALICOPC study, a survey among 61,931 patients that recently visited GP services in 34 countries. Propensity to seek care was estimated by two questions: one question focusing on health care seeking behavior for serious symptoms and the other question focused minor complaints. Data on country level rates of avoidable hospitalization for CHF, COPD, asthma and diabetes were obtained from the OECD health care quality indicators project.ResultsBeside patient characteristics, various organizational factors, such as better accessible and continuous primary care, and better experienced communication between patient and GPs was associated with a higher propensity to seek care for both severe and minor complaints. A higher propensity to seek care was associated with a slightly higher health care utilization in terms of GP visits, with no differences between the severity of the experienced symptoms (OR 1.08 for severe complaints and OR 1.05 for minor complaints). At country level, no association was found between propensity to seek care and rates of avoidable hospitalization for CHF, COPD, asthma and diabetes, possibly due to low statistical power at country level.ConclusionsThe organization of primary care and patients’ perceived communication with their GP were found to be highly correlated with patients’ decision to seek health care for minor or severe complaints, suggesting that characteristics of healthcare systems directly influence patients’ care seeking behavior, potentially leading to overuse or underuse of health services. However, we also observed that patients’ propensity to seek care is only weakly associated with more GP use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1119-2) contains supplementary material, which is available to authorized users.

Horizontal Inequity in Elderly Health Care Utilization: Evidence from India.

Against the backdrop of population aging, this paper presents the analysis of need-standardised health care utilization among elderly in India. Based on nationally representative morbidity and health care survey 2004, we demonstrate that the need for health care utilization is indeed pro-poor in nature. However, the actual health care utilization is concentrated among richer sections of the population. Further, the decomposition analysis reveals that income has a very strong role in shifting the distribution of health care away from the poor elderly. The impact of income on utilization is well-demonstrated even at the ecological-level as states with higher per capita incomes have higher elderly health care utilization even as the levels of need-predicted distribution across these states are similar. We also find that the distribution of elderly across social groups and their educational achievements favours the rich and significantly contributes to overall inequality. Nevertheless, contribution of need-related self-assessed health clearly favours pro-poor inequality. In concluding, we argue that to reduce such inequities in health care utilization it is necessary to increase public investments in health care infrastructure including geriatric care particularly in rural areas and underdeveloped regions to enhance access and quality of health care for the elderly.

Developing a dashboard to help measure and achieve the triple aim: a population-based cohort study.

BackgroundHealth system planners aim to pursue the three goals of Triple Aim: 1) reduce health care costs; 2) improve population health; and 3) improve the care experience. Moreover, they also need measures that can reliably predict future health care needs in order to manage effectively the health system performance. Yet few measures exist to assess Triple Aim and predict future needs at a health system level. The purpose of this study is to explore the novel application of a case-mix adjustment method in order to measure and help improve the Triple Aim of health system performance.MethodsWe applied a case-mix adjustment method to a population-based analysis to assess its usefulness as a measure of health system performance and Triple Aim. The study design was a retrospective, cohort study of adults from Ontario, Canada using administrative databases: individuals were assigned a predicted illness burden score using a case-mix adjustment system from diagnoses and health utilization data in 2008, and then followed forward to assess the actual health care utilization and costs in the following year (2009). We applied the Johns Hopkins Adjusted Clinical Group (ACG) Case-Mix System to categorize individuals into 60 levels of healthcare need, called ACGs. The outcomes were: 1) Number of individuals per ACG; 2) Total system costs per ACG; and 3) Mean cost per person per ACG, which together formed a health system “dashboard”.ResultsWe identified 11.4 million adults. 16.1% were aged 65 or older, 3.2 million (28%) did not use health care services that year, and 45,000 (0.4%) were in the highest acuity ACG category using 12 times more than an average adult. The sickest 1%, 5% and 15% of the population use about 10%, 30% and 50% of total health system costs respectively. The dashboard measures 2 dimensions of Triple Aim: 1) reduced costs: when total system costs per ACG or when average costs per person is reduced; and 2) improved population health: when more people move into healthier rather than sicker ACGs. It can help to achieve the third aim, improved care experience, when ACG utilization predictions are reported to providers to proactively develop care plans.ConclusionsThe dashboard, developed via case-mix methods, measures 2 of the Triple Aim goals and can help health system planners better manage their health delivery systems.

Massachusetts reform and disparities in inpatient care utilization.

The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform's impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral. Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006-12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ≥70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40-64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform. Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [-3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [-20%, 30%]), and whites=7% (95% CI [5%, 10%]). Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Health-related factors associated with hospitalization for old people: Comparisons of elderly aged 85 in a population cohort study

The aim of this population-based study was to (1) describe living conditions and actual health care utilization among 85 year olds; (2) determine factors that affect hospital admissions in this age. The study was conducted on 85-year-old residents in Linköping municipality, Sweden. The data collected included medical records, health care utilization during the preceding 12 months and a postal questionnaire on assistance, assistive technology, functional impairment, feelings of loneliness, worries and health-related quality of life measured by the EQ-5D. Out of 650 eligible individuals, 496 (78% of those alive) participated. Despite the prevalence of multi-morbidity (68%) and mental discomfort, the majority managed self-care (85%), usual activities (74%) and had high (>60/100) self-rated health evaluated by a visual analog scale (VAS). The non-hospitalized group reported a better health status than the hospitalized group in terms of medical aspects, living conditions and subjective estimation. Factors associated with in-patient care were an increased number of general practitioner visits, more assistive technology, community assistance, multimorbidity and/or diagnosed congestive heart failure and arrhythmia.

Health Care Utilization of Home Care Patients at an Academic Medical Center in Taiwan

Previous surveys of home care patients in Taiwan have primarily concentrated on patients' status and needs. The aim of this study was to review the actual health care utilization of home care patients during the course of 1 year. Home care patients at an academic medical center in Taiwan were selected and their insurance claims data at this hospital in 2001 were analyzed. Analyses included the patients' patterns and diagnoses of visits and admissions, and their drug utilization. For diagnoses made at outpatient departments, the grouping system from the National Hospital Ambulatory Medical Care Survey in the United States was used. The Anatomical Therapeutic Chemical Classification system was applied to drug grouping. The home care agency of the hospital cared for 165 patients (66 women, 99 men) in 2001. In total, these 165 patients received 1,358 home visits, 2,751 outpatient visits, and 108 inpatient admissions. While the most frequent diagnoses for all visits were cerebrovascular disease, hypertension, diabetes mellitus, chronic and unspecified bronchitis, psychoses, and other disorders of the central nervous system, the most frequent diagnoses at discharge from the hospital were urinary tract infection and pneumonia. In all visits, 12,282 items of drugs were prescribed in 2,337 prescriptions. On average, each prescription contained 5.3 +/- 2.8 items of drugs. The most frequently prescribed drugs were antacids, expectorants, laxatives, selective calcium channel blockers, and antithrombotic agents. The home care agency of the hospital should pay more attention to provision of comprehensive care and review of drug prescribing.

Use of the Internet and e-mail for health care information: results from a national survey.

The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities. To measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care system. Survey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users. Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care use. Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six percent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical products. Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization.