Annual Outpatient Visits Research Articles

THE GENDER PAY GAP IN NON-PROCEDURAL CARDIOLOGY - EVIDENCE FROM A POPULATION-BASED STUDY

<h3>BACKGROUND</h3> The gender pay gap in medicine is well documented. Frequently cited drivers of gender-based billings disparities are women entering lower-remunerated specialties and fewer hours worked. To date, there has not been a population-based analysis of the gender pay gap and gender-based practice differences in a highly remunerated specialty like cardiology in a fee-for-service system (FFS). Our objectives were to assess differences in billings, practice patterns, and patient outcomes between male and female non-procedural cardiologists in a FFS system. <h3>METHODS AND RESULTS</h3> We used linked population-based administrative health databases to conduct a retrospective cohort study of cardiologists practicing in Ontario, Canada between April 2011 and March 2016. All cardiologists submitting outpatient claims during the study period were included, with cardiologists practicing interventional cardiology or electrophysiology being excluded. Outpatients of study cardiologists were identified and followed as a patient cohort. Our primary outcome was overall annual physician billings. We assessed practice patterns by identifying days worked and volumes billed for outpatient visits, inpatient visits, and diagnostic test interpretation. Patient outcomes included healthcare utilization, all-cause mortality, all-cause hospital admission, and emergency department visit or hospitalization for cardiovascular cause. We developed multivariable regression models to estimate the effect of gender on billings and each patient outcome. We identified 394 cardiologists, of whom 20% were women. The patient cohort included 818,122 patients. Unadjusted annual billings were significantly higher among male cardiologists than female ($769,371 vs. $515,997 p < 0.0001). Men billed more annual outpatient visits (1,808 vs. 1,169, p < 0.0001) and outpatient visits per day (11 patients per day vs. 9, p = 0.0004) than women. Male cardiologists billed more days for diagnostic test interpretation than women (for echocardiograms, 172 vs. 146, p = 0.016) though the numbers of echocardiograms billed per day were similar. Billings were significantly associated with outpatient practice size and echocardiogram reading, but not cardiologist gender after adjustment for patient and provider factors. There were no differences by cardiologist gender for patient outcomes after adjustment for cardiologist and patient factors. <h3>CONCLUSION</h3> Our results demonstrate substantial gender-based billings disparity, which may be driven by practice styles in terms of days worked and patients seen per day in outpatient cardiology and diagnostic test interpretation. Our findings contribute to the growing body of evidence on the gender pay gap in medicine, as well as discussion of the equity of FFS remuneration. Further research is needed to understand what drives these differences in practice choices.

The effect of home visits on healthcare resource utilisation.

Home visits may change patients' healthcare resource utilisation, including hospital admission, medications, outpatient and emergency room visits. The aim of the present study was to report changes in healthcare resource utilisation after the provision of home healthcare services. This was a multicentre follow-up study. Data on health and functional statuses were collected during home visits. Electronic medical records of 12 medical institutions were retrieved (outpatient visits, emergency care use, hospital admissions and prescription medications). The researchers analysed healthcare utilisation and medications before and after enrolment. There were 246 participants. The mean age was 85.5 years (52% men). There was an increase in annual outpatient visits and a decrease in hospital admission days after enrolment (13.7-15.3 visits/year and 17.5-15 days/year, respectively). The number of medical institutions visited increased, but specialties and doctors visited decreased. Oral medications also increased (3.3-4.3 types). Home visits help decrease days of hospital admission, but not medications or outpatient or emergency room visits.

Healthcare utilization among children with early autism diagnoses, children with other developmental delaysand a comparison group.

Aim: Todescribe healthcare utilization patterns among children with autism (n=1821), andcompare these patterns to children with other developmental delays (DD;n=12,336)and a population comparison (PC;n=18,210) cohort. Materials & methods: Retrospective study of administrative billing data. Results: Children with autism had roughly six-times more annual outpatient visits as PC children and twice as many as children with DD. Children with autism were more likely than PC children to use nearly all services, but comparisons between the autism and DD cohorts were mixed. Children with autism were more likely to have psychiatry/psychology visits, 'other'specialty care visitsand psychotropic prescriptions, but less likely to have pediatric specialty care visits, immunizationsand some prescriptions. Conclusion: Findings reveal opportunities to streamline, coordinateor improve care for young children with autism, particularly for outpatient services, and to give caregivers appropriate anticipatory guidance about what to expect after an autism diagnosis.

Use of Chest X-ray in the Evaluation of Acute Cough in the Pediatric Emergency Department of an Inner-City Hospital

Background: Cough has been identified as one of the most common complaints at physician visits and accounts for an estimated 29.5 million annual outpatient visits [1]. Acute cough is defined as cough of less than 2 weeks in duration [2]. Current clinical practice guidelines have recommended against routine use of chest x-rays in evaluation of common causes of cough in the emergency department (ED) except in cases with significant respiratory distress or hypoxemia [3–5]. Despite these guidelines, there is still an increased use of chest x-ray in evaluation of children in the pediatric ED. We aimed to determine the prevalence of children presenting with acute cough in the pediatric ED, the proportion of these patients evaluated with chest x-ray, and to review their chest x-ray findings. Methods: The study was a retrospective cross-sectional study involving patients aged 1 month – 21 years presenting to the pediatric ED of BronxCare Health System with acute cough from January 2019 to December 2019. Data was extracted from the hospital’s Electronic Health Record. Frequency tables were used to describe sociodemographic and clinical characteristics, and chest x-ray findings. Results: Of the 30,014 patients who presented to the pediatric ED during the study period, 3560 (11.9%) had acute cough, of whom 949 (26.7%) had a chest x-ray done. Most of the patients with acute cough (75.6%) had no respiratory distress. Majority of them (68.4%) had fever for 1–14 days, and the most frequent cough duration was 2 days (28.7%). The most common chest x-ray finding was peri-bronchial cuffing (52.6%), while 33% of the chest x-rays were normal (Table 1). Most of the patients (70.4%) were discharged home. Conclusion: A significant proportion of children presenting with acute cough to the pediatric ED routinely have a chest x-ray done as part of their management, findings of which are mostly insignificant and contribute little to their care. We therefore recommend judicious use of chest x-ray and adherence to existing guidelines in cases of acute cough presenting to the pediatric ED.

A novel model to improve access to care for patients with chronic hepatitis C attended in behavioral health facilities

Background: Chronic hepatitis C (C-HCV) is more prevalent in individuals with behavioral health (BH) diagnoses and those on opioid replacement therapy than in other groups. Accordingly, our aim was to evaluate the effect of C-HCV treatment on the quality of life (QOL) of individuals receiving opioid replacement therapy in a newly created C-HCV clinic attached to the methadone clinic in our 338 beds and 355,702 annual outpatient visits community hospital, serving the population of East Harlem, New York City, where it is located. Methods: Adult patients with behavioral health diagnoses were screened for C-HCV upon entry to the hospital and were referred for evaluation and treatment, as appropriate. The effect of treatment of C-HCV on the quality of life (QOL) was assessed by a questionnaire in which a maximum score of 174 is the worst QOL, and a score of zero is the best, at baseline, and at least 12 weeks post treatment. Results: Three hundred and eighty-seven patients with behavioral health diagnoses were screened. One hundred and fifteen of them had confirmed C-HCV. Twenty-one of those patients had attended the BH HCV clinic. Fourteen additional patients were evaluated at a later date. Nineteen patients agreed to participate in the QOL study. Of these, 15 (79%) completed therapy and were cured. A marked improvement in their QOL scores was documented at least 12 weeks after treatment. Conclusion: A model of care that includes C-HCV treatment in BH facilities leads to adherence to therapy and cure, which is associated with improved QOL and should be the standard practice.

Associations Between a New York City Paid Sick Leave Mandate and Health Care Utilization Among Medicaid Beneficiaries in New York City and New York State.

ImportanceMore evidence on associations between mandated paid sick leave and health service utilization among low-income adults is needed to guide health policy and legislation nationwide.ObjectiveTo evaluate the association between New York City’s 2014 paid sick leave mandate and health care utilization among Medicaid-enrolled adults.Design, Setting, and ParticipantsThis retrospective cohort study used New York State Medicaid administrative data for adults 18 to 64 years old continuously enrolled in Medicaid from August 1, 2011, through July 31, 2017. A difference-in-differences approach with entropy balancing weights was used to compare New York City with the rest of New York State to assess the association of the paid sick leave mandate with health care utilization, and for those 40 to 64 years old, with preventive care utilization. The data analysis was performed from June through August 2020.ExposuresTemporal and spatial variation in exposure to the mandate.Main Outcomes and MeasuresAnnual health care utilization (emergency care, specialist visits, and primary care clinician visits) per Medicaid-enrolled adult. Secondary outcomes include categories of emergency utilization and utilization of 5 preventive services.ResultsOf 552 857 individuals (mean [SD] age, 43 [12] years; 351 130 [64%] women) who met inclusion criteria, 99 181 (18%) were White, 162 492 (29%) Black, and 138 061 (25%) Hispanic. Paid sick leave was significantly associated with a reduction in the probability of emergency care (−0.6 percentage points [pp]; 95% CI, −0.7 to −0.5 pp; P < .001), including a 0.3 pp reduction (95% CI, −0.4 to −0.2; P < .001) in care for conditions treatable in a primary care setting and an increase in annual outpatient visits (0.124 pp; 95% CI, 0.040 to 0.208 pp; P < .001). Among those 40 to 64 years old, the mandate was significantly associated with increased probabilities of glycated hemoglobin A1c level testing (2.9 pp; 95% CI, 2.5-3.3 pp; P < .001), blood cholesterol testing (2.7 pp; 95% CI, 2.5-2.9 pp; P < .001), and colon cancer screening (0.4 pp; 95% CI, 0.2-0.6 pp; P < .001).Conclusions and RelevanceThis retrospective cohort study of nonelderly adults enrolled in Medicaid New York State showed that mandated paid sick leave in New York City was significantly associated with differences in several dimensions of health care services use.

Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services.

Because veterans who use Veterans Health Administration (VA) health care retain VA eligibility while enrolling in Medicaid, increasing Medicaid eligibility may create improved health system access but also create unique challenges for the quality and coordination of health care for veterans. We analyze how pre-Affordable Care Act (ACA) state Medicaid expansions influence VA and Medicaid-funded outpatient care utilization. This study uses Difference-in-difference analysis to evaluate association between pre-ACA 2001 Medicaid expansions and VA utilization in a natural experiment. Veterans aged 18-64 years living in a study state during the study period were the participants. Dependent variables included participants' proportion of outpatient care received at the VA, whether a participant recorded care with both Medicaid and the VA, and total outpatient utilization. We analyzed changes between two states that expanded Medicaid in 2001 against three similar states that did not from 1999 to 2006. We adjusted for age, non-White race, gender, disease burden, and distance to VA facilities. This study was approved by the Baylor College of Medicine Institutional Review Board (IRB), protocol number H-40441. In total, 346,364 VA-enrolled veterans lived in the five study states during the time of our study, 70,987 of whom were enrolled in Medicaid for at least 1 month. For low-income veterans, Medicaid expansion was associated with a 2.88 percentage-point decline in the VA proportion of outpatient services (99% CI -3.26 to -2.49), and a 2.07-point increase (1.80 to 2.35) in the percentage of patients using both VA and Medicaid services. Results also showed small increases in total (VA plus Medicaid) annual per-capita outpatient visits among low-income veterans. We estimate that this corresponds to an annual reduction of 80,338 VA visits across study states (66,155-94,521). This study shows usage shifts when Medicaid expansion allows veterans to gain access to non-VA care. It highlights increased potential for care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional public health insurance options, as well as programs like CHOICE and the MISSION Act that increase veteran choices of traditional VA and community care providers.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal diagnosis made in outpatient clinics, responsible for over 5 million annual outpatient visits and likely hundreds of thousands of inpatient stays for noncardiac chest pain. GERD’s current definition, based on international consensus, is a “condition which develops when the reflux of stomach contents causes troublesome symptoms (i.e., at least two heartburn episodes per week) and/or complications.” Also defining GERD is the presence of erosive esophagitis on upper endoscopy (esophagogastroduodenoscopy [EGD]) with or without the presence of troublesome symptoms or the presence of troublesome symptoms without endoscopic evidence of erosive esophagitis (also known as nonerosive reflux disease). This review looks at GERD in detail, including its epidemiology and risk factors, genetics, pathogenesis and etiologic factors, clinical presentation and symptoms, differentials, diagnosis, and complications. Figures presented are an EGD image showing signs of erosive esophagitis, Barrett esophagus, and hiatal hernia and sample recordings from a 24-hour combined multichannel intraluminal impedance and pH testing. Tables list differential diagnoses for GERD, indications for performing EGD in patients with GERD symptoms, and a summary of GERD therapies. This review contains ­2 figures, 4 tables, and 74 references.

Different impacts of the zero-markup drug policy on county general and traditional Chinese medicine hospitals: evidence from Shandong province, China

BackgroundAs a key part of the new round of health reform, the zero-markup drug policy (ZMDP) removed the profit margins of drug sales at public health care facilities, and had some effects to the operation of these institutions. This study aims to assess whether the ZMDP has different impacts between county general and traditional Chinese medicine (TCM) hospitals.MethodsWe obtained longitudinal data from all county general and TCM hospitals of Shandong province in 2007–2017. We used difference-in-difference (DID) method to identify the overall and dynamic effects of the ZMDP.ResultsOn average, after the implementation of the ZMDP, the share of revenue from medicine sales reduced by 16.47 and 10.42%, the revenue from medicine sales reduced by 24.04 and 11.58%, in county general and TCM hospitals, respectively. The gross revenue reduced by 5.07% in county general hospitals. The number of annual outpatient visits reduced by 11.22% in county TCM hospitals. Government subsidies increased by 199.22 and 89.3% in county general and TCM hospitals, respectively. The ZMDP reform was not significantly associated with the revenue and expenditure surplus, the number of annual outpatient visits and the number of annual inpatient visits in county general hospitals, the gross revenue, the revenue and expenditure surplus and the number of annual inpatient visits in county TCM hospitals. In terms of dynamic effects, the share of revenue from medicine sales, revenue from medicine sales, and gross revenue decreased by 20.20, 32.58 and 6.08% respectively, and up to 28.53, 63.89 and 17.94% after adoption, while government subsidies increased by around 170 to 200% in county general hospitals. The number of annual outpatient visits decreased by 9.70% and up to 18.84% in county TCM hospitals.ConclusionThe ZMDP achieved its some initial goals of removing the profits from western medicines in county hospitals’ revenue without disrupting the normal operation, and had different impacts between county general and TCM hospitals. Meanwhile, some unintended consequences were also recognized through the analysis, such as the decline of the utilization of the TCM.

Comparison of health service use and costs in stroke with and without comorbidities: a cross-sectional analysis using China urban medical claims data

ObjectivesStroke is the leading cause of death and disability in China, but there is scare of evidence on whether and to what extent comorbidity affects the stroke-related costs in health...

The Effect of Ethiopia's Community-Based Health Insurance Scheme on Revenues and Quality of Care.

Ethiopia’s Community-Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure (OOP), mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced health care access and led to reductions in OOP. This paper examines the impact of the scheme on health facility revenues and quality of care. This paper relies on a difference-in-differences approach applied to both panel and cross-section data. We find that CBHI-affiliated facilities experience a 111% increase in annual outpatient visits and annual revenues increase by 47%. Increased revenues are used to ameliorate drug shortages. These increases have translated into enhanced patient satisfaction. Patient satisfaction increased by 11 percentage points. Despite the increase in patient volume, there is no discernible increase in waiting time to see medical professionals. These results and the relatively high levels of CBHI enrollment suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block—that is, the poor quality of care—which has plagued similar CBHI schemes in Sub-Saharan Africa.

Association of Medicaid-Focused or Commercial Medicaid Managed Care Plan Type With Outpatient and Acute Care

Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown. To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan. This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020. Assignment to a Medicaid-focused insurance plan or a commercial managed care plan. Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations. A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching. Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Health care use and expenditures attributable to cancer: A population-based study.

As more people are living with cancer due to increases in cancer survival, it is important to understand cancer burden. Studies have examined cancer-related costs using data more than a decade ago. To update the economic burden and uniquely provide health care service use attributable to cancer using a nationally representative sample of the U.S. Data were obtained from the 2008-2015 Medical Expenditure Panel Survey (MEPS). Individuals with cancer were matched to those without cancer in terms of demographics and comorbidities based on a propensity score (PS). For outcomes of health care use, a (zero-inflated) negative binomial model was employed. To analyze the outcomes of health care spending, a generalized linear model with a log link function and gamma distributed errors (or a two-part model) was used. Compared to the PS-matched noncancer controls, individuals with cancer received 1.05, 1.08, and 1.76 times more frequent annual emergency department (ED) visit care, hospitalization care, and hospital outpatient visit care, respectively. Additionally, people with cancer received prescriptions and office-based visit care about 5 times and 20 times more frequently. An average annual total health care spending among those with cancer was about $4100 higher. Average annual expenses on hospitalizations, office-based visits, hospital outpatient visits, and prescriptions among those with cancer were also about $1,400, $1,400, $700, and $300 higher. However, there was no significant difference in expenses on ED visit and out-of-pocket expenses on prescriptions between people with cancer and noncancer controls. Individuals with cancer used all types of health care services more frequently than noncancer controls. Accordingly, expenditures on various types of health care services among those with cancer were higher.

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees

Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.

Educational Inequalities in Hospital Use Among Older Adults in England, 2004-2015.

Policy Points US policymakers considering proposals to expand public health care (such as “Medicare for all”) as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well‐funded universal health care systems are already in place.In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity.Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups. ContextExpanding access to health care is once again high on the US political agenda, as is concern about those who are being “left behind.” But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education‐level‐defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use.MethodsNovel linkage of data from six waves (2004‐2015) of the English Longitudinal Study of Ageing (ELSA) with participants’ hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004‐2005 to 2008‐2009 and 2010‐2011 to 2014‐2015 to examine whether potential education‐related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010.FindingsFor the study period, our sample of ELSA respondents in the low‐education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high‐education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11‐0.47). Additional outpatient health care use in the high‐education group was driven by follow‐up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high‐education group made 0.48 (95% CI, 0.21‐0.74) more annual outpatient visits than those in the low‐education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high‐education group made 0.04 (95% CI, −0.075 to 0.001) fewer annual ED visits than the low‐education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period.ConclusionsAfter controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high‐education group using more outpatient care and less ED care than peers in the low‐education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.

Roles of peer specialists and use of mental health services among youth with serious mental illness.

To examine whether roles of peer specialists affect service use among Black, Latinx and White youth ages 16-24 with serious mental illness (SMI) in Los Angeles and San Diego Counties. Administrative data from 2015 to 2018 was used to summarize service use among 6329 transition age youth age 16-24 with SMI who received services from 76 outpatient public mental health programs with peer specialists on staff. Roles of peer specialists were assessed via a program survey. Generalized linear models were used to assess the relationship between peer specialist characteristics and service use outcomes (ie, outpatient and inpatient). Having a transition age youth peer specialist on staff (vs older peer specialists) and having peer specialists that provide four or more services (vs fewer services) was associated with an increase in annual outpatient visits in both counties (P=<.001 each). In Los Angeles County, having three or more peer specialist trainings (vs fewer trainings) was associated with lower use of inpatient services (P < .001). In San Diego County, having a transition age youth peer specialist and peer specialists that provide four or more services was associated with lower use of inpatient services (P < .001 each). Types of peer support and number of types of peer services were associated with mental health service utilization. Detailed examination of the roles of peer specialists is merited to identify the specific pathways that improve outcomes.

Measures taken to alleviate the impact of COVID-19 outbreak on surgical patients.

Measures taken to alleviate the impact of COVID-19 outbreak on surgical patients.

Social Determinants of Outcomes in Inflammatory Bowel Disease.

In a population-based inflammatory bowel disease (IBD) cohort, we aimed to determine whether having lower socioeconomic status (LSS) impacted on outcomes. We identified all 9,298 Manitoba residents with IBD from April 1, 1995, to March 31, 2018 by applying a validated case definition to the Manitoba Health administrative database. We could identify all outpatient physician visits, hospitalizations, surgeries, intensive care unit admissions, and prescription medications. Their data were linked with 2 Manitoba databases, one identifying all persons who received Employment and Income Assistance and another identifying all persons with Child and Family Services contact. Area-level socioeconomic status was defined by a factor score incorporating average household income, single parent households, unemployment rate, and high school education rate. LSS was identified by any of ever being registered for Employment and Income Assistance or with Child and Family Services or being in the lowest area-level socioeconomic status quintile. Comparing persons with LSS vs those without any markers of LSS, there were increased rates of annual outpatient physician visits (relative risk [RR] = 1.10, 95% confidence interval [CI] = 1.06-1.13), hospitalizations (RR = 1.38, 95% CI = 1.31-1.44), intensive care unit admission (RR = 1.94, 95% CI = 1.65-2.27), use of corticosteroids >2,000 mg/yr (RR = 1.12, 95% CI = 1.03-1.21), and death (hazard ratio 1.53, 95% CI = 1.36-1.73). Narcotics (RR = 2.17, 95% CI = 2.01-2.34) and psychotropic medication use (RR = 1.98, 95% CI = 1.84-2.13) were increased. The impact of LSS was greater for those with Crohn's disease than for those with ulcerative colitis. LSS was associated with worse outcomes in persons with IBD. Social determinants of health at time of diagnosis should be highly considered and addressed.

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16–24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015–2018 was used to summarize service use among 13,363 transition age youth age 16–24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

Health Care Utilization and Costs of Patients With Prostate Cancer in China Based on National Health Insurance Database From 2015 to 2017.

BackgroundIn terms of medical costs, prostate cancer is on the increase as one of the most costly cancers, posing a tremendous economic burden, but evidence on the health care utilization and medical expenditure of prostate cancer has been absent in China.ObjectiveThis study aimed to analyze health care utilization and direct medical costs of patients with prostate cancer in China.MethodsHealth care service data with a national representative sample of basic medical insurance beneficiaries between 2015 and 2017 were obtained from the China Health Insurance Association database. We conducted descriptive and statistical analyses of health care utilization, annual direct medical costs, and composition based on cancer-related medical records. Health care utilization was measured by the number of hospital visits and the length of stay.ResultsA total of 3,936 patients with prostate cancer and 24,686 cancer-related visits between 2015 and 2017 were identified in the database. The number of annual outpatient and inpatient visits per patient differed significantly from 2015 to 2017. There was no obvious change in length of stay and annual direct medical costs from 2015 to 2017. The number of annual visits per patient (outpatient: 3.0 vs. 4.0, P < 0.01; inpatient: 1.5 vs. 2.0, P < 0.001) and the annual medical direct costs per patient (US$2,300.1 vs. US$3,543.3, P < 0.001) of patients covered by the Urban Rural Resident Basic Medical Insurance (URRBMI) were both lower than those of patients covered by the Urban Employee Basic Medical Insurance (UEBMI), and the median out-of-pocket expense of URRBMI was higher than that of UEBMI (US$926.6 vs. US$594.0, P < 0.001). The annual direct medical costs of patients with prostate cancer in Western regions were significantly lower than those of patients in Eastern and Central regions (East: US$4011.9; Central: US$3458.6; West: US$2115.5) (P < 0.001).ConclusionsThere was an imbalanced distribution of health care utilization among regions in China. The direct medical costs of Chinese patients with prostate cancer remained stable, but the gap in health care utilization and medical costs between two different insurance schemes and among regions still needed to be further addressed.