Changes In Use Of Health Services Research Articles

The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses.

Community treatment orders have been introduced in many jurisdictions with increasing use over time. We conducted a rapid umbrella review to synthesise the quantitative and qualitative evidence from systematic reviews and/or meta-analyses of their potential harms and benefits. A systematic search of Medline, PubMed, Embase and PsycINFO for relevant systematic reviews and/or meta-analyses. Where available, participants on community treatment orders were compared with controls receiving voluntary psychiatric treatment. This review is registered with PROSPERO (CRD42023398767) and the Open Science Framework (https://osf.io/zeq35). In all, 17 publications from 14 studies met the inclusion criteria. Quantitative synthesis of data from different systematic reviews was not possible. There were mixed findings on the effects of community treatment orders on health service use, and clinical, psychosocial or forensic outcomes. Whereas uncontrolled evidence suggested benefits, results were more equivocal from controlled studies and randomised controlled trials showed no effect. Any changes in health service use took several years to become apparent. There was evidence that better targeting of community treatment order use led to improved outcomes. Although there were other benefits, such as in mortality, findings were mostly rated as suggestive using predetermined and standardised criteria. Qualitative findings suggested that family members and clinicians were generally positive about the effect of community treatment orders but those subjected to them were more ambivalent. Any possible harms were under-researched, particularly in quantitative designs. The evidence for the benefits of community treatment orders remains inconclusive. At the very least, use should be better targeted to people most likely to benefit. More quantitative research on harms is indicated.

Impact of non-medical cannabis legalization with market restrictions on health service use and incident cases of psychotic disorder in Ontario, Canada

BackgroundCannabis is a risk factor in the onset and persistence of psychotic disorders. There is concern that non-medical cannabis legalization in Canada may have population-level impacts on psychotic disorders. We sought to examine changes in health service use and incident cases of psychotic disorder following cannabis legalization, during a period of tight restrictions on retail stores and product types. MethodsWe conducted a cross-sectional interrupted time-series analysis using linked population-based health administrative data from Ontario (Canada) from January 2014 to March 2020. We identified psychosis-related outpatient visits, emergency department visits, hospitalizations, and inpatient length of stay, as well as incident cases of psychotic disorders, among people aged 14 to 60 years. ResultsWe did not find evidence of increases in health service use or incident cases of psychotic disorders over the short-term (17 month) period following cannabis legalization. However, we found clear increasing trends in health service use and incident cases of substance-induced psychotic disorders over the entire observation window (2014–2020). ConclusionOur findings suggest that the initial period of tight market restriction following legalization of non-medical cannabis was not associated with an increase in health service use or frequency of psychotic disorders. A longer post-legalization observation period, which includes expansion of the commercial cannabis market, is needed to fully understand the population-level impacts of non-medical cannabis legalization; thus, it would be premature to conclude that the legalization of non-medical cannabis did not lead to increases in health service use and incident cases of psychotic disorder.

Changes in health service use due to alcohol during the COVID-19 pandemic among individuals with and individuals without pre-existing alcohol-related medical diagnoses.

To compare changes in outpatient and acute care visits due to alcohol during the COVID-19 pandemic between individuals with and those without a history of alcohol-related health service use (AHSU). We conducted a cross-sectional analysis of health administrative data in Ontario, Canada. The Ontario population was stratified into those with and those without 1+ health service encounter(s) due to alcohol in the past 2 years. We compared age- and sex-standardized rates of alcohol-related outpatient visits, emergency department (ED) visits, and hospitalizations during the first 15 months of the pandemic (March 2020-May 2021) to those during the same 15-month period prior to the pandemic (March 2018-May 2019). Of 13,450,750 eligible Ontarians on March 11, 2022, 129,434 (1.0%) had AHSU in the previous 2 years. Overall, rates of alcohol-related outpatient visits and hospitalizations increased, while rates of alcohol-related ED visits decreased during the pandemic. There was a similar relative increase in rates of alcohol-related outpatient visits and hospitalizations between those with and those without prior AHSU. However, the absolute increase in rates of alcohol-related outpatient visits and hospitalizations was higher among those with prior AHSU (outpatient rate difference (RD) per 10,000 population: 852.3, 95% confidence interval (CI): 792.7, 911.9; inpatient RD: 26.0, 95% CI: -2.3, 54.2) than among those without (outpatient RD: 6.5, 95% CI: 6.0, 6.9; inpatient RD: 0.4, 95% CI: 0.2, 0.7). Rates of alcohol-related outpatient and inpatient care increased during the COVID-19 pandemic, and high rate of recurrent harm among individuals with pre-pandemic AHSU was an important contributor to this trend.

Trends in Health Service Use for Canadian Adults With Dementia and Parkinson Disease During the First Wave of the COVID-19 Pandemic

Persons with dementia and Parkinson disease (PD) are vulnerable to disruptions in health care and services. To examine changes in health service use among community-dwelling persons with dementia, persons with PD, and older adults without neurodegenerative disease during the first wave of the COVID-19 pandemic. Repeated cross-sectional analysis using population-based administrative data among community-dwelling persons with dementia, persons with PD, and adults 65 years and older at the start of each week from March 1 through the week of September 20, 2020 (pandemic period), and March 3 through the week of September 22, 2019 (historical period), in Ontario, Canada. COVID-19 pandemic as of March 1, 2020. Main outcomes were weekly rates of emergency department visits, hospitalizations, nursing home admissions, home care, virtual and in-person physician visits, and all-cause mortality. Poisson regression models were used to calculate weekly rate ratios (RRs) with 95% CIs comparing pandemic weeks with historical levels. Among those living in the community as of March 1, 2020, persons with dementia (n = 131 466; mean [SD] age, 80.1 [10.1] years) were older than persons with PD (n = 30 606; 73.7 [10.2] years) and older adults (n = 2 363 742; 74.0 [7.1] years). While all services experienced declines, the largest drops occurred in nursing home admissions (RR for dementia: 0.10; 95% CI, 0.07-0.15; RR for PD: 0.03; 95% CI, 0.00-0.21; RR for older adults: 0.11; 95% CI, 0.06-0.18) and emergency department visits (RR for dementia: 0.45; 95% CI, 0.41-0.48; RR for PD: 0.40; 95% CI, 0.34-0.48; RR for older adults: 0.45; 95% CI, 0.44-0.47). After the first wave, most services returned to historical levels except physician visits, which remained elevated (RR for dementia: 1.07; 95% CI, 1.05-1.09; RR for PD: 1.10, 95% CI, 1.06-1.13) and shifted toward virtual visits. Older adults continued to experience lower hospitalizations. All-cause mortality was elevated across cohorts. In this population-based repeated cross-sectional study in Ontario, Canada, those with dementia, those with PD, and older adults sought hospital care far less than usual, were not admitted to nursing homes, and experienced excess mortality during the first wave of the pandemic. Most services returned to historical levels, but virtual physician visits remained a feature of care. While issues of equity and quality of care are still emerging among persons with neurodegenerative diseases, policies to support virtual care are necessary.

How does general practitioner discontinuity affect healthcare utilisation? An observational cohort study of 2.4 million Norwegians 2007–2017

ObjectivesPatients may benefit from continuity of care by a personal physician general practitioner (GP), but there are few studies on consequences of a break in continuity of GP. Investigate how...

PMH47 THE IMPACT OF A DIGITAL SLEEP-IMPROVEMENT PROGRAM ON HEALTH CARE COSTS

Access to non-pharmacological interventions for insomnia is limited, despite evidence for their effectiveness. This is due in part to a shortage of trained providers. Digital cognitive behavioural therapy for insomnia (dCBT-I), which requires less input per session, is therefore an attractive complement or substitute to face-to-face cognitive behavioural therapy. Sleepio is a self-help programme for sleep improvement, which has been shown to improve sleep quality. However, there is little evidence available regarding its impact on health care use. In this study, we sought to identify whether providing access to Sleepio results in a change in the trend of patients' primary care costs. The study adopted a before and after quasi-experimental design alongside population-wide rollout of Sleepio in a region of England. A segmented regression analysis of the interrupted time series data was used to estimate the change in trend of the average primary care costs per patient per week. Data were collected from two sources: i) primary care providers, and ii) Sleepio user data collected through the app. Interim results are presented, based on data from 12 months pre-intervention (October 2017) to 6 months post-intervention (May 2019). More than 6,000 individuals used the Sleepio service, with around a third converting to dCBT-I and gaining 30 minutes extra sleep per night, on average. Of dCBT-I users within the clinical range on the Sleep Condition Indicator, 42% moved to a non-clinical range. Preliminary results show that people with a diagnosis of insomnia who were referred to Sleepio had a lower rate of hospital referrals and hypnotics prescriptions. Interim findings show that population rollout of Sleepio may be effective in improving sleep for people with clinically significant sleep problems, and that this is associated with changes in health service use that may be cost-saving.

Racial/Ethnic and Gender Disparities in Health Care Use and Access.

To document racial/ethnic and gender differences in health service use and access after the Affordable Care Act went into effect. Secondary data from the 2006-2014 National Health Interview Survey. Linear probability models were used to estimate changes in health service use and access (i.e., unmet medical need) in two separate analyses using data from 2006 to 2014 and 2012 to 2014. Adult respondents aged 18years and older (N=257,560). Results from the 2006-2014 and 2012-2014 analyses show differential patterns in health service use and access by race/ethnicity and gender. Non-Hispanic whites had the greatest gains in health service use and access across both analyses. While there was significant progress among Hispanic respondents from 2012 to 2014, no significant changes were found pre-post-health care reform, suggesting access may have worsened before improving for this group. Asian men had the largest increase in office visits between 2006 and 2014, and although not statistically significant, the increase continued 2012-2014. Black women and men fared the worst with respect to changes in health care access. Ongoing research is needed to track patterns of health service use and access, especially among vulnerable racial/ethnic and gender groups, to determine whether existing efforts under health care reform reduce long-standing disparities.

Full-service partnerships among adults with serious mental illness in California: impact on utilization and costs.

California's full-service partnerships (FSPs) provide a combination of subsidized permanent housing and multidisciplinary team-based services with a focus on rehabilitation and recovery. The goal of the study was to examine whether participation in FSPs is associated with changes in health service use and costs compared with usual care. A quasi-experimental, pre-post, intent-to-treat design with a propensity score-matched contemporaneous control group was used to compare health service use and costs among 10,231 FSP clients and 10,231 matched clients with serious mental illness who were receiving public mental health services in California from January 1, 2004, through June 30, 2010. Among FSP participants, the mean annual number of mental health outpatient visits increased by 55.5, and annual mental health costs increased by $11,725 relative to the matched control group. Total service costs increased by $12,056. Participation in an FSP was associated with increases in outpatient visits and their associated costs. As supportive housing programs are implemented nationally and on a large scale, these programs will likely need to be more effectively designed and targeted in order to achieve reductions in costly inpatient services.

Using U.S. Medicare records to evaluate the indirect health effects on spouses: a case study in Alzheimer's disease patients.

BackgroundThe burden experienced by spouses of patients with Alzheimer’s disease (AD) may have negative consequences for their physical health. We describe here a method for analyzing United States Medicare records to determine the changes in health service use and costs experienced by spouses after their marital partner receives an AD diagnosis.MethodsWe initially identified all beneficiaries in the 2001–2005 Medicare 5% sample who had multiple claims listing the ICD-9 diagnostic code for AD, 331.0. The 5% sample includes spouses who share a Medicare account with their marital partners because they lack a sufficient work history for full eligibility on their own. A matched cohort study assessed incremental health costs in the spouses of AD patients versus a control group of spouses of non-AD patients. Longitudinal and cross-sectional analyses tracked the impact of a patient’s AD diagnosis on his or her spouse’s healthcare costs.ResultsOur method located 54,593 AD patients of whom 11.5% had spouses identifiable via a shared Medicare account. AD diagnosis in one member of a couple was associated with significantly higher monthly Medicare payments for the other member’s healthcare. The spouses’ elevated costs commenced 2 to 3 months before their partners’ AD diagnosis and persisted over the follow-up period. After 31 months, the cumulative additional Medicare reimbursements totaled a mean $4,600 in the spouses of AD patients. This excess was significant even after accounting for differences in baseline health status between the cohorts.ConclusionThe study methodology provides a framework for comprehensively evaluating medical costs of both chronically ill patients and their spouses. This method also provides monthly data, which makes possible a longitudinal evaluation of the cost effects of specific health events. The observed correlations provide a coherent demonstration of the interdependence between AD patients’ and spouses’ health. Future research should examine caregiving burden and other possible factors contributing to the AD spouses’ health outcomes. It should also extend the method presented here to evaluations of other chronic diseases of the elderly.

Association Between Prior Authorization for Medications and Health Service Use by Medicaid Patients With Bipolar Disorder

Objective: This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder. Methods: A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003–February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002–February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated. Results: Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental disorders and use of medications and health services. The policy was associated with increased medication discontinuation among attenders and nonattenders, reductions in mental health visits after discontinuation among attenders (−.64 per patient per month; p<.05), and increases in emergency room visits after discontinuation among nonattenders (.16 per patient per month; p<.05). During the eight-month policy period, the policy had no detectable impact on hospitalization risk. Conclusions: The prior-authorization policy was associated with increased medication discontinuation and subsequent changes in health service use. Although small, these unintended effects raise concerns about quality of care for a group of vulnerable patients. Long-term consequences of prior-authorization policies on patient outcomes warrant further investigation. (Psychiatric Services 62:186–193, 2011)

Association Between Prior Authorization for Medications and Health Service Use by Medicaid Patients With Bipolar Disorder

This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder. A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003-February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002-February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated. Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental disorders and use of medications and health services. The policy was associated with increased medication discontinuation among attenders and nonattenders, reductions in mental health visits after discontinuation among attenders (-.64 per patient per month; p<.05), and increases in emergency room visits after discontinuation among nonattenders (.16 per patient per month; p<.05). During the eight-month policy period, the policy had no detectable impact on hospitalization risk. The prior-authorization policy was associated with increased medication discontinuation and subsequent changes in health service use. Although small, these unintended effects raise concerns about quality of care for a group of vulnerable patients. Long-term consequences of prior-authorization policies on patient outcomes warrant further investigation.

Randomised controlled trial of two brief interventions against long-term benzodiazepine use: Cost-effectiveness

Previous findings have indicated that a letter from a patient's General Practitioner (GP) and a short GP consultation leads to reduced intake among long-term benzodiazepine (BZD) users. To compare the cost-effectiveness and potential cost savings of these two brief interventions. Economic evaluation conducted alongside a prospective randomised controlled trial from the perspective of the NHS. A total of 273 long-term BZD users (=>6 mos) at seven general practices and regarded by their GPs as suitable to take part in the study within the Newcastle and North Tyneside District Health Authority were identified from repeat prescription computer records. Patients were randomised to usual GP care + assessment only or the offer of a short consultation (12 mins approx) with the patient's GP (or practice pharmacist/practice nurse) or a letter signed by the GP advising gradual reduction in BZD intake. Economic measures taken were: costs of intervention; savings (costs) of changes in health service use from before to after intervention; savings to the NHS from reductions in drug use and dispensing costs; total costs of brief intervention; simulations of savings (costs) extrapolated to the District Health Authority. The letter was the more cost-effective intervention when taking into account changes in health service use and savings to the drugs bill. If all GPs in Newcastle and North Tyneside screened long-term BZD users on their lists and sent the letter studied here to those considered suitable to receive it, it is estimated that savings to the District Health Authority would be a minimum of £4.9 million per annum. Routine implementation of the letter intervention in general practice throughout the UK would result in large financial gains to the NHS. These savings represent a conservative estimate of savings to the public sector, as wider savings to the social care system may also be expected as a result of the policy.

Information for decision making from imperfect national data: tracking major changes in health care use in Kenya using geostatistics

BackgroundMost Ministries of Health across Africa invest substantial resources in some form of health management information system (HMIS) to coordinate the routine acquisition and compilation of monthly treatment and attendance records from health facilities nationwide. Despite the expense of these systems, poor data coverage means they are rarely, if ever, used to generate reliable evidence for decision makers. One critical weakness across Africa is the current lack of capacity to effectively monitor patterns of service use through time so that the impacts of changes in policy or service delivery can be evaluated. Here, we present a new approach that, for the first time, allows national changes in health service use during a time of major health policy change to be tracked reliably using imperfect data from a national HMIS.MethodsMonthly attendance records were obtained from the Kenyan HMIS for 1 271 government-run and 402 faith-based outpatient facilities nationwide between 1996 and 2004. A space-time geostatistical model was used to compensate for the large proportion of missing records caused by non-reporting health facilities, allowing robust estimation of monthly and annual use of services by outpatients during this period.ResultsWe were able to reconstruct robust time series of mean levels of outpatient utilisation of health facilities at the national level and for all six major provinces in Kenya. These plots revealed reliably for the first time a period of steady nationwide decline in the use of health facilities in Kenya between 1996 and 2002, followed by a dramatic increase from 2003. This pattern was consistent across different causes of attendance and was observed independently in each province.ConclusionThe methodological approach presented can compensate for missing records in health information systems to provide robust estimates of national patterns of outpatient service use. This represents the first such use of HMIS data and contributes to the resurrection of these hugely expensive but underused systems as national monitoring tools. Applying this approach to Kenya has yielded output with immediate potential to enhance the capacity of decision makers in monitoring nationwide patterns of service use and assessing the impact of changes in health policy and service delivery.

An Investigation of the Impact of Supplementary Health Benefits for Low-income Families in Saskatchewan

To examine the changes in health service use by recipients of Family Health Benefits, a supplementary benefits program that was introduced to lower-income, working families in Saskatchewan beginning in July 1998. These benefits reduced or eliminated fees for prescription drugs and for chiropractic, optometric and dental services.The study population included program beneficiaries between July 1998 and January 2000. Administrative data maintained by Saskatchewan Health were used to capture information on changes in benefits coverage and use of hospital, physician, prescription drug, chiropractic and optometric services from 1997 to 2000. Demographic characteristics of the study population were described. Utilization rates were compared for periods prior to and following introduction of the program.Almost three quarters of Family Health Benefit beneficiaries had not had any form of prior supplementary health coverage in the previous year. A large proportion of these beneficiaries lived in rural Saskatchewan. Distinct demographic characteristics were observed for rural and urban beneficiaries. While utilization of physician and hospitalization services was lower following the introduction of the program, utilization of prescription drugs, and both chiropractic and optometric services increased.The reduction in user fees for non-insured services resulted in an increased use of these health services, suggesting that user fees can act as a barrier to the use of medical services by low-income families.

Changes in health service use and mortality among U.S. elderly in 1980-1986.

Concern has emerged about the impact on quality of care of recent changes in Medicare reimbursement for acute hospital episodes (i.e., the introduction of the Prospective Payment System based on the Diagnosis Related Groups Reimbursement methodology). One aspect of those concerns is that very sick patients would be prematurely discharged to nursing homes in which the high level of medical care required would not be available. This was recently studied in terms of changes between 1981 and 1985 in the location of deaths (e.g., hospital, institutional) reported on U.S. death certificates. We analyzed the death certificate data for a longer period of time (1980 to 1986) and stratified the analysis by both age and cause of death--which we felt were important determinants of location of death. We also examined data from the 1982 and 1984 National Long Term Care Surveys linked to data on Medicare service use. In those analyses we could explicitly identify chronically disabled and institutionalized populations and study death rates in different locations within those populations. Our analyses showed little evidence of increased mortality rates due to premature hospital discharge. There were, however, significant changes in the patterns of service use. More home health agency (HHA) and skilled nursing facility (SNF) services were consumed though the rates of death per episode in those venues declined.