Changes In Health Care Utilization Research Articles

Changes in healthcare utilization and costs associated with sildenafil therapy for pulmonary arterial hypertension: a retrospective cohort study

BackgroundLittle is known concerning the degree to which initiation of sildenafil for pulmonary arterial hypertension (PAH) impacts patterns of healthcare utilization and costs.MethodsUsing a large US health insurance claims database, we identified all patients with evidence of PAH (ICD-9-CM diagnosis codes 416.0, 416.8) who received sildenafil between 1/1/2005 and 9/30/2008. Date of the first-noted prescription for sildenafil was designated the “index date,” and claims data were compiled for all study subjects for 6 months prior to their index date (“pretreatment”) and 6 months thereafter (“follow-up”); patients with incomplete data during either of these periods were excluded. Healthcare utilization and costs were then compared between pretreatment and follow-up for all study subjects.ResultsA total of 567 PAH patients were identified who began therapy with sildenafil and met all other study entry criteria. Mean (SD) age was 52 (10) years; 73% were women. Healthcare utilization was largely unchanged between pretreatment and follow-up, the only exceptions being decreases in the mean number of emergency department visits (from 0.7 to 0.5 per patient; p < 0.01) and the percentage of patients hospitalized (from 35% to 29%; p = 0.01). The mean cost of all PAH-related medication was $7139 during pretreatment and $14,095 during follow-up (sildenafil cost during follow-up = $5236); exclusive of PAH-related medications, however, total healthcare costs decreased modestly (from $30,104 to $27,605) (p < 0.01 for all comparisons).ConclusionsThe cost of sildenafil therapy may be partially offset by reductions in other healthcare costs.

Change in healthcare utilization and costs following initiation of benzodiazepine therapy for long-term treatment of generalized anxiety disorder: a retrospective cohort study

BackgroundSelective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and benzodiazepine anxiolytics are used in the US to treat generalized anxiety disorder (GAD). While benzodiazepines typically provide rapid symptomatic relief, long-term use is not recommended due to risks of dependency, sedation, falls, and accidents.MethodsUsing a US health insurance database, we identified all persons with GAD (ICD-9-CM diagnosis code 300.02) who began a long-term course of treatment (≥90 days) with a benzodiazepine anxiolytic between 1/1/2003 and 12/31/2007, We compared healthcare utilization and costs over the six-month periods preceding and following the date of treatment initiation (“pretreatment” and “post-treatment”, respectively), and focused attention on accident-related encounters (e.g., for treatment of fractures) and care received for other reasons possibly related benzodiazepine use (e.g., sedation, dizziness).ResultsA total of 866 patients met all study entry criteria; 25% of patients began treatment on an add-on basis (i.e., adjunctive to escitalopram, paroxetine, sertraline, or venlafaxine), while 75% of patients did not receive concomitant therapy. Mean total healthcare costs increased by $2334 between the pretreatment and post-treatment periods (from $4637 [SD=$9840] to $6971 [$17,002]; p<0.01); costs of accident-related encounters and other care that was possibly related to use of benzodiazepines increased by an average of $1099 ($1757 [$7656] vs $2856 [$14,836]; p=0.03).ConclusionsHealthcare costs increase in patients with GAD beginning long-term (≥90 days) treatment with a benzodiazepine anxiolytic; a substantial proportion of this increase is attributable to care associated with accidents and other known sequelae of long-term benzodiazepine use.

Cost implications of self-management education intervention programmes in arthritis

The purpose of this review is to examine cost implications, including cost-effectiveness analyses, cost-savings calculated from health-care utilisation and intervention delivery costs of arthritis-related self-management education (SME) interventions. Literature searches, covering 1980-March 2012, using arthritis, self-management and cost-related terms, identified 487 articles; abstracts were reviewed to identify those with cost information. Three formal cost-effectiveness analyses emerged; results were equivocal but analyses done from the societal perspective, including out-of-pocket and other indirect costs, were more promising. Eight studies of individual, group and telephone-delivered SME calculated cost-savings based on health-care utilisation changes. These studies had variable results but the costs-savings extrapolation methods are questionable. Meta-analyses of health-care utilisation changes in two specific SME interventions demonstrated only one significant result at 6 months, which did not persist at 12 months. Eleven studies reported intervention delivery costs ranging from $35 to $740 per participant; the variability is likely due to costing methods and differences in delivery mode. Economic analysis in arthritis-related SME is in its infancy; more robust economic evaluations are required to reach sound conclusions. The most common form of analysis used changes in health-care utilisation as a proxy for cost-savings; the results are less than compelling. However, other value metrics, including the value of SME as part of health systems' self-management support efforts, to population health (from improved self-efficacy, psychological well-being and physical activity), and to igniting patient activation, are all important to consider.

Benefits of a self-management program in low-income African-American women with systemic lupus erythematosus: results of a pilot test

Minorities with systemic lupus erythematosus (SLE) are at high risk of poor disease outcomes and may face challenges in effectively self-managing multiple health problems. The Chronic Disease Self-Management Program (CDSMP) is an evidence-based intervention that improves the health of people with chronic illnesses. Although the CDSMP is offered by organizations throughout the United States and many countries around the world, it has not been tested among SLE patients. We pilot tested the benefits of the CDSMP in low-income African American patients with SLE. CDSMP workshops were delivered to 49 African American women with SLE who received medical care at a public lupus clinic in Atlanta, Georgia, US. We compared pre-post CDSMP changes (from baseline to 4 months after the start of the intervention) in health status, self-efficacy and self-management behaviors using self-reported measures. Additionally, we assessed health care utilization changes using electronic administrative records in the 6-month periods before and after the intervention. We observed significant improvements post-intervention in the SF-36 physical health component summary (mean change = 2.4, p = 0.032); self-efficacy (mean change = 0.5, p = 0.035); and several self-management behaviors: cognitive symptoms management (mean change = 0.3, p = 0.036); communication with physicians (mean change = 0.4, p = 0.01); and treatment adherence (mean change = 0.4, p = 0.01). The median number of outpatient visits decreased from 3 to 1 (p < .0001). The CDSMP is a promising intervention for low-income African Americans with SLE. It is an inexpensive program with growing availability around the world that should be further evaluated as a resource to improve patient-centered outcomes and decrease health service utilization among SLE patients.

Longitudinal changes in health care utilization by adult survivors of childhood cancer in the Childhood Cancer Survivor Study (CCSS).

6030 Background: The incidence of late effects increases as childhood cancer survivors age. Survivors require lifelong care focused on the risks arising from prior cancer therapy (survivor-focused care). Methods: We assessed longitudinal changes in health care utilization in adult survivors of childhood cancer participating in the CCSS. Utilization at baseline and most recent follow-up was classified into one of three mutually exclusive hierarchical categories: no health care, general medical care, or survivor-focused care. Relative risk (RR) and 95% confidence intervals (CI) were calculated for predictors of reduction in care over time from survivor-focused to general or no care. Multivariable models, adjusted for key treatment exposures, were created to assess the risk factors for reductions in level of care over time. Results: Among 8591 eligible survivors, mean age at last follow-up was 35.1 years (SD=7.8) with a mean of 11.6 years (SD=2.2) since baseline. Of 3993 (46%) survivors who reported survivor-focused care at baseline, 2383 (59.7%) reported a lower level of care at follow-up. Among 4598 (54%) not receiving survivor-focused care at baseline, 915 (20%) reported survivor-focused care at follow-up. Baseline predictors of a decreased level of care were no health insurance (RR=1.5, 95% CI 1.2-1.9), male sex (RR=1.4, 95% CI 1.2-1.6), being 10-19 years from diagnosis compared with 20+ years (RR=1.4, 95% CI 1.1-1.7). In contrast, factors associated with a maintenance in survivor-focused care were Canadian residency compared to U.S. residency with insurance (RR=0.7, 95% CI 0.6-0.9), unemployment (RR=0.8, 95% CI 0.7-0.9), physical limitations (RR=0.7, 95% CI 0.6-0.9), cancer-related pain (RR=0.7, 95% CI 0.5-0.8), poor emotional health (RR=0.7, 95% CI 0.5-0.9), having mild-moderate (RR=0.5, 95% CI 0.4-0.6) or severe-disabling chronic health condition (RR=0.6, 95% CI 0.5-0.7). Conclusions: Less than a third of adult survivors of childhood cancer report survivor-focused care. Rates decrease over time. Targeted interventions to maximize survivor-focused care in at-risk survivors should be tested so preventive and risk-reducing opportunities are not lost.

Changes in Utilization and Costs for Patients with Rheumatoid Arthritis, 1997 to 2006

Rheumatoid arthritis (RA) is a chronic autoimmune disease that often results in joint pain, inflammation and bone erosions. Perhaps the most notable change in RA treatment during the last decade is the advent of biologics, and, in particular, anti-tumour necrosis factor agents. Given these advances, it is useful to assess how healthcare and work-loss costs of patients with RA have changed. Our objective was to assess changes in healthcare utilization and costs from 1997 to 2006 for patients diagnosed with RA. Two cohorts (1997 and 2006) of patients with RA and matched controls were identified from two administrative claims databases along with subsamples of employed patients and matched controls. The analysis focused on the more homogeneous employee subsample. We compared annual excess co-morbidity rates, resource utilization and healthcare and work-loss costs per patient between the 1997 (n = 279) and 2006 cohorts (n = 837) with difference-in-differences methodology. Results with p < 0.05 were considered statistically significant. In the employee subsample, there were no statistically significant differences in the excess prevalence of non-RA co-morbidities or Charlson Co-morbidity Index results, except for cardiovascular disease, which decreased by 11.1%. Excess number of ED visits and days hospitalized decreased by 1.1 visits/patient and 0.9 days/patient, respectively, while rheumatologist visits increased by 0.9 visits/patient. Excess per-patient direct costs were unchanged. However, drug costs increased by $US633/patient, but medical costs decreased by $US618/patient (not significant) [year 2006 values]. For employed patients with RA, there were significant reductions in per-patient excess hospital days, as well as ED visits, and no changes in excess total direct costs over time. New treatments introduced during the study period may be associated with cost savings that offset changes in employee utilization of drug and medical services. In addition, the reductions in excess ED visits and hospital days suggest improvements in patient quality of life.

The Impact of Behavioral Feeding Intervention on Health Care Utilization

This study examined health care utilization pre- and post-referral to a behaviorally based treatment program for feeding difficulties in children. Physician contacts and associated costs for a feeding clinic group (n = 490) and a group of matched population controls (n = 1,548) were examined across a 3-year period. Children with feeding difficulties had an increased frequency of physician visits and higher costs compared to controls. A subsample (n = 86) of clinic children revealed that successful behavioral feeding intervention resulted in a change in health care utilization, as demonstrated by a reduction in physician visits.

Cancer Patients Use Hospital-Based Care Until Death: A Further Analysis of the Dutch Bone Metastasis Study

To describe health care utilization (HCU) at the end of life in cancer patients. These data are relevant to plan palliative care services, and to develop training programs for involved health care professionals. The Dutch Bone Metastasis Study (DBMS) was a nationwide study proving equal effectiveness of single fraction palliative radiotherapy compared with multiple fractions for painful bone metastases in 1157 patients. The 860 (74%) patients who died during follow-up were included in the current analysis. The main outcome was the frequency of hospital-based (outpatient contact or admission) and/or general practitioner (GP) contact during the last 12 weeks of life. Changes in HCU towards death were related to data on quality of life and pain intensity using a multilevel regression model. Hospital-based HCU was reported in 1801 (63%) returned questionnaires, whereas GP contact was stated in 1246 (43%). In 573 (20%) questionnaires, both types of HCU were reported. In multilevel regression analyses, the frequency of outpatient contacts remained constant during the weeks towards death, whereas the frequency of GP contacts increased. Lower valuation of quality of life was related to both GP- and hospital-based HCU. There was a high consumption of hospital-based HCU in the last 12 weeks of life of cancer patients with bone metastases. Hospital-based HCU did not decrease during the weeks towards death, despite an increase in GP contacts. Future planning of palliative care and training programs should encompass close collaboration between medical specialists and GPs to optimize end-of-life care.

Improving utilization of antimicrobial drugs among physician assistants in the ED

This study examines the effectiveness of an educational intervention that used audit and feedback to influence physician assistant (PA) antimicrobial utilization in an emergency department (ED). Twelve ED PAs participated in this pre- and postintervention study. Their prescribing patterns were retrospectively reviewed and classified as appropriate, effective but inappropriate, or inappropriate using a previously developed methodology. A hospitalist physician conducted a 1-hour academic detailing intervention session with each PA that reviewed inappropriate prescribing practices and provided feedback for improvement based on current guidelines. After the meetings, the prescribing patterns of the providers were followed prospectively and comparisons were made between the proportions of antimicrobials prescribed appropriately and inappropriately before and after the intervention. The percentage of appropriate prescriptions increased from 64% (95% CI, 58-72) to 81% (95% CI, 75-86), whereas the proportion of inappropriate prescriptions decreased from 36% (95% CI, 31-43) to 19% (95% CI, 14-23) across the study periods (both P < .001). PA antimicrobial utilization was responsive to an academic detailing initiative that relied heavily on audit and feedback of past performance. Targeting PAs in quality improvement initiatives may be a highly effective way to influence change in health care utilization.

A Case–Control Study of Home Foreclosure, Health Conditions, and Health Care Utilization

Though rates of foreclosure are at a historic high, relatively little is known about the link between foreclosure and health. We performed a case-control study to examine health conditions and health care utilization in the time period prior to foreclosure. Homeowners who received a home foreclosure notice from 2005 to 2008 were matched (by name and address) to a university hospital system in Philadelphia and compared with controls who received care from the hospital system and who lived in the same zip code as cases. Outcome measures included prevalent health conditions and visit history in the 2years prior to foreclosure. We found that people undergoing foreclosure were similar to controls with regard to age, gender, and insurance status but significantly more likely to be African American. Rates of hypertension and renal disease were significantly higher among cases after adjustment for sociodemographic characteristics. In the 2years prior to foreclosure, cases were more likely to visit the emergency department, have an outpatient visit, and have a no-show appointment. Cases were less likely to have a primary care physicians (PCP) visit in the 6months immediately prior to the receipt of a foreclosure notice. The results suggest changes in health care utilization in the time period prior to foreclosure. Policies designed to decrease the incidence of home foreclosure and support people during the process should consider its association with poor health and changes in health care utilization.

A Equity Changes in Health Care Utilization According to Health Status

A Equity Changes in Health Care Utilization According to Health Status

The effect of health promotion on diagnosis and management of diabetes

BackgroundUndiagnosed disease is one of the critical public health problems in the world. In 2002 South Korea introduced the nation's first comprehensive public health promotion policy, Health Plan 2010. The...

On decomposing the inequality and inequity change in health care utilization: change in means, or change in the distributions?

Health care financing arrangements not only have strong implications for income distribution, but also affect health care utilization. Therefore, a comparison of the equity in health care utilization for those health systems with different financing arrangements has important policy implications for health care policymakers. The concentration index (CI) and the horizontal inequity index (HI) are commonly used to measure inequality and inequity in health care utilization. In this paper, we propose simple methods to decompose the difference between two CIs and two HIs into two factors: one factor reflects the difference between the means, and the other factor reflects the difference between the distributions. The proposed decomposition method might be useful since the means are likely to be caused by factors that do not constitute unfair inequalities (inequities). We also present two empirical applications of the decomposition methods for the purpose of illustration.

Abstract A21: Changes in healthcare utilization following community cancer education programs

Abstract Introduction: The Por la Vida community health advisor intervention programs target low-income and low-acculturation Latinos in a border region of the United States. These underserved individuals are less likely to have a usual source of healthcare and receive preventive services as there are numerous linguistic, cultural, and financial barriers that contribute to health disparities (Flores &amp; Vega, 1998; Rivers &amp; Patino, 2006). An important goal of these health education programs is to encourage the regular use of preventive and treatment-oriented health services. The current analyses examine whether there are differences in having a usual source of healthcare preand postintervention, as well as changes in the identified barriers to engaging in healthcare services. The natural differences across the Por la Vida programs provide the opportunity to examine differences in change depending on the focus of the health programs. Method: Participants include 744 adult Latina women, predominantly first generation Mexican-American (95%), who participated in a 12-session nutrition education, tobacco-free communities program, or a women and cancer program that focused on the importance of preventive screening services and a range of other lifestyle factors. Chi-squared analyses of group differences in having a usual source of care in pre-and posttest assessments (6 months postintervention) were compared across groups. For the two programs which assessed barriers to healthcare, pre-and posttest reports on the experience of nine different barriers (e.g., cost, lack of Spanish-speaking staff, lack of childcare, and losing pay from work to go to an appointment) to accessing healthcare also were compared. Results: Three of the four groups reported significant increases in having a usual source of care at post-assessment. Only the tobacco-free communities program showed no change in having a usual source of care at post-assessment. For the two programs assessed for changes in barriers, there were also reductions in the reports of barriers which prevented them from accessing care, such as cost and having to wait too long for an appointment. All nine of the identified barriers decreased from pre-to post-assessment. Discussion: While the topic-specific gains for these programs have been reported elsewhere, the current analyses indicate there were positive changes to increase regular utilization of healthcare services for the nutrition and cancer-specific programs. The tobacco-free communities program did not evidence the same changes in regular healthcare use, which is consistent with the focus and content of the program. While many of the barriers examined in this study cannot be modified through the health education program content, there were reported reductions in all nine of the barriers in preventing participants from accessing care at post-assessment. This suggests additional gains for the health education programs beyond the targeted content and intervention goals. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A21.

Impact of discontinuity in health insurance on resource utilization

BackgroundThis study sought to describe the incidence of transitions into and out of Medicaid, characterize the populations that transition and determine if health insurance instability is associated with changes in healthcare utilization.Methods2000-2004 Medical Expenditure Panel Survey (MEPS) was used to identify adults enrolled in Medicaid at any time during the survey period (n = 6,247). We estimate both static and dynamic panel data models to examine the effect of health insurance instability on health care resource utilization.ResultsWe find that, after controlling for observed factors like employment and health status, and after specifying a dynamic model that attempts to capture time-dependent unobserved effects, individuals who have multiple transitions into and out of Medicaid have higher emergency room utilization, more office visits, more hospitalizations, and refill their prescriptions less often.ConclusionsIndividuals with more than one transition in health insurance status over the study period were likely to have higher health care utilization than individuals with one or fewer transitions. If these effects are causal, in addition to individual benefits, there are potentially large benefits for Medicaid programs from reducing avoidable insurance instability. These results suggest the importance of including provisions to facilitate continuous enrollment in public programs as the United States pursues health reform.

Change in Healthcare Utilization by Disease Severity after Case Management for Medicaid

Purpose:Thisstudy examinedchangeinhealthcareutilization bydisease severityafter casemanagement (CM) for Medicaid. Methods: Data were extracted from survey data on Healthcare utilization and health status of Medicaid conducted in 2007 and 2008 by theMinistry for Health, Welfare and Family Affairs. This study was designed to compare change in healthcare utilization between the CM group and the non-CM group. The subjects were 528 Type I Medicaid beneficiaries who utilized healthcare more than 365 days during 2006. Results:Inbeneficiarieshavingfewerthan3amongthe11notifieddiseases, theCMgroup showedasignificantly larger decrease inoutpatient day,outpatient expense, medicationday,andmedication expense than thenon-CM group. In beneficiaries having 3 or more among the 11 notified diseases, however, there was no significant difference in healthcare utilization between the CM group and the non-CM group. Conclusion: CM worked effectively on Medicaid beneficiaries outpatient healthcare utilization for mild diseases. However, its effects on hospitalization,whichisa major cause increasing thetotal expense, were not observed. Therefore, afuturestudy is needed to develope strategies to reduce hospitalization and care for Medicaid beneficiaries with severe diseases.

Healthcare utilization changes in relation to treatment intensification with insulin aspart in patients with type 2 diabetes. Data from a large US managed-care organization

ABSTRACTObjective: Most patients with type 2 diabetes eventually require exogenous insulin therapy to achieve good glycemic control due to the progressive nature of the disease. Insulin aspart is a rapid-acting insulin analog developed for prandial use. This study aimed to illustrate the implications on healthcare costs of adding insulin aspart to basal therapy in a real-world setting.Methods: Patients with type 2 diabetes who intensified previous basal therapy with insulin aspart were identified from a large commercial US healthcare data source between April 2007 and September 2008. Patients were required to have received basal insulin treatment with or without concomitant oral antidiabetic (OAD) therapy for at least 90 days pre- and post-initiation of insulin aspart. Wilcoxon signed-rank test and McNemar's test were used for continuous and categorical variables, respectively, to analyze the difference of self-comparison between pre- and post insulin aspart add-on.Results: In total, 1,739 patients with an average age of 56 years were identified, of whom 55% were male. After initiation of insulin aspart, a significant improvement in glycemic control was observed (change in HbA1c: –0.5%, p=0.0013). Similarly, a reduction of 0.4% in HbA1c was observed for the subpopulation of 151 patients, who had both pre-and post-index HbA1c data (p=0.0085). Also, significantly fewer patients used OADs after insulin aspart initiation (56 vs. 64%, p< 0.0001). Overall and diabetes-related healthcare costs also significantly decreased by $2,283 and $2,028, respectively (p≤0.0001). Diabetes-related inpatient visits appear to be the main contributor to total cost (46%); however, after initiation of insulin aspart the number of inpatient visits decreased by 0.50 visits/patient/year (p< 0.05). This decrease was reflected in a large reduction in cost related to inpatient visits ($3,019/patient).Limitations: A regression to the mean effect may be associated with this pre-post comparison. The ability to make conclusions regarding cause and effect may be limited due to the retrospective design of this study.Conclusions: Patients with type 2 diabetes achieved better glycemic control and needed less OAD treatment after adding insulin aspart to previous basal therapy. Furthermore, patients experienced on average reduced healthcare utilization after initiation of insulin aspart, which resulted in significant cost savings.

School age outcome of hospitalisation with respiratory syncytial virus infection of prematurely born infants

Background:Hospitalisation due to respiratory syncytial virus (RSV) infection in the first 2 years after birth has been associated with increased healthcare utilisation and associated costs up to 5 years of...

Health care service utilization among the elderly: findings from the Study to Understand the Chronic Condition Experience of the Elderly and the Disabled (SUCCEED project)

Age-related effects on health service utilization are not well understood. Most previous studies have examined only a single specific health care service or disease condition or have focused exclusively on economic variables. We aim to measure age-related change in health care utilization among the elderly. A population-based retrospective cohort study was conducted using linked data from four administrative databases (OHIP, ODB, CIHI and RPDB). All Ontario residents over the age of 65 years and eligible for public health coverage were included in the analysis (approximately 1.6 million residents). Main outcome measures include utilization indicators for family physician visits, specialist physician visits, Emergency Department visits, drugs, lab claims, X-rays, inpatient admissions, CT scans and MRI scans. The mean number of utilization events for Ontarians aged 65+ years for the 1-year study period was 70 events (women = 76, men = 63). The overall absolute difference between the 65-69 age group and the 85+ age group was 155% (women = 162%, men = 130%), or 76 more events per person in the older group (women = 82, men = 61). Women averaged more events per person than men, as well as greater percentage differences by age. Drugs and diagnostics account for the majority of events. Only MRI and specialist visits were not higher among the older age groups. At the population level, overall health care utilization would appear to increase significantly with age. It is unclear whether increasing health care utilization prevents morbidity, decreases mortality, or improves quality of life.

Health care utilization and costs of adult asthma in Taiwan

The burden of asthma is sufficient to warrant its recognition as a high-priority disorder in governmental health strategies in many countries. However, the components of the total health care costs for patients with asthma have not been well studied, and an overall understanding of health care utilization patterns in this population is lacking in Taiwan. We evaluated 95,110 patients aged 18-55 years who were enrolled in the National Health Insurance Research Database from January 1 to December 31, 2002. Health care utilization and costs, including those related to office, outpatient hospital, emergency department, and inpatient hospital visits were compared between patients with and patients without asthma. In 2002, the period prevalence of treated asthma was 1.8%. Patients with asthma used substantially more services than did those without asthma in all categories. The mean costs of hospitalizations for patients with asthma were 2.7-fold higher than those of patients without asthma. Asthma care represented 26% of all health-care services that patients with asthma received, while the remaining 74% were for nonasthma care. Almost one-half of all asthma-related costs were attributable to hospitalizations. These findings may serve as baseline data for future evaluations of changes in health care utilization and expenditures among asthmatic patients.