Frequent Health Care Use Research Articles

Health Insurance and Access to Care in U.S. Working-Age Adults Experiencing Long COVID

IntroductionLong COVID encompasses a wide range of health problems that emerge, persist, or recur following acute COVID-19 illness. Given that the prevalence of self-reported Long COVID is highest among U.S. adults in their prime working years, it is important to identify unmet needs and gaps in healthcare access and coverage among working age adults. MethodsPrevalences (95% CI) of health insurance coverage and access to care by Long COVID status were estimated among adults 18-64 years (n = 18,117), accounting for survey design and weighted to the U.S. non-institutionalized population in the 2022 National Health Interview Survey. Analyses were conducted in 2023. ResultsOverall, 3.7% (95% CI 3.4, 4.0) of respondents were experiencing Long COVID. Adults experiencing Long COVID were less likely to report being uninsured relative to adults not experiencing Long COVID (P=0.004); however, 49.0% (95% CI 43.2, 54.7) had high deductible health plans. Adjusting for sociodemographic characteristics, adults experiencing Long COVID were more likely to access healthcare compared to adults not experiencing Long COVID (P<0.01 for seeing a doctor, telemedicine appointments, ≥2 urgent care visits, ≥2 emergency department visits, and hospitalized overnight). Despite more frequent healthcare use, adults experiencing Long COVID were also more likely to abstain from and delay medical care, therapy, and prescriptions due to cost compared to adults not experiencing Long COVID (P<0.0001 for all comparisons). ConclusionsThese findings may be used to inform healthcare planning for adults experiencing Long COVID and highlight the ongoing need to improve access and affordability of quality and comprehensive care.

The use of healthcare services and disabling chronic pain: results from the cross-sectional population-based Andalusian Health Survey.

Several factors seem to be related to the use of healthcare services, and chronic pain (CP) is among these characteristics. The objective is to describe the number of visits to a doctor's surgery or emergency rooms, and the periods of hospitalization; to identify characteristics associated with frequent healthcare use, including disabling chronic pain (DCP) and non-disabling chronic pain (n-DCP). Representative population-based cross-sectional study of 6569 people older than 16 years from southern Spain was collected. The frequency of visits to a doctor's surgery or emergency rooms and periods of hospitalization were defined as at or above the 90th percentile. Binary logistic regression analyses were conducted separately on women and men to identify characteristics associated with being frequent visitors. People with DCP are more frequent visitors to a doctor's surgery and emergency rooms and endure longer periods of hospitalization compared to people with n-DCP and without pain. In logistic regression models, people with DCP are twice as likely to over-visit a doctor's surgery; to endure longer periods of hospitalization and more visits to an emergency room service. No relationship was found in n-DCP. Disability seems to modulate a greater use of health services among the population with CP, doubling it when compared to n-DCP and n-CP, both in women and men. Understanding the role of disability in the use of healthcare services for individuals with CP allows for the identification of needs and strategies to optimize resources.

Incidence and adverse clinical events of primary sclerosing cholangitis with ulcerative colitis.

The aim of this study was to conduct a nationwide population-based study to estimate the incidence of primary sclerosing cholangitis in patients with ulcerative colitis (UC-PSC) and investigate healthcare use, medication use, surgery, cancer, and death as adverse clinical events of UC-PSC. We identified incident cases of UC with (UC-PSC) or without PSC (UC-alone) between 2008 and 2018 using health insurance claims data in Korea. Univariate (crude hazard ratio (HR)) and multivariate analyses were performed to compare the risk of adverse clinical events between groups. A total of 14,406 patients with UC using population-based claims data were detected in the cohort. Overall, 3.38% (487/14,406) of patients developed UC-PSC. During a mean follow-up duration of approximately 5.92years, the incidence of PSC in patients with UC was 185 per 100,000 person-years. The UC-PSC group showed statistically more frequent healthcare use (hospitalization and emergency department visits: HRs, 5.986 and 9.302, respectively; P < .001), higher immunomodulator and biologic use (azathioprine, infliximab, and adalimumab: HRs, 2.061, 3.457, and 3.170, respectively; P < .001), and higher surgery rate (operation for intestinal obstruction, and colectomy: HRs, 9.728 and 2.940, respectively; P < .001) than did the UC-alone group. The UC-PSC group also showed significantly higher colorectal cancer and biliary tract cancer (HRs, 2.799 and 36.343, respectively; P < .001) and mortality (HR, 4.257) rates than did the UC-alone group. Patients with UC-PSC have higher risks of colorectal cancer, biliary tract cancer, and death than do patients with UC-alone. Although considered a rare disease, managing this complex and costly disease requires recognition of the impact of increased burden on healthcare services.

Psychosomatic symptoms according to psychiatric diagnosis

IntroductionPsychosomatic symptoms are an important problem that is frequently presented in medical consultations. These symptoms are often associated with psychiatric disorders, especially depressive and anxiety disorders.ObjectivesTo study the association between anxiety disorders and psychosomatic symptoms in a sample of patients referred for pathology of functional origin.MethodsWe made a descriptive retrospective study through the use of electronic medical records. The symptom onset and diagnosis were obtained for all patients referred to outpatients for psychosomatic symptoms during a 1-year period. We performed χ² Tests to assess the association of the diagnosis with the occurrence of psychosomatic symptoms.ResultsThe only diagnosis that presented statistically significant association was anxiety disorder (χ² = 11.1; p&lt;0.001).Anxiety disorderPsychosomatic symptomsNoSiTotalNoObserved3127319Expected30613.47319YesObserved11912131Expected1255.53131TotalObserved43119450Expected43119450ConclusionsOur study finds results that follow the line of other studies that show this association, such as Campo’s study which finds that functional somatic symptoms are consistently associated cross-sectionally with anxiety and depressive symptoms (Campo, 2012) or Imran’s study which finds that higher levels of somatization independently and significantly predicted higher anxiety (β=.37, p=.0001) (Imran et al., 2013). However, our results show no association with depressive disorders whereas frequent associations are found in the literature; for example, a recent meta-analysis found that neuroticism and depression had the strongest influence on the association of medically unexplained physical symptoms and frequent healthcare use (den Boeft et al., 2016). This lack of association is probably due to greater ease in identifying depressive disorders as the main pathology versus anxiety disorders.ReferencesCampo J. V. (2012). Annual research review: functional somatic symptoms and associated anxiety and depression--developmental psychopathology in pediatric practice. Journal of child psychology and psychiatry, and allied disciplines, 53(5), 575–592. den Boeft, M., Twisk, J. W., Terluin, B., Penninx, B. W., van Marwijk, H. W., Numans, M. E., van der Wouden, J. C., &amp; van der Horst, H. E. (2016). The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study. BMC health services research, 16, 100Imran, N., Ani, C., Mahmood, Z., Hassan, K. A., &amp; Bhatti, M. R. (2014). Anxiety and depression predicted by medically unexplained symptoms in Pakistani children: a case-control study. Journal of psychosomatic research, 76(2), 105–112.Disclosure of InterestNone Declared

Use of Health Services and Rehabilitation before and after the Beginning of Long-Term Sickness Absence-Comparing the Use by Employment and Disability Pension Transition after the Sickness Absence in Finland.

The objective of the study was to follow the health care and rehabilitation use before, during and after long-term sickness absence (LTSA), and to compare the use by post-LTSA labour market situation in terms of disability pension and employment. Individuals aged 18–58 with a ≥30-day LTSA spell in 2015 (N = 2427) were included from the total population of the city of Oulu, Finland. Register data included LTSA spells, outpatient health care visits, inpatient care spells and rehabilitation spells, disability pensions (DP), employment dates, and demographic, socioeconomic and disability-related covariates. The study population was followed for one year before, and three years after the start of LTSA. Negative binomial regression models were utilized to examine covariate-adjusted use of the three service types and group differences. The use of outpatient health care peaked at the start of the LTSA spell, and adjusted for covariates, the height of the peak was similar regardless of post-LTSA labour market situation. Adjusted for covariates, those who transferred to permanent DP after an LTSA used more outpatient (predicted mean 4.87 for attendance days quarterly, 95% CI 4.36–5.38) and inpatient (predicted mean 84 days quarterly, 95% CI 0.62–1.06) health care than others during three years after the start of LTSA. Individuals not employed after an LTSA showed the highest and increasing level of rehabilitation use. The results indicate that Individuals returning to employment after an LTSA are provided with relatively high amount of early outpatient care, possibly aiding the return. For individuals not employed after an LTSA, rehabilitation is used quite frequently but rather late in the disability process. The frequent use of health care among future disability pensioners is consistent with their increasing health problems leading to retirement.

Parental and physician disagreement on help-seeking in paediatric case scenarios

ObjectiveWhenever a child falls ill, parents need to decide whether there is a need to contact medical professionals. Parental and physician perspectives on the severity of a child’s illness differ....

Clinical features of chronic obstructive pulmonary disease in the elderly

Analysis of randomized, retrospective and prospective clinical, case-control, and observational studies revealed the following main features of COPD in the elderly: (1) COPD is a complex and common condition in elderly patients, characterized by high rates of disturbing symptoms, significant risk of cognitive and functional decline, disease progression, frequent use of health care, extremely difficult treatment and increased mortality. (2) The elderly have an increased prevalence of COPD: in subjects aged 65 years and over, it represents 14,2% (from 11,0% to 18,0%), compared to 9,9% (from 8.2% to 11.8%) in those aged 40 and over. (3) Simultaneously with the 2-4 times higher prevalence of COPD, the elderly patients, especially those aged 75 years or older, also have a higher burden of the disease: frequency, severity and impact of symptoms significantly higher. higher, tolerance to effort and lower daily activities, higher incidence of severe acute exacerbations and higher prevalence of systemic comorbidities. (4) COPD acute exacerbations and comorbidities have poorer results in elderly patients, fact manifested by an increased rate and duration of the hospitalization, an increased rate of repeted hospitalizations and a higher mortality rate. (5) COPD is a multifaceted condition that involves more than just obstruction of the airflow. Systemic inflammation contributes to the development of systemic effects (loss and dysfunction of skeletal muscle, osteoporosis, anemia, cachexia, neurocognitive dysfunction). (6) Multidimensional assessment and multidisciplinary intervention, well recognized in the geriatric population, should be extended to patients with COPD

Contemporary diagnosis of chronic obstructive pulmonary disease in the elderly

In order to elucidate the clinical features and diagnostic problems specific to geriatric patients, was studied the international scientific literature, thus establishing the following relevant features (1) Lung diseases, in particular COPD is a complex condition with higher incidence and prevalence in geriatric patients, characterized by high rates of disturbing symptoms, significant risk of cognitive, affective and functional decline, disease progression, frequent use of health care, extremely difficult treatment and increased mortality. (2) Atypical clinical presentation and confusion of comorbidities, limited use of spirometry and lack of clinical suspicion in primary care lead to underdiagnosis of COPD in the elderly population. (3) Spirometry is essential in the diagnostic procedure, but only through harmonization with other appropriate contemporary predictive diagnostic methods such as questionnaires and investigations, can prevent the overdiagnosis caused by normal aging of the lungs. (4) Acute exacerbations and comorbidities can cause diagnostic confusion, poorer therapeutic results, which confirms the need for early, complex diagnosis in order to maintain the sanogenic path of the elderly patient. (5) Clinico-paraclinical, diagnostic and therapeutic features validate the need for multidimensional evaluation and multidisciplinary intervention of geriatric COPD patients.

Perceptions of Endocrine Therapy in African-American Breast Cancer Survivors: Mixed Methods Study.

BackgroundAlthough the incidence of breast cancer is lower in African-American women than in White women, African-American women have a decreased survival rate. The difference in survival rate may stem from poor endocrine therapy adherence, which increases breast cancer recurrence. Therefore, accessible and culturally sensitive interventions to increase endocrine therapy adherence are necessary.ObjectiveThe purpose of this concurrent convergent mixed methods study was to provide further data to guide the development of the proposed culturally sensitive mHealth app, STORY+ for African-American women with breast cancer.MethodsWe recruited 20 African-American women diagnosed with estrogen-positive breast cancer and currently prescribed endocrine therapy. We used a concurrent convergent data collection method to (1) assess the use of smartphones and computers related to health care and (2) identify foundational aspects to support endocrine therapy adherence for incorporation in a mobile health app.ResultsOverwhelmingly, the participants preferred using smartphones to using computers for health care. Communicating with health care providers and pharmacies was the most frequent health care use of smartphones, followed by exercise tracking, and accessing the patient portal. We identified 4 aspects of adherence to endocrine therapy and smartphone use for incorporation in app development. The factors that emerged from the integrated qualitative and quantitative data were (1) willingness to use, (2) side effects, (3) social connection, and (4) beliefs about endocrine therapy.ConclusionsFurther research is needed to develop a culturally sensitive app for African-American women with breast cancer to improve adherence to endocrine therapy. Our work strongly suggests that this population would use the app to connect with other African-American breast cancer survivors and manage endocrine therapy.

Identifying Multisite Chronic Pain with Electronic Health Records Data.

Multisite chronic pain (MSCP) is associated with increased chronic pain impact, but methods for identifying MSCP for epidemiological research have not been evaluated. We assessed the validity of identifying MSCP using electronic health care data compared with survey questionnaires. Stratified random samples of adults served by Kaiser Permanente Northwest and Washington (N = 2,059) were drawn for a survey, oversampling persons with frequent use of health care for pain. MSCP and single-site chronic pain were identified by two methods, with electronic health care data and with self-report of common chronic pain conditions by survey questionnaire. Analyses were weighted to adjust for stratified sampling. MSCP was somewhat less common when ascertained by electronic health records (14.7% weighted prevalence) than by survey questionnaire (25.9% weighted prevalence). Agreement of the two MSCP classifications was low (kappa agreement statistic of 0.21). Ascertainment of MSCP with electronic health records was 30.9% sensitive, 91.0% specific, and had a positive predictive value of 54.5% relative to MSCP identified by self-report as the standard. After adjusting for age and gender, patients with MSCP identified by either electronic health records or self-report showed higher levels of pain-related disability, pain severity, depressive symptoms, and long-term opioid use than persons with single-site chronic pain identified by the same method. Identification of MSCP with electronic health care data was insufficiently accurate to be used as a surrogate or screener for MSCP identified by self-report, but both methods identified persons with heightened chronic pain impact.

Fibromyalgia

Fibromyalgia is characterized by chronic, widespread musculoskeletal pain and associated fatigue, sleep disturbances, and other cognitive and somatic symptoms. For many patients, these symptoms persist for years and lead to frequent health care use; for some, fibromyalgia and its symptoms can be debilitating. Although many treatments are available, management remains challenging. This article highlights the clinical features of fibromyalgia, discusses diagnostic criteria and their evolution, and reviews treatment options.

Self-Management, Self-Efficacy, and Health-Related Quality of Life in Children With Chronic Illness and Medical Complexity.

Children with chronic illnesses and medical complexity (CIMC) require frequent health-care use, thereby increasing medical care costs. We evaluated parent-child perceptions of self-management, self-efficacy, and health-related quality of life (HRQOL) in children with CIMC. Parent-children pairs (n = 32) completed three measures before discharge from the hospital (Patient Activation Measure, Self-Efficacy Scale, and Acute Care-Pediatric Quality of Life for Children 8-12 and 13-17 years). Parents (56.3%) and children (40.6%) reported moderate levels of self-management. HRQOL was correlated with both self-management (r = .441, p = .12) and self-efficacy (r = .464, p = .008). At least 25% to 50% reported low PedsQL subscale scores (< 70), which indicate problems with physical, emotional, social, and mental domains. Our findings support the assessment of not only physical but also mental, emotional, and social needs in children with CIMC. We recommend development and testing strategies promoting self-management and self-efficacy to maximize HRQOL and improve health outcomes in children with CIMC.

Sickle-Cell Disease Co-Management, Health Care Utilization, and Hydroxyurea Use.

Sickle-cell disease (SCD) causes significant morbidity, premature mortality, and high disease burden, resulting in frequent health care use. Comanagement may improve utilization and patient adherence with treatments such as Hydroxyurea. The purpose of this study was to describe acute-care utilization in Medicaid-enrolled patients with SCD, patient factors associated with comanagement, and adherence to Hydroxyurea. Data from 2790 patients diagnosed with SCD, age 1 to 65+ years, enrolled at least 1 month in North Carolina Medicaid between March 2016 and February 2017, were analyzed. Outpatient visits were categorized as primary care, hematologist, and nonhematologist specialist. Nurse practitioners or physician assistants with unidentified specialty type or family practice were categorized separately. Comanagement was defined as a minimum of 1 primary care and 1 hematologist visit/patient during the study period. There were notable age-related differences in utilization of health care services. Only 34.82% of the sample was comanaged. Comanagement was higher in the 1-to-9-year-old (44.88%) and 10-to-17-year-old groups (39.22%) versus the 31-to-45-year-old (30.26%) and 65+-year-old (18.75%) age groups. Age had the greatest influence (AUC = 0.599) on whether or not a patient was comanaged. Only a third of the sample (32.24%) had at least 1 Hydroxyurea (HU) prescription. Age was the most predictive factor of good HUadherence (AUC = 0.6503). Prediction by comanagement was minimal with an AUC = 0.5615. Comanagement was a factor in predicting HUadherence, but further studies are needed to identify the frequency and components of comanagement needed to increase adherence and reduce acute care utilization.

Review article: the incidence and risk factors for irritable bowel syndrome in population-based studies.

In the absence of prior gastrointestinal infection, the risk factors for irritable bowel syndrome (IBS) are not well established. To identify the incidence and risk factors for IBS in general population samples METHODS: Narrative review of population-based studies. Electronic databases were searched using the keywords "incidence," "onset," "epidemiology," "population," "risk factors" with "irritable bowel syndrome" with subsequent hand searching. Inclusion criteria were: population-based, adults, prospective design (including retrospective case cohorts), clinical or research diagnosis of IBS and exclusion of individuals who had IBS prior to recruitment. Of 1963 papers, 38 were included; all provided data on risk factors, 27 reported incidence. The median incidence of physician-diagnosed IBS in 19 general population cohorts was 38.5 per 10000 person-years (interquartile range=20-45.3). In 14 cohorts with specific medical disorders, median incidence was 92 per 10000 person-years (IQR: 73.9-119). Apart from gastroenteritis, the most common risk factors were other medical disorders, female sex, age (both young and old), anxiety and depression, life events/stress, frequent healthcare use, pain and sleep disorders. The results were conflicting for alcohol consumption, smoking and BMI. Incidence rates were similar in different countries but risk factors differed. Incidence rates were generally lower than previous estimates reflecting physician-diagnosed IBS. The results highlight the importance of other medical and psychosocial problems in the onset of IBS in addition to prior gastrointestinal infections. Aetiological research could be enhanced by studying the underlying mechanisms relating to all of these risk factors.

Why Do Japan and South Korea Record Very Low Levels of Perceived Health Despite Having Very High Life Expectancies?

Japan and Korea follow a unique trend in which, despite reporting two of the highest life expectancies (LEs) among the Organization for Economic Co-operation and Development (OECD) countries, the proportion of people with good self-rated health (SRH) is disproportionately low. We sought to explain this high-LE-low-SRH paradox by examining associations among LE, the prevalence of good SRH, and healthcare utilization. Our hypothesis was that countries with more frequent healthcare use would demonstrate poorer SRH and that SRH would not show a meaningful association with LE among developed countries. This study extracted data from Health at a Glance 2017 by the OECD for 26 countries with valid and comparable information on LE, SRH, and the number of doctor consultations per capita. Correlations among LE, good SRH, and number of doctor consultations per capita were analyzed. The number of annual doctor consultations per capita and the prevalence of good SRH were closely correlated (correlation coefficient=−0.610); excluding outliers produced a higher correlation coefficient (−0.839). Similar patterns were observed when we replaced good SRH with poor SRH. Meanwhile, the correlation coefficient between annual per capita doctor consultations and LE was quite low (−0.216). Although good SRH is closely related to better LE at the individual level, this was not true at the national level. Frequent use of healthcare in Japan and Korea was strongly correlated with poorer SRH, without any meaningful correlation with LE.

Patterns and costs of health-care utilisation in Australian children: The first 5 years.

To describe patterns of health-care utilisation and costs of a cohort of Australian children in the first 5 years of life and to investigate demographic factors associated with high health-care utilisation. This was a secondary data analysis of prospectively linked health-care utilisation data, including primary and secondary health-care consults, hospitalisations and emergency. The subjects were 350 children from a disadvantaged area of Sydney. Outcomes were the frequency and cost of all health-care consults from birth to 5 years of age. Multivariable logistic regression examined the odds of being a high health-care user in relation to child and family characteristics. Children had more health-care consults and higher annual health-care costs in the first 2 years of life (mean 12 health-care visits per year, mean cost Australian dollars (AUD) 1400 per child) than in the next 3 years (8 visits per year, AUD 900 per child). Primary care consults formed 86% of all health-care encounters but only contributed to 30% of the total costs. Factors positively associated with frequent use of health care in the first 2 years of life included being male, mother not married/de facto and annual household income of less than AUD 40000. Frequent users mostly accessed primary care services. There was no association between demographic factors and frequent use of health care in years 3-5 of life. Children from low-income or single-parent families may require additional support services during the first 2 years of life. Maintaining or increasing access to free or very low-cost primary health-care services for disadvantaged families will promote equity in health.

Experiences of health services among patients with chronic conditions

Introduction : Patients with chronic illnesses often have complex health care needs and use multiple social and health care services. This study examined experiences about health care use among persons with chronic conditions and whether these experiences were associated with sociodemographic factors, health care needs and use of health care services. Methods : The data were from a randomly sampled population survey concerning health care experiences n=2626, response rate 46%. In this study we used a subgroup of persons with a chronic illness n=1282. The outcome measures were experiences about: access to care, respectful treatment, participation to care and coordination of care during the last 12 months. The explanatory factors were sociodemographic factors, need for care functional limitation, depression, use of health services ambulatory care and hospitalization and having a continuous therapeutic relationship regular physician. Multivariate logistic regression was used to analyze the relationships between the explanatory and outcome variables. Results : In fully adjusted models, more negative experience of care on all dimensions were reported by those with sever functional limitations ORs 0.35-0.49 and frequent visit to ambulatory care ORs 0.43-0.59, while continuous therapeutic relationship was related better experiences on all dimensions ORs 1.50-1.91. Depression was related to more negative experiences in respectful treatment OR= 0.54 and poorer coordination of care OR=0.61. Those who had been hospitalized during the past year reported more problems in respectful treatment OR=0.57 and coordination of care OR=0.41. Compared to those using public health centers as the main site of ambulatory care, better access to care was reported by those using private clinic OR=2.24, occupational health care OR=1.91 or hospital outpatient clinic OR=2.45. Participation to care was more often reported by those using hospital outpatient clinic as main site of care compared to other groups. Discussion : In conclusion, these results indicate poor responsiveness of the health care system among those with complex health care needs and frequent use of health care. The lesson learned from the study is that many of the common problems of the Finnish health care system, such as poor and inequitable access to care and problems in integration, are reflected also in experiences of those with higher health care needs. Frequent attenders 10% of health care users are estimated to cause a substantial proportion of all health care costs. Thus, organizations and responsiveness of health care should be monitored from the point of view of these vulnerable users. The limitation of the study is that we were not able to examine experiences in terms of specific illnesses. Future studies should focus on condition specific health care needs and experiences.

Update on Diagnosis and Management of Severe Asthma

Patients with severe asthma comprise 5% to 10% of the patient population with asthma, but they use 60% of treatment costs. As a result of high morbidity and mortality rates and frequent health care use, these patients are commonly encountered in primary care settings. Treatment is complex and often requires an interdisciplinary approach to reduce risks, treat comorbidities, optimize medications, and to engage patients in care. Through early diagnosis, patient education, the provision of standard of care asthma management, and close collaboration with specialists, nurse practitioners can facilitate timely and comprehensive treatment that can improve patient outcomes.

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: a cluster preference randomized controlled trial

BackgroundThe consequences of treatment for Head and Neck cancer (HNC) patients has profound detrimental impacts such as impaired QOL, emotional distress, delayed recovery and frequent use of healthcare. The aim of this trial is to determine if the routine use of the Patients Concerns Inventory (PCI) package in review clinics during the first year following treatment can improve overall quality of life, reduce the social-emotional impact of cancer and reduce levels of distress. Furthermore, we aim to describe the economic costs and benefits of using the PCI.MethodsThis will be a cluster preference randomised control trial with consultants either ‘using’ or ‘not using’ the PCI package at clinic. It will involve two centres Leeds and Liverpool. 416 eligible patients from at least 10 consultant clusters are required to show a clinically meaningful difference in the primary outcome. The primary outcome is the percentage of participants with less than good overall quality of life at the final one-year clinic as measured by the University of Washington QOL questionnaire version 4 (UWQOLv4). Secondary outcomes at one-year are the mean social-emotional subscale (UWQOLv4) score, Distress Thermometer (DT) score ≥ 4, and key health economic measures (QALY-EQ-5D-5 L; CSRI).DiscussionThis trial will provide knowledge on the effectiveness of a consultation intervention package based around the PCI used at routine follow-up clinics following treatment of head and neck cancer with curative intent. If this intervention is (cost) effective for patients, the next step will be to promote wider use of this approach as standard care in clinical practice.Trial registration32,382. Clinical Trials Identifier, NCT03086629. Protocol: Version 3.0, 1st July 2017.

Health-care use before a first demyelinating event suggestive of a multiple sclerosis prodrome: a matched cohort study

Degenerative processes in neurodegenerative diseases can start years before clinical manifestation. We aimed to establish whether a multiple sclerosis prodromal period exists by examining patterns of health-care use before a first demyelinating event. In this matched cohort study, we used data from linked health administrative and clinical databases from four Canadian provinces (British Columbia, Saskatchewan, Manitoba, and Nova Scotia) to compare hospital, physician, and prescription use data from people with multiple sclerosis and matched general population controls in the 5 years before the first demyelinating disease claim (health administrative index date) or clinically reported symptom onset (clinical index date). Rate ratios (RRs) were estimated using negative binomial regression and combined across provinces using random effect models. The primary outcome was all-cause use of health care during each of the 5 years before the health administrative or clinical index date. The health administrative cohort included 14 428 multiple sclerosis cases and 72 059 matched controls for whom data were available between April, 1984, and April, 2014. Annual health-care use increased steadily between 5 years and 1 year before the first demyelinating disease claim in people with multiple sclerosis compared with controls (from RR 1·26 [95% CI 1·16-1·36] to 1·78 [1·50-2·10] for hospital admissions; from 1·24 [1·16-1·32] to 1·88 [1·72-2·07] for physician claims; and from 1·23 [1·06-1·41] to 1·49 [1·41-1·59] for prescriptions, assessed as drug classes). Similar patterns for physician claims and prescriptions were observed in the cohort with available clinical symptom onset (3202 individuals with multiple sclerosis and 16 006 controls), although the differences in use in each of the 5 years mostly did not reach statistical significance. More frequent use of health care in patients with multiple sclerosis than in controls in the 5 years before a first demyelinating event, according to health administrative data, suggests the existence of a measurable multiple sclerosis prodrome. These findings have clinical and research implications, including the establishment of an earlier window of opportunity to identify and potentially treat multiple sclerosis. National Multiple Sclerosis Society.