Future Healthcare Use Research Articles

A study on investigating unplanned readmission patterns

To explain frequent hospital readmissions, this study aimed to determine whether definable subtypes exist within a cohort of subjects with chronic illness with regard to factors associated with a patient's readmission patterns and to compare whether these factors vary between subjects in groups with different profiles. A descriptive correlational survey was conducted and data were collected by using a structured questionnaire. Seventy-four readmitted subjects were recruited in three general hospitals in Hong Kong. Five outcome variables were employed in the study: predisposing characteristic, need factors, health behaviour, health status or outcomes and enabling resources. A cluster analysis yielded two clusters. Each cluster represented a different profile of the sample on patient use of healthcare services. Cluster A consisted of 41.9% (n = 31) and Cluster B consisted of 58.1% (n = 43) of the patients. Cluster A patients, more of whom were male, were younger, more educated, had higher activities of daily living scores and fewer of them had received community nurse services than patients of Cluster B. Cluster A patients (32.3%) had more than one readmission record within 28 days than Cluster B patients (9.3%, p = 0.017). Our study shows that community nurse services can reduce the rate at which they are readmitted a second time. However, such services may have a positive effect only on a group of patients whose profile is similar to the patients in Cluster B and not for patients such as those in Cluster A. A clear profile may help healthcare policy makers make appropriate strategies to target a specific group of patients to reduce their readmission rates. The identification of risk for future healthcare use could enable better targeting of interventional strategies within these groups. The results of this study might provide hospital managers with a model to design specified interventions to reduce unplanned hospital readmissions for each profile group.

Does Current Asthma Control Predict Future Health Care Use Among Black Preschool-aged Inner-City Children?

Factors predictive of future asthma must be identified among young inner-city children, who suffer disproportionately from asthma. We investigated whether current asthma control predicts future asthma-related health care use among inner-city preschool-aged children with asthma. A total of 150 inner-city preschool-aged children with asthma were followed prospectively for 6 months. At baseline, symptom frequency and reliever-medication use were assessed to classify children into National Asthma Education and Prevention Program-derived control categories. Long-term controller-medication use was also assessed, as well as asthma-related health care use at baseline and at 3 and 6 months. The mean age was 4.4 years, 92% were black, and 39% reported long-term controller use. At baseline, 37% were classified as having mild-intermittent, 17% had mild-persistent, 21% had moderate-persistent, and 25% had severe-persistent asthma control. Significant changes in asthma control were observed over time, including 46% of children originally categorized with mild-intermittent asthma who had worsened asthma control by 3 months. Asthma control significantly predicted future health care use 3 months later but not 6 months later. Multivariate analyses showed that, once control status was known, reported use of long-term controller medication added little additional predictive value. Among inner-city preschool-aged children, significant fluctuations in asthma control occur as early as 3 months after assessment. Poor control but not long-term controller-medication use is an independent predictor of future asthma-related health care use at 3 months but is not significantly predictive of 6-month outcomes. Therefore, clinicians caring for inner-city children with asthma should consider reassessing asthma control at least every 3 months to identify those at highest future risk and to provide early interventions.

Psychological morbidity and illness appraisals of patients with cardiac and non-cardiac chest pain attending a rapid access chest pain clinic: a longitudinal cohort study

Objectives:To assess the psychological morbidity and illness beliefs in newly referred patients with chest pain, and to compare the psychological morbidity of patients with pain of cardiac origin with that...

The role of illness perceptions in patients with medical conditions

In this article we summarize recent investigations into the influence of illness perceptions on outcomes in patients with medical conditions. Developments in assessment include the publishing of a new brief scale to assess illness perceptions and the examination of the relationship between patient drawings of their illness and outcomes. Recent studies in primary care highlight the importance of patients' beliefs and emotional responses to their illness as being important in influencing their satisfaction with the consultation, reassurance following negative medical testing and future healthcare use. Recent research shows illness perceptions to have associations with a number of outcomes in chronic illness including self-management behaviours and quality of life. As yet, however, few interventions have been developed designed to change illness perceptions and improve illness outcomes. Emerging areas of research include the application of illness perceptions to mental illness and genetic and risk factor testing. Research on illness perceptions has confirmed that patients' beliefs are associated with important outcomes in a broadening range of illnesses and risk factor testing. New interventions based on this model have the potential to improve patient outcomes but have yet to be widely developed and applied.

Predicting the Risk of Hospital Admission in Older Persons—Validation of a Brief Self‐Administered Questionnaire in Three European Countries

To validate the Probability of Repeated Admission (Pra) questionnaire, a widely used self-administered tool for predicting future healthcare use in older persons, in three European healthcare systems. Prospective study with 1-year follow-up. Hamburg, Germany; London, United Kingdom; Canton of Solothurn, Switzerland. Nine thousand seven hundred thirteen independently living community-dwelling people aged 65 and older. Self-administered eight-item Pra questionnaire at baseline. Self-reported number of hospital admissions and physician visits during 1 year of follow-up. In the combined sample, areas under the receiver operating characteristic curves (AUCs) were 0.64 (95% confidence interval (CI)=0.62-0.66) for the prediction of one or more hospital admissions and 0.68 (95% CI=0.66-0.69) for the prediction of more than six physician visits during the following year. AUCs were similar between sites. In comparison, prediction models based on a person's age and sex alone exhibited poor predictive validity (AUC <or= 0.57). High-risk individuals (Pra score >or= 0.5) were 2.3 times as likely (95% CI=2.1-2.6) as low-risk individuals to have a hospital admission, and 2.1 times as likely (95% CI=2.0-2.2) to have more than six physician visits. The Pra instrument exhibits good validity for predicting future health service use on a population level in different healthcare settings. Administrative data have shown similar predictive validity, but in practice, such data are often not available. The Pra is likely of high interest to governments and health insurance companies worldwide as a basis for programs aimed at health risk management in older persons.

Beware the pitfalls of ill-placed questions – revisiting questionnaire ordering

One of the early lessons of good questionnaire design is the ordering of the questions – making sure that bias is not introduced by the inappropriate placement of a question or series of questions. Sometimes the bias can be intentional when questions are strategically placed in order to infl uence the respondent’s response and encourage recall (Sudman et al. 1996). This is usually the exception – not the rule. A lesson learnt and willingly shared involves the placement of a single question asking respondents to rate their overall health. The use of a single question is increasingly being used as other measures of overall health status and functioning can be lengthy and diffi cult to interpret and score. A general health question often used is the fi rst question of the MOS Short Form 36 (SF36) (Ware & Sherbourne 1992), and is commonly referred to as the SF1. The SF1 refers to physical and mental health, as assessed by individuals, according to their own values, and has been found to be a strong indicator of future health care use and mortality (McCallum et al. 1994). Based on fundamentals of good survey design that the questionnaire should start with “something easy” so as to build respondent confi dence and rapport (Dillman 1978; O’Rourke 2001), the SF1 has been included in many South Australian (SA) telephone surveys – usually as the fi rst health question. This question is deemed to be of interest, non-threatening and easy to answer (Trochim 2000).

The Implications of Unmet Need for Future Health Care Use: Findings for a Sample of Disabled Medicaid Beneficiaries in New York

Using survey data linked with Medicaid claims data, this study examines the consequences of unmet need for future health care use for a sample of disabled Medicaid beneficiaries in Westchester County, New York. Among other things, we find that individuals reporting unmet need in 1999 were more likely to use emergency room and hospital care in 2000 than those not reporting unmet need. Addressing the barriers to care that underlie unmet need could generate cost savings to Medicaid and provide better health outcomes for program beneficiaries.

Impact of depressive symptoms on adult asthma outcomes

Psychological disorders, including depression, are common in adults with asthma. Although depression is treatable, its impact on longitudinal asthma outcomes is not clear. To elucidate the impact of depressive symptoms on patient-centered outcomes and emergency health care use in adults with asthma. We conducted a prospective cohort study of 743 adults with asthma who were recruited after hospitalization for asthma. Depressive symptoms were defined as having a score of 16 or more on the Center for Epidemiologic Studies Depression Scale. We examined the impact of depressive symptoms on patient-centered outcomes (validated severity-of-asthma score, Marks Asthma Quality of Life Questionnaire, and 12-Item Short-Form Health Survey physical component summary score) and on future emergency health care use for asthma ascertained from computerized databases. The prevalence of depressive symptoms was 18% (95% confidence interval [CI], 15%-21%) among adults with asthma. Depressive symptoms were associated with greater severity-of-asthma scores after controlling for age, sex, race/ ethnicity, educational attainment, and cigarette smoking (mean score increment, 2.6 points; 95% CI, 1.8-3.4 points). Furthermore, depressive symptoms were associated with poorer asthma-specific quality of life (mean score increment, 19.9 points; 95% CI, 17.7-22.1 points) and poorer physical health status (mean score decrement, 3.7 points; 95% CI, 1.5-5.8 points). Depressive symptoms were associated with a greater longitudinal risk of hospitalization for asthma (hazard ratio, 1.34; 95% CI, 0.98-1.84). After controlling for differences in preventive care for asthma, the relationship was stronger (hazard ratio, 1.45; 95% CI, 1.05-2.0). Depressive symptoms are common in adults with asthma and are associated with poorer health outcomes, including greater asthma severity and risk of hospitalization for asthma.

Health-related quality of life and health service use among older adults with osteoarthritis.

To examine the relationship between health-related quality of life (HRQOL) and health service use among older adults with osteoarthritis (OA). Subjects were 9,043 Medicare-enrolled survey respondents with a prior International Classification of Diseases, Ninth Revision code for OA. Analyses examined the relationship of 5 Centers for Disease Control and Prevention HRQOL items (general health, mental health, pain, activity limitation, and sleep) to physician visits, prescription analgesic or antiinflammatory use, and arthroplasty during 1 year of followup. In analyses controlling for demographic and health-related variables, greater pain frequency was associated with increased odds of visiting a physician, using analgesic or antiinflammatory drugs, and having arthroplasty (P < 0.001). Poorer general health was associated with increased odds of analgesic or antiinflammatory use but decreased odds of arthroplasty (P < 0.01). More days of activity limitation and poor mental health were associated with decreased odds of analgesic or antiinflammatory use (P < 0.01). These HRQOL variables, especially pain frequency, can be valuable tools for estimating future health care use among older adults with OA.

Predicting Elderly at Risk of Increased Future Healthcare Use: How Much Does Diagnostic Information Add to Prior Utilization?

We determined whether case-mix information from administrative data can identify those likely to be high users of healthcare in the following year. An individual's healthcare utilization equaled the number of days (between 1 and 365) during the year on which an individual received inpatient or outpatient services. A binary outcome was defined as using 92 days or more (i.e., being in the top 2%) in year two. We included case-mix data in the models from two risk adjustment systems, Adjusted Diagnostic Groups (ADGs) from Adjusted Clinical Groups and Hierarchical Condition Categories (HCCs) from Diagnostic Cost Groups. We examined three types of logistic regression models: (1) prior use models (year one utilization plus age and sex), (2) diagnostic models (HCCs and ADGs as dummy variables plus age and sex), and (3) combined models (prior use plus diagnostic models). For the models with the best c-statistics (i.e., area under the receiver operating characteristic (ROC) curve), we compared ROC curve plots. We also fit linear regression models and compared their sensitivity and specificity to the logistic models.

Children's health care use: a prospective investigation of factors related to care-seeking.

To determine the best predictors of the amount of children's health care use. Child health, psychosocial, and family status variables were collected. Families were then followed prospectively for 2 years to gather health care use data. Multivariate regression analysis was used to determine factors related to volume of child health care use. 367 mothers and children ages 5 to 11 years continuously enrolled in a staff model HMO. Child health care visits obtained from a computerized database comprised the dependent variable. Independent variables were organized into a 5-component framework including: Demographic Characteristics; Family Characteristics; Child Health and Prior Health Care Use; Child Behavior and Mental Health; and Mothers' Mental Health and Health Care Use. The volume of a child's past health care use was the best predictor of future health care use, with the presence of past acute recurring illnesses, child pain and mother's retrospective health care use also serving as significant predictors in the model. Analysis of a second model was conducted omitting children's past use of health care. In this model the mother's worry about child health was the best predictor of use, with child health and child and maternal psychosocial variables significantly contributing to explained variance in the model. This study supports prior research indicating past use is the best predictor of future health care use. In addition, the study suggests that maternal perceptions of child health and maternal emotional functioning influence the decision-making process involved in seeking health care on behalf of children. Effective management of pediatric health care use needs to address broader needs of the child and family beyond solely the child's health, most notably maternal functioning.

Prediction of physician visits and prescription medicine use for back pain

The primary purpose of this study was to examine the extent to which specific patient attitudes and beliefs about medical care and self-care for back pain predict future healthcare use. An automated database allowed examination of the predictive relationships in two primary care patient samples. In general, beliefs that physicians should find a definitive cause and permanent cure for back pain predicted neither physician visits nor prescription medication fills. Patient attitudes endorsing the benefits of medical treatment for back pain (as opposed to a permanent cure) predicted the use of these specific healthcare services. In a third sample of primary care back pain patients, we assessed whether a four-session self-care intervention modified those attitudes and beliefs shown to predict future healthcare use. The group intervention was associated with changes in attitudes about use of physician services but not medication use. A secondary purpose was to examine initial psychometric properties of a proposed back pain Self-Care Orientation Scale made up of the original 11 items. Factor analyses of the item set yielded three factors, but inconclusive results; the internal consistency of the identified sub-scales was only moderate. However, findings that a subset of items predicted physician visits and prescriptions medication fills, and was sensitive to change following a self-care intervention, suggest avenues for improving measurement of self-care orientation. These findings help clarify specific patient attitudes and beliefs that are related to healthcare utilization and suggest that a subset of these beliefs can be modified through a brief educational intervention.

Socioeconomic outcomes of combined spine surgery and functional restoration in workers' compensation spinal disorders with matched controls.

A longitudinal cohort study (n = 448) comparing functionally restored discectomy (n = 123) and fusion (n = 101) workers' compensation patients to matched, unoperated control patients (n = 123 and n = 101, respectively). To determine successful treatment outcomes uniquely important in a workers' compensation environment when spine surgery is combined with comprehensive tertiary rehabilitation, to optimize anatomic and social sequelae. Multiple recent studies confirm suboptimal socioeconomic outcomes for spinal surgery for degenerative conditions in a workers' compensation venue. In other musculoskeletal regions, there is a clear relationship between the quality of postsurgical rehabilitation and the impact on disability, recurrent injury, and future health care use. It is hypothesized that poor surgical outcomes in compensation injuries may result from outmoded postoperative methods, rather than failures of patient selection or surgical technique. No previous combination of surgery plus rehabilitation has been carefully evaluated with disabled workers undergoing spine surgery. Functional restoration is an individualized medically directed, interdisciplinary program using quantitatively directed exercise progression, psychotherapeutic interventions, and monitoring of specific socioeconomic outcomes for chronically disabled workers. This study prospectively evaluated a cohort of consecutive functional restoration program graduates (n = 1202). Two surgical groups, discectomy (n = 123) and fusion (n = 101) were matched to two groups of unoperated control patients, control/discectomy and control/fusion, selected from the same cohort of patients with chronic spinal disorders based on age, gender, race, length of disability, and workers' compensation jurisdiction. A structured clinical interview was administered 12 months after program completion, with a contact rate of 95% to 98%. Socioeconomic outcomes for work return, health care use, and recurrent lost-time injury were assessed. All groups demonstrated a return-to-work incidence of more than 85%, but work retention at 1 year was higher for the fusion group than for the discectomy or control/fusion groups. Health care use was significantly higher for the discectomy group than the control/discectomy or fusion groups for reoperation (8% vs. 4%/ 2%), as well as other factors. All groups showed comparable recurrent lost-time injury rates (2-3.3%), and made comparable improvements in prospectively collected physical and psychological measures. Discectomy patients had work, health care utilization, and recurrent injury outcomes comparable with those for unoperated control patients. Fusion patients had better outcomes of work retention, reoperation, and health care use compared with the unoperated control patients and even with discectomy patients, in spite of more cases of previous surgery and greater duration of disability. The discectomy and fusion cohorts of operated chronic spinal disorder compensation patients with subsequent functional restoration had the best documented outcomes found in the literature for this population. In spite of the common presumption that spine surgery patients fare poorly in a workers' compensation environment, these results demonstrate that such patients can show remarkably successful objective outcomes if accompanied by effective rehabilitation, documenting efficacy and clinical utility. A new clinical approach is required to evaluate prospectively the combination of surgery and rehabilitation in chronic pain/disability workers' compensation patients, in which the surgical role is to correct an anatomic lesion, but the socioeconomic outcomes either occur spontaneously or are effected through some form of rehabilitation.