Utilization Of Health Care System Research Articles

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study.

This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia. Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits. There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14days, access to homecare services, and previous hyperglycemia encounters in the past 5years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group. This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

Market resilience of orthopaedic hip/knee arthroplasty sales during COVID-19.

The coronavirus 2019 (COVID-19) pandemic led to a marked decrease in elective surgical volume and orthopaedic device sales. The aim of this paper was to quantify this decrease and the related financial impact on the largest hip/knee arthroplasty companies by: (1) tracking individual hip/knee company valuations; (2) calculating aggregate changes in overall hip/knee arthroplasty market valuations; and (3) quantifying quarterly hip/knee revenues relative to prior years. Financial data on the top five hip/knee arthroplasty companies by size between January 1, 2019, and October 1, 2020, was collected from a Wall Street financial database, S&P Capital IQ. Changes in valuation of these companies were compared against benchmark market indices, the S&P500 and Vanguard Healthcare ETF. U.S. hip/knee arthroplasty-specific revenue for Q1 and Q2 of 2019 and 2020 was collected from Securities Exchange Commission 10-Q forms. Quarterly revenue changes were calculated using 1-2Q19 revenues as baselines and aggregate to approximate the overall hip/knee arthroplasty market. The top five hip/knee companies lost $179.2billion (32.7% loss) in market value from pre COVID-19 market highs to COVID-19 market lows (March 2020), while S&P500 and Vanguard Healthcare ETF decreased 36.1 and 33.2%, respectively. From market lows to October 2020, arthroplasty companies rallied 38.6% while the S&P500 and Vanguard Healthcare ETF regained 43.5 and 56.4% respectively. Notably, this occurred while aggregate 1Q/2Q20 revenue lagged 7.1/41.8% relative to 2019, with an overall decrease of $1.58B (24.8%). Similar to the overall market and healthcare sector, the top five hip/knee arthroplasty companies have recovered from their COVID market lows. Our results reveal that the valuations of hip/knee companies remained robust during COVID, even as revenues fell, likely due to strong investor confidence in the industry outlook and the greater overall healthcare system utilization.

1339. Effects of Tixagevimab-Cilgavimab in Clinical Practice is Consistent with Preliminary Neutralization Studies

Abstract Background Emergency use of tixagevimab-cilgavimab was based on data collected prior to the emergence of SARS-CoV-2 omicron variant and subvariants. Dosing recommendations changed twice based on neutralization data alone, leading to patients receiving different doses at varying intervals. We provide real-world data on efficacy of tixagevimab-cilgavimab in immunocompromised patients throughout 2022, including the incidence and timing of infection based on dosing scheme. Methods Charts of 471 patients who received and 126 patients who declined administration of tixagevimab-cilgavimab were analyzed through December 14th, 2022. We evaluated incidence of SARS-CoV2, severity, risk factors and vaccination status. For analysis, we grouped patients with similar dosing: Group A received one initial dose of 150mg/150mg of tixagevimab-cilgavimab, Group B received at least 300 mg/300 mg of tixagevimab-cilgavimab before July 1st, and Group C patients were up to date with the FDA dosing guidelines. Results The tixagevimab-cilgavimab group had higher incidence of stem cell transplant or CAR T-cell therapy (115/471, 24% compared to 18/126, 14% p < 0.01) and had higher vaccination status (411/471, 89% compared to 37/126, 29%, p < 0.0001). Patients that received tixagevimab-cilgavimab had a trend towards higher incidence of SARS-CoV-2 infection (70/471, 15% compared to 11/126, 9%; p = 0.08). Incidence of SARS-CoV-2 was similar amongst all dosing groups (6/21, 29% in Group A; 37/251, 15% in Group B, and 27/199, 14% in Group C, p = 0.188). Group C experienced the most infections in November and early December 2022.Figure 1.Number of SARS-CoV-2 infections per month based on dosing regimen Group A patients received one initial dose of 150 mg/150mg of tixagevimab-cilgavimab. Group B patients received at least 300 mg/300 mg of tixagevimab-cilgavimab before July 1st, 2022 . Group C patients were up to date with the FDA dosing guidelines. Conclusion The tixagevimab-cilgavimab group demonstrated increased incidence of SARS-CoV-2. This may reflect increased healthcare system utilization, as most infections were self-reported in this study. Those with the FDA recommended dose were most likely to develop SARS-CoV-2 in November and December 2022 when circulating variants were not neutralized by tixagevimab-cilgavimab in vitro. This suggests in vitro neutralization data correlates with clinical efficacy. Disclosures All Authors: No reported disclosures

Public healthcare system utilization for chronic hepatitis C infection in Vietnam

BackgroundHealthcare utilization is typically adversely affected when the treatment is expensive and requires multiple visits. We examined the determinants of healthcare-seeking for Hepatitis C virus (HCV) infection which is asymptomatic, chronic, and requires costly treatment in an urban tertiary care referral hospital in Vietnam.MethodsWe conducted a secondary analysis of hospital data for patients attending the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam between 2017 and 2020 specifically for HCV infection treatment. Poisson regression was used to determine the effect of personal factors (age, sex, comorbidities) and structural factors (health insurance, proximity to the facility, seasonality, year of visit) on the number of hospital visits.ResultsFrom 2017 to 2020 a total of 22,052 eligible patients sought treatment in the hospital. Among the patients, 50.4% were males and 58.7% were > 50 years of age. The mean number of visits per person was 2.17. In the multivariate analysis compared to 2017, the number of hospital visits increased by 4% in 2018 and then significantly decreased in 2019 and 2020. Visit numbers were significantly lower (6%) among South East region residents compared to those from Central Highlands and for those who lived further away from the hospital. The visit numbers were significantly higher among older age groups (5–11%), those with health insurance (6%), and those with comorbidities (5%) compared to others. Although the number of hospital visits by females was higher (7%) than males in 2017, it significantly decreased in subsequent years.ConclusionsOur study indicated that there are both structural and individual factors affecting the number of visits for HCV treatment. To meet the global strategy for elimination of HCV, Vietnam Government needs to address the structural and personal barriers to healthcare seeking, with a special focus on women.

Dialysis resource allocation in critical care: the impact of the COVID-19 pandemic and the promise of big data analytics.

The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.

Real-Time Continuous Glucose Monitoring Reduced Costly Diabetes-Related Events in Adolescents and Young Adults despite Lack of Short-Term Reduction in Hemoglobin A1c

Real-time continuous glucose monitoring (rtCGM) can directly improve patient outcomes, including decreased health care system utilization and associated costs. The purpose of this study was to evaluate the clinical benefits of rtCGM use in a high-risk, under-resourced cohort of adolescents and young adults (AYA) with type 1 diabetes (T1D) who had no prior access to rtCGM. The effects of rtCGM use on hemoglobin A1c (A1c) and the frequency of health care events (i.e., diabetes-related emergency room (ER) visits, hospitalizations, emergency medical services (EMS), and after-hour emergency calls) were evaluated regarding payor costs in 33 AYA with ≥70% rtCGM use. Secondary aims included the evaluation of a phone-based pattern management intervention. The frequency of health care events decreased at 12 and 24 weeks for all participants, and there was no significant difference by treatment group. We estimated that the use of rtCGM in this cohort results in a projected annualized cost-savings of $195,943 to $294,864 or 43–65% per year based on Medicare or list pricing for rtCGM, respectively. Results also revealed improvements in A1c at 12 weeks for all study participants, but this was not maintained at 24 weeks for the phone-based pattern management intervention group. Our findings suggest that rtCGM may be an effective tool for reducing diabetes-related events and underscores the importance of access. Future studies are needed to further examine tailored interventions and support to optimize rtCGM use and glycemic health in high-risk AYA.

Effectiveness of Structured Care Coordination for Children With Medical Complexity

Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care. To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care. This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months. Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care. Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost. Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01). The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions. ClinicalTrials.gov Identifier: NCT02928757.

A patient navigation model to improve complex wound care outcomes.

In Brief The authors created a blended model to navigate interprofessional team assessments of patients with complex wounds. This model benefited patients and improved health care system utilization with projected cost savings.

A Patient Navigation Model to Improve Complex Wound Care Outcomes.

To create a blended format model to navigate interprofessional team assessments of patients with complex wounds during COVID-19 as a quality improvement process. During clinical assessments, patients were interviewed in their homes with representation from their circle of care and primary nurse on site linked to a live virtual interprofessional blended remote team model (wound care nurse specialist, advanced wound care doctor). Eligible patients had completed a wound care clinical pathway without wound closure. Palliative patients with complex wounds and patients without precise/accurate diagnoses were also included. This process addressed the components of Wound Bed Preparation 2021: manage the cause, address patient-centered concerns, determine the ability to heal, optimize local wound care, and evaluate outcomes on an ongoing basis. Since April 2020, 48 patients were referred to the Home and Community Care Support Services patient navigation interprofessional team. Patients' home-care services were initiated between 2012 and 2021. The team provided closure in 29% of patients and the wound surface area reduced in 66%. Pain was reduced in 73% of patients and appropriate infection management was implemented in 79%. In addition, nursing visits were reduced by 73% and there was a 77% decrease in supply usage. This project validated the Wound Bed Preparation Paradigm 2021 as a process for assessing patients with complex wounds using a blended virtual and home-based assessment. Patient navigation with this blended model benefited patients and improved healthcare system utilization with projected cost savings.

Does What Happens in the ED Stay in the ED? The Effects of Emergency Department Physician Workload on Post-ED Care Use.

Emergency department (ED) crowding has been a pressing concern in healthcare systems in the U.S. and other developed countries. As such, many researchers have studied its effects on outcomes within the ED. In contrast, we study the effects of ED crowding on system performance outside the ED-specifically, on post-ED care utilization. Further, we explore the mediating effects of care intensity in the ED on post-ED care use. We utilize a dataset assembled from more than four years of microdata from a large U.S. hospital and exhaustive billing data in an integrated health system. By using count models and instrumental variable analyses to answer the proposed research questions, we find that there is an increasing concave relationship between ED physician workload and post-ED care use. When ED workload increases from its 5th percentile to the median, the number of post-discharge care events (i.e., medical services) for patients who are discharged home from the ED increases by 5% and it is stable afterwards. Further, we identify physician test-ordering behavior as a mechanism for this effect: when the physician is busier, she responds by ordering more tests for less severe patients. We document that this "extra" testing generates "extra" post-ED care utilization for these patients. This paper contributes new insights on how physician and patient behaviors under ED crowding impact a previously unstudied system performance measure: post-ED care utilization. Our findings suggest that prior studies estimating the cost of ED crowding underestimate the true effect, as they do not consider the "extra" post-ED care utilization.

Patient Health Questionnaire (PHQ-9): A depression screening tool for people with epilepsy in Vietnam

BackgroundDepression is a common mental disorder in people with epilepsy. Depression has a negative impact on medical and surgical treatment of epilepsy thus affecting the quality of life. Despite its high prevalence, depression has been under-recognized and treated improperly. It may also lead to missed work, increased healthcare system utilization, and higher direct medical costs. ObjectivesThis study aimed to evaluate the accuracy of the Vietnamese Patient Health Questionnaire (PHQ-9) as a screening tool for depression in people with epilepsy. MethodsThis cross-sectional study was conducted prospectively at epilepsy clinic at Nguyen Tri Phuong hospital, Ho Chi Minh City, Viet Nam from December 2019 to March 2020. A total of 91 adult people with epilepsy were recruited. After completing the Vietnamese PHQ-9 questionnaires, each participant was interviewed in a structured clinical interview for DSM-5 (SCID-5) to establish a diagnosis of major depressive disorder. The diagnostic accuracy of the PHQ-9 was assessed using diagnostic efficiency statistics compared with the gold standard structured interview. ResultsThe prevalence of major depression in this sample was 25.3%. The areas under receiver operating characteristic (ROC) curve index of PHQ-9 had an estimated value of 0.91. The PHQ-9 at a cutoff point of 8 had the great overall balance of sensitivity (87.0%) and specificity (82.4%). At the cutoff point of 10, PHQ-9 had a higher specificity of 94.1%, but a lower sensitivity of 78.0%. ConclusionsThe Vietnamese version PHQ-9 is an efficient and valid screening tool for depression in people with epilepsy in clinic settings.

Evaluating racial disparities in healthcare system utilization and caregiver burden among older adults with dementia

ABSTRACT Objective: To evaluate racial differences in healthcare utilization and caregiver burden in a culturally diverse population of older adults with dementia. Method: One hundred and thirty-three dyads (person with dementia, PWD and caregiver, CG), with at least one emergency department (ED) visit or hospitalization 12 months prior, were enrolled. Independent sample t-tests and chi-squared analyses were performed to compare racial groups on healthcare utilization and CG burden. Mann–Whitney U test was used for item-level analyses, principal component analysis was used to examine relationships among outcomes, and regressions were used to identify the relationship between race and potential covariates. Results: PWD sample mean age was 79 years, predominantly female, and with high school education. Racial distribution was 65% White and 35% Black. CG sample mean age was 64 years, predominantly female, with more than 12 years of education. No differences were found for age or dementia severity across racial groups. Black PWD experienced more ED and ambulance utilization when compared to White counterparts. Non-emergency hospitalization rates were higher for White PWD. No significant differences were found by race for CG burden total score; however, item-level analysis suggested more anger, reduced social life, uncertainty, and inadequacy in White CGs. Regressions demonstrated a positive relationship between Black race and adult-child CGs with increased ED visits, while dyad educational attainment was associated with hospitalizations independent of race. Conclusions: Healthcare utilization disparities extend to older adults with dementia diagnoses. Our findings suggest that culturally tailored interventions may be appropriate. Future research is encouraged to explore the effect of other covariates.

Role of Community Health Workers in Addressing Dementia: A Scoping Review and Global Perspective.

The current increase in global dementia prevalence deserves public health intervention. While limited access to health care and a shortage of health care workers are significant shortcomings, utilizing community health workers (CHWs) could be a promising way to improve dementia care through cost-effective approaches. This scoping review synthesizes existing research on roles of CHWs in dementia-related services. PubMed, CINAHL, Scopus, CABI Global Health, Web of Science, PsycINFO, and Cochrane Library were searched from inception to October 2, 2019, and yielded 1,594 articles. Five broad areas emerged as potential roles of CHWs from 10 eligible articles: educational and community awareness, screening for dementia, screening for HIV-associated dementia, utilization of health care systems and other dementia-related resources by patients, and services to dementia caregivers. This scoping review sheds light on important contributions of CHWs in addressing dementia among vulnerable communities/groups around the world.

Development and validation of a machine learning model predicting illness trajectory and hospital utilization of COVID-19 patients: A nationwide study.

ObjectiveThe spread of coronavirus disease 2019 (COVID-19) has led to severe strain on hospital capacity in many countries. We aim to develop a model helping planners assess expected COVID-19 hospital resource utilization based on individual patient characteristics.Materials and MethodsWe develop a model of patient clinical course based on an advanced multistate survival model. The model predicts the patient's disease course in terms of clinical states—critical, severe, or moderate. The model also predicts hospital utilization on the level of entire hospitals or healthcare systems. We cross-validated the model using a nationwide registry following the day-by-day clinical status of all hospitalized COVID-19 patients in Israel from March 1 to May 2, 2020 (n = 2703).ResultsPer-day mean absolute errors for predicted total and critical care hospital bed utilization were 4.72 ± 1.07 and 1.68 ± 0.40, respectively, over cohorts of 330 hospitalized patients; areas under the curve for prediction of critical illness and in-hospital mortality were 0.88 ± 0.04 and 0.96 ± 0.04, respectively. We further present the impact of patient influx scenarios on day-by-day healthcare system utilization. We provide an accompanying R software package.DiscussionThe proposed model accurately predicts total and critical care hospital utilization. The model enables evaluating impacts of patient influx scenarios on utilization, accounting for the state of currently hospitalized patients and characteristics of incoming patients. We show that accurate hospital load predictions were possible using only a patient’s age, sex, and day-by-day clinical state (critical, severe, or moderate).ConclusionsThe multistate model we develop is a powerful tool for predicting individual-level patient outcomes and hospital-level utilization.

Sociocultural barriers to hepatitis B health literacy in an immigrant population: a focus group study in Korean Americans

BackgroundChronic hepatitis B (CHB) is a major global health issue disproportionately affecting Asian Americans and other immigrant populations in the United States. Despite the high risk of morbid complications from CHB, the majority of individuals with CHB do not access healthcare due to a complex of barriers. These barriers influence health literacy which may affect behaviors linked to hepatitis B care. We aimed to identify and evaluate various sociocultural factors and how they interact with health literacy to impact CHB care and health seeking in a Korean American population.MethodsA total of 28 Korean American individuals with CHB were divided into 5 different focus discussion groups. This study investigated the participants’ sociocultural backgrounds as well as their awareness and utilization of the healthcare system that could influence their health literacy and behaviors in accessing care.ResultsOur analysis identified and concentrated on three themes that emerged from these discussions: low risk perception and knowledge of CHB and its complications; language, immigrant status, and stigma; and financial and institutional barriers. The participants’ overall awareness of the disease and prevention methods demonstrated poor understanding of important characteristics and potential outcomes of the disease. Additionally, differences in cultural expectations and a lack of understanding and utilization of healthcare systems affected health literacy in further limiting participants’ motivation to seek care.ConclusionsThe present study suggests that there are culture-specific barriers to health literacy governing individuals’ health behavior in accessing hepatitis B care. These findings may inform strategies for developing culturally tailored resources and programs and for facilitating the implementation of community-wide hepatitis B education and screening initiatives in immigrant communities.

Evaluation of the effect of store-and-forward teledermatology on in-person health care system utilization in a safety-net public health and hospital system

To the Editor: Store-and-forward (SAF) teledermatology has demonstrated cost effectiveness in several studies, particularly by reducing in-person dermatology visits and travel costs for patients.1-4 However, few studies have evaluated its effects on health care system utilization over a specific period. We sought to evaluate the effect of teledermatology on dermatology referral–related in-person health care facility utilization at Parkland Health and Hospital System (PHHS), a Dallas safety-net hospital system.

Agreement in the CARTaGENE cohort between self-reported medication use and claim data.

To describe the agreement of self-reported medication use with claim prescription records and to ascertain factors associated with agreement between the two data sources. Baseline data on self-reported medication use was extracted from CARTaGENE, a cohort study in Quebec, Canada, and from the provincial health insurance records (dispensation database) of the same individuals. Kappa statistics were used to estimate concordance beyond chance between the two data sources. Logistic regression models were adjusted to estimate the association between agreement and selected individual's characteristics (sex, age, education, region, income, utilization of health care system, and comorbidities). Agreement between self-reported medication use and administrative data varied considerably across medication classes (kappa 0.54 for respiratory system and 0.91 for systemic hormonal preparations). Overall, agreement improved when a fixed time window of 90 days was used for exposure measurement. Sex, education level, frequency of health care use and the number of reported medications were associated with agreement. Overall, there was a reasonable agreement between the two data sources, but important variations were found for the different drug classes. These results could be used by researchers to more accurately assess drug exposures using real-world data, which are increasingly important to regulators.

A Framework for the Community Psychiatrist's Role in the COVID-19 Response.

The COVID-19 pandemic has disrupted community mental health center (CMHC) operations by limiting in-person access to patients and contributing to staff absenteeism. States adjust social distancing levels over time in response to changes in economic needs, healthcare system utilization, and COVID-19 virus transmission levels. Community mental health centers also need to balance service needs with infection risk, which requires adjusting social distancing levels in response to changes in the local conditions. This article will: (1) briefly describe epidemiological indicators most useful for judging the local infection trends, (2) describe a strategy for organizing specific agency clinical functions on a social distancing level scale, (3) propose a set of agency phases to inform administrative responses to changes in the risk to operations, and (4) discuss the role of psychiatrists as physicians in a mental health agency during a pandemic.

Burden of influenza in Romania. A retrospective analysis of 2014/15 - 2018/19 seasons in Romania.

Influenza is a seasonal epidemic with a heavy negative impact both on population health, and healthcare system utilization; until now, there are only two burden of disease studies in the Romanian context. This study aims to quantify the burden of influenza for the Romanian population for the seasons 2014/15 to 2018/19, using health administrative databases. Incidence, hospitalization and mortality rates attributable to influenza as well as total number of influenza cases and deaths were estimated, for each season in the analyzed period, by combining the new cases reported by General Practitioners, Emergency Department presentations, hospitalizations, number of deaths, positivity rate of influenza, and probability to be consulted by a physician. Years of life lost due to premature death attributable to influenza complications were also computed. On average, 591,151 cases/season attributable to influenza were estimated during the period 2014/15 - 2018/19. The highest rates for incidence, hospitalization and presentation to emergency department were found in the age groups 0-4 years and 65 years and above. Influenza mortality rate was estimated at 3 per 100,000 persons and the 65 and above age group had the highest rate. About 3% of the total Romanian population is estimated to develop an influenza attributable disease in a non-pandemic season. An overall increasing trend of the mortality rate attributable to influenza may be also underlined. On average, a person loses 12 years due to premature death caused by complications of influenza.

An Evaluation of Statin Use Among Patients with Type 2 Diabetes at High Risk of Cardiovascular Events Across Multiple Health Care Systems.

Patients with more than one chronic condition often receive care from several providers and facilities, which may lead to fragmentation of care. Poor care coordination in dual health care system use has been associated with increased emergency department visits, hospitalizations, and costs. Dual health care system use is increasing among veterans, and we sought to evaluate the effect of dual health care system use on statin treatment in veterans with type 2 diabetes at high risk of cardiovascular events, using varying degrees of Centers for Medicare & Medicaid Services (CMS) services. This was a 10-year retrospective longitudinal cohort study of national clinical and administrative data that included 689,138 veterans with type 2 diabetes who were aged 65 years or older on January 1, 2006. Patients were followed from January 1, 2007, until December 31, 2016. Administrative and clinical data from the Veterans Health Administration's (VHA) Corporate Data Warehouse were merged with CMS inpatient, outpatient, and pharmacy data. Statin use was defined as any therapy and subcategorized as high versus low or moderate intensity per the American College of Cardiology/American Heart Association guidelines. Marginal generalized estimating equation-type models for longitudinal data were used to model the association between dual health care utilization status (< 50%, 50%-80%, and > 80% VHA utilization, with the first group serving as the reference group) and statin use after adjusting for measured covariates. The mean ages at baseline for each group were similar and ranged between 75.4 and 76.9 years. For the outcome of any statin use, the group with < 50% VHA utilization was significantly less likely to receive statin therapy compared with the group with > 80% VHA utilization (OR = 0.26, 95% CI = 0.26-0.26), while the group with 50%-80% VHA utilization was slightly more likely (OR = 1.05, 95% CI = 1.04-1.07). Similarly, for the high-intensity versus low-/moderate-intensity or no statins outcome, the group with < 50% VHA utilization was significantly less likely to receive a high-intensity statin compared with the group with > 80% VHA utilization (OR = 0.56, 95% CI = 0.55-0.57), while the group with 50%-80% VHA utilization was only slightly less likely (OR = 0.95, 95% CI =0.94-0.96). Among veterans with diabetes at high risk of cardiovascular events, dual health care system utilization status appeared to affect statin use. We observed lower odds for any statin use and high-intensity statin therapy among the cohort with the lowest degree of VHA utilization (i.e., < 50%). Interventions to increase statin use among veterans at high risk of cardiovascular events with lower degrees of VHA utilization should be explored. This study was supported by a grant funded by the Department of Veterans Affairs' Health Services Research and Development Service and was undertaken at the Health Equity and Rural Outreach Center (HEROIC) at Ralph H. Johnson Veteran Affairs Medical Center, Charleston, SC. The authors report no potential conflicts of interest relevant to this article. This article represents the views of the authors and not those of the Medical University of South Carolina or Veteran Health Administration.