Individual Healthcare Utilization Research Articles

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use – results of a scoping review

BackgroundBesides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.MethodsWe used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the ‘Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)’ recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.ResultsOf the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.ConclusionsSocioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California.

The impacts of homelessness on health and health care access are detrimental. Intervention and efforts to improve outcomes and increase availability of affordable housing have mainly originated from the public health sector and government. The role that large community-based health systems may play has yet to be established. This study characterizes patients self-identified as homeless in acute care facilities in a large integrated health care system in Northern California to inform the development of collaborative interventions addressing unmet needs of this vulnerable population. The authors compared sociodemographic characteristics, clinical conditions, and health care utilization of individuals who did and did not self-identify as homeless and characterized their geographical distribution in relation to Sutter hospitals and homeless resources. Between July 1, 2019 and June 30, 2020, 5% (N = 20,259) of the acute care settings patients had evidence of homelessness, among which 51.1% age <45 years, 66.4% males, and 24% non-Hispanic Black. Patients experiencing homelessness had higher emergency department utilization and lower utilization of outpatient and urgent care services. Mental health conditions were more common among patients experiencing homelessness. More than half of the hospitals had >5% of patients who identified as homeless. Some hospitals with higher proportions of patients experiencing homelessness are not located near many shelter resources. By understanding patients who self-identify as homeless, it is possible to assess the role of the health system in addressing their unmet needs. Accurate identification is the first step for the health systems to develop and deliver better solutions through collaborations with nonprofit organizations, community partners, and government agencies.

Impact of COVID-19 related movement restrictions on the follow-up care visits of adults with chronic conditions: A Saudi arabian survey study

AimsLockdown measures implemented during the initial phase of the pandemic resulted in the delay and disruption of healthcare utilization for individuals with chronic conditions. We aimed to evaluate the impact of COVID-19 movement restrictions on the follow-up care visits of individuals with chronic illnesses. We also assessed the possible reasons patients missed their follow-ups and the potential barriers impeding follow-up during the pandemic. MethodsA total of 397 adults with pre-existing medical conditions participated in an online cross-sectional survey from October to December 2022. The study sample comprised 57 % females and 43 % males, with a mean age of 43 years. A 36-item online self-report survey was used for data collection.Results: Fifty-five percent of participants reported missing their follow-up during COVID-19 pandemic, and 14 % made emergency department visits due to their missed follow-up appointments. In addition, 24 % experienced complications due to their missed appointments. The mean score on the fear of COVID-19 scale was 17.8 ± 6.5 (SD). For the majority of participants (60 %), pandemic-related restrictions were the predominant barrier to their follow-up visits. Additionally, we found that as individuals’ COVID-19 fear scores increased, the likelihood of missing a follow-up care visit also increased (AOR: 1.067; p-value = 0.001). However, participants who did not perceive COVID-19 pandemic–related restrictions as a barrier were less likely to miss their follow-up visits (AOR: 0.581; p-value = 0.031). Furthermore, those who understood the significance of follow-up care were less likely to miss any of their follow-up visits (AOR: 0.224; p-value < 0.001) than those who had limited understanding of its importance. ConclusionThe results showed that pandemic-related movement restrictions negatively affected attendance at follow-up visits for people with pre-existing health conditions. Initiatives should therefore be undertaken during global public health emergencies to provide medical and psychological support to vulnerable and high-risk groups.

Regional Variation in Health Care Utilization Among Adults With Inadequate Cardiovascular Health in the USA.

Background Prior evidence of region-level differences in health outcomes and specialized healthcare services in the US poses questions of whether there are differences in utilization of healthcare that may account for regional differences in healthcare outcomes. This study aimed to examine regional differences in healthcare utilization for individuals with poor cardiovascular health (CVH) compared to those with ideal/intermediate CVH. Methods In this cross-sectional analytical study, two 3-year periods (2008-2010 and 2018-2020) were pooled and analyzed using multivariate Poisson's regression of region on counts of healthcare utilization, while controlling for relevant covariates. The interaction of the non-southern regions with recent years was to reveal how the regional dispersion in healthcare usage was changing over time for the non-southern regions compared to the south. Results The results showed significant regional variation in healthcare usage for individuals with poor CVH, with lower health utilization rates observed primarily in southern states, consistent with higher rates of coronary heart disease in those regions. The impact of a unit improvement on CVH score was to reduce the level of healthcare utilization by 15.7% ([95% CI, 15 - 17%; p < 0.001]) for individuals with poor CVH and 19.1% ([95% CI, 19 - 20%; p < 0.001]) for the intermediate and ideal subgroups, with the Northeast exhibiting the highest level of healthcare usage. Conclusion Our results suggest that there is a need for public health interventions to reduce regional disparities in access to healthcare for the people at greatest risk of cardiovascular events by considering individual factors as well as the broader regional and policy contexts where these people live.

The effect of income shocks on health behaviors: Evidence from a low-income country

This study examines the income effect on health spending and health behaviors in Vietnam. We measure income shock by lottery prizes, controlling for spending on the lottery. Lottery prizes have no significant effect on the healthcare utilization of individuals. However, we find that lottery winnings result in a significant increase in spending on healthcare. A 1% increase in lottery winnings results in a 0.08% increase in expenditure on medicine and a 0.09% increase in the total amount individuals spend on healthcare. The effect on expenditure on healthcare tends to be larger for older people. A concern with increased income is the unexpected effect on risky health behaviors, such as smoking and drinking. In this study, we do not find that lottery prizes lead to greater spending on tobacco and alcohol.

HSD19 Comparing the Health Care Utilization of Those with Limited English Proficiency and Use of a Language Interpreter to Similar Individuals without Use of a Language Interpreter at Mayo Clinic

Evidence is unclear on whether individuals with Limited English Proficiency (LEP) and access to a trained language interpreter have greater or less health care utilization compared to similar individuals without access to an interpreter. This paper seeks to examine the health care utilization of individuals with LEP at Mayo Clinic who used an interpreter compared to those who did not.

Association of Comorbidity With Healthcare Utilization in People Living With Dementia, 2010-2019: A Population-Based Cohort Study.

Evidence on the healthcare utilization associated with comorbidity in people with dementia is lacking in Chinese societies. This study aimed to quantify healthcare utilization associated with comorbidity that is common in people living with dementia. We conducted a cohort study using population-based data from Hong Kong public hospitals. Individuals aged 35+ with a dementia diagnosis between 2010 and 2019 were included. Among 88,151 participants, people with at least two comorbidities accounted for 81.2%. Estimates from negative binomial regressions showed that compared to those with one or no comorbid condition other than dementia, adjusted rate ratios of hospitalizations among individuals with six or seven and eight or more conditions were 1.97 [98.75% CI, 1.89-2.05] and 2.74 [2.63-2.86], respectively; adjusted rate ratios of Accident and Emergency department visits among individuals with six or seven and eight or more conditions were 1.53 [1.44-1.63] and 1.92 [1.80-2.05], respectively. Comorbid chronic kidney diseases were associated with the highest adjusted rate ratios of hospitalizations (1.81 [1.74-1.89]), whereas comorbid chronic ulcer of the skin was associated with the highest adjusted rate ratios of Accident and Emergency department visits (1.73 [1.61-1.85]). Healthcare utilization for individuals with dementia differed substantially by both the number of comorbid chronic conditions and the presence of some specific comorbid conditions. These findings further highlight the importance of taking account of multiple long-term conditions in tailoring the care approach and developing healthcare plans for people with dementia.

Disparities in Guideline Concordant Statin Treatment in Individuals With Chronic Obstructive Pulmonary Disease.

Cardiovascular disease (CVD) affects the prognosis of patients with chronic obstructive pulmonary disease (COPD). Black women with COPD have a disproportionate risk of CVD-related mortality, yet disparities in CVD prevention in COPD are unknown. We aimed to identify race-sex differences in the receipt of statin treatment for CVD prevention, and whether these differences were explained by factors influencing health care utilization in the REasons for Geographic And Racial Differences in Stroke (REGARDS) COPD study sub-cohort. We conducted a cross-sectional analysis among REGARDS Medicare beneficiaries with COPD. Our primary outcome was the presence of statin on in-home pill bottle review among individuals with an indication. Prevalence ratios (PR) for statin treatment among race-sex groups compared to White men were estimated using Poisson regression with robust variance. We then adjusted for covariates previously shown to impact health care utilization. Of the 2032 members within the COPD sub-cohort with sufficient data, 1435 participants (19% Black women, 14% Black men, 28% White women, and 39% White men) had a statin indication. All race-sex groups were less likely to receive statins than White men in unadjusted models. After adjusting for covariates that influence health care utilization, Black women (PR 0.76, 95% confidence interval [CI] 0.67 to 0.86) and White women (PR 0.84 95% CI 0.76 to 0.91) remained less likely to be treated compared to White men. All race-sex groups were less likely to receive statin treatment in the REGARDS COPD sub-cohort compared to White men. This difference persisted in women after controlling for individual health care utilization factors, suggesting structural interventions are needed.

Income, education, and hospitalization in Canada: results from linked census and administrative data

BackgroundAddressing population health inequities begins with quantifying how social factors affect the health and health care utilization of individuals. Such quantification relies on the availability of detailed health and demographic data. Unfortunately, administrative health care data rarely includes detailed demographic information. Data linkage, which combines administrative health data with national-level census or survey data, enables researchers to examine socio-economic inequalities in health care utilization in greater detail.Data and methodsWith access to a unique Canadian dataset linking data from the Hospital Discharge Database (DAD) from 2006 to 2007 with detailed individual-level socio-demographic data from the 2006 Canadian Census, we are able to examine the patterning of hospitalization in Canada in the early 2000s across a variety of socio-demographic variables. We examine the association of education and income, controlling for immigration status, rural residence, marital status and ethnicity, with hospitalization rates for both ambulatory care sensitive conditions (ACSCs) and non-ambulatory care sensitive conditions (non-ACSCs) for children and youth, working-age adults, and older adults, in models stratified by sex.ResultsAge standardized hospitalization rates show that there is a clear socio-economic gradient in hospitalization in Canada in the 2000s. Education and income are independently, inversely associated with hospitalization for males and females across three broad age groups. These associations are stronger for ACSCs than non-ACSCs. The association of other socio-demographic variables, such as immigrant status, and rural residence is also stronger for hospitalization for ACSCs. The association of socio-economic status with hospitalization for ACSCs is strongest for working age women and men, and is somewhat attenuated for older adults.ConclusionsLower socio-economic status is associated with a higher likelihood of hospitalization for men and women in Canada across three broad age groups in the 2000s. These associations are stronger for ACSCs, suggesting that in addition to increased likelihood of disease, decreased access to preventative care may be driving up hospitalization rates for marginalized groups. We conclude with the recommendation that in order to track progress in reducing health inequities, health systems should either collect detailed individual-level socio-demographic data or link their administrative health data to existing demographic data sets.

Health care utilization of individuals with Rome IV irritable bowel syndrome in the general population.

BackgroundIrritable bowel syndrome (IBS) is highly prevalent worldwide but mechanisms for healthcare seeking behaviours in this patient group are poorly understood.ObjectiveTo describe healthcare utilization and identify factors associated with seeking healthcare amongst IBS subjects in the general population.MethodsAn internet survey was completed by 6,300 individuals equally distributed between United States, United Kingdom and Canada. The Rome IV diagnostic questionnaire was used to identify subjects with IBS. Data on demographics, medical history, gastrointestinal (GI) and non‐GI symptoms, quality of life and health care consumption was collected.ResultsA total of 5,931 subjects were included; 274 (4.6%) IBS subjects and 5657 (95.3%) non‐IBS controls. IBS subjects reported more doctor consultations for both GI and other health problems as well as increased use of medication and rate of abdominal surgery (appendectomy excluded). Having healthcare insurance or access to free public healthcare (adjusted odds ratio (AOR) 4.49, 95% confidence interval (CI) 1.31–15.44), followed by high frequency of bloating (AOR 2.65, 95% CI 1.42–4.93) and increasing age (AOR 1.02, 95% CI 1.01–1.05) were found to be independently associated with being an IBS consulter while doctor‐diagnosed IBS subjects were more likely to be female and to report abdominal pain as their most bothersome GI symptom than other consulters with IBS.ConclusionIBS subjects have higher healthcare utilization than non‐IBS controls, medication use and abdominal surgery included. Furthermore, consulters with and without an IBS diagnosis differ in sex distribution and symptom profiles. Hence, awareness of the possibility of unnecessary medical and surgical treatment in IBS subjects and a sex‐related diagnostic bias by doctors is warranted.

424 - Cardiac Healthcare Disparities in Schizophrenia at the End-of-Life

Background:Schizophrenia is a serious mental illness associated an early mortality of 15 to 20 years. Eighty percent of deaths are due to cardiovascular disease, and the risk of sudden cardiac death is three- times greater than the general population. Both modifiable and non-modifiable risk factors like lifestyle, medication side-effects, genetics, and healthcare disparities have been identified, but this relationship is not fully understood.Research Objective:To examine cardiac-related healthcare utilization of individuals with schizophrenia at the end-of-life.Method:As a retrospective cohort study the Mayo Clinic Unified Data Platform (UDP) was used to identify a schizophrenia group (SG) (n = 610) 50 years or older with a death date between 1/1/1999 – 1/1/2019 and control group (n = 610) matched by gender (53% women) and age of death (72.8 ± 12.4 years). Measures of cardiovascular healthcare utilization were evaluated within a 12-month period prior to death. Pearson’s chi-square (χ2), analysis of variance was used (ANOVA), and logistic regression were used for statistical analysis.Results:SG was more likely than controls to be unmarried, unemployed, or from racial minority groups (all p&lt;0.001) and was more likely to have diabetes mellitus (p&lt;0.001) or cardiovascular disease (p=0.004). SG was less likely to receive an electrocardiogram (ECG) (p&lt;0.001), echocardiogram (p=0.003), or cardiac catheterization procedure (p&lt;0.001), and more likely to receive hemoglobin A1C testing (p&lt;0.001). Of those receiving an ECG, SG had a greater mean QTc interval (453.8 ms vs. 438.0 ms; p&lt;0.001) and were twice as likely to have an ECG result interpreted as “prolonged QTc” (p&lt;0.001).Between group differences for utilization of troponin or low-density lipoprotein testing, or pacemaker- related procedures were not statistically significant.Conclusion:Individuals with schizophrenia in this cohort were less likely to receive cardiovascular evaluations and interventions during their last year of life. Despite the higher likelihood for prolonged QTc, a recognized biomarker of cardiac risk, SG was less likely to receive an ECG. Given the greater cardiac comorbidity and higher risk of sudden cardiac death in schizophrenia, interventions are needed to address these disparities in care.

Healthcare Utilization Among Justice‐Involved Individuals Enrolled in Medicaid: Lessons from a Midwestern State

Research ObjectiveJustice‐involved individuals have historically faced numerous barriers to accessing timely healthcare, especially after release from incarceration. This population disproportionately needs behavioral health services, for which continuity of care is crucial to prevent poor outcomes. To address this need, several states including Indiana have implemented policies to facilitate Medicaid enrollment for justice‐involved adults. Specifically, Indiana implemented policies and procedures, including Medicaid eligibility expansion through an 1115 waiver, the ability of the Indiana Department of Corrections (IDOC) to submit applications for coverage on behalf of the individuals prior to release, and allowing for coverage to be suspended rather than terminated during incarceration. Increased Medicaid coverage after release followed, but healthcare utilization patterns after release are not yet well understood. The purpose of this study is to describe healthcare utilization for individuals released from state prisons and enrolled in the Healthy Indiana Plan, Indiana's Medicaid coverage for adults.Study DesignIn this retrospective, observational study, we linked IDOC release data to Medicaid enrollment, claims data, and other state program data. We described trends in healthcare utilization in the four months following Medicaid coverage and further explore trends by time between release and Medicaid coverage.Population StudiedJustice‐involved adults released from IDOC state correctional facilities and subsequently enrolled in Medicaid between 2013‐2018 (n=19,636).Principal FindingsApproximately 80% of individuals received some sort of healthcare within the first 4 months of becoming enrolled in Medicaid, with the highest utilization occurring in the emergency department (ED, 44.1%) and office visits (41.2%). The average time to first service was approximately 55 days (SD: 37.4). The ED was the most common first setting for care (30.8%) and 20.3% of first encounters were for mental health and substance use‐related services. Those who were enrolled in Medicaid shortly after their release (within 7 days) were more likely to utilize any care compared to those who were enrolled later (89.5% vs 77.0%, p &lt;0.0001) and received care an average of 27 days quicker (p&lt;0.0001). In addition, those who were enrolled quickly were more likely to receive any care in almost all settings, receive substance use and mental health services, and seek care faster than those who were enrolled later.ConclusionsWe identify high healthcare utilization in this population after release from prison, largely higher than among the general population. In addition, we find that individuals who receive Medicaid coverage shortly after release are more likely to seek care in most settings and faster. While this may be indicative of better access to care, this may also be driven by selection or individuals becoming enrolled presumptively at the time of an acute encounter.Implications for Policy or PracticeThe transition that occurs when individuals are released from prison represents an important opportunity to fill gaps in coverage and facilitate continuous access to needed services. Findings from this study provide a better understanding of the patterns of healthcare utilized after release from prison, including the settings and types of care received. Further research is needed to understand of the extent to which Medicaid coverage improves behavioral health outcomes and chronic disease management.Primary Funding SourceState of Indiana

Monitoring health services delivery: Evidence from civil conflict in Nepal

• This paper explores the short- and medium-term health consequences of moderate-intensity conflicts. • Results show short-term improvement in health status while short- and medium-term increase in healthcare utilization. • The study unfolds the role of exposure to new social norms through civil conflicts in changing people’s behavior. • The results suggest regular monitoring of public services provisions may result in ensuring qualified public services. The effects of armed conflict on delivery of public services such as health and education is a contested issue. Poor health and education have important consequences on the process of human capital formation. We analyze the short- and medium-term effects of the civil conflict in Nepal from 1996 to 2006 on individual health status and institutional healthcare utilization. Using three waves of nationally representative household surveys before, during, and after the conflict period and by exploiting district level variations in the exposure to conflict, measured by the number of conflict-related casualties, we estimate the relationship between armed conflict and individual health status and healthcare utilization during and after the conflict period. Our estimates using the difference-in-differences approach reveal that conflict is associated with short-term improvement in individual health status: a one standard-deviation increase in conflict-related casualties is associated with an approximately 4-percentage point improvement in individual health status, as measured by the incidence of sickness. We find that conflict is associated with both short- and medium-term increases in healthcare utilization; a one standard-deviation increase in conflict-related casualties is associated with an approximately 10-percentage point improvement in individual healthcare utilization probability. We provide evidence for the possible mechanisms of these conflict health associations. We find that improvements in the quality of healthcare services, particularly through Maoists’ monitoring of staff absenteeism in healthcare facilities, has led to better health outcomes in conflict-intense areas. These findings suggest that monitoring improves the quality of public services provisions and, therefore, is an important tool to ensure the resilience of human capital formation process in conflict-hit societies.

Health Care Utilization of Individuals Affected by Homelessness: Illinois, 2011-2018.

To describe individuals coded as homeless in state-level data comprising of outpatient and inpatient cases over a multi-year period to provide public health surveillance data on the health care utilization and needs of this population. In this cross-sectional study, outpatient and inpatient visits coded for homelessness were identified from the Illinois Hospital Discharge Database from January 1, 2011 through December 31, 2018. Demographic characteristics, primary diagnosis and comorbid conditions, and hospital course of treatment were described. Predictors of discharge to a health care facility versus routine discharge to home or self-care were evaluated using multivariable logistic regression. There were 154,173 patient visits predominantly involving males, those aged 25-64 years, and non-Hispanic Whites and African Americans. The majority had comorbidities of depression, psychosis, and/or substance abuse (70.2%) and a routine discharge to home or self-care (81.9%). Discharge to home or self-care relative to another health care institution was associated with having charity coverage and being Black/African American. Those experiencing homelessness experience a high burden of health concerns. Hospital billing records can be used to prioritize the distribution of limited public health resources for health care programs and interventions among those experiencing homelessness.

Eviction as a Disruptive Factor in Health Care Utilization: Impact on Hospital Readmissions and No-show Rates.

Residential eviction is a component of housing instability that negatively affects physical and mental health, but the effect of eviction on health care utilization, specifically hospital readmissions and outpatient no-show rates, is not known. We conducted a retrospective review of health care utilization of individuals evicted from public housing between January 2013 and December 2017, investigating hospital readmissions and no-show rates one year before and after eviction. 131 individuals who had been evicted had one year of data pre-and post-eviction. The majority were African American (97.7%) and female (80.9%). There was no significant change in 30-, 60-, and 90-day hospital readmissions (p>.05). No-show rate decreased from 27.57 per person per year to 20.13 (p=.05). For our study population, health care utilization was not disrupted. The decreased no-show rate represents an opportunity for health systems to engage with patients on social factors affecting their health post-eviction.

Mental Illness Inequalities by Multimorbidity, Use of Health Resources and Socio-Economic Status in an Aging Society.

Background: Mental illness, multi-morbidity, and socio-economic inequalities are some of the main challenges for the public health system nowadays, and are further aggravated by the process of population aging. Therefore, it is widely accepted that health systems need to focus their strategies for confronting such concerns. With guaranteed access to health care services under universal coverage in many health systems, it is expected that all services be provided equally to patients with the same level of need. Methods: In this paper, we explore the existence of inequalities in the access to services of patients with mental illness taking into account whether they are multimorbid patients, their socioeconomic status, and their age. We take advantage of a one-year (2010–2011) database on individual healthcare utilization and expenditures for the total population (N = 2,262,698) of the Basque Country. Results: More comorbidity leads to greater inequality in prevalence, being the poor sicker, although with age, this inequality decreases. All health services are more oriented towards greater utilization of the poor and sicker, particularly in the case of visits to specialists and emergency care. Conclusions: Mental health inequalities in prevalence have been identified as being disproportionally concentrated in the least affluent areas of the Basque Country. However, inequalities in the utilization of publicly-provided health services present a pro-poor orientation. As this region has adopted a system-wide transformation towards integrated care, its mental health delivery model offers excellent potential for international comparisons and benchlearning.

Life expectancy and health care utilization of individuals with dementia in Ontario, Canada: A population-level study

IntroductionIt is important for dementia patients, their families and caregivers, and health planners to have an understanding of life expectancy and the likely care experience of patients from dementia diagnosis to end-of-life.&#x0D; Objectives and ApproachUsing administrative health data of all dementia patients in Ontario, Canada (2014 to 2017) and period life table methodology, life expectancy and average health care use and cost for individuals from dementia diagnosis to death was examined. Dementia was ascertained by a validated case ascertainment definition and information from long-term care, home care and complex continuing care assessments. Formal care was categorized as inpatient, outpatient, home care or long-term care.&#x0D; ResultsLife expectancy at dementia diagnosis was 8.7 years and 9.8 years for men and women diagnosed prior to age 75, of which 3.7 years (42%) and 4.7 years (49%) was spent receiving formal care, respectively. Life expectancy was 4.4 and 5.2 years for men and women diagnosed after age 75, of which 2.2 years (50%) and 3.1 years (60%) was spent receiving care, respectively. Women received proportionally more long-term and home care compared to men, while men received more inpatient and outpatient care. In the year prior to dementia diagnosis, individuals received formal care for 20 days per 100 person-days. Those at the end-of-life received care for 79 days per 100 person-days, including 55 long-term care days and 7.8 inpatient care days. Average direct health care costs from diagnosis to end-of-life was $230,000 and was higer for women and those diagnosed before age 75.&#x0D; ConclusionThe burden of formal care for those with dementia is substantial. The results of this study will be used by physicians to inform conversations with patients, their families and caregivers around what to expect after a dementia diagnosis, and by health care planners for population health planning.

The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis.

BackgroundGeographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use.MethodsUsing data from a nationally representative survey (N = 649 625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities.ResultsWide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR) = 0.82, 95% confidence interval (CI) = 0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR = 1.23, 95% CI = 1.05-1.43) and with travel times (OR = 0.72 95% CI = 0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR = 1.65, 95% CrI = 1.59-1.70 decreasing to 1.61, 95% CrI = 1.56-1.67) or inpatient care utilisation (MOR = 1.63, 95% CrI = 1.55-1.69 decreasing to 1.60 95% CrI = 1.54-1.66).ConclusionsSupply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.

Healthcare utilization of individuals with substance use disorders following Affordable Care Act implementation in a California healthcare system

BackgroundPractitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy. MethodsWe conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1–$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood. ResultsService utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2–3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment. ConclusionsHigher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves.

Socio-economic and behavioral determinants of prescription and non-prescription medicine use: the case of Turkey

Demographic and socio-economic factors determine pharmaceutical health care utilization for individuals. Prescription and non-prescription medicine use are expected to have different determinants. Even though prescription and non-prescription medicine use is being well researched for developed countries, there are only a few studies for developing countries. This paper aims to analyze the socio-economic and individual characteristics that determine the use of prescription and non-prescription medicine. We examine the issue for the specific case of Turkey since Turkey's health system has undertaken significant changes in the last two decades and especially after 2003 with the "Health Transformation Programme". Data from the nationally representative "Health Survey" are used in the analysis. The data set covers the 2008-2016 period with two-year intervals. Pooled multivariate logistic regression is employed to identify the underlying determinants of prescription and non-prescription medicine use. When compared to 2008, non-prescription medicine use decreases until 2012, however, an increasing trend appears after 2012. For prescription medicine use, a decreasing trend emerges after 2012. Findings from the marginal effects indicate that for non-prescription medicine use, the highest effect stems from the health status. For prescription medicine use, the highest marginal effects arise from age, health and employment status indicating the importance of the need and predisposing factors. Decreasing non-prescription medicine use largely depends on easier access to health care service utilization. Although having a health insurance has a positive relationship with prescription medicine use, there is still a problem for individuals living a rural area and heaving a lower income level since they are more likely to use non-prescription medicine.