Health Service Utilization Outcomes Research Articles

An umbrella review of pharmacist prescribing: stakeholders’ views and impact on patient outcomes

Abstract Introduction There is great geographical diversity in the degree of prescribing rights pharmacists have. In some countries such as the United Kingdom (UK), pharmacists have unrestricted prescribing rights following appropriate training; in other countries, pharmacists cannot legally prescribe. The impact of pharmacist prescribing (PP) has been studied in various qualitative and quantitative research studies, but this evidence has not been synthesised to support the development of PP internationally. Aim The aim of this umbrella review was to describe the international PP models, establish the impact of PP on patient outcomes and describe key stakeholders’ views of PP, by synthesising all the available systematic reviews (SRs). Methods Six databases (Embase, CINAHL, MEDLINE, Web of Science, Cochrane Library and PsycINFO) were searched, from January 2003 to June 2023, for key terms such as ‘pharmacist’, ‘prescribing’, ‘prescription’ and ‘systematic review’, ‘meta-analysis’, ‘meta-synthesis’. Systematic reviews that examined PP for any clinical condition, for patients of any age and in any healthcare setting were eligible for inclusion. SRs examining pharmacists’ interventions other than PP were excluded as were articles not published in English. Two researchers independently screened titles, abstracts and full texts for eligibility; discrepancies were resolved by discussion with a third reviewer. A data extraction tool was developed, piloted and refined prior to data extraction based on guidance from PRIOR[1] and the Joanna Briggs Institute (JBI).[2] Extracted information included: SR characteristics; inclusion and exclusion criteria; description of prescribing models, setting, clinical conditions, clinical and health service utilisation outcomes and key stakeholders’ views of PP. Data have been synthesised narratively due to the heterogeneity of included studies. Results A total of 6439 titles were retrieved from searches, with 917 duplicates removed. Following abstracts and full text screening (5522 and 129 respectively), 39 systematic reviews (8 qualitative; 19 quantitative and 12 mixed-methods) were included. The description of PP models varied within and between the SRs and demonstrated implementation of different PP models globally. Collaborative practice agreement with a physician, dependant prescribing by protocol and/or formularies were common in Canada and the United States, while supplementary prescribing and independent prescribing models were described in the UK. Prescribing activity was evident in all care settings and for a wide range of clinical conditions. SRs reporting on targeted clinical conditions, noted that patients of pharmacist prescribers had similar blood pressure control and depressive symptoms, better cholesterol and blood glucose control and reduced pain intensity when compared with patients of medical prescribers. SRs also suggests that pharmacist prescribers make fewer errors than non-pharmacists. Key stakeholders noted largely positive views towards PP, with a reduction in physician workload, an improvement in pharmacist job satisfaction, better utilisation of pharmacist knowledge and skills noted. Concerns over pharmacists’ diagnostic abilities, legal accountability for errors and appropriate implementation of PP models were noted. Conclusion A variety of PP models exist internationally. Careful examination of each model should be undertaken prior to adoption and implementation in countries where PP is currently not permitted.

The heterogeneous effects of China's hierarchical medical system reforms on health service utilisation and health outcomes among elderly populations: a longitudinal quasi-experimental study

BackgroundSystem-wide, comprehensive, primary health care (PHC)-oriented health reforms are infrequently introduced in low-income and middle-income countries and often poorly studied. China initiated a large-scale reform in 2015 that included multiple policies: partial gatekeeping, a family physician scheme, and increased system integration. These policies aimed to build a PHC-oriented health system and improve primary care utilisation. This study assessed the heterogeneous effects of the reforms on health service utilisation and health outcomes across regions and over time. MethodsIn this longitudinal quasi-experimental study, we used longitudinal data (2011–18) from a national survey on elderly populations and governmental yearbooks. This study exploits the staggered rollout of the reforms at the city level identified using web-scrapping. We employed an event study design to assess reform effects on (1) visits to PHC facilities, (2) admissions to hospital, (3) out-of-pocket expenditures (OOPEs), and (4) self-reported health. Models were adjusted for city and time fixed effects, along with demographic and socioeconomic characteristics at individual and provincial levels. Analysis was separated into rural and urban populations. Findings18 988 Chinese individuals aged 45 and older (mean age 60·4 years [SD 10·3], 9990 [52·6%] women, 8998 [47·4%] men) were included in the analysis. The reform was associated with increasing odds of visiting PHC facilities among rural populations, which became stronger in the 2 years after the reform (adjusted odd ratio [aOR] 1·35, 95% CI 1·02–1·84, p=0·0374; absolute effect sizes [probability] 3%) before it faded. Meanwhile, urban populations were unaffected (from aOR 1·22, 0·82–1·81 to 0·89, 0·50–1·57). The reform did not have a significant effect on admission to hospital (rural: from 0·97, 0·72–1·31 to 1·47, 0·85–2·55; urban: from 1·00, 0·69–1·43 to 1·59, 0·76–3·30) or OOPEs (rural: from 260·32 Chinese Yuan, 95% CI –6·34 to 526·97, to 693·07 Chinese Yuan, –102·96 to 1489·09; urban: from 235·37 Chinese Yuan, –405·10 to 875·83, to 859·93 Chinese Yuan, –199·02 to 1918·88). Urban populations reported higher self-reported health after the reforms than the year before the reforms (1·50, 1·12–2·01, p=0·0002; 5%). InterpretationSystem-wide PHC-oriented reforms might contribute to short-term increases in primary care utilisation in elderly populations with implications for urban–rural inequalities. Effects on financial protection and health inequality were limited. Efforts in improving the accessibility and quality of primary care in deprived areas are indispensable to addressing the persistent inverse care law and to achieving Universal Health Coverage for all countries. FundingNone.

The effectiveness of a transitional care program for frail older adults between hospital and home: A randomized controlled trial

This study evaluated the effectiveness of a transitional care program developed for frail older adults. A single-blinded randomized controlled trial was conducted. Thirty-two frail older adults were enrolled in the study. The experimental group was provided the transitional care program for 12 weeks (e.g., inpatient intervention, discharge intervention, and follow-up intervention), while the control group was provided the usual care. The program improved transition conditions (i.e., family interaction and community resource utilization) and transition response (i.e., unplanned emergency room visit rate, depression, and self-rated health). The transitional care program was effective in improving some health service utilization and clinical outcomes of frail older adults experiencing hospital-to-home transition; it thus contributed to promoting a safe transition experience.

Association between immigrant concentration and mental health service utilization in the United States over time: A geospatial big data analysis.

Immigrants (foreign-born United States [US] citizens) generally have lower utilization of mental health services compared with US-born counterparts, but extant studies have not investigated the disparities in mental health service utilization within immigrant population nationwide over time. Leveraging mobile phone-based visitation data, we estimated the average mental health utilization in contiguous US census tracts in 2019, 2020, and 2021 by employing two novel outcomes: mental health service visits and visit-to-need ratio (i.e., visits per depression diagnosis). We then investigated the tract-level association between immigration concentration and mental health service utilization outcomes using mixed-effects linear regression models that accounted for spatial lag effects, time effects, and covariates. This study reveals spatial and temporal disparities in mental health service visits and visit-to-need ratio among different levels of immigrant concentration across the US, both before and during the pandemic. Tracts with higher concentrations of Latin American immigrants showed significantly lower mental health service utilization visits and visit-to-need ratio, particularly in the US West. Tracts with Asian and European immigrant concentrations experienced a more significant decline in mental health service utilization visits and visit-to-need ratio from 2019 to 2020 than those with Latin American concentrations. Meanwhile, in 2021, tracts with Latin American concentrations had the least recovery in mental health service utilization visits. The study highlights the potential of geospatial big data for mental health research and informs public health interventions.

Cochlear implantation impact on health service utilisation and social outcomes: a systematic review

BackgroundHearing loss can have a negative impact on individuals’ health and engagement with social activities. Integrated approaches that tackle barriers and social outcomes could mitigate some of these effects for cochlear implants (CI) users. This review aims to synthesise the evidence of the impact of a CI on adults’ health service utilisation and social outcomes.MethodsFive databases (MEDLINE, Scopus, ERIC, CINAHL and PsychINFO) were searched from 1st January 2000 to 16 January 2023 and May 2023. Articles that reported on health service utilisation or social outcomes post-CI in adults aged ≥ 18 years were included. Health service utilisation includes hospital admissions, emergency department (ED) presentations, general practitioner (GP) visits, CI revision surgery and pharmaceutical use. Social outcomes include education, autonomy, social participation, training, disability, social housing, social welfare benefits, occupation, employment, income level, anxiety, depression, quality of life (QoL), communication and cognition. Searched articles were screened in two stages ̶̶̶ by going through the title and abstract then full text. Information extracted from the included studies was narratively synthesised.ResultsThere were 44 studies included in this review, with 20 (45.5%) cohort studies, 18 (40.9%) cross-sectional and six (13.6%) qualitative studies. Nine studies (20.5%) reported on health service utilisation and 35 (79.5%) on social outcomes. Five out of nine studies showed benefits of CI in improving adults’ health service utilisation including reduced use of prescription medication, reduced number of surgical and audiological visits. Most of the studies 27 (77.1%) revealed improvements for at least one social outcome, such as work or employment 18 (85.7%), social participation 14 (93.3%), autonomy 8 (88.9%), education (all nine studies), perceived hearing disability (five out of six studies) and income (all three studies) post-CI. None of the included studies had a low risk of bias.ConclusionsThis review identified beneficial impacts of CI in improving adults’ health service utilisation and social outcomes. Improvement in hearing enhanced social interactions and working lives. There is a need for large scale, well-designed epidemiological studies examining health and social outcomes post-CI.

Musculoskeletal pain during and after SARS-CoV-2 infection and healthcare utilization: a cross-sectional study

BackgroundThe COVID-19 pandemic necessitated the reorganization of health services to cater to the needs of individuals affected by the virus.ObjectiveThis study aimed to examine the association between musculoskeletal pain during and after SARS-CoV-2 infection and the utilization of health services among adults in southern Brazil. MethodsA cross-sectional study was conducted with individuals aged 18 years and older, who were diagnosed with COVID-19 between December 2020 and March 2021. Questionnaires were electronically collected using tablets through the REDCap platform via phone calls. The health service utilization outcomes assessed included Primary Health Care, general practitioners, private emergency care, and specialized services. The exposure variable was the presence of musculoskeletal pain during and after SARS-CoV-2 infection in different regions, such as cervical, upper limbs, thoracic, lumbar, and lower limbs. Poisson regression analysis was employed to assess the relationship between health service utilization during and after SARS-CoV-2 infection and musculoskeletal pain during and after the infection with SARS-CoV-2 among adults in southern Brazil. Data were analyzed using the Stata 16.1 statistical package. ResultsA total of 2,919 individuals were interviewed. Overall, individuals with musculoskeletal pain were found to utilize health services approximately 15 percentage points higher when compared to those without musculoskeletal pain. In adjusted analysis, individuals who reported musculoskeletal pain during and after SARS-CoV-2 infection were up to twice as likely to use health services. Among them, the emergency care unit was the most frequently used service, particularly in those with pain in the lower limbs (RP=2.19, 95% CI 1.66-2.87) and thoracic region (RP=2.04, 95% CI 1.47-2.84). Notably, the highest magnitudes of association were observed with emergency care units, specialist doctors, and specialized services, especially neurologists, who were two to three times more likely to be sought, followed by pulmonologists. ConclusionHealth service utilization was significantly associated with musculoskeletal pain during and after SARS-CoV-2 infection. All regions, except for the cervical region, showed a correlation with the use of Primary Health Care. The thoracic region featured an association with pulmonologists and emergency room utilization. Additionally, health services like emergency care units, specialist doctors, and specialized services, including cardiologists and neurologists, were commonly utilized across all regions in southern Brazil.

Effect of the COVID-19 pandemic on maternal and neonatal health services in three referral hospitals in Guinea: an interrupted time-series analysis

IntroductionIn sub-Saharan Africa, there is limited evidence on the COVID-19 health-related effect from front-line health provision settings. Therefore, this study aimed to analyse the effect of the COVID-19 pandemic on routine maternal and neonatal health services in three referral hospitals.Materials and methodsWe conducted an observational study using aggregate monthly maternal and neonatal health services routine data for two years (March 2019–February 2021) in three referral hospitals including two maternities: Hôpital National Ignace Deen (HNID) in Conakry and Hôpital Regional de Mamou (HRM) in Mamou and one neonatology ward: Institut de Nutrition et de Santé de l’Enfant (INSE) in Conakry. We compared indicators of health service utilisation, provision and health outcomes before and during the COVID-19 pandemic periods. An interrupted time-series analysis (ITSA) was performed to assess the relationship between changes in maternal and neonatal health indicators and COVID-19 through cross-correlation.ResultsDuring COVID-19, the mean monthly number (MMN) of deliveries decreased significantly in HNID (p = 0.039) and slightly increased in HRM. In the two maternities, the change in the MMN of deliveries were significantly associated with COVID-19. The ITSA confirmed the association between the increase in the MMN of deliveries and COVID-19 in HRM (bootstrapped F-value = 1.46, 95%CI [0.036–8.047], p < 0.01). We observed an increasing trend in obstetric complications in HNID, while the trend declined in HRM. The MMN of maternal deaths increased significantly (p = 0.011) in HNID, while it slightly increased in HRM. In INSE, the MMN of neonatal admissions significantly declined (p < 0.001) and this decline was associated with COVID-19. The MMN of neonatal deaths significantly decreased (p = 0.009) in INSE and this decrease was related to COVID-19.ConclusionThe pandemic negatively affected the maternal and neonatal care provision, health service utilisation and health outcomes in two referral hospitals located in Conakry, the COVID-19 most-affected region.

A189 EMERGENCY DEPARTMENT UTILIZATION AND RISK OF INTESTINAL RESECTION IS LOWER AMONG CHILDREN DIAGNOSED WITH INFLAMMATORY BOWEL DISEASE BEFORE 10 YEARS OF AGE: A MULTIPROVINCE POPULATION-BASED COHORT STUDY

Abstract Background In Canada, the incidence of inflammatory bowel disease (IBD) is increasing faster among those &amp;lt;10 years (y) of age than in any other age group. Understanding the health services burden of IBD in this population is important for health system planning. Purpose To compare healthcare utilization and risk of surgery among children diagnosed with IBD across age groups defined by the Paris Classification (A1a: &amp;lt;10y; A1b: 10 to &amp;lt;16y) across 5 Canadian provinces. Method Children diagnosed with IBD &amp;lt;16 years of age were identified from health administrative data using validated algorithms in Alberta, Manitoba, Nova Scotia, Ontario, and Québec. Negative binomial regression models were used to compare (1) the pre-diagnosis frequency of health services utilization (outpatient, emergency department (ED), and hospitalization) using diagnostic codes suggestive of future IBD and (2) the annual post-diagnosis frequency of IBD-specific and IBD-related (signs, symptoms, and extra-intestinal manifestations of IBD) visits among children diagnosed &amp;lt;10y (A1a) and 10 to &amp;lt;16y (A1b). Cox proportional hazard models compared the risk of surgery (identified with validated procedure codes) across age groups. All regression models were adjusted for sex, rural/urban residence, and mean neighbourhood income quintile. Province-specific event counts (all ages combined) and models (comparing age groups; reference: A1b [10 to &amp;lt;16y]) were pooled using random-effects meta-analysis. Result(s) Among 5124 children with IBD (1165 [23%] were &amp;lt;10y at diagnosis), the mean number of pre-diagnosis healthcare encounters was 1.0 (95% CI 0.38 to 1.68, I2=99.6%). The mean annual post-diagnosis number of IBD-specific outpatient visits was 3.2 (95% CI 1.9-4.4, I2=99.6%); hospitalizations, 0.19 (95% CI 0.17-0.21, I2=74%); ED visits, 0.17 (95% CI 0.19-0.39, I2=99%). The mean annual post-diagnosis number of IBD-related outpatient visits was 3.9 (95% CI 2.3-5.5, I2=99.7%); hospitalizations, 0.21 (95% CI 0.19-0.23, I2=79%); ED visits, 0.29 (95% CI 0.19-0.39, I2=97%). Intestinal resection or colectomy within 5y of diagnosis occurred in 13% (95%CI 8-22, I2=93%) with Crohn’s disease (CD) and 16% (95% CI 14-18, I2=40%) with ulcerative colitis. IBD-specific ED visits (RR 0.70, 95% CI 0.50-0.97, I2=80) and the risk of intestinal resection in CD (HR 0.49, 95% CI 0.26-0.92, I2=40%) were significantly lower among children diagnosed &amp;lt;10y. There were no age-related differences in pre-diagnosis health services utilization or other post-diagnosis outcomes, including frequency of outpatient visits to a gastroenterologist. Conclusion(s) Health services utilization was generally similar for children diagnosed with IBD at &amp;lt;10y and between 10 and &amp;lt;16y, except for lower rates of IBD-specific ED visits and intestinal resection in children with CD. Further exploration of between-province differences, represented by the high statistical heterogeneity (I2) in the meta-analyses, is needed to understand sources of variation in care. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest E. Kuenzig: None Declared, H. Singh Consultant of: Amgen Canada, Bristol-Myers Squibb Canada, Sandoz Canada, Roche Canada, Takeda Canada and Guardant Health, A. Bitton: None Declared, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, M. Carroll: None Declared, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, T. Stukel: None Declared, S. Spruin: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, D. Mack: None Declared, K. Jacobson Grant / Research support from: Abbvie Canada and Janssen Canada, Consultant of: Abbvie Canada, Janssen Canada, Merck Canada and Mylan Pharmaceuticals, Speakers bureau of: Abbvie Canada and Janssen Canada, G. Nguyen: None Declared, L. Targownik Grant / Research support from: Janssen Canada, Consultant of: AbbVie Canada, Sandoz Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, and Roche Canada, W. El-Matary Consultant of: Abbvie and MERCK, Speakers bureau of: Abbvie and MERCK, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)

Antenatal dietary supplementation with myo-inositol for preventing gestational diabetes.

Gestational diabetes with onset or first recognition during pregnancy is an increasing problem worldwide. Myo-inositol, an isomer of inositol, is a naturally occurring sugar commonly found in cereals, corn, legumes and meat. Myo-inositol is one of the intracellular mediators of the insulin signal and correlates with insulin sensitivity in type 2 diabetes. The potential beneficial effect of improving insulin sensitivity suggests that myo-inositol may be useful for women in preventing gestational diabetes. This is an update of a review first published in 2015. To assess if antenatal dietary supplementation with myo-inositol is safe and effective, for the mother and fetus, in preventing gestational diabetes. We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, WHO ICTRP (17 March 2022) and the reference lists of retrieved studies. We included published and unpublished randomised controlled trials (RCTs) including cluster-RCTs and conference abstracts, assessing the effects of myo-inositol for the prevention of gestational diabetes in pregnant women. We included studies that compared any dose of myo-inositol, alone or in a combination preparation, with no treatment, placebo or another intervention. Quasi-randomised and cross-over trials were not eligible. We excluded women with pre-existing type 1 or type 2 diabetes. Two review authors independently assessed studies for inclusion, assessed risk of bias and extracted the data. We checked the data for accuracy. We assessed the certainty of the evidence using the GRADE approach. We included seven RCTs (one conducted in Ireland, six conducted in Italy) reporting on 1319 women who were 10 weeks to 24 weeks pregnant at the start of the studies. The studies had relatively small sample sizes and the overall risk of bias was low. For the primary maternal outcomes, meta-analysis showed that myo-inositol may reduce the incidence of gestational diabetes (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.31 to 0.90; 6 studies, 1140 women) and hypertensive disorders of pregnancy (RR 0.34, 95% CI 0.19 to 0.61; 5 studies, 1052 women). However, the certainty of the evidence was low to very low. For the primary neonatal outcomes, only one study measured the risk of a large-for-gestational-age infant and found myo-inositol was associated with both appreciable benefit and harm (RR 1.40, 95% CI 0.65 to 3.02; 1 study, 234 infants; low-certainty evidence). None of the included studies reported on the other primary neonatal outcomes (perinatal mortality, mortality or morbidity composite). For the secondary maternal outcomes, we are unclear about the effect of myo-inositol on weight gain during pregnancy (mean difference (MD) -0.25 kilogram (kg), 95% CI -1.26 to 0.75 kg; 4 studies, 831 women) and perineal trauma (RR 4.0, 95% CI 0.45 to 35.25; 1 study, 234 women) because the evidence was assessed as being very low-certainty. Further, myo-inositol may result in little to no difference in caesarean section (RR 0.91, 95% CI 0.77 to 1.07; 4 studies, 829 women; low-certainty evidence). None of the included studies reported on the other secondary maternal outcomes (postnatal depression and the development of subsequent type 2 diabetes mellitus). For the secondary neonatal outcomes, meta-analysis showed no neonatal hypoglycaemia (RR 3.07, 95% CI 0.90 to 10.52; 4 studies; 671 infants; very low-certainty evidence). However, myo-inositol may be associated with a reduction in the incidence of preterm birth (RR 0.35, 95% CI 0.17 to 0.70; 4 studies; 829 infants). There were insufficient data for a number of maternal and neonatal secondary outcomes, and no data were reported for any of the long-term childhood or adulthood outcomes, or for health service utilisation outcomes. Evidence from seven studies shows that antenatal dietary supplementation with myo-inositol during pregnancy may reduce the incidence of gestational diabetes, hypertensive disorders of pregnancy and preterm birth. Limited data suggest that supplementation with myo-inositol may not reduce the risk of a large-for-gestational-age infant. The current evidence is based on small studies that were not powered to detect differences in outcomes such as perinatal mortality and serious infant morbidity. Six of the included studies were conducted in Italy and one in Ireland, which raises concerns about the lack of generalisability to other settings. There is evidence of inconsistency among doses of myo-inositol, the timing of administration and study population. As a result, we downgraded the certainty of the evidence for many outcomes to low or very low certainty. Further studies for this promising antenatal intervention for preventing gestational diabetes are encouraged and should include pregnant women of different ethnicities and varying risk factors. Myo-inositol at different doses, frequency and timing of administration, should be compared with placebo, diet and exercise, and pharmacological interventions. Long-term follow-up should be considered and outcomes should include potential harms, including adverse effects.

DOP61 Ethnic disparities in the management of Inflammatory Bowel Disease in Israel and impact on outcomes

Abstract Background In this nationwide study, we aimed to explore health services utilization, medical management, and disease outcomes of inflammatory bowel diseases (IBD) between Jews and Arabs, the two major ethnic groups in Israel. Methods We utilized a cohort including all patients diagnosed with IBD in Israel since 2005. The primary outcome was steroid-dependency, with secondary outcomes including use of biologics, time to surgery, and IBD-related admissions. Outcomes were controlled for possible inherent differences in disease course and phenotype. Results Of the 32,491 included patients, 18,252 (56%) had Crohn’s disease (CD) and 14,239 (44%) had ulcerative colitis (UC); 10% were Arabs and 90% were Jews. Jewish ethnicity was associated with lower rates of steroid-dependency compared to Arab ethnicity in both CD )HR=0.7 [95%CI 0.6-0.8]) and UC (HR=0.7 [95%CI 0.6-0.8]). In addition, Jewish ethnicity was associated with increased use of biologics during the first year from diagnosis in patients with CD (HR=1.3 [95%CI 1.1-1.6]) but not with UC. The risk of IBD-related surgery in CD at 3 and 5 years was higher in the Arab group at all time points (13% vs 10%, 16% vs 14%, respectively, p=0.005). Arabs had higher number of IBD-related hospitalizations than Jews (19% vs. 28% with two or more IBD-related hospitalizations at 5 years, p&amp;lt;0.001). Conclusion Arab ethnicity is associated with higher rate of hospitalizations, steroid-dependency and surgeries on one hand, and lower utilization of biologics on the other. The results should be considered by policy makers to improve access to medical care across all populations.

PROMOTING HEALTHY AGING THROUGH LGBTQ+ AFFIRMING CARE

Abstract This study examines variation in health service utilization and aging outcomes among older LGBTQ+ adults by access to an LGBTQ+ affirming health care provider. Primary survey data (n=1128) come from the Vanderbilt University Social Networks, Aging, and Policy Study, a panel study of older LGBTQ+ adults residing Alabama, Georgia, North Carolina, and Tennessee. Respondents with an LGBTQ+ affirming health care provider were more likely to seek preventative care, including routine checkups, colorectal screenings, flu shots, and HIV tests. Respondents with an LGBTQ+ affirming health care provider also reported higher control over their mental health and lower levels of cognitive decline. Overall, this study suggests that increasing access to LGBTQ+ affirming care could reduce health disparities among aging LGBTQ+ populations.

EXPERIENCES OF LESBIAN, GAY, BISEXUAL, TRANSGENDER, AND/OR QUEER (LGBTQ) OLDER ADULTS WITH SERVICE PROVIDERS

Abstract Many lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) older adults have experienced a lifetime of oppression and discrimination that often results in significant health, economic, and social disparities in comparison to their peers. Historically labeled as illegal, immoral, and/or sick, LGBTQ older adults often fear, hide, and distrust health care and other social services providers. This symposium will highlight contemporary research on the experiences and perceptions of LGBTQ older adults in relation to service providers. The first presentation will contextual factors that influence the healthcare utilization of LGBTQ middle-aged and older adults. The second presentation will explore older adult couples’ experiences of minority stress with service providers and effects on their relationships. The third presentation will explore explore the beliefs, experiences, and needs related to housing and housing discrimination in LGBTQ older adults living in coastal North Carolina. The fourth presentation will explore panel data of older LGBTQ adults residing in the U.S South and examine the effects of access to an LGBTQ affirming provider on health service utilization and aging outcomes.. The final presentation will explore the association between increased awareness, understanding, and belief in the Undetectable equals Unstransmittable campaign and having an LGBTQ affirming care provider. The symposium will conclude with a discussion on policy and practice impacts for aging services and health care providers.

Association of mental health and behavioral disorders with health care and service utilization in children before and after diagnosis.

Mental health is one of the most important contributors to the global burden of disease in children and adolescents. Mental health conditions are associated with lower quality of life in adulthood. These conditions have an early onset and typically first occur in childhood. However, little is known about how these conditions are related to service utilization before the initial diagnosis, or about the significance of the diagnosis on later service utilization. To study this, register data on 5-15-year-old children in the city of Oulu, Finland, covering the years 2013-2018 were used. To identify the association of mental health and behavioral conditions with service utilization, counterfactuals were constructed from children who were similarly diagnosed three years later. Event study regressions on several health care and service utilization outcomes were estimated. The findings showed that primary and specialized health care utilization increased sharply before the initial diagnosis and peaked during the time of diagnosis. Primary care utilization started decreasing slowly after, while specialized health care utilization remained high for two years after the diagnosis. Probability of visiting a mental health professional, use of rehabilitation services, psychiatric medication, and utilization of child protection services increased significantly after the diagnosis. The results highlighted the importance of outpatient health care in detecting and treating the conditions in children. In a fragmented system, knowledge on utilization trajectories in different services may be of help in allocating resources to improve the health of these children.

Abstract 214: Non-Health Professional Interventions For Hypertension: Systematic Review Comparing Interventions Leveraged In Developed And Developing Economies

Background: Non-health professionals, most often in the form of community health workers, have been deployed in both developed and developing economies to improve hypertension outcomes. Variation between developed and developing economies in the type and outcome of these interventions is unknown. Aim: Compare the deployment and efficacy of non-health professional interventions targeting hypertension in developed and developing economies. Methods: Several databases including Medline were systematically searched until December 2020. All study designs with non-health professional interventions for hypertension were included. Eligible articles were coded by two independent reviewers. Results: Of the 23 articles eligible for inclusion, 15 studies (65%) were from developed economies and 8 (35%) from developing economies. Non-health professional recruitment, selection and intervention durations were similar in developed and developing economies. Positive hypertension and health service utilization outcomes were seen in most studies. Interventions in developed economies: Only 33% (5 of 15) of the studies included some form of home visits, while 60% (9 of 15) of interventions focused on group education. Phone calls were incorporated into 47% (7 of 15) of the studies to further promote medication adherence, appointment keeping, or to discuss progress. Interventions in developing economies: Home visits were part of 75% (6 of 8) of the studies and only 25% (2 of 8) focused on group education. A single study of the 8 (13%) included phone calls for appointment reminders and was the sole study that was clinic, not community based, and did not report positive outcomes. One study also included one-way outgoing text messages to promote lifestyle changes and medication adherence. Conclusions: Developed and developing economies diverge in the type of non-health professional intervention employed. Studies from developed economies mainly include group education with phone calls for individualization, whereas studies in developing economies prioritized home visits. Most studies resulted in positive outcomes suggesting that various forms of non-health professional support are effective for improving hypertension outcomes in diverse settings.

Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic

Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown. To evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes. This retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022. Receipt of a video-enabled tablet. Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs). The study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, -0.012; 95% CI, -0.014 to -0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, -0.0017; 95% CI, -0.0023 to -0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, -0.0011; 95% CI, -0.0016 to -0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide. This cohort study of rural US veterans with a history of mental health care use found that receipt of a video-enabled tablet was associated with increased use of mental health care via video, increased psychotherapy visits (across all modalities), and reduced suicide behavior and ED visits. These findings suggest that the VA and other health systems should consider leveraging video-enabled tablets for improving access to mental health care via telehealth and for preventing suicides among rural residents.

Decomposing maternal socioeconomic inequalities in Zimbabwe; leaving no woman behind

BackgroundSeveral studies in the literature have shown the existence of large disparities in the use of maternal health services by socioeconomic status (SES) in developing countries. The persistence of the socioeconomic disparities is problematic, as the global community is currently advocating for not leaving anyone behind in attaining Sustainable Development Goals (SDGs). However, health care facilities in developing countries continue to report high maternal deaths. Improved accessibility and strengthening of quality in the uptake of maternal health services (skilled birth attendance, antenatal care, and postnatal care) plays an important role in reducing maternal deaths which eventually leads to the attainment of SDG 3, Good Health, and Well-being.MethodsThis study used the Zimbabwe Demographic Health Survey (ZDHS) of 2015. The ZDHS survey used the principal components analysis in estimating the economic status of households. We computed binary logistic regressions on maternal health services attributes (skilled birth attendance, antenatal care, and postnatal care) against demographic characteristics. Furthermore, concentration indices were then used to measure of socio-economic inequalities in the use of maternal health services, and the Erreygers decomposable concentration index was then used to identify the factors that contributed to the socio-economic inequalities in maternal health utilization in Zimbabwe.ResultsOverall maternal health utilization was skilled birth attendance (SBA), 93.63%; antenatal-care (ANC) 76.33% and postnatal-care (PNC) 84.27%. SBA and PNC utilization rates were significantly higher than the rates reported in the 2015 Zimbabwe Demographic Health Survey. Residence status was a significant determinant for antenatal care with rural women 2.25 times (CI: 1.55–3.27) more likely to utilize ANC. Richer women were less likely to utilize skilled birth attendance services [OR: 0.20 (CI: 0.08–0.50)] compared to women from the poorest households. While women from middle-income households [OR: 1.40 (CI: 1.03–1.90)] and richest households [OR: 2.36 (CI: 1.39–3.99)] were more likely to utilize antenatal care services compared to women from the poorest households. Maternal service utilization among women in Zimbabwe was pro-rich, meaning that maternal health utilization favoured women from wealthy households [SBA (0.05), ANC (0.09), PNC (0.08)]. Wealthy women were more likely to be assisted by a doctor, while midwives were more likely to assist women from poor households [Doctor (0.22), Midwife (− 0.10)].ConclusionDecomposition analysis showed household wealth, husband’s education, women’s education, and residence status as important positive contributors of the three maternal health service (skilled birth attendance, antenatal care, and postnatal care) utilization outcomes. Educating women and their spouses on the importance of maternal health services usage is significant to increase maternal health service utilization and consequently reduce maternal mortality.

Antenatal Doppler screening for fetuses at risk of adverse outcomes: a multicountry cohort study of the prevalence of abnormal resistance index in low-risk pregnant women

IntroductionFew interventions exist to address the high burden of stillbirths in apparently healthy pregnant women in low- and middle-income countries (LMICs). To establish whether a trial on the impact of...

The effect of Ebola virus disease on maternal health service utilisation and perinatal outcomes in West Africa: a systematic review

BackgroundEbola outbreaks pose a major threat to global public health, especially in Sub-Saharan Africa. These outbreaks disrupt the already fragile maternal health services in West Africa. The aims of this study is to assess the effect of Ebola virus disease (EVD) on maternal health service utilisation and perinatal outcomes.MethodsThis systematic review was conducted in West Africa, and the databases used were Medline, PubMed, CINAHL, Scopus, EMBASE and African journals online. Studies that reported the effect of the Ebola outbreak on maternal health services in West Africa were eligible for this systematic review. The search was limited to articles written in the English language only and published between 2013 and 2020. Three authors independently appraised the articles, and the data were extracted using a standardised data extraction format. The findings were synthesised using a narrative summary, tables, and figures.ResultsTwelve studies met the inclusion criteria and were used for this systematic review synthesis. The results showed that antenatal care significantly decreased during Ebola virus disease and strove to recover post-Ebola virus disease. Women were less likely to have institutional childbirth during Ebola virus disease and struggled to recover post-Ebola virus disease. In addition, this review revealed a substantially higher rate of maternal mortality post EVD than those observed before or during the outbreak.ConclusionBased on our findings, antenatal care, institutional childbirth, and postnatal care are attempting to recover post-Ebola virus disease. We recommended that responsible bodies and stakeholders need to prepare locally tailored interventions to increase the number of women attending ANC, institutional childbirth, and PNC services post-EVD and future outbreaks including COVID-19. In order to build trust, creating community networks between health care providers and trusted community leaders may increase the number of women attending antenatal care (ANC), institutional childbirth and postnatal care (PNC) post-EVD and during future outbreaks. Further studies are needed to examine health centre and hospital availability and accessibility, and capacity to deliver maternal health services post-Ebola virus disease and future outbreaks.

Generic Drug Effectiveness: An Empirical Study on Health Service Utilization and Clinical Outcomes

Generic Drug Effectiveness: An Empirical Study on Health Service Utilization and Clinical Outcomes

Masculinity and Asian Men’s Health: a Critical Review

Literature demonstrated significant consequences to men’s health outcome secondary to their adherenceto certain masculine behaviour and norm. In the West, the norms surrounding masculinity includesthe idea that men should be healthy, strong, and self-sufficient. Western studies revealed that menadherence to this ideology of masculinity reflects their reluctance to seek for health help resulting intheir poor health service utilisation and poor health outcomes. However, it is posited that masculinityis not the declaration of one’s true self, but it is rather socially constructed, rather fluid in its nature andvaries across different context. Therefore, this concept of masculinity needs to be carefully analysedand examine whether it also fits for every man coming from other parts of the world. This paper looksat this issue and questioned its applicability for men living outside the Global North, which has beenoverlooked.