Health Service Utilization Outcomes Research Articles

Payment methods may influence behaviour of primary care dentists.

The Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, EconLit the NHS Economic Evaluation Database (EED) and the Health Economic Evaluations Database (HEED). Randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies were considered. Study selection was undertaken independently by three reviewers. Fee-for-service payments, fixed salary payments, capitation payments of combinations thereof included. Standard Cochrane methodological procedures were followed. Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. The risk of bias for the two studies was considered to be high and the overall quality of evidence for the outcomes was low/very low for all outcomes, as assessed using the GRADE approach.One study conducted in the four most deprived areas of Scotland used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. Measures of health service utilisation or patient outcomes were not reported. The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity, patient outcomes and healthcare costs. Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release.

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies. Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release. Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.

The impact of health insurance on health services utilization and health outcomes in Vietnam

In recent years, a number of low- and middle-income country governments have introduced health insurance schemes. Yet not a great deal is known about the impact of such policy shifts. Vietnam's recent health insurance experience including a health insurance scheme for the poor in 2003 and a compulsory scheme that provides health insurance to all children under six years of age combined with Vietnam's commitment to universal coverage calls for research that examines the impact of health insurance. Taking advantage of Vietnam's unique policy environment, data from the 2002, 2004 and 2006 waves of the Vietnam Household Living Standard Survey and single-difference and difference-in-differences approaches are used to assess whether access to health insurance--for the poor, for children and for students--impacts on health services utilization and health outcomes in Vietnam. For the poor and for students, results suggest health insurance increased the use of inpatient services but not of outpatient services or health outcomes. For young children, results suggest health insurance increased the use of outpatient services (including the use of preventive health services such as vaccination and check-up) but not of inpatient services.

Interventions to improve cultural competency in healthcare: a systematic review of reviews

BackgroundCultural competency is a recognized and popular approach to improving the provision of health care to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities. The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field to form a comprehensive understanding of the current evidence base that can guide future interventions and research in the area.MethodsA systematic review of review articles published between January 2000 and June 2012 was conducted. Electronic databases (including Medline, Cinahl and PsycINFO), reference lists of articles, and key websites were searched. Reviews of cultural competency in health settings only were included. Each review was critically appraised by two authors using a study appraisal tool and were given a quality assessment rating of weak, moderate or strong.ResultsNineteen published reviews were identified. Reviews consisted of between 5 and 38 studies, included a variety of health care settings/contexts and a range of study types. There were three main categories of study outcomes: patient-related outcomes, provider-related outcomes, and health service access and utilization outcomes. The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilization outcomes but weaker evidence for improvements in patient/client outcomes.ConclusionThis review of reviews indicates that there is some evidence that interventions to improve cultural competency can improve patient/client health outcomes. However, a lack of methodological rigor is common amongst the studies included in reviews and many of the studies rely on self-report, which is subject to a range of biases, while objective evidence of intervention effectiveness was rare. Future research should measure both healthcare provider and patient/client health outcomes, consider organizational factors, and utilize more rigorous study designs.

Community-Based Case Management, Hospital Utilization, and Patient-Focused Outcomes in Medicare Beneficiaries

There is limited research about the impact of community-based case management (CBCM) services and its outcomes with longitudinal analysis. The purpose of this study was to evaluate the effectiveness of a CBCM intervention on patient outcomes in Medicare beneficiaries with chronic illness in a CBCM service in the rural Midwest. A descriptive, repeated-measures design was used, and a secondary analysis of a data set containing longitudinal CBCM data, originally collected from 2002 to 2007, was conducted. Two years of case management (CM) interventions, three health-service utilization outcomes, and three patient-focused outcomes were examined. The study findings showed that a CBCM had significant effect on reducing patients' number of hospitalizations and increasing patients' symptom control and quality of life. The impact of CM on length of stay and emergency department visits was indeterminate. Findings suggest that CBCM can be used as an effective intervention program for Medicare beneficiaries.

Randomised controlled trial of a service brokerage intervention for ex-prisoners in Australia

BackgroundHealth outcomes after release from prison are typically poor with elevated rates of morbidity and mortality widely documented. Under-utilisation of health services contributes to these outcomes, but interventions to increase health service utilisation in ex-prisoners are in their infancy and few have been rigorously evaluated. MethodsSingle-blinded randomised controlled trial of a service brokerage intervention (the ‘Passports study’) for N=1325 adult ex-prisoners in Queensland, Australia. Participants in the intervention group received a personalised booklet summarising their health status and identifying appropriate community health services; trained workers made weekly telephone contact in the first 4weeks post-release to identify health needs and facilitate health service utilisation. Participants in the control arm received usual care. Baseline data were collected within 6weeks of expected release from custody with follow-up telephone interviews 1, 3 and 6months post-release. Participant identities were linked with federal health service utilisation records, a national death register and corrective services records, two years post-release. The primary outcome was self-reported health service utilisation in the first 6months post-release. ResultsBetween 2008 and 2010 1976 prisoners were screened for eligibility, 1665 met eligibility criteria and 1325 were recruited; 665 were randomised to the intervention and 660 to the control condition. Participants were broadly representative of adults being released from prison in Queensland except that women were intentionally oversampled (21% vs. 11%). ConclusionsOutcomes from this large RCT will provide the first robust evidence of the effect of service brokerage on health service utilisation and health outcomes for ex-prisoners.

Pregnancy care and birth outcomes for women with moderate to super-extreme obesity

To describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity. Maternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40. Women with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women. 153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1-16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n=150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n=74, 48.4%). Clinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.

The effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries.

The role of pharmacists has expanded beyond dispensing and packaging over the past two decades, and now includes ensuring rational use of drugs, improving clinical outcomes and promoting health status by working with the public and other healthcare professionals. To examine the effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries. Studies were identified by electronically searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (February 2010), MEDLINE (1949 to February 2010), Scopus (1960 to March 2010) and International Pharmaceutical Abstracts (1970 to January 2010) databases. An update of this review is currently ongoing. The search was re-run September 2012 and the potentially relevant studies are awaiting classification. Randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted time series analyses comparing 1. pharmacist-provided non-dispensing services targeted at patients versus (a) the same services provided by other healthcare professionals, (b) the same services provided by untrained health workers, and (c) usual care; and 2. pharmacist-provided non-dispensing services targeted at healthcare professionals versus (a) the same services provided by other healthcare professionals, (b) the same services provided by untrained health workers, and (c) usual care in low- and middle-income countries. The research sites must have been located in low or middle income countries according to World Bank Group 2009 at the time of the study, regardless of the location or the origin of the researchers. Two authors independently reviewed studies for inclusion in the review. Two review authors independently extracted data for each study. Risk of bias of the included studies was also assessed independently by two authors. Twelve studies comparing pharmacist-provided services versus usual care were included in this review. Of the 12 studies, seven were from lower middle income countries and five were from upper middle income countries. Eleven studies examined pharmacist-provided services targeted at patients and one study evaluated pharmacist interventions targeted at healthcare professionals. Pharmacist-provided services targeting patients resulted in a small improvement of clinical outcomes such as blood pressure (-25 mm Hg/-6 mm Hg and -4.56 mm Hg/-2.45 mm Hg), blood glucose (-39.84 mg/dl and -16.16 mg/dl), blood cholesterol (-25.7 mg/dl)/ triglyceride levels (-80.1 mg/dl) and asthma outcomes (peak expiratory flow rate 1.76 l/min). Moreover, there was a small improvement in the quality of life, although four studies did not report the effect size explicitly. Health service utilisation, such as rate of hospitalisation and general practice and emergency room visits, was also found to be reduced by the patient targeted pharmacist-provided services. A single study examined the effect of patient targeted pharmacist interventions on medical expenses and the cost was found to be reduced. A single study that examined pharmacist services that targeted healthcare professionals demonstrated a very small impact on asthma symptom scores. No studies assessing the impact of pharmacist-provided non-dispensing services that targeted healthcare professionals reported health service utilisation and cost outcomes. Overall, five studies did not adequately report the numerical data for outcomes but instead reported qualitative statements about results, which prevented an estimation of the effect size.Studies for the comparison of patient targeted services provided by pharmacists versus the same services provided by other healthcare professionals or untrained healthcare workers were not found. Similarly, studies for the comparison of healthcare professional targeted services provided by pharmacists versus the same services provided by other healthcare professionals or untrained healthcare workers were not found. Pharmacist-provided services that target patients may improve clinical outcomes such as management of high glucose levels among diabetic patients, management of blood pressure and cholesterol levels and may improve the quality of life of patients with chronic conditions such as diabetes, hypertension and asthma. Pharmacist services may reduce health service utilisation such as visits to general practitioners and hospitalisation rates. We are uncertain about the effect of educational sessions by pharmacists for healthcare professionals due to the imprecision of a single study included in this review. Similarly, conclusions could not be drawn for health service utilisation and costs due to lack of evidence on interventions delivered by pharmacists to healthcare professionals. These results were heterogenous in the types of outcomes measured, clinical conditions and approaches to measurement of outcomes, and require cautious interpretation. All eligible studies were from middle income countries and the results may not be applicable to low income countries.

Thinking beyond the mean: a practical guide for using quantile regression methods for health services research.

Health services and health economics research articles commonly use multivariate regression techniques to measure the relationship of health service utilization and health outcomes (the outcomes of interest) with clinical characteristics, sociodemographic factors, and policy changes (usually treated as explanatory variables). Common regression methods measure differences in outcome variables between populations at the mean (i.e., ordinary least squares regression), or a population average effect (i.e., logistic regression models), after adjustment for other explanatory variables of interest. These are often done assuming that the regression coefficients are constant across the population – in other words, the relationships between the outcomes of interest and the explanatory variables remain the same across different values of the variables. There are times, however, when researchers, policymakers, and clinicians may be interested in group differences across the distribution of a given dependent variable rather than only at the mean. Taking a more concrete example from the literature, research on individuals' consumption of alcohol consistently reported that higher alcohol prices were associated with lower alcohol consumption.[1] This led to a call for increases in taxes as a policy lever to reduce alcohol consumption and the subsequent social costs of alcoholism and alcohol abuse. However, these studies did not provide any information about whether increased price decreased alcohol use similarly for light drinkers, moderate drinkers, and heavy drinkers. Because there are positive social benefits for light drinkers and negative health and social consequences for heavy drinkers, analyzing the demand response of different types of drinkers was important to understanding who was most likely to modify their behavior due to increasing alcohol taxes. A subsequent study[2] found light and heavy drinkers were much less price elastic than moderate drinkers; that is, higher taxes did not reduce consumption nearly as much for light and heavy drinkers as it did for moderate drinkers. The policy implication is that increasing alcohol taxes might bring in revenue (and reduce alcohol-related accidents among moderate drinkers) but will have limited success in reducing the prevalence of heavy drinking and its sequelae. Another example is that associations of interest explaining health care and health outcomes may be very different among the highest utilizers of health care, compared to individuals at the bottom or middle of the distribution of health care utilization. As a simple illustration, Figure 1 plots the relationship between the number of hours attended of a hypothetical psychotherapy intervention (x-axis) and a fictitious scale of post-intervention mental health (higher score indicates better mental health on the y-axis) for a group of 400 individuals. In this example, the regression line from an ordinary least squares (OLS) regression model is essentially flat, suggesting that there is no relationship between number of psychotherapy session-hours and mental health at follow-up. To describe the association between number of session-hours and mental health for individuals with low and high post-treatment scores on the mental health scale using OLS, the analyst extends the line up or down to the 90th and 10th quantiles in a parallel fashion, as the OLS model assumes the association between hours of psychotherapy and mental health outcome remains the same at different levels of the mental health scale. Figure 1. Prediction lines at 10th quantile, mean, and 90th quantile using ordinary least squares (OLS) regression

Impact of user fees on maternal health service utilization and related health outcomes: a systematic review

To assess the evidence of the impact of user fees on maternal health service utilization and related health outcomes in low- and middle-income countries, as well as their impact on inequalities in these outcomes. Studies were identified by modifying a search strategy from a related systematic review. Primary studies of any design were included if they reported the effect of fee changes on maternal health service utilization, related health outcomes and inequalities in these outcomes. For each study, data were systematically extracted and a quality assessment conducted. Due to the heterogeneity of study methods, results were examined narratively. Twenty studies were included. Designs and analytic approaches comprised: two interrupted time series, eight repeated cross-sectional, nine before-and-after without comparison groups and one before-and-after in three groups. Overall, the quality of studies was poor. Few studies addressed potential sources of bias, such as secular trends over time, and even basic tests of statistical significance were often not reported. Consistency in the direction of effects provided some evidence of an increase in facility delivery in particular after fees were removed, as well as possible increases in the number of managed delivery complications. There was little evidence of the effect on health outcomes or inequality in accessing care and, where available, the direction of effect varied. Despite the global momentum to abolish user fees for maternal and child health services, robust evidence quantifying impact remains scant. Improved methods for evaluating and reporting on these interventions are recommended, including better descriptions of the interventions and context, looking at a range of outcome measures, and adopting robust analytical methods that allow for adjustment of underlying and seasonal trends, reporting immediate as well as longer-term (e.g. at 6 months and 1 year) effects and using comparison groups where possible.

Educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases: A systematic review protocol

Review question/objective The objective of this systematic review is to identify the best available research evidence related to the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases, focusing on measures of adherence and health outcomes. The specific review questions to be addressed are: 1. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in terms of inhalation regimens and inhalation techniques in people with chronic respiratory diseases? 2. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy on health service utilization and patient outcomes including symptoms, pulmonary function, and quality of life? 3. What is the effectiveness of various designs, in terms of components, modes and intensities, of educational and supportive interventions for improving adherence to inhalation therapy? Inclusion criteria Types of participants This review will consider studies that include adults aged 18 or above, with a clinical diagnosis of chronic respiratory disease and prescribed self-administered inhalation therapy as a long term regular treatment, irrespective of the type of inhaler used. For the purposes of this review, "chronic respiratory diseases" is defined by WHO in 2007 as "the chronic diseases of the airways and other structures of the lung" (p.5). 1 Inhalation therapy is defined as "a treatment in which a substance is administered to the respiratory tract with inspired air". 6 This review will focus on inhalation of drugs. Those studies with prescribed administration of oxygen and water will be excluded. There is no universal standard for how long a treatment is undertaken to be defined as a "long term treatment". Acute episodic drug treatments, such as a course of antibiotics, will be excluded. Types of interventions of interest All educational interventions, with or without supportive programs, designed to improve the chronic respiratory disease sufferers inhalation technique and adherence to their prescribed inhalation therapy will be considered. Those studies that involve comparison of different types of inhalation medications, inhaler devices or inhalation methods to improve the adherence to inhalation therapy will be excluded. For the TRUNCATED AT 350 WORDS

Outcomes associated with a negotiated asthma treatment plan.

Negotiated treatment plans are increasingly recommended in asthma clinical care. However, limited data are available to indicate whether this more patient-engaged process results in improved health outcomes. The aim of this study was to determine the associations between the presence of a negotiated treatment plan and the outcomes related to adherence to the medical regimen, symptom control, and health care use. The focus of the study was on women, the subgroup of adult patients, who are most vulnerable for negative asthma outcomes. Data were collected by telephone interview and medical record review from 808 women diagnosed with asthma at baseline, first year, and second year follow-up. Associations were examined between the presence of a negotiated treatment plan at baseline and subsequent asthma outcomes. Women with a negotiated treatment plan reported more adherent to prescribed asthma medicines (odds ratio (OR) = 2.41, 95% confidence interval (CI) = (1.82, 3.19)) and those with a plan and using oral steroids at baseline had less oral steroid use at follow-up (OR = 0.21, 95% CI = (0.05, 0.93)). Women with a negotiated plan also had more days (17%, 95% CI = (8, 27)) and nights (31%, 95% CI = (16, 48)) with symptoms than those without such a plan. No differences in hospitalizations, emergency department visits, or urgent physician office visits were noted between the groups. Patients with higher education levels were more likely to have a negotiated treatment plan. Negotiated treatment plans appear to have achieved greater adherence to prescribed asthma medicines and less need for oral steroids but were not related to fewer symptoms of asthma or reductions in urgent health care use. Additional strategies may be needed to reduce symptom and health services utilization outcomes.

Report of an HIV clinic-based pain management program and utilization of health status and health service by HIV patients

Current reports on human immunodeficiency virus (HIV) pain are limited to epidemiological data on neuropathic pain in HIV and most studies were conducted before the availability of highly active antiretroviral therapy. Complex pain was reported to be highly prevalent and associated with advanced disease. The authors conducted a retrospective review of the medical records of 81 patients from the Center for Positive Living (CPL) at Montefiore Medical Center who were newly referred to a pain management program in 2006 to identify the potential benefits of integrating a pain management team into the care of persons living with HIV and etiologies of pain. A standardized chart abstraction tool was used to capture clinical data. Data related to health service utilization and viral outcomes were obtained from the clinical information systems. The most common pain diagnoses were multiple syndromes, degenerative disc disease or spinal stenosis, and neuropathy. There was a decrease in emergency room utilization in the 12 months following an initial pain management appointment (p < 0.0001) and an increase in use of primary care (p = 0.0017). The use of adjuvant medications increased after intake into the pain clinic (p < 0.0001). Having an opioid dose in excess of 200 mg/d oral morphine equivalents and maintenance of each palliative care and infectious disease clinic appointment were inversely associated with viral loads in excess of 75 copies: odds ratio (OR) = 0.21 (95% confidence interval/CI], 0.11-0.44), OR = 0.77 (95% CI, 0.68-0.86), and 0.94 (95% CI, 0.93-0.99), respectively. The decrease in emergency room visits and increase in use of adjuvant analgesics and compliance with primary care and nonmedication approaches for the management of pain in the 12 months subsequent to initial palliative/pain clinic appointments highlight potential improved quality of care associated with the integration of a pain management team into the primary care of persons living with HIV disease.

Diagnosis of Pulmonary Hypertension in the Congenital Heart Disease Adult Population: Impact on Outcomes

The aim of this study was to assess the impact of the diagnosis of pulmonary hypertension (PH) on mortality, morbidity, and health services utilization (HSU) in an adult congenital heart disease (CHD) population. Although PH is a well-recognized complication of CHD, population-based studies of its significance on the survival and functional capacity of patients are uncommon. A retrospective longitudinal cohort study was conducted in an adult CHD population with 23 years of follow-up, from 1983 to 2005. The prevalence of PH was measured in 2005. Mortality, morbidity, and HSU outcomes were compared between patients with and without diagnoses of PH using multivariate Cox (mortality and morbidity) and Poisson (HSU) regression models within a subcohort matched for age and CHD lesion type. Of 38,430 adults alive with CHD in 2005, 2,212 (5.8%) had diagnoses of PH (median age 67 years, 59% women). The diagnosis of PH increased the all-cause mortality rate of adults with CHD more than 2-fold compared with patients without PH (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.41 to 2.99). Morbid complications including heart failure and arrhythmia occurred with a 3-fold higher risk compared with patients without PH (HR: 3.01; 95% CI: 2.80 to 3.22). The utilization of inpatient and outpatient services was increased, especially cardiac catheterization, excluding the index diagnostic study (rate ratio: 5.04; 95% CI: 4.27 to 5.93) and coronary and intensive care hospitalizations (rate ratio: 5.03; 95% CI: 4.86 to 5.20). A diagnosis of PH in adults with CHD is associated with a more than 2-fold higher risk for all-cause mortality and 3-fold higher rates of HSU, reflecting high morbidity.

From hospital to home: The quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia

Objectiveto examine the transition of care in the postnatal period from a regional hospital to a remote health service and describe the quality and safety implications for remote dwelling Aboriginal mothers and infants. Designa retrospective cohort study of maternal health service utilisation and birth outcomes, key informant interviews with health service providers and participant observation in a hospital and two remote health centres. Data were analysed using descriptive statistics and content analysis. Settinga maternity unit in a regional public hospital and two remote health centres within large Aboriginal communities in the Top End of the Northern Territory, Australia. Findingspoor discharge documentation, communication and co-ordination between hospital and remote health centre staff occurred. In addition, the lack of clinical governance and a specific position holding responsibility for the postnatal discharge planning process in the hospital system were identified as serious risks to the safety of the mother and infant. Conclusions and implications for practicethe quality and safety of discharge practices for remote dwelling mothers and their infants in the transition from hospital to their remote health service following birth need to be improved. The discharge process and service delivery model must be restructured to reduce the adverse effects of poor standards of care on mothers and infants.

A Systematic Review and Qualitative Analysis to Inform the Development of a New Emergency Department-Based Geriatric Case Management Model

We inform the future development of a new geriatric emergency management practice model. We perform a systematic review of the existing evidence for emergency department (ED)-based case management models designed to improve the health, social, and health service utilization outcomes for noninstitutionalized older patients within the context of an index ED visit. This was a systematic review of English-language articles indexed in MEDLINE and CINAHL (1966 to 2010), describing ED-based case management models for older adults. Bibliographies of the retrieved articles were reviewed to identify additional references. A systematic qualitative case study analytic approach was used to identify the core operational components and outcome measures of the described clinical interventions. The authors of the included studies were also invited to verify our interpretations of their work. The determined patterns of component adherence were then used to postulate the relative importance and effect of the presence or absence of a particular component in influencing the overall effectiveness of their respective interventions. Eighteen of 352 studies (reported in 20 articles) met study criteria. Qualitative analyses identified 28 outcome measures and 8 distinct model characteristic components that included having an evidence-based practice model, nursing clinical involvement or leadership, high-risk screening processes, focused geriatric assessments, the initiation of care and disposition planning in the ED, interprofessional and capacity-building work practices, post-ED discharge follow-up with patients, and evaluation and monitoring processes. Of the 15 positive study results, 6 had all 8 characteristic components and 9 were found to be lacking at least 1 component. Two studies with positive results lacked 2 characteristic components and none lacked more than 2 components. Of the 3 studies with negative results demonstrating no positive effects based on any outcome tested, one lacked 2, one lacked 3, and one lacked 4 of the 8 model components. Successful models of ED-based case management models for older adults share certain key characteristics. This study builds on the emerging literature in this area and leverages the differences in these models and their associated outcomes to support the development of an evidence-based normative and effective geriatric emergency management practice model designed to address the special care needs and thereby improve the health and health service utilization outcomes of older patients.

Food Insufficiency and Health Services Utilization in a National Sample of Homeless Adults

Homeless people have high rates of hospitalization and emergency department (ED) use. Obtaining adequate food is a common concern among homeless people and may influence health care utilization. We tested the hypothesis that food insufficiency is related to higher rates of hospitalization and ED use in a national sample of homeless adults. We analyzed data from the 2003 Health Care for the Homeless (HCH) User Survey. Participants were 966 adults surveyed at 79 HCH clinic sites throughout the US. The study sample was representative of over 436,000 HCH clinic users nationally. We determined the prevalence and characteristics of food insufficiency among respondents. Using multivariable logistic regression, we examined the association between food insufficiency and four past-year acute health services utilization outcomes: (1) hospitalization for any reason, (2) psychiatric hospitalization, (3) any ED use, and (4) high ED use (≥ 4 visits). Overall, 25% of respondents reported food insufficiency. Among them, 68% went a whole day without eating in the past month. Chronically homeless (p = 0.01) and traumatically victimized (p = 0.001) respondents were more likely to be food insufficient. In multivariable analyses, food insufficiency was associated with significantly greater odds of hospitalization for any reason (AOR 1.59, 95% CI 1.07, 2.36), psychiatric hospitalization (AOR 3.12, 95% CI 1.73, 5.62), and high ED utilization (AOR 2.83, 95% CI 1.32, 6.08). One-fourth of homeless adults in this national survey were food insufficient, and this was associated with increased odds of acute health services utilization. Addressing the adverse health services utilization patterns of homeless adults will require attention to the social circumstances that may contribute to this issue.

Performance of comorbidity measures for predicting outcomes in population-based osteoporosis cohorts

The performance of five comorbidity measures, including the Charlson and Elixhauser indices, was investigated for predicting mortality, hospitalization, and fracture outcomes in two osteoporosis cohorts defined from administrative databases. The optimal comorbidity measure depended on the outcome of interest, although overall the Elixhauser index performed well. Studies that use administrative data to investigate population-based health outcomes often adopt risk-adjustment models that include comorbidities, conditions that coexist with the index disease. There has been limited research about the measurement of comorbidity in osteoporotic populations. The study purpose was to compare the performance of comorbidity measures for predicting mortality, fracture, and health service utilization outcomes in two cohorts with diagnosed or treated osteoporosis. Administrative data were from the province of Saskatchewan, Canada. Osteoporosis cohorts were identified from diagnoses in hospital and physician data and prescriptions for osteo-protective medications using case definitions with high sensitivity or high specificity. Five diagnosis- and medication-based comorbidity measures and five 1-year outcomes, including mortality, hospitalization (two measures), osteoporotic-related fracture, and hip fracture, were defined. Performance of the comorbidity measures was assessed using the c-statistic (discrimination) and Brier score (prediction error) for multiple logistic regression models. In the specific cohort (n = 9,849) for the mortality outcome, the Elixhauser index resulted in the largest improvement (8.96%) in the c-statistic and lowest Brier score compared to a model that contained demographic and socioeconomic variables, followed by the Charlson index (6.06%). For hospitalization, the number of different diagnoses resulted in the largest improvement (14.01%) in the c-statistic. The Elixhauser index resulted in significant improvements in the c-statistic for osteoporosis-related and hip fractures. Similar results were observed for the sensitive cohort (n = 28,068). Recommendations about the optimal comorbidity measure will vary with the outcome under investigation. Overall, the Elixhauser index performed well.

Mental Health Service Utilization and Drinking Outcomes in a National Population Sample: Are There Racial/Ethnic Differences?

ABSTRACT Racial and ethnic disparities in alcohol use and alcohol-related problems have been well-documented. Less information is available about possible disparities in outcomes related to mental health services utilization. The differential effect of mental health services use by race on drinking outcomes was examined. Wave 2 of a national population sample of employed adults who reported having at least one alcoholic drink in the past year (N = 1,058) encompassed measures of the prevalence of mental health services use in response to stress, and alcohol-related outcomes. Non-white participants who reported using any mental health services, four or more mental health visits in the past year, and eight or more mental health visits in the past year reported lower rates of problematic drinking behaviors, including frequency of drinking to intoxication, heavy episodic drinking, and modified Brief MAST scores, than whites who reported similar use of mental health services.

Burden of COPD, Asthma, and Concomitant COPD and Asthma Among Adults: Racial Disparities in a Medicaid Population

Asthma and COPD are characterized by substantial racial disparities in morbidity and mortality. We hypothesized that because African-American patients with these conditions experience greater mortality and morbidity than their white counterparts, they would use more health-care resources when no difference in health insurance exists. A retrospective, population-based cohort study was conducted using Maryland Medicaid Managed Care patient encounter data. We compared health services utilization and cost outcomes in both African-American and white patients with COPD, asthma, or coexisting COPD and asthma. The study population consisted of 9,131 patients with COPD, asthma, or both conditions. Of the total population, 52% were African American (n = 4,723), and 44% were white (n = 4,021); all other races were combined into the "unknown race" category to account for the remaining 4% (n = 387). After controlling for age, gender, cohort allocation, and comorbidities, we found that African-American adults with COPD, asthma, or coexisting COPD and asthma actually used fewer medical services and accounted for lower medical costs than white adults. Lower health services utilization and medical costs among African-American patients with COPD and asthma may provide a possible explanation for the racial disparities in outcomes of patients with these conditions.