Higher Health Care Use Research Articles

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada

BackgroundCase management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services.MethodsA qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out.ResultsLeadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an “individualized services plan” with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers’ concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care.ConclusionResults of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.

Comparison of Machine Learning Algorithms for Predicting Hospital Readmissions and Worsening Heart Failure Events in Patients With Heart Failure With Reduced Ejection Fraction: Modeling Study.

Heart failure (HF) is highly prevalent in the United States. Approximately one-third to one-half of HF cases are categorized as HF with reduced ejection fraction (HFrEF). Patients with HFrEF are at risk of worsening HF, have a high risk of adverse outcomes, and experience higher health care use and costs. Therefore, it is crucial to identify patients with HFrEF who are at high risk of subsequent events after HF hospitalization. Machine learning (ML) has been used to predict HF-related outcomes. The objective of this study was to compare different ML prediction models and feature construction methods to predict 30-, 90-, and 365-day hospital readmissions and worsening HF events (WHFEs). We used the Veradigm PINNACLE outpatient registry linked to Symphony Health's Integrated Dataverse data from July 1, 2013, to September 30, 2017. Adults with a confirmed diagnosis of HFrEF and HF-related hospitalization were included. WHFEs were defined as HF-related hospitalizations or outpatient intravenous diuretic use within 1 year of the first HF hospitalization. We used different approaches to construct ML features from clinical codes, including frequencies of clinical classification software (CCS) categories, Bidirectional Encoder Representations From Transformers (BERT) trained with CCS sequences (BERT + CCS), BERT trained on raw clinical codes (BERT + raw), and prespecified features based on clinical knowledge. A multilayer perceptron neural network, extreme gradient boosting (XGBoost), random forest, and logistic regression prediction models were applied and compared. A total of 30,687 adult patients with HFrEF were included in the analysis; 11.41% (3184/27,917) of adults experienced a hospital readmission within 30 days of their first HF hospitalization, and nearly half (9231/21,562, 42.81%) of the patients experienced at least 1 WHFE within 1 year after HF hospitalization. The prediction models and feature combinations with the best area under the receiver operating characteristic curve (AUC) for each outcome were XGBoost with CCS frequency (AUC=0.595) for 30-day readmission, random forest with CCS frequency (AUC=0.630) for 90-day readmission, XGBoost with CCS frequency (AUC=0.649) for 365-day readmission, and XGBoost with CCS frequency (AUC=0.640) for WHFEs. Our ML models could discriminate between readmission and WHFE among patients with HFrEF. Our model performance was mediocre, especially for the 30-day readmission events, most likely owing to limitations of the data, including an imbalance between positive and negative cases and high missing rates of many clinical variables and outcome definitions. We predicted readmissions and WHFEs after HF hospitalizations in patients with HFrEF. Features identified by data-driven approaches may be comparable with those identified by clinical domain knowledge. Future work may be warranted to validate and improve the models using more longitudinal electronic health records that are complete, are comprehensive, and have a longer follow-up time.

Epidemiology of Community-Acquired Acute Kidney Injury Among US Veterans

Community-acquired acute kidney injury (CA-AKI) develops outside of the hospital and is the most common form of AKI globally. National estimates of CA-AKI in the United States are absent due to limited availability of laboratory data. This study leverages national data from the Veterans Health Administration (VA) to estimate incidence and risk factors of CA-AKI. Retrospective cohort study using national VA administrative and laboratory data to assess cumulative CA-AKI incidence. VA primary care patients in 2013-2017 with recorded outpatient serum creatinine (Scr) and no history of chronic kidney disease≥stage5. Sociodemographics, comorbidities, medication use, and health care utilization. Annual incidence of CA-AKI defined as a≥1.5-fold relative increase in Scr on either a subsequent outpatient Scr or inpatient Scr obtained within≤24 hours of admission. We calculated the relative change in Scr within 12 months of an outpatient Scr value. A Cox model was used to estimate the association between CA-AKI and baseline characteristics, accounting for repeated measurements. Of approximately 2.5 million eligible veterans each year, the cumulative incidence of CA-AKI was approximately 2% annually. Only 27% of CA-AKI was detected at hospital admission. In adjusted analyses, high health care utilization, chronic illness, cancer, rural location, female sex, and use of renin-angiotensin aldosterone system inhibitors or diuretics were associated with increased CA-AKI risk (all, HR>1.20). Limited generalizability of results outside a veteran population, lack of a standardized definition for CA-AKI, and possibility of surveillance bias and misclassification. CA-AKI affects 1 of every 50 US veterans annually. With less than a third of CA-AKI observed in the inpatient hospital setting, reliance on inpatient evaluation of AKI suggests significant underrecognition and missed opportunities to prevent and manage the long-term consequences of AKI.

Persistent physical symptoms after COVID-19 infection and the risk of Somatic Symptom Disorder

ObjectiveEvidence shows that many patients with COVID-19 present persistent symptoms after the acute infection. Some patients may be at a high risk of developing Somatic Symptom Disorder (SSD), in which persistent symptoms are accompanied by excessive and disproportionate health-related thoughts, feelings and behaviors regarding these symptoms. This study assessed the frequency of persistent physical symptoms and SSD and their associated factors in patients with confirmed COVID-19. MethodsWe conducted a longitudinal retrospective study after the first two French lockdowns at the Lille University Hospital (France), including all patients with confirmed COVID-19. Persistent physical symptoms and excessive preoccupations for these symptoms were measured 8 to 10 months after the onset of COVID-19. The combination of the Patient Health Questionnaire-15 and the Somatic Symptom Disorder-B Criteria Scale was used to identify the individuals likely to present with SSD. Two linear regression models were performed to identify sociodemographic and medical risk factors of SSD. ResultsAmong the 377 patients with a laboratory-confirmed diagnosis, 220 (58.4%) completed the questionnaires. Sixty-five percent of the 220 included patients required hospitalization, 53.6% presented at least one persistent physical symptom and 10.4% were considered to present SSD. Female sex, older age, infection during the second wave and having probable PTSD were significantly associated with the severity of SSD and SSD was associated with a significantly higher healthcare use. ConclusionsThe identification of SSD should encourage clinicians to move beyond the artificial somatic/psychiatric dualism and contribute to a better alliance based on multi-disciplinary care.

Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis.

Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers. To identify characteristics and criteria to distinguish HNHC patients. Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022. English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost. Independent, dual-review extraction and quality assessment. The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC. Little evidence distinguished potentially preventable or modifiable health care use from overall use. A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services. Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).

Studying the Long-term Impact of COVID-19 in Kids (SLICK). Healthcare use and costs in children and young people following community-acquired SARS-CoV-2 infection: protocol for an observational study using linked primary and secondary routinely collected healthcare data from England, Scotland and Wales

IntroductionSARS-CoV-2 infection rarely causes hospitalisation in children and young people (CYP), but mild or asymptomatic infections are common. Persistent symptoms following infection have been reported in CYP but subsequent healthcare...

Better use of inhaled medication in asthma and COPD through training, preparation and counselling: the On TRACk study protocol for a cluster randomised controlled trial

IntroductionAbout 70% of patients with asthma and/or chronic obstructive pulmonary disease (COPD) use their inhaled medication incorrectly, leading to reduced disease control, higher healthcare use and costs. Adequate guidance from...

Admitting what is needed: How the health system and society can reduce hospitalizations for children with medical complexity.

Admitting what is needed: How the health system and society can reduce hospitalizations for children with medical complexity.

Healthcare utilization and health-related quality of life of severe asthma patients in Singapore

Background Notwithstanding unequivocal consensus on the disproportionate effect of severe asthma (SA) on asthma morbidity, healthcare utilization, quality of life, work impairment and socioeconomic burden, the burden of SA patients in Singapore has not been appraised. Objectives To determine the burden of disease and extent of quality of life impairment in SA patients in Singapore. Methods A cross-sectional analysis of SA patients seen in Singapore General Hospital (2020–2021) to investigate emergency healthcare utilization, oral corticosteroid (OCS) burden and health-related quality of life (HRQoL) with primary endpoint EuroQoL-5 Dimension three-level (EQ-5D-3L) scores. The empirical measurement properties of the EQ-5D utility index in SA were comprehensively assessed through multivariate regression analyses. Results A total of 336 SA patients were recruited, 51.2% of SA patients had at least one acute healthcare resource utilization during the previous year, with 25.6% of patients having an emergency healthcare visit to the hospital. Overall mean (SD) EQ-5D-3L and EQ-5D-3L utility scores in SA patients were 6.22 (1.51) and 0.77 (0.30), respectively. EQ-5D utility scores were 0.14 lower in uncontrolled vs controlled asthma and 0.09 lower in the presence of severe exacerbation, whereas barely changed by maintenance OCS dose and airflow limitation. Conclusion SA patients were found to have high disease burden, high healthcare resource utilization and OCS use, low biologics usage, poor HRQoL and utility in comparison with other chronic diseases.

The Predictors of Somatic Symptoms in a Population Sample: The Lifelines Cohort Study.

Multiple bodily symptoms predict poor health status, high healthcare use, and onset of functional somatic syndromes. This study aimed to identify the predictors of somatic symptoms with special reference to mental disorders. The prospective, population-based Lifelines cohort study included 80,888 adults who were followed up for a mean of 2.4 years. At baseline sociodemographic status, self-reported medical disorders, functional somatic syndromes, stress, neuroticism, mental disorders (assessed with Mini-International Neuropsychiatric Interview), health perception, and analgesic use were assessed. These variables were tested as predictors of number of somatic symptoms at follow-up using linear regression analysis, which adjusted for baseline somatic symptoms ( n = 65,904). Logistic regression was used to identify the predictors of a persistently high number of somatic symptoms. The strongest predictors of somatic symptoms at follow-up were life events and difficulties score, and number of general medical illnesses/functional somatic syndromes. Neuroticism and mental disorders were also independent predictors in all analyses. Generalized anxiety, major depressive, and panic disorders were all independent predictors when entered individually into the regression analysis. A persistently high number of somatic symptoms were predicted most strongly by functional somatic syndromes, negative health perception, and paracetamol use. Number of somatic symptoms should be regarded as a multifactorial measure with many predictors. Mental disorders form one predictor, but there are other stronger ones, including stress and general medical disorders. The bidirectional relationship between functional somatic syndromes and multiple somatic symptoms is compatible with the notion that perception of bodily symptoms is a key component of both.

P-789 Early childhood respiratory tract infections according to parental subfertility and conception by assisted reproductive technologies

Abstract Study question Are children conceived by assisted reproductive technologies (ART) or born to subfertile parents more susceptible for upper- or lower respiratory infections (URTI, LRTI)? Summary answer ART-conceived children had higher frequency and risk of hospitalization for respiratory infections up to age 3, which can only partly be explained by parental subfertility. What is known already Some studies report higher health care use, health care costs and increased risks of infections in children conceived by ART. Results for URTIs and LRTIs are inconclusive, and the contribution of underlying parental subfertility remains unclear. Study design, size, duration We included 84 102 singletons of the prospective Norwegian Mother, Father and Child Cohort Study (MoBa) born between 1999-2008. Mothers reported time-to-pregnancy at recruitment and respiratory infections, frequency, and hospitalisation by questionnaires when the child was 6, 18 and 36 months old. The birth registry provided information on ART and subfertility was defined ≥ 12 months to conception. URTI included throat and ear infections, while LRTI included bronchitis, bronchiolitis, respiratory syncytial virus, and pneumonia. Participants/materials, setting, methods We used log-binomial regression to estimate risk ratios (RR) and 95% confidence intervals (CI) of any infection and hospitalisation. We used negative-binomial regression receiving incidence rate ratios (IRR) and 95% CI for number of infections. We compared children conceived by ART and naturally conceived by subfertile parents to children of fertile parents (reference) while adjusting for maternal age, education, body-mass-index and smoking during pregnancy and previous livebirths. We clustered children born to the same mother. Main results and the role of chance A total of 7334 (8.7%) singletons were naturally conceived by subfertile parents and 1901 (2.3%) by ART. Between age 0-36 months, 41 639 (49.5%) of children experienced any URTI, 15 542 (18.5%) any LRTI, and 4134 (4.9%) were hospitalized due to LRTI. Over the first three years of life, the risk for higher frequency of URTI (aIRR 1.16; 95% CI 1.05-1.28) and any hospitalisation due to LRTI (aRR 1.25; 95% CI 1.02-1.53) was increased for children conceived by ART but not for children of subfertile parents. Risks of respiratory infections were not increased at age 0-6 or 7-18 months. Only at age 19-36 months, children of subfertile parents had higher risk of LRTIs (adjusted relative risk (aRR) 1.09, 95%CI 1.01-1.17). Children conceived by ART had an increased risk of any LRTI (aRR 1.16, 95% CI 1.01-1.33), increased frequency of LRTI’s (IRR 1.26; 95%CI 1.04- 1.51) and higher risk of hospitalisation for LRTI (aRR 1.38; 95% CI 1.03-1.84) at 19-36 months as well as an increased frequency of URTI’s (aIRR 1.20; 95% CI 1.08-1.34). Limitations, reasons for caution Use of self-reported time-to-pregnancy and respiratory tract infections by parents could lead to misclassification. Selection bias makes the MoBa Cohort somewhat different from the general Norwegian population and lost to follow-up is not at random. Wider implications of the findings ART-conceived children might be more susceptible to respiratory tract infections in early childhood. This appears to be only partly explained by factors related to underlying parental subfertility. The immune response in children might be affected by parental subfertility or through ART technology and this should be further investigated. Trial registration number not applicable

Internet-delivered psychological treatment of functional gastrointestinal disorders in youth: Study protocol for exploration of cognitive biases

Introduction Functional gastrointestinal disorders (FGID) are common in children and adolescents (CA), cause functional disability and high health care use. Internet based cognitive behavioral therapy (i-CBT) have shown promising effect in Sweden. The treatment is exposure based and target avoidance behavior. Cognitive biases regarding bodily symptoms are suggested to be part of development and maintenance of functional disorders in adults, and could therefore be an important treatment target. Little is known about cognitive biases in CA with FGID, and hence the potential importance, it is crucial to explore more in depth. This study is embedded in The Danish FGID Treatment Study which aims to test Swedish i-CBT treatment in a Danish context.Objectives1) Examine cognitive biases in CA with FGID, compared with healthy controls. 2) Asses these biases before and after treatment for FGID to investigate changes and impact on treatment effect.MethodsWe developed a novel experimental approach to examine possible cognitive biases in CA. It consists of a picture task and a FGID-specific version of the Health Norms Sorting Task. We will examine 60 CA with FGID, who are included in The Danish FGID Treatment Study before and after treatment. In addition we will perform the test on 100 healthy controls.ResultsThe results are expected to improve our understanding of maintaining cognitive factors in CA with FGID, and how these may affect outcome and change during treatment, and how they differ from the general population.ConclusionsThis study can provide new targets for treatment approaches.DisclosureNo significant relationships.

Multidimensional analysis of adult patients’ care trajectories before a first diagnosis of schizophrenia

For patients at high-risk for developing schizophrenia, a delayed diagnosis could be affected, among many reasons, by their patterns of healthcare use. This study aims to describe and generate a typology of patients’ care trajectories (CTs) in the 2 years preceding a first diagnosis of schizophrenia, over a medico-administrative database of 3712 adults with a first diagnosis between April 2014 and March 2015 in Quebec, Canada. This study applied a multidimensional approach of State Sequence Analysis, considering together sequences of patients’ diagnoses, care settings and care providers. Five types of distinct CTs have emerged from this data-driven analysis: The type 1, shared by 77.6% of patients, predominantly younger men, shows that this group sought little healthcare, among which 17.5% had no healthcare contact for mental disorders. These individuals might benefit from improved promotion and prevention of mental healthcare at the community level. The types 2, 3 and 4, with higher occurrence of mental disorder diagnoses, represent together 19.5% of the study cohort, mostly middle-aged and women. These CTs, although displaying roughly similar profiles of mental disorders, revealed very dissimilar sequences and levels of care providers encounters, primary and specialized care use, and hospitalizations. Surprisingly, patients of these CTs had few consultations with general practitioners. An increased attentiveness for middle-aged patients and women with high healthcare use for mental disorders could help to reduce delayed diagnosis of schizophrenia. This calls for further consideration of healthcare services for severe mental illness beyond those offered to young adults.

Healthcare Use in the Five Years Before a First Infertility Diagnosis: A Danish Register-Based Case-Control Study in the CROSS-TRACKS Cohort.

PurposeInfertility may affect somatic and mental health later in life. Nevertheless, health status before diagnosed infertility is sparsely studied in women. We aimed to describe healthcare use in primary and secondary care before a first infertility diagnosis and compare use between cases and controls.Materials and MethodsThe case–control study was based on register data and used incidence density sampling. From the CROSS-TRACKS Cohort, we included women residing in the Horsens area in Denmark in 2012–2018 (n = 54,175). Eligible women were aged 18–40 years, nulliparous, and living in heterosexual relationships. Cases were women with a first infertility diagnosis in the Danish National Patient Registry (index date). Five controls were matched on age, birth year, and calendar time. Through linkage to Danish national health registries, we identified general practitioner (GP) attendance, paraclinical examinations, hospital contacts, diagnoses, and redeemed prescriptions. Healthcare use from one year to five years before index date was compared with conditional logistic regression.ResultsWe identified 711 cases and 3555 controls. At one year before index date, cases consulted their GP (odds ratio (OR) = 5.2, 95% confidence interval (CI): 3.2, 8.3) and visited hospital (OR = 1.2, 95% CI: 1.0, 1.4) and redeemed prescriptions (OR = 2.3 95% CI: 1.9, 2.7) more often compared to controls. Cases more often had blood and hemoglobin tests performed, redeemed more drugs related to genitourinary and hormonal diseases, and were more often diagnosed with endocrine and genitourinary diseases in the year before a first infertility diagnosis compared to controls. Cases and controls had comparable healthcare use from five years to one year before a first infertility diagnosis.ConclusionCases and controls had similar healthcare use from five years to one year before a first infertility diagnosis. However, cases had a higher healthcare use in the year preceding a first infertility diagnosis compared to controls.

Perinatal Outcomes of Fetuses and Infants Diagnosed with Trisomy 13 or Trisomy 18

To identify factors associated with prenatal, perinatal, and postnatal outcomes, and determine medical care use for fetuses and infants with trisomy 13 (T13) and trisomy 18 (T18). This population-based retrospective cohort study included all prenatal and postnatal diagnoses of T13 or T18 in the greater Cincinnati area from January 1, 2012, to December 31, 2018. Overall survival, survival to hospital discharge, medical management, and maternal, fetal, and neonatal characteristics are analyzed. There were 124 pregnancies (125 fetuses) that were identified, which resulted in 72 liveborn infants. Male fetal sex and hydrops were associated with a higher rate of spontaneous loss. The median length of survival was 7 and 29days, for infants with T13 and T18, respectively. Of the 27 infants alive at 1month of age, 13 (48%) were alive at 1year of age. Only trisomy type (T13), goals of care (comfort care), and extremely low birthweight were associated with a shorter length of survival. A high degree of variability existed in the use of medical services, with 28% of infants undergoing at least 1 surgical procedure and some children requiring repeated (≤29) or prolonged (>1year) hospitalizations. Although many infants with T13 or T18 did not survive past the first week of life, nearly 20% lived for more than 1year with varying degrees of medical support. The length of survival for an infant cannot be easily predicted, and surviving infants have high health care use throughout their lifespans.

Healthcare Utilization and Medical Cost of Gastrointestinal Reflux Disease in Non-tuberculous Mycobacterial Pulmonary Disease: A Population-Based Study, South Korea, 2009-2017.

Gastroesophageal reflux disease (GERD) is a common non-respiratory comorbidity in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD). However, little is known about the association between GERD and healthcare utilization and medical costs of NTM-PD. Thus, we evaluated this association using the Health Insurance Review and Assessment Service National Patient Sample. NTM-PD patients with GERD had significantly higher healthcare use and spent a higher total on medical costs (5,098 vs. 2,675 USD/person/year) than those without GERD (P <0.001 for all). Therefore, an appropriate management of GERD in NTM-PD patients can be an important factor to reduce the disease burden.

Exploring Patient Multimorbidity and Complexity Using Health Insurance Claims Data: A Cluster Analysis Approach.

BackgroundAlthough the trend of progressing morbidity is widely recognized, there are numerous challenges when studying multimorbidity and patient complexity. For multimorbid or complex patients, prone to fragmented care and high health care use, novel estimation approaches need to be developed.ObjectiveThis study aims to investigate the patient multimorbidity and complexity of Swiss residents aged ≥50 years using clustering methodology in claims data.MethodsWe adopted a clustering methodology based on random forests and used 34 pharmacy-based cost groups as the only input feature for the procedure. To detect clusters, we applied hierarchical density-based spatial clustering of applications with noise. The reasonable hyperparameters were chosen based on various metrics embedded in the algorithms (out-of-bag misclassification error, normalized stress, and cluster persistence) and the clinical relevance of the obtained clusters.ResultsBased on cluster analysis output for 18,732 individuals, we identified an outlier group and 7 clusters: individuals without diseases, patients with only hypertension-related diseases, patients with only mental diseases, complex high-cost high-need patients, slightly complex patients with inexpensive low-severity pharmacy-based cost groups, patients with 1 costly disease, and older high-risk patients.ConclusionsOur study demonstrated that cluster analysis based on pharmacy-based cost group information from claims-based data is feasible and highlights clinically relevant clusters. Such an approach allows expanding the understanding of multimorbidity beyond simple disease counts and can identify the population profiles with increased health care use and costs. This study may foster the development of integrated and coordinated care, which is high on the agenda in policy making, care planning, and delivery.

Associations between probable eating disorders and healthcare use among post-9/11 veteran men and women

ObjectiveHealthcare use is elevated among individuals with eating disorders (EDs); however, most people with EDs do not receive ED-specific care, likely due to factors such as the cost and availability of treatment as well as stigma. U.S. military veterans historically have been understudied in ED research. We investigated healthcare use and barriers to care among recently separated veteran men and women. MethodIn this cross-sectional study, 1494 participants completed an online or paper survey assessing ED symptoms, healthcare use, and logistical and attitudinal barriers to care. We estimated logistic regression models to investigate the association of ED status with healthcare use variables and examined gender similarities and differences in barriers to care. ResultsMen and women with probable EDs reported low rates of ED treatment but greater healthcare use, during military service and since separating from service, compared to veterans without probable EDs (odds ratios = 1.57–7.05). Large proportions of participants reported that they did not know where to get help for EDs and that treatment is too costly. There were few gender differences in barriers to care (Cramer's V = 0.02–0.32). ConclusionVeterans reported high healthcare use but low rates of ED treatment. Findings underscore the need to increase the reach and accessibility of ED treatment in potentially vulnerable groups.

Patterns of healthcare utilization with placement changes for youth in foster care

BackgroundChildren in foster care experience poor health and high healthcare use. Child welfare agencies frequently require healthcare visits when children enter foster care; subsequent placement changes also disrupt healthcare. Studies of healthcare use have not accounted for placement changes. ObjectiveTo understand patterns of healthcare use throughout the time a child enters foster care and with placement changes, accounting for mandated visits when children enter foster care or experience a placement change. Participants and settingChildren 4 and older in foster care between 2012 and 2017 (N = 2787) with linked child welfare administrative data from one county child welfare agency and one Midwest pediatric healthcare system. MethodsNegative binomial models predicted healthcare days per month that were planned (e.g., scheduled primary/specialty care), unplanned (e.g., emergency care), or missed. ResultsPlanned healthcare days increased as a function of placement changes (Incident Rate Ratio [IRR] =1.69, p < .05) and decreased with placement stability (IRR = 0.92, p < .01). Mandated visits that occurred later in a placement were associated with fewer planned (IRR = 0.81, p < .01) and unplanned (IRR = 0.82, p < .01) healthcare days during that placement. ConclusionsPatterns of planned healthcare over the time children are in one placement and move between placements suggest more can be done to ensure youth remain connected to primary and specialty care throughout placements and placement transitions, s that children are seen as clinically appropriate rather than a function of placement disruption. Findings regarding the timing of mandated visits suggest that delays in mandated care may also reflect lower healthcare use overall.

Certificate of Need Laws and Health Care Use during the COVID-19 Pandemic

This paper investigates the impact of state-level Certificate-of-Need (CON) laws on COVID and non-COVID deaths in the United States during the SARS-CoV-2 pandemic. CON laws limit the expansion and acquisition of new medical services, such as new hospital beds. The coronavirus pandemic created a surge in demand for medical services, which might be exacerbated in some states that have CON laws. Our investigation focuses on mortality due to COVID and non-COVID reasons and understanding how these laws affect access to healthcare for illnesses that might require similar medical equipment to COVID patients. We find that states with high healthcare use due to COVID that reformed their CON laws during the pandemic had a reduction in mortality resulting from COVID-19, septicemia, diabetes, chronic lower respiratory disease, influenza or pneumonia, and Alzheimer’s Disease, relative to non-reforming CON states.