High Health Care Research Articles

Referral to a Functional Seizures Clinic Reduces Inpatient and Emergency Department Health Care Utilization and Costs.

People with functional seizures (FSs) experience high health care utilization and costs revolving around the emergency department (ED). Overall, appropriate treatment of FS is underused, and better care pathways are associated with lower ED reattendance. Our objective was to assess changes in total ED and inpatient visits and costs before and after referral to a specialized, comprehensive FS treatment clinic. We collected data from 100 consecutive patients referred to the University of Colorado (CU) FS Clinic between July 2019 and December 2021. Hospital account data were obtained directly from the electronic health record. Total ED and inpatient visits, charges, and payments 1 year before and 1 year after referral were collected and analyzed using the Wilcoxon signed-rank test. Ninety-four patients were included for analysis. 79% were female, 52% were on Medicaid, and the mean age was 41 (SD 13) years. Total visits after referral (ED and inpatient) were significantly reduced compared with total visits before referral (mean = 1.44 (SD 3.52) vs 1.83 (SD 3.52), p = 0.045). The same test was performed for total charges after and before referral ($15,551 (SD $38,712) vs $30,257 (SD $81,589), p = 0.03) and for total payments after and before referral ($2,469 (SD $6,682) vs $5,199 (SD $15,084), p = 0.02). Referral to a specialized FS clinic is associated with reduced health care utilization and costs. This proof-of-concept study reveals that hospitals should implement policies to support efficient care pathways to comprehensive FS treatment programs with potential for cost savings.

End-of-life (EOL) outcomes and healthcare utilization for patients with hepatocellular carcinoma (HCC) who received immune checkpoint inhibition (ICI).

560 Background: ICI is standard of care treatment for advanced HCC. EOL outcomes for patients with HCC who receive ICI prior to death are unknown. We examine relationships between EOL outcomes, healthcare utilization, and receipt of ICI for patients with advanced HCC referred to our tertiary center. Methods: Patients with advanced HCC evaluated at our center on or after January 1, 2020 and who died by March 29, 2024 were included. Patients were identified using diagnostic codes for liver cancer and HCC, and subsequently verified by manual review of the electronic health record. Demographic data, Child-Pugh (CP) status, and treatment history were collected. Primary EOL outcomes include: documentation of advance directives and goals of care (GOC) conversations, location of death, palliative care referral, hospice referral, days in hospice, and code status. Secondary healthcare utilization outcomes include: systemic therapy receipt, emergency department (ED) visits, hospitalization, and intensive care unit (ICU) admissions within 14, 30, and 90 days of death. Outcomes were stratified by ICI or non-ICI as last therapy received and p-values were derived using Pearson’s chi-square test for equality of proportions. Results: Of 221 evaluated patients, 71 died and met criteria for analysis. Baseline characteristics include mean age 64.1 years, 70.8% male, 71.8% received systemic treatment (median 1 line, range [1-7]), 54.1% CPA, 37.5% CPB, and 8.3% CPC at the time of last treatment. No statistically significant differences in primary EOL outcomes were detected when stratified by receipt of ICI or non-ICI as last therapy. Median days enrolled in hospice were not statistically significant between groups (24.5 days [non-ICI] vs 10 days [ICI]; p = 0.39). A higher proportion of patients who received ICI as last therapy had increased healthcare utilization across all outcomes (see Table). Conclusions: Patients with advanced HCC receiving ICI as their last treatment before death compared to those receiving non-ICI had similar EOL outcomes but higher healthcare utilization. This may be due to increased real-world use of ICI in CPB patients. Further investigation into risk stratification to predict high healthcare utilizers could guide decision-making and conversations around ongoing use of ICI, particularly near the EOL. Healthcare utilization outcomes stratified by receipt of ICI. Outcome Before Death n = 71 90 days 30 days 14 days Therapy within Total: Last therapy ICI 33/71 (46.5%)69.7% 18/71 (25.4%)66.7% 6/71 (8.5%)33.3% ED visit Total: Last therapy ICI 29/71 (40.8%)58.6% 27/71 (38.0%)55.6% 22/71 (30.1%)59.1% Hospitalization Total: Last therapy ICI 32/71 (45.1%)59.4% 30/71 (42.3%)56.6% 29/71 (40.8%)58.6% ICU admission Total: Last therapy ICI 6/71 (8.5%)66.7% 6/71 (8.5%)66.7% 6/71 (8.5%)66.7%

Digital Home-Based Self-Monitoring System for People with Heart Failure: Protocol for Development of SmartHeart and Evaluation of Feasibility and Acceptability.

Heart failure (HF) is a chronic, progressive condition where the heart cannot pump enough blood to meet the body's needs. In addition to the daily challenges that HF poses, acute exacerbations can lead to costly hospitalizations and increased mortality. High health care costs and the burden of HF have led to the emerging application of new technologies to support people living with HF to stay well while living in the community. However, many digital solutions have not involved consumers and health care professionals in their design, leading to poor adoption. The SmartHeart project aimed to codevelop a smart health ecosystem to support the early detection of HF deterioration and encourage self-care, potentially preventing hospitalizations. This study aims to provide an overview of the SmartHeart project by describing our approach to designing the SmartHeart system, outlining its features, and describing the planned pilot study to determine the feasibility of the system. We used the Integrate, Design, Assess, and Share (IDEAS) framework to guide the development of the SmartHeart system, involving users (people with HF and their caregivers) and stakeholders (health care providers involved in the management of HF) in its design. SmartHeart is a complete remote heart health monitoring and automated feedback delivery system. It includes 2 user interfaces for patients: an Amazon Alexa conversational agent and a smartphone app. The system collects physiological, symptom, and behavioral data through wireless sensors and self-reports from users. These data are processed and analyzed to provide personalized health insights, self-care support, and alerts in case of health deterioration. The system also includes a web-based user interface for health care professionals, allowing them to access data, send messages to users, and receive notifications about potential health deterioration. A single-arm, multicenter pilot trial (N=20) is planned to determine the feasibility and acceptability of SmartHeart before evaluation through a randomized controlled trial. The primary outcome will be a description of the study's feasibility (recruitment, attrition, engagement, and changes in self-care). The SmartHeart study started in January 2021 on procurement of funding. Recruitment for the pilot trial started in August 2024 and will be completed by March 2025. We have currently enrolled 12 participants. Follow-up of all participants will be completed by the end of May 2025. We have co-designed and developed a complete remote heart health monitoring and automated feedback delivery system for the early detection of HF deterioration and prevention of HF-related hospitalizations. The next step is a pilot study, which will provide valuable information on feasibility and preliminary effects to inform a larger evaluation trial. SmartHeart has the potential to augment existing health services and help people with HF stay well while living in the community. DERR1-10.2196/62964.

Maternal mental health matters: Indicators for perinatal mental health-A scoping review.

Perinatal mental health disorders are a significant contributor to morbidity and mortality in childbearing women. The World Health Organization recommends all women be screened for mental health disorders postnatally and have diagnostic and management services available. There are, however, currently no global indicators in use which measure the status and progress of perinatal mental health. The aim of this scoping review was to identify existing perinatal mental health indicators and propose a core set which could be used at a global level. We used the Global Perinatal Mental Health Theory of Change as the conceptual framework. We found 25 indicators for PMH aligned with the Global Perinatal Mental Health Theory of Change, which were condensed to form a core set of nine indicators These core indicators include the proportion of women with depression, anxiety, post-traumatic stress disorder, psychosis, or adjustment disorders in the perinatal period; the proportion of women screened for these services; the proportion who have access to services following a positive diagnosis; and, the proportion of healthcare providers trained to provide mental health care. This review forms part of the foundational work for the development of a global monitoring framework which would be able to monitor progress towards the provision of universal high quality perinatal mental health care.

Association of Frailty Index at 66 Years of Age with Health Care Costs and Utilization Over 10 Years in Korea: Retrospective Cohort Study.

The long-term economic impact of frailty measured at the beginning of elderhood is unknown. The objective of our study was to examine the association between an individual's frailty index at 66 years of age and their health care costs and utilization over 10 years. This retrospective cohort study included 215,887 Koreans who participated in the National Screening Program for Transitional Ages at 66 years of age between 2007-2009. Frailty was categorized using a 39-item deficit accumulation frailty index: robust (<0.15), prefrail (0.15-0.24), and frail (≥0.25). The primary outcome was total health care cost, while the secondary outcomes were inpatient and outpatient health care costs, inpatient days, and number of outpatient visits. Generalized estimating equations with a gamma distribution and identity link function were used to investigate the association between the frailty index and health care costs and utilization until December 31, 2019. The study population included 53.3% (n=115,113) women, 32.9% (n=71,082) with prefrailty, and 9.7% (n=21,010) with frailty. The frailty level at 66 years of age was associated with higher cumulative total costs (robust to frail: $19,815 to $28.281; P<.001), inpatient costs (US $11,189 to US $16,627; P<.001), and outpatient costs (US $8,625 to US $11,654; P<.001) over the next 10 years. In the robust group, a one-year increase in age was associated with increased total health care costs (mean change per beneficiary per year: US $206.2; SE: $1.2; P<.001), inpatient costs (US $126.8; SE: $1.0; P<.001), and outpatient costs (US $74.4; SE: $0.4; P<.001). In the frail group, the increase in total health care costs was greater compared to the robust group (difference in mean cost per beneficiary per year: US $120.9; SE: $5.3; P<.001), inpatient costs (US $102.8; SE: $5.22; P<.001), and outpatient costs (US $15.6; SE: $1.5; P<.001). Similar results were observed for health care utilization (P<.001). Among the robust group, a one-year increase in age was associated with increased inpatient days (mean change per beneficiary per year: 0.9 d; P<.001) and outpatient visits (2.1 visits; P<.001). In the frail group, inpatient days increased annually compared to the robust group (difference in the mean inpatient days per beneficiary per year: 1.5 d; P<.001), while outpatient visits increased to a lesser extent (difference in the mean outpatient visits per beneficiary per year: -0.2 visits; P<.001). Our study demonstrates the potential utility of assessing frailty at 66 years of age in identifying older adults who are more likely to incur high health care costs and utilize health care services over the subsequent 10 years. The long-term high health care costs and utilization associated with frailty and prefrailty warrants public health strategies to prevent and manage frailty in aging populations.

P0108 Exploring Microbiota-Immune Interactions in Short Bowel Syndrome and Crohn’s Disease in a model of human microbiota associated mice

Abstract Background Short bowel syndrome (SBS) is a malabsorptive condition mostly caused by massive surgical resection of the small intestine and is associated with significant morbidity and mortality, reduced quality of life, and high healthcare costs1. Crohn’s disease (CD) represents a potential cause leading to an increased risk of SBS with considerable clinical consequences2. Human microbiota-associated (HMA) mice represent a model to establish human fecal microbiota in preclinical models3-4. Here, for the first time, we tried to conduct a “humanized” model of SBS, using faeces from patients affected by this disease. The aim of the current study is to determine the functional role of the gut microbiota of CD patients with or without SBS. Methods A dextran sodium sulphate model of colitis on C57BL/6 mice was employed to assess immune and metabolic signatures following faecal transplantation from patients affected by SBS/IF, CD with high or low risk for SBS/IF. Lymph node samples were collected to examine differences in T cell populations, and disease activity index and bronchoscopy were used to evaluate the activity of the disease. Results Fecal microbiota transplantation (FMT) from CD patient with a low risk of SBS/IF was associated with worse disease activity and endoscopic scores in colitis mice. Additionally, an increase in the percentages of Treg, Tnaive, Th1, and Th17 cells was observed in mice that received FMT from CD patient with a low risk of SBS/IF, compared to controls and those that received FMT from patient with SBS/IF or from CD patient with a high risk of SBS/IF. Conclusion Our data underscore the complex interactions between gut microbiota and host immunity and highlight the importance of careful donor selection in FMT applications, particularly for inflammatory conditions. Further research is warranted to characterize specific microbial and immunological factors that drive these effects and to identify microbiota profiles that could potentially confer therapeutic benefits. References Fundings: 2.1 “Rafforzamento e potenziamento della ricerca biomedica del SSN”, finanziato dall’Unione europea – NextGenerationEU, CUP C53C22001140007. 2022 PNRR Project “Changing the future of intestinal failure in intestinal chronic inflammation: towards innovative predictive factors and therapeutic targets” code: PNRR-MAD-2022-12376791. 1.Massironi S, Cavalcoli F, Rausa E, Invernizzi P, Braga M, Vecchi M. Understanding short bowel syndrome: current status and future perspectives. Dig Liver Dis. 2020;52(3):253-261. doi:10.1016/j.dld.2019.11.013 2.Aksan A, Farrag K, Blumenstein I, Schröder O, Dignass AU, Stein J. Chronic intestinal failure and short bowel syndrome in Crohn's disease. World J Gastroenterol. 2021;27(24):3440-3465. doi: 10.3748/wjg.v27.i24.3440. 3.Staley C, Kaiser T, Beura LK, Hamilton MJ, Weingarden AR, Bobr A, Kang J, Masopust D, Sadowsky MJ, Khoruts A. Stable engraftment of human microbiota into mice with a single oral gavage following antibiotic conditioning. Microbiome. 2017;5(1):87. doi: 10.1186/s40168-017-0306-2. 4.Zhu Z, Kaiser T, Staley C. Antibiotic Conditioning and Single Gavage Allows Stable Engraftment of Human Microbiota in Mice. Methods Mol Biol. 2021;2327:281-291. doi: 10.1007/978-1-0716-1518-8_17.

Protocol for the enhanced management of multimorbid patients with COPD and severe asthma: role of indoor air quality

IntroductionReducing unplanned hospital admissions in chronic patients at risk is a key area for action due to the high healthcare and societal burden of the phenomenon. The inconclusive results of...

Factors affecting cancer care delivery in primary care: a qualitative study.

One role of primary care is to support people living with and beyond cancer, the number of whom is increasing worldwide. This study aimed to identify factors affecting cancer care provision within English primary care after the start of the coronavirus pandemic, during high healthcare service demand, and a depleted workforce. An exploratory qualitative descriptive approach was used to collect data via remote semi-structured interviews with primary care staff after gaining informed consent. Interview transcripts were analysed using reflexive thematic analysis. Fifteen primary care staff were interviewed (11 general practitioners, 3 practice nurses, and 1 physician associate). Factors affecting cancer care delivery in primary care were: (i) patient level: acceptance of healthcare and understanding of cancer; (ii) clinician level: personal experience with cancer and knowledge; (iii) general practice level: care coordinators and cancer registers, and (iv) system level: lack of healthcare resourcing and political inaction. The ability of primary care to deliver cancer care is affected by multiple factors at various levels. Future studies should identify the implementation strategies of local and national policies to better understand how to improve cancer care education, practice-level infrastructure, evidence-based workforce planning, and healthcare resourcing.

Accuracy of pulse wave velocity for screening coronary artery disease: a systematic review and meta-analysis.

Coronary artery disease (CAD) is the leading cause of cardiovascular events and showed high prevalence and healthcare costs in 2019. However, CAD screening for cardiovascular event prevention is invasive and expensive. This study aims to estimate the ability of a noninvasive method, pulse wave velocity (PWV), to detect the presence or absence of coronary artery disease in patients with suspected CAD. A systematic review and meta-analysis of the available evidence was conducted, comparing PWV with the gold standard diagnostic method, angiography. The literature search was systematically performed in the PubMed, Scopus and Web of Science databases from inception to August 2024. Study quality assessment was performed using the Diagnostic Accuracy Study Quality Assessment Tool (QUADAS-2). Publication bias was assessed using the method proposed by Deeks. Statistical analyses were performed with the STATA SE software, version 15. The eight included studies had a cross-sectional design, in which the presence of CAD was measured simultaneously by PWV and angiography. To assess the accuracy of the tests, the overall sensitivity and specificity were combined into a single value, the diagnostic odds ratio (dOR), which provided a value of 3.61, indicating a high probability of detecting CAD by PWV. The implementation of PWV as a screening technique in healthcare centers could bring great benefits to patients with suspected CAD and increase efficiency in the use of healthcare resources.

Prevalence and Economic Impact of Acute Respiratory Failure in the Prehospital Emergency Medical Service of the Madrid Community: Retrospective Cohort Study.

Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute pulmonary edema (APE) are serious illnesses that often require acute care from prehospital emergency medical services (EMSs). These respiratory diseases that cause acute respiratory failure (ARF) are one of the main reasons for hospitalization and death, generating high health care costs. The prevalence of the main respiratory diseases treated in a prehospital environment in the prepandemic period and during the COVID-19 pandemic in Spain is unknown. The Madrid Community EMS is a public service that serves all types of populations and represents an epidemiological reference for supporting a population of 6.4 million inhabitants. The high volume of patients treated by Madrid's medical advanced life supports (ALSs) allows us to analyze this little-studied problem. Our goal was to lay the groundwork for comprehensive data collection and surveillance of respiratory failure, with an emphasis on the most prevalent diseases that cause it, an aspect that has been largely overlooked in previous initiatives. By achieving these objectives, we hope to inform efforts to address respiratory failure and establish a standardized methodology and framework that can facilitate expansion to a continuous community-wide registry in Madrid, driving advances in emergency care and care practices in these pathologies. The aim of this retrospective observational study was to determine the pathologies that have mainly caused respiratory failure in patients and required medicalized ALS and to evaluate the cost of care for these pathologies collected through this pilot registry. A multicenter descriptive study was carried out in the Madrid Community EMS. The anonymized medical records of patients treated with medical ALS, who received any of the following medical diagnoses, were extracted: ARF not related to chronic respiratory disease, ARF in chronic respiratory failure, exacerbations of COPD, APE, CHF, and bronchospasm (not from asthma or COPD). The prevalence of each pathology, its evolution from 2014 to 2020, and the economic impact of the Medical ALSs were calculated. The study included 96,221 patients. The most common pathology was exacerbation of COPD, with a prevalence of 0.07% in 2014; it decreased to 0.03% in 2020. CHF followed at 0.06% in 2014 and 0.03% in 2020. APE had a prevalence of 0.01% in 2014, decreasing to 0.005% in 2020 with the pandemic. The greatest economic impact was on exacerbation of COPD in 2015, with an annual cost of €2,726,893 (which equals to US $2,864,628). COPD exacerbations had the higher prevalence in the Madrid region among the respiratory diseases studied. With the COVID-19 pandemic, the prevalence and costs of almost all these diseases decreased, except for ARF not related to chronic disease. The cost of these pathologies over 5 years was €58,791,031 (US $61,832,879).

Goals of Care Discussion Characteristics and Disparities in Children with Medical Complexity.

Children with medical complexity (CMC) have disproportionately high healthcare utilization and mortality. Goals of care (GOC) discussions improve goal-concordance and subjective outcomes for CMC and their caregivers; however, little is known about the frequency or characteristics of GOC discussions in CMC. We sought to define GOC discussion frequency and attributes in CMC and identify patient characteristics that may influence GOC discussion occurrence. This was a single-institution retrospective cohort study including CMC with at least one complex, chronic condition (CCC) and one hospitalization in 2021. GOC discussion documentation prior to or during 2021 was identified by structured chart review. GOC discussion frequency and attributes were compared by category of patient medical complexity. Patient characteristics were analyzed as predictors of GOC discussion occurrence. Out of 1235 CMC, documented GOC discussions were uncommon (22%) and 70% occurred in the intensive care unit. In patients who died, 78% of GOC discussions occurred within 6 months of death. In multivariable regression analysis, increased odds of GOC discussion occurrence was observed in CMC who died (p<0.001), spent fewer days at home (p<0.001), had ≥4 CCCs or technology dependence (p<0.001), were uninsured (p=0.008), or identified as Black (p<0.001), Hispanic (p=0.02), or non-Hispanic Other race (p=0.001). GOC discussions in CMC were infrequent and typically occurred around critical illness or death. Increased GOC discussion occurrence in racial and ethnic minority CMC may be a proxy for disparate morbidity and mortality and indicates racial and ethnic differences in communication regularity and intensity that warrant further investigation.

Genetic Variants Related to Increased CKD Progression-A Systematic Review.

The incidence and prevalence of chronic kidney disease (CKD) are increasing worldwide. CKD is associated with high morbidity, premature mortality, and high healthcare costs. Genetic variants may influence CKD development and progression. This study aimed to identify the associations between allelic variants and CKD progression. We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed, Embase, and Cochrane Central databases were used for data collection. Hereditary causes of CKD were excluded from the analysis. A total of 38 reports were included. The selected studies included cohort studies, case-control studies, and genome-wide association studies (GWASs). The studies involved patients of different ethnicities and with comorbid diseases. Several genetic variants were identified in genes that encode proteins related to metabolic processes, oxidative stress, immune regulation, the renin-angiotensin-aldosterone pathway, and epigenetics, among others. These genetic alterations can affect protein function and lead to renal damage, impacting CKD development and progression. Gene polymorphisms can influence CKD progression. Many of these are population-specific, and their relevance may be influenced by the presence of other diseases and environmental factors. Larger studies are needed to confirm the associations described here.

Description of Borderline Personality Disorder Hospitalizations for Adolescents and Adults in France Between 2013 and 2022: A Nationwide Retrospective Study.

Borderline personality disorder (BPD) is a frequent disorder with high mental health care utilization. This study aims to describe BPD hospitalization in France: using the French national hospitals database from 2013 to 2022, regarding sociodemographic factors and hospitalization characteristics. In total, this study included 121,235 patients. The sex ratio was 1.76 female for 1 male. The median age at hospitalization was 33 years. Most hospitalizations concerned female patients around 30 years old, were voluntary, full-time, in public facilities, and lasted around 14 days. Age at first hospitalization decreased between 2015 and 2022. Male patients were more often in public and compulsory care. Hospitalizations were longer when there were comorbidities. The most common comorbidities were mood disorders. The prevalence of BPD inpatients in 2022 approximates 6%. This is the first nationwide French study describing hospitalizations of patients with BPD. Factors influencing inpatient care should be further studied.

Trends in cutaneous melanoma mortality and incidence in European Union 15+ countries between 1990 and 2019.

Cutaneous melanoma (CM) is the leading cause of skin cancer mortality with associated high healthcare costs. Up-to-date reporting of epidemiological trends for CM is required to project future trends, assess the burden of disease and aid evaluation of new diagnostic, therapeutic and preventative strategies. To describe the trends in CM mortality, incidence, mortality-to-incidence indices (MIIs) and disability-adjusted life years (DALYs) over the last three decades. A population-based cross-sectional study of the Global Burden of Disease (GBD) database between 1990 and 2019 was performed. Nineteen high-income countries with similar health expenditure and classified as having high-quality mortality data including the United Kingdom, the United States, Australia and selected European Union countries were included. Annual age-standardized incidence rates (ASIRs), age-standardized death rates (ASDRs) and DALYs for each country were extracted. Mortality-to-incidence indexes were calculated by dividing the ASDR by the ASIR. Trends were described using Joinpoint regression analysis. Almost all countries demonstrated increasing ASDR in males over the observation period with greatest percentage increase in Greece (+87%), and there was greater heterogeneity between countries in females. CM mortality was greater for males than females in all countries. Most recent Joinpoint analysis shows significantly decreasing mortality in all countries except the United Kingdom (+0.5% males between 2007 and 2019, +0.1% females between 2002 and 2019). Incidence rates increased in all countries, with evidence of plateau from 2015 onwards. While MIIs cannot be used as a proxy for survival, statistically significant decreases in MII were observed in all countries. Overall, DALYs remained static. Over the past 30 years, CM mortality and incidence has increased in most EU15+ countries. There is evidence that in recent years, CM mortality is decreasing. The burden of disease as assessed using DALYs has remained mostly unchanged. Future work should not solely focus on expensive innovative therapies, but also on optimizing primary prevention.

Outcomes Associated With Care Models for Neonates With Complex Medical Needs: A Scoping Review to Support Program Evaluation.

Neonates with complex medical needs (NCMNs) are a small proportion of neonatal intensive care unit admissions but are high healthcare utilizers. Since 2018, NCMNs at our hospital have been cared for by the Neonatal Complex Care Team. This model has yet to be evaluated. To inform the evaluation of our care model, we examined literature on care practices for the management of NCMNs and utilized that to define outcome measures. MEDLINE and Cumulated Index to Nursing and Allied Health Literature were searched. Inclusion dates: January 1, 1993, until July 15, 2023. The PRISMA extension for scoping reviews was used. The population was neonates in the neonatal intensive care unit, the concept was models of care, and the context was medical complexity. Two reviewers performed the title/abstract screening and full-text review. A total of 148 articles were screened, 17 fully reviewed, and 5 articles included. Data extraction was completed by one reviewer utilizing resources from the Joanna Briggs Institute. Care practices ranged from structured discharge meetings with families to an inpatient care model. Few reported new clinical models, and long-term health outcome data were limited. Multidisciplinary care teams emerged as crucial to in-hospital care and smooth discharge. Length of stay and readmission were identified as key outcomes for clinical program evaluation. There is limited literature on this topic; however, we identified themes and outcomes that are useful for clinical program evaluation. Long-term evaluation of novel models of care is needed.

High Intensity Physician-Based Service Use for Mental Health Concerns in a General-Population Sample of Children and Youth: Utilisation des services de haute intensité dispensés par des médecins pour les problèmes de santé mentale dans un échantillon d'enfants et de jeunes de la population générale.

To examine factors associated with high intensity physician-based mental health care services in a population-based sample of children and youth in Ontario, Canada. Data from the 2014 Ontario Child Health Study (OCHS) were linked at the person-level to longitudinal health administrative databases containing physician contacts in outpatient settings, emergency departments and hospitals. Our analytical sample (15.8% of 9,301, n = 1,423) included children and youth with at least one physician-based contact for a mental health concern in the 24-month period post-OCHS. Over the same follow-up period, we classified high intensity service use as those in the top 10th and fifth percentiles of physician-based mental health service cost contributors. Costs were assessed using physician billing data, as well as estimated emergency department visit and hospitalization costs. Among those with at least one contact, being older (PR: 1.15, 95% CI: 1.04, 1.25), having more severe symptoms of mental ill-health (PR: 1.04, 95% CI: 1.01, 1.06) and having a history of mental health service use (PR: 3.99, 95% CI: 1.37, 11.61), were positively associated with high-intensity service use, while living in a rural setting (PR: 0.35, 95% CI: 0.15, 0.30) was negatively associated. Findings were largely consistent between the top 10th and fifth percentiles. Notably, among youth ages 14-17 years, self-reported prior suicide attempt was positively associated with high-intensity (top fifth percentile) service use (PR: 6.09, 95% CI: 1.41, 26.26). Our findings suggest older age, non-rural residency, mental health symptom severity and suicidal behaviour are important factors associated with high-intensity physician-based mental health service use. Our findings will inform efforts to better identify children and youth who may benefit from early and personalized interventions.

Health-Fots- A Latency Aware Fog Based IoT Environment and Efficient Monitoring of Body’s Vital Parameters in Smart Health Care Environment

Internet of Things (IoT) integrated with the disruptive technologies are becoming increasingly popular and they have extended their capabilities in all domains such as automotive, health care and automation. IoT is connecting the billions of devices and humans to bring the fruitful advantages to society. Since IoT devices are operated with the centralized cloud environment, pervasive and continuous monitoring of the user information can be facilitated. However, owing to the inherent characteristics of cloud, such as large end-to-end latency, larger bandwidth consumption, handling the larger volume of data from the IoT devices would be bottleneck for implementing the IoT for the smart health care system that aids for the treatment and diagnosis process. To address these issues, this research article proposes powerful paradigm, Heath-FoTs (Fog of things) which incorporates the fog devices where the data are processed and filtered near the IoT nodes which is useful for improving the quality of services. To further improve the speed of communication, distributed fogs are introduced between the IoT devices and Cloud to process the health care data and provides the optimal solution to tackle the latencies problems and bandwidth requirements. The complete experimentation is carried out using the NodeMCU and Raspberry Pi 3 Model in which the MQTT (Message Queuing Telemetry Transportation) protocol is used as the major communication protocol between the IoT and Fog Nodes. To evaluate the proposed model, performance metrics such as latency, throughput, and communication cost is measured and compared with the traditional environments. Results demonstrate the Health-FoTs environment has shown the promising performance with the 23% lesser latency, 32% higher throughputs and 25% less communication overhead than the traditional IoT infrastructure and proves its strong place for the high speed health care environment.

Demand and Supply Drivers of Medicare and Non-Medicare Health Spending: An Analysis of U.S. States, 1991-2019.

For the last four decades, policymakers have attempted to control the United States's high health care costs by reducing patients' demand for care (e.g., by imposing managed-care restrictions or high costs on patients at the time of use). Yet studies based mostly on data from the public Medicare program, which covers mostly elderly Americans, suggest that supply (e.g., number of physicians or hospital beds) rather than demand drives aggregate service use and, hence, costs. Using variation between U.S. states in per enrollee Medicare spending versus per capita spending of all other (non-Medicare) individuals, we find that greater supply boosts costs for the entire population. Furthermore, we find that factors that suppress demand in the non-Medicare population do reduce non-Medicare health care spending, but simultaneously increase Medicare spending. This suggests that for a given supply of medical resources, suppressing demand for one group of patients may produce a compensatory increase in provision of care to those whose demand has not been suppressed. Health planning to assure adequate medical resources where they are needed while preventing excess supply where it is duplicative and wasteful is likely a more effective cost control strategy than the imposition of managed-care restrictions or imposing higher costs onto patients seeking care.

Healthcare utilization and costs following molecular diagnostic testing among patients with vaginitis.

Aim: Vaginitis and other vaginal discharge syndromes lead to high healthcare utilization. Molecular tests like syndromic multiplex real-time (RT) polymerase chain reaction (PCR)-based tests are highly sensitive and specific at diagnosing the infectious causes of vaginitis. This study compared the healthcare resource utilization (HCRU) and direct all-cause healthcare costs among patients with vaginitis in the US receiving next-day syndromic multiplex RT-PCR tests with those receiving other PCR tests or no diagnostic test of interest. Patients & methods: This retrospective study utilized claims data from IQVIA PharMetrics® Plus database to identify adult patients with a diagnosis for vaginitis (first claim=index) from January 2021 to April 2023, with 6months of continuous enrollment prior to (baseline) and after index (follow-up). Pairwise comparisons were conducted between RT-PCR and 1:1 propensity matched Other PCR and No Test subcohorts for all-cause HCRU and costs during follow-up. Results: Each of the RT-PCR, Other PCR and No Test subcohorts included 1946 matched patients. Mean(SD) follow-up total cost was significantly lower for the RT-PCR than the No Test subcohort ($5607[$15,122] vs $6680[$20,751], p=0.0023). Mean(SD) overall outpatient and other medical service costs were lower for RT-PCR versus Other PCR (outpatient: $2964[$9666] vs $3174[$7113], p=0.0110; other medical: $1961[$9244] vs $2099[$6475], p=0.0002) and No Test subcohorts (outpatient: $2964 [$9666] vs $4067[$12,341], p<0.0001; other medical: $1961[$9244] vs $2973[$11,685]; p<0.0001). A lower proportion had any outpatient service HCRU in RT-PCR versus Other PCR subcohort (92.6% vs 94.2%, p=0.0349). A lower proportion had any other medical service claim in RT-PCR versus Other PCR (78.3% vs 83.2%, p<0.0001) and No Test subcohorts (78.3% vs 83.0%, p=0.0001). Physician office, emergency room (ER), prescription use and costs were similar between the subcohorts. Conclusion: The use of syndromic multiplex RT-PCR diagnostics with next day test results in patients with vaginitis was associated with lower outpatient costs and total healthcare costs than those in the no test cohort over 6months. These findings indicate that use of syndromic multiplex RT-PCR diagnostics may contribute to improved patient management compared with clinical diagnosis alone.

Non-communicable diseases and their associations with outpatient services utilisation: insight from a population-based survey in Malaysia

ObjectivesMultimorbidity has been recognised as a global public health issue, and individuals with multimorbidity have been found to have high healthcare utilisation. This study aims to estimate the prevalence of...