Higher Rates Of Outpatient Visits Research Articles

Drivers of Geographic Patterns in Outpatient Antibiotic Prescribing in the United States.

In a retrospective, ecological analysis of US medical claims, visit rates explained more of the geographic variation in outpatient antibiotic prescribing rates than per-visit prescribing. Efforts to reduce antibiotic use may benefit from addressing the factors that drive higher rates of outpatient visits, in addition to continued focus on stewardship.

Venous-thromboembolism and associated health care utilization in elderly patients with diffuse large B cell lymphoma.

Patients with lymphoma have an increased risk of venous thromboembolism (VTE). The authors examined the risk of VTE and subsequent health care utilization in elderly patients with diffuse large B cell lymphoma (DLBCL). A total of 5537 DLBCL patients ≥66 years old enrolled in Medicare from the Surveillance, Epidemiology, and End Results registry and a noncancer control group of Medicare beneficiaries (n = 5537) were identified. Cumulative incidence function to examine the risk of VTE 12 months after DLBCL diagnosis was used. Fine and Gray method was used to examine the risk factors associated with VTE risk in multivariable models. Total number of hospitalizations, outpatient visits, and Medicare spending were compared in DLBCL patients with and without VTE. VTE was diagnosed in 8.3% DLBCL patients and 1.5% controls, yielding an 8.6-fold higher risk of VTE in DLBCL in adjusted analysis (95% confidence interval [CI], 6.62-11.20; P < .001). Multivariable regression analysis showed that precancer VTE history was associated with an increased risk of developing VTE after a DLBCL diagnosis (hazard ratio [HR], 5.39; 95% CI, 4.39-6.63), and Asian individuals were associated with a lower risk (HR, 0.54; 95% CI, 0.29-1.00). Patients newly diagnosed with VTE after lymphoma had a 1.7-fold higher rate of hospitalization and a 1.2-fold higher rate of outpatient visits compared to those without, resulting in excess Medicare spending of $22,208 in the first year after DLBCL diagnosis. Elderly patients with DLBCL have an elevated risk of VTE resulting in excess health care utilization. VTE history before DLBCL was associated with increased risk of post-DLBCL VTE, and Asian individuals were associated with a lower risk of VTE.

Health Disparities and Differences in Health-Care-Utilization in Patients With Pulmonary Arterial Hypertension.

IntroductionMental disorders are common in patients with pulmonary arterial hypertension (PAH) and contribute to impaired quality of life (QoL). The impact of mental disorders on access to health care, differences in clinical parameters and treatment in patients with PAH is unclear. In this study we sought to assess the impact of mental disorders and other health disparities on health-care-utilization in patients with PAH.MethodsIn a cross-sectional observational study of patients with PAH, mental disorders were characterized using a structed clinical interview. In addition, patients completed a self-administered questionnaire to assess QoL, symptoms of anxiety and depression, lifestyle-factors and educational status. Number of outpatient visits and communication events per year were calculated as a surrogate for health-care-utilization and were compared by the presence of mental disorder. Linear regression analysis was conducted to assess the impact on health-care-utilization.Results117 patients with PAH participated in this study (70% female, median age 59 (interquartile range, 49–70) years). Significant differences between patients with or without mental disorders were found in anxiety, depression and QoL. There were no significant differences in clinical parameters. Patients with mental disorders had higher rates of outpatient visits and communication events than patients without mental disorders. Linear regression revealed a gain of 2.2 communication events per year in the presence of any mental disorders.ConclusionMental disorders in patients with PAH are common and significantly affect health-care-utilization. This higher demand in patients with mental disorder needs to be addressed by physicians, psychiatrists and specialized nurses offering therapeutic strategies.

Effect of COVID-19 on Clinical Spectrum of patients presenting to the Dermatology Outpatient Department of a Tertiary Care Hospital in Rawalpindi

Introduction: COVID-19 has significantly decreased the influx of patients presenting with dermatologic diseases at hospitals due to lockdown and restrictions pertaining to stop the spread of COVID-19.&#x0D; Objective: To describe the effect of changes of COVID-19 on the clinical spectrum of patients presenting in dermatology OPD at a tertiary care unit in Rawalpindi, Pakistan.&#x0D; Method: A comparison of the census of the dermatology outpatient department of three corresponding months before and after COVID-19 was done. During the pandemic year (2020) a significant decrease in patients visiting the dermatology outpatient department was observed.&#x0D; Results: This reduction was much more prominent for the extreme of ages i.e. children and elderly. Infections and infestations were the predominant causes of presentation of patients at our dermatology outpatient department in pre-COVID-19 as well as during the pandemic. Patients with serious dermatologic conditions (e.g., pemphigus vulgaris, erythroderma, and cellulitis), however, had significantly fewer visits during the pandemic as compared to Pre COVID-19 era. In contrast, patients suffering from eczema constituted a significantly higher rate of outpatient visits during the pandemic.&#x0D; Conclusion: Patients with serious dermatologic conditions (e.g., pemphigus vulgaris, erythroderma, and cellulitis), had significantly fewer visits during the pandemic as compared to the Pre COVID-19 era. In contrast, patients suffering from eczema constituted a significantly higher rate of outpatient visits during the pandemic.

PMU77 OPIOID USE PATTERNS AND HEALTHCARE USE AMONG INDIVIDUALS WITH COMORBID CHRONIC NON-CANCER PAIN AND OBSTRUCTIVE SLEEP APNEA

Preliminary evidence suggests that opioid use indicated for chronic pain may exacerbate obstructive sleep apnea (OSA). The purpose of the present study was to evaluate the association between opioid utilization and healthcare use (HCU) among individuals with comorbid chronic non-cancer pain (CNCP) and OSA. This retrospective study used a 10% random sample of commercially insured enrollees in the IQVIATM Health Plans Claims Data. We identified individuals aged 18-64 diagnosed with comorbid CNCP and OSA between 2007 - 2014. We identified three groups of individuals based on opioid use patterns: chronic, non-chronic, and no opioid use in the 12-months prior to index OSA diagnosis. We quantified the association between opioid use and binary outcomes of inpatient hospitalization and emergency department (ED) visits in the 12-months post OSA diagnosis. We also quantified the association between opioid use and HCU counts (physician office visits, outpatient visits, and number of unique drugs prescribed) using generalized linear models. We identified 46,921 individuals with comorbid CNCP and OSA during our study period. Compared to non-chronic opioid users, chronic opioid users were more likely to have an inpatient visit (adjusted odds ratio [AOR]: 1.71; 95% CI: 1.57, 1.86) and an ED visit (AOR: 1.34; 95% CI: 1.25, 1.45). They also had higher rates of outpatient visits (incident rate ratios [IRR]: 1.20; 95% CI: 1.17, 1.22), physician office visits (IRR: 1.20; 95% CI: 1.17, 1.24) and drug use (IRR: 1.80; 95% CI: 1.74, 1.86) compared to non-chronic users. Finally, relative to non-users, both chronic and non-chronic opioid users consistently displayed increased HCU across all points of service. This study provides evidence that chronic-opioid exposure in individuals with comorbid CNCP and OSA is associated with increased HCU. These findings can guide healthcare planners to target allocation of resources effectively toward this at-risk subgroup of OSA patients with CNCP.

CR2 US NATIONAL PAYERS ANALYSIS OF THE INCREMENTAL HEALTHCARE BURDEN AMONG PATIENTS WITH TREATMENT-RESISTANT DEPRESSION

Treatment-resistant depression (TRD) affects an estimated 20-30% of patients with Major Depressive Disorder (MDD) and represents a critical unmet need in the management of the disease. This study compared the healthcare burden of patients with TRD versus non-TRD MDD covered by Commercial, Medicaid, and Medicare health plans. This retrospective longitudinal study used Truven Health Analytics’ Commercial (2006-2016), Medicaid (2007-2015), and Medicare Supplemental (2006-2016) claims databases. Each sample included adults (age ≥18) with MDD, who had received ≥1 antidepressant treatment. Patients with TRD were defined as those who failed ≥2 antidepressants of adequate dose and duration. Within each sample, 15% of the remaining patients were randomly selected to represent the patients with non-TRD MDD. Annual healthcare utilization (hospitalization, outpatient and emergency department/ED visits) and costs were compared across patients with TRD and non-TRD MDD in each of the three cohorts. Logistic, linear, or negative binomial regressions were used to estimate the incremental burden of TRD during the 12-month period immediately following the date of antidepressant treatment initiation (index date), adjusted for demographic and baseline characteristics assessed during 6-month pre-index period. A total of 27,595, 5,556, and 1,856 patients with TRD and 83,949, 18,480, and 7,033 non-TRD MDD in Commercial, Medicaid, and Medicare health plans were analyzed, respectively. TRD was associated with higher healthcare utilization and costs versus non-TRD MDD in all three samples assessed. Patients with TRD had 32%-76% more odds of hospitalization, 38%-45% more odds of ED visits, and 1.29-1.54 times higher rates of outpatient visits compared to non-TRD MDD across all three databases (all p<0.0001). Further, patients with TRD incurred approximately $4,093-$8,054 higher annual treatment costs compared to non-TRD MDD (p<0.0001). Patients with TRD consistently incur higher healthcare burden across health plans. These findings highlight the need for more effective treatments to manage TRD burden.

Prevalence of Psychotropic Polypharmacy and Associated Healthcare Resource Utilization during Initial Phase of Care among Adults with Cancer in USA.

BackgroundThe use of psychotropic medications is not uncommon among patients with newly diagnosed cancer. However, the impact of psychotropic polypharmacy on healthcare utilization during the initial phase of cancer care is largely unknown.MethodsWe used a claims database to identify adults with incident breast, prostate, lung, and colorectal cancers diagnosed during 2011–12. Psychotropic polypharmacy was defined as concurrent use of two or more psychotropic medication classes for at least 90 days. A multivariable logistic regression was performed to identify significant predictors of psychotropic polypharmacy. Multivariable Poisson and negative binomial regressions were used to assess the associations between psychotropic polypharmacy and healthcare utilization.ResultsAmong 5604 patients included in the study, 52.6% had breast cancer, 30.6% had prostate cancer, 11.4% had colorectal cancer, and 5.5% had lung cancer. During the year following incident cancer diagnosis, psychotropic polypharmacy was reported in 7.4% of patients, with the highest prevalence among patients with lung cancer (14.4%). Compared with patients without psychotropic polypharmacy during the initial phase of care, patients with newly diagnosed cancer with psychotropic polypharmacy had a 30% higher rate of physician office visits, an 18% higher rate of hospitalization, and a 30% higher rate of outpatient visits. The rate of emergency room visits was similar between the two groups.ConclusionPsychotropic polypharmacy during the initial phase of cancer care was associated with significantly increased healthcare resource utilization, and the proportion of patients receiving psychotropic polypharmacy differed by type of cancer.ImpactFindings emphasize the importance of evidence-based psychotropic prescribing and close surveillance of events causing increased healthcare utilization among patients with cancer receiving psychotropic polypharmacy.Electronic supplementary materialThe online version of this article (10.1007/s40801-019-0153-5) contains supplementary material, which is available to authorized users.

False-Positive Newborn Screening for Cystic Fibrosis and Health Care Use.

Evidence is mixed regarding the impact of false-positive (FP) newborn bloodspot screening (NBS) results on health care use. Using cystic fibrosis (CF) as an example, we determined the association of FP NBS results with health care use in infants and their mothers in Ontario, Canada. We conducted a population-based cohort study of all infants with FP CF results (N = 1564) and screen-negative matched controls (N = 6256) born between April 2008 and November 2012 using linked health administrative data. Outcomes included maternal and infant physician and emergency visits and inpatient hospitalizations from the infant's third to 15th month of age. Negative binomial regression tested associations of NBS status with outcomes, adjusting for infant and maternal characteristics. A greater proportion of infants with FP results had >2 outpatient visits (16.2% vs 13.2%) and >2 hospital admissions (1.5% vs 0.7%) compared with controls; CF-related admissions and emergency department visits were not different from controls. Differences persisted after adjustment, with higher rates of outpatient visits (relative risk 1.39; 95% confidence interval 1.20-1.60) and hospital admissions (relative risk 1.67; 95% confidence interval 1.21-2.31) for FP infants. Stratified models indicated the effect of FP status was greater among those whose primary care provider was a pediatrician. No differences in health care use among mothers were detected. Higher use of outpatient services among FP infants may relate to a lengthy confirmatory testing process or follow-up carrier testing. However, increased rates of hospitalization might signal heightened perceptions of vulnerability among healthy infants.

Increased healthcare use up to 10 years among relapse-free Hodgkin lymphoma survivors in the era of intensified chemotherapy and limited radiotherapy.

With today's excellent cure rates for Hodgkin lymphoma (HL), the number of long-term survivors is increasing. This study aims to provide a global assessment of late adverse effects for working-age HL survivors treated with contemporary protocols (combination chemotherapy and limited radiotherapy). From Swedish nationwide registers we identified 1017 HL survivors diagnosed in 2000-2009, aged 18-60 years (median 32) and surviving at least one year post-diagnosis, and 4031 age-, sex-, and calendar-year-matched population comparators. Incidence rate ratios (IRR) and 95% confidence intervals (95%CI) for outpatient visits and inpatient bed-days after the first year up to 14 years post-diagnosis (through 2013) were estimated across treatment subgroups, considering relapse-free time and using negative binomial regression. Scheduled outpatient visits for HL were excluded. The rate of outpatient visits was nearly double (IRR = 1.8, 95%CI: 1.6-2.0) that among comparators and higher rates persisted up to 10 years post-diagnosis. The rate of inpatient bed-days among relapse-free survivors was more than three-fold (IRR = 3.6, 95%CI: 2.7-4.7) that of comparators and the increase persisted up to four years post-diagnosis. Patients requiring 6-8 chemotherapy courses had higher rates of outpatient visits (IRR = 1.4, 95%CI: 1.1-1.7) and bed-days (IRR = 4.7, 95%CI: 2.9-7.8) than patients treated with 2-4 courses + radiotherapy. Previously seldom reported reasons for the excess healthcare use included chest pain, keratitis, asthma, diabetes mellitus, and depression. Contemporary treatment, chemotherapy in particular, was associated with excess healthcare use among HL survivors during the first decade postdiagnosis. The reasons for healthcare visits reflected a wide range of disorders, indicating the need of broad individualized care in addition to specific screening programs.

Health Costs and Outcomes Associated with Medicare Part D Prescription Drug Cost-Sharing in Beneficiaries on Dialysis.

High out-of-pocket costs for prescription medications have been associated with poor patient outcomes. A previous study found that the Part D coverage gap was significantly associated with decreases in adherence and persistence for medications frequently used in patients undergoing dialysis. It is not known what effect the decreased use of prescription drugs associated with the coverage gap had on utilization and spending for other medical care. To determine the relationship between the Part D prescription drug cost-sharing structure and health and economic outcomes in Medicare beneficiaries on dialysis. A retrospective analysis using data from the United States Renal Data System (2006-2008) was conducted for Medicare-eligible patients receiving dialysis. Patients were grouped in 1 of 4 cohorts based on low-income subsidy (LIS) receipt and benefit phase in 2007: Cohort 1 (non-LIS and did not reach the coverage gap); Cohort 2 (non-LIS and reached the coverage gap); Cohort 3 (non-LIS and reached catastrophic coverage after the gap); and Cohort 4 (received an LIS, and none of the LIS patients reached the coverage gap). Outcomes included medical care utilization, direct medical costs, and mortality. A total of 11,732 subjects met the inclusion criteria. Patients in Cohorts 1, 2, and 3 had $3,222 lower, $2,457 lower, and $1,182 higher adjusted pharmacy costs (P less than 0.001), but their adjusted hospitalization costs were $1,499 (P = 0.09), $2,287 (P = 0.01), and $2,959 (P = 0.01) higher, respectively, compared with Cohort 4 (LIS). In the propensity score-matched cohorts, patients who reached the coverage gap (Cohort 2) had higher rates of hospitalization (relative risk [RR] = 1.02, 95% CI = 0.94-1.10), outpatient visits (RR = 1.16, 95% CI = 1.08-1.25), and other visits (RR = 1.17, 95% CI = 1.03-1.32) compared with those who had an LIS (Cohort 4). Patients in Cohort 3 had a higher rate of outpatient visits compared with those in Cohort 4 (RR = 1.14, 95% CI = 1.03-1.25). There were no differences in medical care utilization between patients in Cohort 1 and Cohort 4. Compared with patients in Cohort 4 (LIS), patients in Cohort 2 (those who reached the coverage gap) had 9% higher hospitalization costs (RR = 1.09, 95% CI = 1.01-1.18) and 6% higher outpatient costs (RR = 1.06, 95% CI = 0.97-1.17), respectively. During the 1-year follow-up period, patients in Cohort 2 had a 20% (HR = 1.20, 95% CI = 1.05-1.37) and a 22% (HR = 1.22, 95% CI = 1.01-1.47) increased risk of all-cause and cardiovascular-related mortality compared with those in Cohort 4, respectively. Our findings suggest that reaching the Part D coverage gap was associated with unfavorable clinical and economic outcomes in patients undergoing dialysis.

Comparison of treatment patterns and economic outcomes in metastatic breast cancer patients initiated on trastuzumab versus lapatinib: a retrospective analysis.

Few studies have compared treatment patterns, healthcare resource utilization (HRU), and costs in patients with metastatic breast cancer (mBC) receiving HER2 directed therapy. This study evaluated these outcomes in patients receiving trastuzumab or lapatinib. Adult women with mBC, who were initiated on trastuzumab or lapatinib, on or after March 13, 2007, were selected from the US-based PharMetrics® Integrated Database (2000–2011). Patients were required to be continuously enrolled in their healthcare plan for ≥6 months prior to and ≥30 days following trastuzumab or lapatinib initiation. Trastuzumab or lapatinib discontinuation rates (defined as a gap ≥45 consecutive days) were compared using multivariate Cox proportional-hazards models. HRU and monthly healthcare cost differences were estimated using multivariate negative binomial regression models and generalized linear models, respectively. Among the 643 patients who met the inclusion criteria, 381 and 262 patients were included in the trastuzumab and lapatinib groups, respectively. The majority of the 262 patients receiving lapatinib previously received trastuzumab (N = 171 [65.3%]). After adjustment for potential confounders, when compared to trastuzumab patients, lapatinib patients had a higher rate of treatment discontinuation (hazard ratio [HR] = 1.57; P < 0.001), a higher rate of outpatient visits (not treatment administration related) (IRR = 1.19; P < 0.004), and a lower rate of medical visits associated with treatment administration (IRR = 0.34; P < 0.001). There were no significant differences between the two groups in total monthly healthcare costs ($11,920 vs. $11,898 for trastuzumab and lapatinib patients, respectively; P = 0.451). Findings from our study show that, irrespective of the treatment initiated at index date, disease management in patients with mBC is associated with similar and substantial healthcare costs. Any differences in specific components of healthcare costs were associated with differences in the mode of treatment administration. Approximately 50% of all costs were non-drug related, and future studies should focus on how these costs may be controlled, regardless of mode of treatment administration.

Health Impacts of Caregiving for Older Adults With Functional Limitations

To estimate the health impact, in terms of depression, self-rated health, and health services utilization, of providing care to older adults (75+) requiring human assistance in at least one activity of daily living (ADL) limitation. Data from 1,077 caregivers and 318 noncaregivers, interviewed in the Singapore Survey on Informal Caregiving, was used to examine differences in depressive symptoms, self-rated health, and number of outpatient visits in the last 1 month between caregivers and noncaregivers. Multivariate models for the outcomes, adjusting for characteristics of the caregiver/noncaregiver and care-recipient/potential care recipient, were run. Caregivers were more depressed, had poorer self-rated health, and had a higher rate of outpatient visits in the past month compared to noncaregivers. The study indicates the need for support services to family caregivers of older adults with ADL limitations.

The association between obesity and outpatient visits for acute respiratory infections in Ontario, Canada

ObjectivesRecent evidence suggests that obesity increases the risk of severe outcomes following respiratory infection. It is less clear whether obesity is associated with the risk of being infected with influenza or other respiratory pathogens. Therefore, we examined the association between obesity and outpatient visits for acute respiratory infections.DesignWe conducted a retrospective cohort study over 13 years on 104,665 individuals in Ontario, Canada who responded to population health surveys and agreed to linkage with health administrative data. Individuals aged 18–64 years who responded to a survey within 5 years prior to the start of an influenza season were included. Poisson regression, with adjustment for relevant confounders, was used to measure the association between self-reported BMI and outpatient visits coded as acute respiratory infection. We conducted numerous sensitivity analyses to assess the robustness of our findings.ResultsWe observed higher rates of outpatient visits for ARI during influenza season periods compared with normal weight individuals for those who were overweight (BMI 25–29.9) (Rate Ratio [RR] 1.10; 95% Confidence Interval [95% CI] 1.07–1.13), obese class I (BMI 30–34.9) (RR 1.17; 95% CI 1.13–1.22), and obese class II or III (BMI ≥35) (RR 1.19; 95% CI 1.12–1.25) Associations of a similar magnitude were observed during non-influenza season periods. Obesity was a greater risk factor for acute respiratory infections managed in emergency departments than physician offices.ConclusionsObese individuals are at an increased risk of outpatient visits for acute respiratory infection during both influenza and non-influenza season periods, suggesting that the effect of obesity on the risk of respiratory infections is not limited to influenza. Interventions designed to reduce the prevalence of obesity may have the added benefit reducing the population burden of respiratory infections.

A National Study of Racial Differences in Pain Screening Rates in the VA Health Care System

To determine whether black patients are less likely to be screened for pain than white patients. A sample of 25,382 black and 220,122 non-Hispanic white Veterans Affairs (VA) patients was identified among the panel surveyed in the ambulatory care module of the 2007 Survey of Health Care Experiences of Patients. This was a cross-sectional analysis of documentation of a pain score in the electronic medical record at the patient's Survey of Health Care Experiences of Patients index visit. Hierarchical logistic regression analyses were used to examine the association between race and documentation of pain screening. After accounting for site and whether the patient was a new or established primary care patient, black VA patients were significantly less likely than their white counterparts to be screened for pain, odds ratio: 0.79, P<0.0001, with estimated screening rates of 78% and 82% for black and white established primary care patients at a typical VA site, respectively. Further adjusting for demographics, medical and psychological comorbidity, prescription of pain medication, and health care utilization reduced the odds ratio to 0.86, P<0.0001). Additional analyses revealed that this reduction in odds ratio was primarily explained by higher rates of outpatient visits to the VA in the previous 2 years among black patients, which was associated with lower rates of screening at the index visit. Rates of screening were lower among black patients. The magnitude of this disparity was small and was explained, in part, by racial variation in prior health care utilization.

Abstract P5-18-12: Comparison of treatment patterns and outcomes in metastatic breast cancer patients initiated on trastuzumab vs. lapatinib; a retrospective analysis

Abstract Background: Trastuzumab-or lapatinib-based therapies are recommended by the National Comprehensive Cancer Network (NCCN) guidelines as preferred agents for metastatic HER2-positive breast cancer. Few studies have compared treatment patterns, healthcare resource utilization (HRU), and costs in metastatic breast cancer (MBC) patients receiving trastuzumab vs. lapatinib. The objective of this study was to compare discontinuation rates, HRU, and costs in MBC patients (pts) initiated on trastuzumab vs. lapatinib. Methods: MBC adult women initiated on trastuzumab or lapatinib on/after 03/13/2007 (lapatinib FDA-approval date) were selected from the US-based PharMetrics® Integrated Database (2000–2011). Selected pts were required to be continuously eligible in their healthcare plan ≥6 months prior to and ≥30 days following trastuzumab or lapatinib initiation date. Pts were observed over the period spanning from trastuzumab or lapatinib initiation date (without restriction on line of therapy) up to the end of continuous health plan enrollment or data availability, whichever occurred first. Trastuzumab or lapatinib discontinuation rates (gap ≥45 consecutive days) were compared using multivariate Cox proportional-hazards models and reported as hazard ratios (HRs). Incremental HRU was estimated using negative binomial regression models and reported as incidence rate ratios (IRRs). Monthly cost difference (2010 USD; measured from a payer perspective) were estimated using multivariate generalized linear or two-part models. Since a large proportion of lapatinib users were previously treated with trastuzumab, a sensitivity analysis was conducted to control for the impact of prior trastuzumab use. Results: Among the 643 pts selected, 381 and 262 pts were initiated on trastuzumab and lapatinib, respectively. Of the 262 pts initiated on lapatinib, 171 (65%) were previously treated with trastuzumab. After adjustment for confounders (demographics, index year, prior MBC therapies, comorbidities, baseline HRU, and MBC duration), compared to trastuzumab users, lapatinib users had a higher rate of treatment discontinuation (HR = 1.57; p &amp;lt; .001). While lapatinib users had a higher rate of outpatient visits (not treatment administration related) compared to trastuzumab users (HR = 1.19; p &amp;lt; 0.004), there were no observed significant differences of other HRU and total monthly healthcare costs between the two groups ($11,138±8,751 vs. $11,159 ±8,674, respectively; adjusted difference=$637 p = .397). Sensitivity analyses showed that pts who were initiated on lapatinib without prior trastuzumab use had a higher incidence of inpatient admissions (IRR = 1.74; p = .002) and greater overall medical service costs compared to pts who were initiated on trastuzumab (adjusted difference=$3,059; p &amp;lt; .001). Conclusion: Overall, while MBC pts initiated on trastuzumab or lapatinib had similar healthcare costs, pts initiated on lapatinib had higher rates of treatment discontinuation and outpatient visits (not treatment administration related). Medical costs were significantly higher among pts initiated on lapatinib without prior trastuzumab use. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-18-12.

Outpatient Visits by Dentists: A Nationwide Cohort Study in Taiwan

We conducted a cohort study of 7,760 dentists in Taiwan between 2003 and 2007 to assess the risk of outpatient visit among dentists. Control groups included physicians and other health personnel. Over the 5-yr study period, the dentist cohort made a total of 270,712 outpatient visits, representing an incidence rate of 7,038 visits /10(3) person-years. Compared to physicians, dentists experienced a significantly reduced covariate adjusted rate ratio (ARR) for all-cause visits (ARR=0.59, 95%CI=0.58-0.59), as well as for nearly all other causes, except neoplasm (ARR=1.06, 95%CI=1.02-1.09). Compared to other health personnel, the dentists still experienced a significantly reduced ARR for all causes (ARR=0.70), but had a slightly but significantly increased risk for endocrine/metabolic/immunity (ARR=1.04, 95%CI=1.02-1.05) and mental (ARR=1.04, 95%CI=1.01-1.07) disorders. Although the dentists in Taiwan utilized lesser outpatient visits than did their medical colleagues, they tended to have slightly higher rates of outpatient visits for neoplasm, endocrine/metabolic/immunity disorders, and mental illnesses. Policy makers and hospital administrators must not overlook dentists' potentially unseen health problems. A mandatory periodical physical examination for dentists can seriously be considered.

Organizational Culture and Its Relationship with Hospital Performance in Public Hospitals in China

To measure perceptions of organizational culture among employees of public hospitals in China and to determine whether perceptions are associated with hospital performance. Hospital, employee, and patient surveys from 87 Chinese public hospitals conducted during 2009. Developed and administered a tool to assess organizational culture in Chinese public hospitals. Used factor analysis to create measures of organizational culture. Analyzed the relationships between employee type and perceptions of culture and between perceptions of culture and hospital performance using multivariate models. Employees perceived the culture of Chinese public hospitals as stronger in internal rules and regulations, and weaker in empowerment. Hospitals in which employees perceived that the culture emphasized cost control were more profitable and had higher rates of outpatient visits and bed days per physician per day but also had lower levels of patient satisfaction. Hospitals with cultures perceived as customer-focused had longer length of stay but lower patient satisfaction. Managers in Chinese public hospitals should consider whether the culture of their organization will enable them to respond effectively to their changing environment.

Race, Outpatient Mental Health Service Use, and Survival After an AIDS Diagnosis in the Highly Active Antiretroviral Therapy Era

We examined the relationships between survival after AIDS diagnosis and outpatient mental health service use among men with history of highly active antiretroviral therapy (HAART). Analysis involved 1913 black and 1684 white men with AIDS who received HIV care in 2003 in the Veterans Affairs health care system. Negative binomial regression was used to assess the association between service use and length of AIDS diagnosis. Patients with longer survival after AIDS had higher rates of outpatient visits for stress and adjustment disorders as well as for mood, anxiety, and sexual disorders. Blacks had more visits for stress and adjustment disorders (7.4 versus 5.1; p < 0.05). Multiple regression analysis showed that prolonged survival after AIDS (incident rate ratios [IRR] = 1.87; 95% confidence interval [CI] = 1.25-2.77), having CD4 cell count less than 200 cells/mm(3) (IRR = 1.91; 95% CI = 1.19-3.04), and mortality (IRR = 3.84; 95% CI = 1.29-11.43) were associated with greater number of visits for mood, anxiety, and sexual disorders. Injection drug users (IRR = 3.52; 95% CI = 1.94-6.38), men who have sex with men (IRR = 2.87; 95% CI = 1.62-5.06), and patients with AIDS-defining illness (IRR = 2.48; 95% CI = 1.47-4.17) had greater rates of visits for stress and adjustment disorders. Survival after AIDS is associated with mental health service use. As more HIV-infected persons survive longer, adequate risk assessment of mental health concerns that considers race and HIV risk factors should be undertaken to effectively address the impact of mental health on treatment outcomes and mortality.

Diabetes Quality of Care and Outpatient Utilization Associated With Electronic Patient-Provider Messaging: A Cross-Sectional Analysis

OBJECTIVETo test the hypothesis that electronic patient-provider messaging is associated with high care quality for diabetes and lower outpatient utilization.RESEARCH DESIGN AND METHODSWe conducted a cross-sectional analysis of electronic patient-provider messaging over a 15-month period between 1 January 2004 and 31 March 2005. The study was set at Group Health Cooperative—a consumer-governed, nonprofit health care system that operates in Washington and Idaho. Participants included all patients aged ≥18 years with a diagnosis of diabetes. In addition to usual care, all patients had the option to use electronic messaging to communicate with their care providers. The primary outcome measures were diabetes-related quality-of-care indicators (A1C, blood pressure, and LDL cholesterol) and outpatient visits (primary care, specialty care, and emergency).RESULTSNineteen percent of patients with diabetes used electronic messaging to communicate with their care providers during the study period (n = 2,924) (overall study cohort: 15,427 subjects). In multivariate models, frequent use of electronic messaging was associated with A1C <7% (relative risk [RR] 1.36 [95% CI 1.16–1.58]). Contrary to our hypothesis, frequent use of electronic messaging was also associated with a higher rate of outpatient visits (1.39 [1.26–1.53]).CONCLUSIONSFrequent use of electronic secure messaging is associated with better glycemic control and increased outpatient utilization. Electronic patient-provider communication may represent one strategy to meet the health care needs of this unique population. More research is necessary to assess the effect of electronic messaging on care quality and utilization.

Gender Differences in Health Care Utilization Among Veterans with Chronic Pain

BackgroundPrevious research reports that 48% of veterans regularly experience and express concern over pain. Outpatient service use is higher for veterans with pain than for veterans without pain. Our study objective was to identify differences in outpatient utilization between men and women veterans with chronic pain.MethodsWe identified all men and women veterans at the Durham Veterans Affairs Medical Center in fiscal year (FY) 2002 between the ages of 21 and 60 that had two visits for the same pain location at least 6 weeks apart as determined by ICD-9 coding. Men and women were age-matched at a 2:1 ratio. We then compared the number of outpatient visits between genders in FY 2003.ResultsWe identified 406 female and 812 male veterans. The mean number of clinic visits for women was 25.2 (SD 30.2) and for men 17.6 (SD 24.1). After adjusting for multiple pain sites, psychiatric diagnoses, age, and comorbidities, women veterans had a 27% higher rate of outpatient visits than men (incidence rate ratio [RR] 1.27, 95% confidence [CI] 1.15 to 1.41). Specifically, women had higher rates of visits to primary care (RR 1.36, 95% CI 1.24 to 1.50), physical therapy (RR 1.67, 95% CI 1.20 to 2.33), and other clinics (RR 1.28, 95% CI 1.14 to 1.44), and had a higher rate of visits to address pain (RR 1.15, 95% CI 1.02 to 1.30) than men.ConclusionsThis is the first study to examine gender differences in chronic pain and utilization in the veteran population. Women veterans with chronic pain may need more resources to adequately manage chronic pain conditions as well as associated comorbidities and psychiatric disease.