Hospital Care Utilization Research Articles

Differences in Characteristics, Hospital Care, and Outcomes between Acute Critically Ill Emergency Department Patients Receiving Palliative Care and Usual Care

Background: The early integration of palliative care in the emergency department (ED-PC) provides several benefits, including improved quality of life with optimal comfort measures, and symptom control. Whether palliative care could affect the intensive care unit admissions, hospital care and resource utilization requires further investigation. Aim: To determine the differences in inpatient characteristics, hospital care, survival, and resource utilization between patients receiving palliative care (ED-PC) and usual care (UC). Design: Retrospective observational study. Setting/participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit at Taipei Veterans General Hospital from 1 February 2018 to 31 January 2020. Results: A total of 1273 patients were evaluated for unmet palliative care needs; 685 patients received ED-PC and 588 received UC. The palliative care patients were more severely frail (AOR 2.217 (1.295–3.797), p = 0.004), had functional deterioration with three ADLs (AOR 1.348 (1.040–1.748), p = 0.024), biopsychosocial discomfort (AOR 1.696 (1.315–2.187), p < 0.001), higher Taiwan Triage and Acuity Scale 1 (p = 0.024), higher in-hospital mortality (AOR 1.983 (1.540–2.555), p < 0.001), were four times more likely to sign an DNR (AOR 4.536 (2.522–8.158), p < 0.001), and were twice as likely to sign an DNR at admission (AOR 2.1331.619–2.811), p < 0.001). Palliative care patients received less epinephrine (AOR 0.424 (0.265–0.678), p < 0.001), more frequent withdrawal of an endotracheal tube (AOR 8.780 (1.122–68.720), p = 0.038), and more narcotics (AOR1.675 (1.132–2.477), p = 0.010). Palliative care patients exhibited lower 7-day, 30-day, and 90-day survival rates (p < 0.001). There was no significant difference in the hospital length of stay (LOS) (21.2 ± 26.6 vs. 21.7 ± 20.6, p = 0.709) nor total hospital expenses (293,169 ± 350,043 vs. 294,161 ± 315,275, p = 0.958). Conclusion: Acute critically ill patients receiving palliative care were more frail, more critical, and had higher in-hospital mortality. Palliative care patients received less epinephrine, more endotracheal extubation, and more narcotics. There was no difference in the hospital LOS or hospital costs between the palliative and usual care groups. The synthesis of ED-PC is new but achievable with potential benefits to align care with patient goals.

Changes in the utilisation of acute hospital care in Ireland during the first wave of COVID-19

BackgroundReduced and delayed presentations for non-COVID-19 illness during the COVID-19 pandemic have implications for population health and health systems. The aim of this study was to quantify and characterise changes in acute hospital healthcare utilisation during the first wave of COVID-19 in Ireland to inform healthcare service planning and public health policy.MethodsA retrospective, population-based, interrupted time-trend study was conducted, using two national datasets, from 6th January to 5th July 2020.ResultsComparison between time periods pre- and post-onset of the COVID-19 pandemic within 2020 showed that there were 81,712 fewer Emergency Department (ED) presentations (-18.8%), 19,692 fewer admissions from ED (-17.4%) and 210,357 fewer non-COVID-19 hospital admissions (-35.0%). Reductions were greatest at the peak of population restrictions, at extremes of age and for elective admissions. In the period immediately following the first wave, healthcare utilisation remained below pre-COVID-19 levels however, there were increases in emergency alcohol-related admissions (Rate Ratio 1.22, 95% CI 1.03, 1.43, p-value 0.016), admissions with self-harm (Rate Ratio 1.39, 95% CI 1.01, 1.91, p-value 0.043) and mental health admissions (Rate Ratio 1.28, 95% CI 1.03, 1.60, p-value 0.028).ConclusionsPublic health implications of delayed and lost care will become fully apparent over time. In the short-term, backlogs in care need to managed and population health impacts of COVID-19 and associated restrictions, particularly in relation to mental health and alcohol, need to be addressed through strong public health and health system responses, including the adoption of a pandemic recovery plan. In the long-term, COVID-19 has highlighted weaknesses in the health system and is an opportunity to progress reform towards a universal, high-quality, sustainable and resilient health system, capable of meeting population health needs and responding to future pandemics.Key messages The COVID-19 pandemic impacted non-COVID-19 healthcare utilisation in Ireland with evidence of delayed and lost acute hospital care and increased need for emergency mental health and alcohol services.Population health and health system recovery from COVID-19 is a public health priority.

Spotlight influenza: Estimation of influenza vaccine effectiveness in elderly people with assessment of residual confounding by negative control outcomes, Finland, 2012/13 to 2019/20.

BackgroundCohort studies on vaccine effectiveness are prone to confounding bias if the distribution of risk factors is unbalanced between vaccinated and unvaccinated study subjects.AimWe aimed to estimate influenza vaccine effectiveness in the elderly population in Finland by controlling for a sufficient set of confounders based on routinely available register data.MethodsFor each of the eight consecutive influenza seasons from 2012/13 through 2019/20, we conducted a cohort study comparing the hazards of laboratory-confirmed influenza in vaccinated and unvaccinated people aged 65–100 years using individual-level medical and demographic data. Vaccine effectiveness was estimated as 1 minus the hazard ratio adjusted for the confounders age, sex, vaccination history, nights hospitalised in the past and presence of underlying chronic conditions. To assess the adequacy of the selected set of confounders, we estimated hazard ratios of off-season hospitalisation for acute respiratory infection as a negative control outcome.ResultsEach analysed cohort comprised around 1 million subjects, of whom 37% to 49% were vaccinated. Vaccine effectiveness against laboratory-confirmed influenza ranged from 16% (95% confidence interval (CI): 12–19) to 48% (95% CI: 41–54). More than 80% of the laboratory-confirmed cases were hospitalised. The adjusted off-season hazard ratio estimates varied between 1.00 (95% CI: 0.94–1.05) and 1.08 (95% CI: 1.01–1.15), indicating that residual confounding was absent or negligible.ConclusionSeasonal influenza vaccination reduces the hazard of severe influenza disease in vaccinated elderly people. Data about age, sex, vaccination history and utilisation of hospital care proved sufficient to control confounding.

Improved Clinical Outcomes in Adults with Sickle Cell Disease and Diabetes Treated with Metformin

▪BackgroundComplications of sickle cell disease (SCD) include pain episodes, chronic anemia, cardiopulmonary disease, and long-term end-organ damage. Hydroxyurea is efficacious in preventing these complications by increasing fetal hemoglobin levels (HbF); however, adherence is limited. Metformin, a Food and Drug Administration-approved drug used for type-2 diabetes mellitus (DM), was recently found to induce HbF through upregulation of FOXO3 and gamma-globin expression. However, the relation of metformin utilization to clinical outcomes and healthcare utilization in adults with SCD and DM has not been studied.ObjectivesOur specific aims were to 1) estimate the prevalence of DM in a cohort of adult patients with SCD and 2) assess the association of metformin with clinical outcomes and healthcare utilization in this population. We hypothesized that adults with SCD and DM on metformin have less frequent SCD-related complication and lower utilization of hospital care for those complications.MethodsWe analyzed subjects with SCD and DM ≥18 years of age from the Truven Health MarketScan® Multi-State Medicaid Database from 2009-2015 with continuous enrollment of ≥365 days. Subjects with SCD and DM were identified through the presence of ≥1 inpatient or ≥2 outpatient disease-specific billing codes or ≥1 outpatient DM code and ≥1 DM-related drug claim. Subjects with drug claims for insulin, hydroxyurea, or iron chelation were excluded. Metformin use was defined as having ≥1 metformin-related drug claim in the study period. Outcomes included annual rates of all-cause inpatient hospitalizations, SCD-related hospitalizations, all-cause emergency department (ED) visits, SCD-related ED visits, vaso-occlusive episodes (VOE), strokes, acute chest syndrome (ACS) episodes, avascular necrosis (AVN) events, and gallstone events. Outcomes were identified based on claims records after the subject's first DM diagnosis record in the dataset. Clinical events among metformin users and non-users were compared using chi square tests. Rate ratios (RR) comparing annual rates of clinical events among metformin users to non-users were estimated using negative binomial regression, controlling for age, sex, and claims-data-defined Charlson Comorbidity Index (CCI) score.ResultsWe identified 7,617 subjects with SCD and 1,296 (17%) of them also had a diagnosis of DM. Our final cohort included a total of 375 subjects who met all our pre-defined criteria; of them, 126 (34%) were treated with metformin. Subjects were 72% female and 82% Black, and had a median age of 44 years (interquartile range (IQR) 33-52) and CCI score of 2 (IQR 0-4). All clinical events were less frequent in metformin users when compared to non-users, summarized in Table 1a, and subjects in both groups were similar in age, sex, race and CCI score. Using negative binomial regression, adjusted for age, sex and CCI score, metformin users had significantly lower all-cause inpatient stays (rate ratio (RR) 0.55; 95% confidence interval (CI) 0.42-0.72), SCD-related inpatient stays (RR 0.36; 95% CI 0.24-0.54), all-cause ED visits (RR 0.65; 95% CI 0.50-0.86), SCD-related ED visits (RR 0.43; 95% CI 0.27-0.68), VOE (RR 0.15; 95% CI 0.08-0.27), ACS (RR 0.14; 95% CI 0.03-0.59) and AVN (RR 0.29; 95% CI 0.09-0.91), compared to metformin non-users (Table 1b). Similar trends were also seen when patients were stratified by age as young adults (<40 years) vs. adults (≥40 years), as shown in Table 1b.ConclusionsThis study is the first to examine clinical associations of metformin use with SDC-related complications in adults with SCD and DM. These findings strongly suggest that metformin has important protective effects on all-cause and SCD-related hospital-treated clinical events. Among adults with SCD and DM, metformin users had 45% fewer SCD-related inpatient stays and roughly 85% fewer VOE or ACS episodes after controlling for confounding variables. These benefits are consistent with the effects of metformin on HbF induction observed in earlier laboratory data. An analysis of the effects of adherence to metformin on clinical outcomes and healthcare utilization in our cohort is ongoing. Given our findings and the known safety profile of metformin, future prospective studies are warranted to evaluate its efficacy and cost-effectiveness in relation to clinical outcomes, quality of life, mortality and healthcare utilization in adults with SCD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The public health and health system implications of changes in the utilisation of acute hospital care in Ireland during the first wave of COVID-19: Lessons for recovery planning

Reduced and delayed presentations for non-COVID-19 illness during the COVID-19 pandemic have implications for population health and health systems. The aim of this study is to quantify and characterise changes in acute hospital healthcare utilisation in Ireland during the first wave of COVID-19 to inform healthcare system planning and recovery. A retrospective, population-based, interrupted time-trend study was conducted using two national datasets, Patient Experience Time (PET) and Hospital In-Patient Enquiry (HIPE). The study period was 6th January to 5th July 2020. Comparison between time periods pre- and post-onset of the COVID-19 pandemic within 2020 showed there were 81,712 fewer Emergency Department (ED) presentations (-18.8%), 19,692 fewer admissions from ED (-17.4%) and 210,357 fewer non-COVID-19 hospital admissions (-35.0%) than expected based on pre-COVID-19 activity. Reductions were greatest at the peak of population-level restrictions, at extremes of age and for elective admissions. In the period immediately following the first wave, acute hospital healthcare utilisation remained below pre-COVID-19 levels, however, there were increases in emergency alcohol-related admissions (Rate Ratio 1.22, 95% CI 1.03, 1.43, p-value 0.016), admissions with self-harm (Rate Ratio 1.39, 95% CI 1.01, 1.91, p-value 0.043) and mental health admissions (Rate Ratio 1.28, 95% CI 1.03, 1.60, p-value 0.028). While public health implications of delayed and lost care will only become fully apparent over time, recovery planning must begin immediately. In the short-term, backlogs in care need to be managed and population health impacts of COVID-19 and associated restrictions, particularly in relation to mental health and alcohol, need to be addressed through strong public health and health system responses. In the long-term, COVID-19 highlights health system weakness and is an opportunity to progress health system reform to deliver a universal, high-quality, sustainable and resilient health system, capable of meeting population health needs and responding to future pandemics.

Utilization of in- and outpatient hospital care in Germany during the Covid-19 pandemic insights from the German-wide Helios hospital network.

BackgroundDuring the early phase of the Covid-19 pandemic, reductions of hospital admissions with a focus on emergencies have been observed for several medical and surgical conditions, while trend data during later stages of the pandemic are scarce. Consequently, this study aims to provide up-to-date hospitalization trends for several conditions including cardiovascular, psychiatry, oncology and surgery cases in both the in- and outpatient setting.Methods and findingsUsing claims data of 86 Helios hospitals in Germany, consecutive cases with an in- or outpatient hospital admission between March 13, 2020 (the begin of the “protection” stage of the German pandemic plan) and December 10, 2020 (end of study period) were analyzed and compared to a corresponding period covering the same weeks in 2019. Cause-specific hospitalizations were defined based on the primary discharge diagnosis according to International Statistical Classification of Diseases and Related Health Problems (ICD-10) or German procedure classification codes for cardiovascular, oncology, psychiatry and surgery cases. Cumulative hospitalization deficit was computed as the difference between the expected and observed cumulative admission number for every week in the study period, expressed as a percentage of the cumulative expected number. The expected admission number was defined as the weekly average during the control period. A total of 1,493,915 hospital admissions (723,364 during the study and 770,551 during the control period) were included. At the end of the study period, total cumulative hospitalization deficit was -10% [95% confidence interval -10; -10] for cardiovascular and -9% [-10; -9] for surgical cases, higher than -4% [-4; -3] in psychiatry and 4% [4; 4] in oncology cases. The utilization of inpatient care and subsequent hospitalization deficit was similar in trend with some variation in magnitude between cardiovascular (-12% [-13; -12]), psychiatry (-18% [-19; -17]), oncology (-7% [-8; -7]) and surgery cases (-11% [-11; -11]). Similarly, cardiovascular and surgical outpatient cases had a deficit of -5% [-6; -5] and -3% [-4; -3], respectively. This was in contrast to psychiatry (2% [1; 2]) and oncology cases (21% [20; 21]) that had a surplus in the outpatient sector. While in-hospital mortality, was higher during the Covid-19 pandemic in cardiovascular (3.9 vs. 3.5%, OR 1.10 [95% CI 1.06–1.15], P<0.01) and in oncology cases (4.5 vs. 4.3%, OR 1.06 [95% CI 1.01–1.11], P<0.01), it was similar in surgical (0.9 vs. 0.8%, OR 1.06 [95% CI 1.00–1.13], P = 0.07) and in psychiatry cases (0.4 vs. 0.5%, OR 1.01 [95% CI 0.78–1.31], P<0.95).ConclusionsThere have been varying changes in care pathways and in-hospital mortality in different disciplines during the Covid-19 pandemic in Germany. Despite all the inherent and well-known limitations of claims data use, this data may be used for health care surveillance as the pandemic continues worldwide. While this study provides an up-to-date analysis of utilization of hospital care in the largest German hospital network, short- and long-term consequences are unknown and deserve further studies.

Medication adherence, utilization of healthcare services, and mortality of patients with epilepsy on opiate replacement therapy: A retrospective cohort study

IntroductionSubstance misuse is not uncommonly recognized in people with epilepsy (PWE). Mortality is significantly greater in those with comorbid substance misuse, but it remains unclear whether epilepsy care and management contribute to this. This cohort study aimed to compare the rates of mortality in PWE receiving opiate replacement therapy (ORT) and PWE alone, as well as evaluate their medication adherence, levels of engagement with epilepsy services as currently delivered, and utilization of unscheduled hospital care. Material and methodsA 5-year historical cohort for PWE was identified and manually validated using electronic patient records registered with NHS Tayside. Overall incidence rates for mortality and contact with emergency health care services were calculated for PWE receiving ORT and PWE alone. Engagement with outpatient epilepsy services was also noted. Adherence to antiepileptic drugs (AEDs) was expressed in terms of medication possession ratio (MPR). ResultsOf the 1297 PWE attending a tertiary care epilepsy service, 68 (5.3%) PWE were receiving ORT. The mortality rate was significantly greater in PWE on ORT in comparison to PWE only (7.4% vs 1.7 %; P < 0.05; relative risk of death: 4.34, 95% CI 1.19–15.7), as well as the incidence of emergency healthcare services contact being higher (24.5% vs 17.7%; P < 0.05; incidence rate ratio: 1.39, 95% CI: 1.12–1.71). Poor adherence to AEDs was also more common in PWE on ORT (28.4% vs 23.5%; P = 0.02), as well as failure to engage with elective outpatient services (8.4% vs 3.0%; P < 0.05; rate ratio 2.77, 95% CI: 1.86–4.1). ConclusionPeople with epilepsy on ORT are less likely to engage with elective epilepsy services as currently delivered or take AEDs as prescribed despite most of these patients having daily attendance at a community pharmacist. This may contribute to the significantly increased rates of mortality and unscheduled hospital care. Clinicians and policymakers should consider service redesign to meet the demands of this high-risk population in an attempt to reduce mortality and morbidity

Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders.

Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.

Multimorbidity Patterns and Unplanned Hospitalisation in a Cohort of Older Adults.

The presence of multiple chronic conditions (i.e., multimorbidity) increases the risk of hospitalisation in older adults. We aimed to examine the association between different multimorbidity patterns and unplanned hospitalisations over 5 years. To that end, 2,250 community-dwelling individuals aged 60 years and older from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) were studied. Participants were grouped into six multimorbidity patterns using a fuzzy c-means cluster analysis. The associations between patterns and outcomes were tested using Cox models and negative binomial models. After 5 years, 937 (41.6%) participants experienced at least one unplanned hospitalisation. Compared to participants in the unspecific multimorbidity pattern, those in the cardiovascular diseases, anaemia and dementia pattern, the psychiatric disorders pattern and the metabolic and sleep disorders pattern presented with a higher hazard of first unplanned hospitalisation (hazard ratio range: 1.49–2.05; p < 0.05 for all), number of unplanned hospitalisations (incidence rate ratio (IRR) range: 1.89–2.44; p < 0.05 for all), in-hospital days (IRR range: 1.91–3.61; p < 0.05 for all), and 30-day unplanned readmissions (IRR range: 2.94–3.65; p < 0.05 for all). Different multimorbidity patterns displayed a differential association with unplanned hospital care utilisation. These findings call for a careful primary care follow-up of older adults with complex multimorbidity patterns.

Subjective reports of physical activity levels and sedentary time prior to hospital admission can predict utilization of hospital care and all-cause mortality among patients with cardiovascular disease.

BackgroundIn prevention, sedentary behaviour and physical activity have been associated with risk of cardiovascular disease and mortality. Less is known about associations with utilization of hospital care.AimTo investigate whether physical activity level and sedentary behaviour prior to cardiac ward admission can predict utilization of hospital care and mortality among patients with cardiovascular disease.MethodsLongitudinal observational study including 1148 patients admitted and treated in cardiac wards in two hospitals. Subjective reports of physical activity levels and sedentary time prior to admission were collected during inpatient care and categorized as low, medium or high. The associations between physical activity level and sedentary time with hospital stay, readmission and mortality were analysed using linear, logistic and Cox regressions.ResultsMedian hospital stay was 2.1 days. One higher step in the physical activity level, or lower sedentary time, was related to an approximately 0.9 days shorter hospital stay. Sixty per cent of patients were readmitted to hospital. The risk of being readmitted was lower for individuals reporting high physical activity and low sedentary time (odds ratios ranging between 0.44 and 0.91). A total of 200 deaths occurred during the study. Mortality was lower among those with high and medium physical activity levels and low sedentary time (hazard ratios ranging between 0.36 and 0.90).ConclusionBoth physical activity level and sedentary time during the period preceding hospitalization for cardiac events were predictors of hospital utilization and mortality. This highlights the prognostic value of assessing patients’ physical activity and sedentary behaviour.

Effects of an Integrated Palliative Care Pathway: More Proactive GPs, Well Timed, and Less Acute Care: A Clustered, Partially Controlled Before-After Study

ObjectivesThis study presents the design of an integrated, proactive palliative care pathway covering the full care cycle and evaluates its effects using 3 types of outcomes: (1) physician-reported outcomes, (2) outcomes reported by family, and (3) (utilization of) health care outcomes. DesignA clustered, partially controlled before-after study with a multidisciplinary integrated palliative care pathway as its main intervention. Setting and Participantsafter assessment in hospital departments of oncology, and geriatrics, and in 13 primary care facilities, terminally ill patients were proactively included into the pathway. Patients' relatives and patients’ general practitioners (GPs) participated in a before/after survey and in interviews and focus groups. InterventionA multidisciplinary, integrated palliative care pathway encompassing (among others) early identification of the palliative phase, multidisciplinary consultation and coordination, and continuous monitoring of outcomes. MeasuresMeasures included GP questionnaire: perceived quality of palliative care; questionnaires by family members: FAMCARE, QOD-LTC, EDIZ; and 3 types of health care outcomes: (1) utilization of primary care: consultations, intensive care, communication, palliative home visits, consultations and home visits during weekends and out-of-office-hours, ambulance, admission to hospital; (2) utilization of hospital care: outpatient ward consultations, day care, emergency room visits, inpatient care, (radio) diagnostics, surgical procedures, other therapeutic activities, intensive care unit activities; (3) pharmaceutical care utilization. ResultsGPs reported that palliative patients die more often at their preferred place of death, and that they now act more proactively toward palliative patients. Relatives of included, deceased patients reported clinically relevant improved quality of dying, and more timely palliative care. Patients in the pathway received more (intensive) primary care, less unexpected care during out-of-office hours, and more often received hospital care in the form of day care. Conclusions and ImplicationsAn integrated palliative care pathway improves a variety of clinical outcomes important to patients, their families, physicians, and the health care system. The integration of palliative care into multidisciplinary, proactive palliative care pathways, is therefore a desirable future development.

Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality

Study objectivePhysician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DesignTime Series of prospectively recorded and historical data. SettingAcademic tertiary care medical center and health system. Patients449 patients undergoing elective primary hip surgery. InterventionsFor the intervention group we redesigned care with a comprehensive 14–16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MeasurementsThe intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. Main resultsCompared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). ConclusionsA perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.

The falling growth in the use of private hospitals in Australia

Australia has a rich public-private mix of financing and provision of healthcare. Since mid-2015, the higher growth in out of pocket costs relative to the growth in wages began to reduce the affordability of private healthcare and marked the start of the drop in private health insurance coverage. Using publicly available data, this paper describes the decline in growth in the utilisation of private hospital care before and after 2015. Growth in the use of elective surgery in private hospitals fell with some indication of increased waiting times in public hospitals, and evidence of doctors spending more of their time in public hospitals rather than in private practice. Private hospitals’ profitability declined, share prices of for-profit private hospital operators fell, and there is evidence of reduced capacity and a fall in long-term investment in the private hospital sector. In 2020, COVID-19 has accelerated these trends and the economic recession is likely to exacerbate reduced affordability of private healthcare. Policy responses should depend on how these changes influence access, cost and quality of care for patients.

Impact of Enhanced Care Coordination on Emergency Department and In-patient Hospital utilization and Hospital Length of Stay for Children with Medical Complexity

PURPOSE: To describe the change in emergency department and acute hospital care utilization after establishing care in a family-centered medical home for children with medical complexity. METHODS: 358 children with medical complexity, defined as three or more chronic health conditions and technology dependence, were enrolled into a patient- and family- centered medical home situated at a pediatric academic institution starting in July 2017. The medical home offers same day appointments for acute care, twenty-four access to medical home clinicians, and …

Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care.

ObjectiveTo examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use.DesignCross-sectional claims data study.SettingThe Netherlands.ParticipantsPatients deceased in 2013–2015 with lung cancer (N = 25 553).Main Outcome MeasuresWe calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization.ResultsThe utilization of hospital services in high-using regions is 2.3–3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level.ConclusionsHospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.

The Effect of Health Insurance on Health Care Utilization in the Justice-Involved Population: United States, 2014-2016.

Objectives. To examine the impact of health insurance coverage on utilization of outpatient, hospital, and emergency department care among justice-involved individuals in the United States.Methods. We performed repeated cross-sectional analyses with data from the National Survey of Drug Use and Health. The study population included 6086 adults with justice involvement within the past year. We used logistic regression to examine the odds of health care utilization based on either a dichotomous or categorical measure of health insurance coverage. We used negative binomial regression to examine the number of times a specific type of care was utilized with both a dichotomous measure of health insurance coverage and a categorical measure of type of health insurance.Results. Health insurance was associated with increased utilization of outpatient, inpatient, and emergency department care.Conclusions. Health insurance coverage was associated with increased utilization of outpatient, inpatient, and emergency department health care among justice-involved individuals. Therefore, expanding access to health insurance in this population has the potential to increase care utilization of all types and decrease barriers to medical services.

Utilisation and financial protection for hospital care under publicly funded health insurance in three states in Southern India

BackgroundMany LMICs have implemented Publicly Funded Health Insurance (PFHI) programmes to improve access and financial protection. The national PFHI scheme implemented in India for a decade has been recently modified and expanded to cover free hospital care for 500 million persons. Since increase in annual cover amount is one of the main design modifications in the new programme, the relevant policy question is whether such design change can improve financial protection for hospital care. An evaluation of state-specific PFHI programmes with vertical cover larger than RSBY can help answer this question.Three states in Southern India - Andhra Pradesh, Karnataka and Tamil Nadu have been pioneers in implementing PFHI with a large insurance cover.MethodsThe current study was meant to evaluate the PFHI in above three states in improving utilisation of hospital services and financial protection against expenses of hospitalization. Two cross-sections from National Sample Survey’s health rounds, the 60th round done in 2004 and the 71st round done in 2014 were analysed. Instrumental Variable method was applied to address endogeneity or the selection problem in insurance.ResultsEnrollment under PFHI was not associated with increase in utilisation of hospital care in the three states. Private hospitals dominated the empanelment of facilities under PFHI as well as utilisation. Out of Pocket Expenditure and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PFHI in the three states. The size of Out of Pocket Expenditure was significantly greater for utilisation in private sector, irrespective of insurance enrollment.ConclusionPFHI in the three states used substantially larger vertical cover than national scheme in 2014. The three states are known for their good governance. Yet, the PFHI programmes in all three states failed in fulfilling their fundamental purpose. Increasing vertical cover of PFHI and using either ‘Trusts’ or Insurance-companies as purchasers may not give desired results in absence of adequate regulation. The study raises doubts regarding effectiveness of contracting under PFHIs to influence provider-behavior in the Indian context. Further research is required to find solutions for addressing gaps that contribute to poor financial outcomes for patients under PFHI.

A Bourdieusian approach to class-related inequalities: the role of capitals and capital structure in the utilisation of healthcare services in later life.

This paper draws on Bourdieu's theory of economic, social and cultural capital to understand the relative effect of the volume and the composition of these capitals on healthcare service use in later life. Based on data from the fifth wave of the Survey of Health, Aging, and Retirement in Europe (n = 64,840), we first look at the contribution of each capital in the use of three healthcare services (general practitioner, dentist and hospital). Using cluster analysis, we then mobilise Bourdieu's concept of habitus to explain how the unequal distribution of material and non‐material capitals acquired in childhood lead to different levels of health and hospital care utilisation in later life. After controlling for demographic and health insurance variables, our results show that economic capital has the strongest individual association among the three capitals. However, the results of a cluster analysis used to distinguish between capital structures show that those with high non‐material capital and low material capital have higher levels of primary healthcare utilisation, and in turn lower levels of hospital use. Bourdieu's approach sheds light on the importance of capitals in all forms and structures to understand the class‐related mechanisms that contribute to different levels of healthcare use.

Timing of Palliative Care in Colorectal Cancer Patients: Does It Matter?

BackgroundPalliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs. MethodsThis is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs. ResultsA total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care. ConclusionsEarly palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.

The Intensity of Hospital Care Utilization by Dutch Patients With Lung or Colorectal Cancer in their Final Months of Life

Understanding the overuse and underuse of health-care services in the end-of-life (EoL) phase for patients with lung cancer (LC) and colorectal cancer (CRC) is important, but knowledge is limited. To help identify inappropriate care, we present the health-care utilization profiles for hospital care at the EoL of patients with LC (N = 25 553) and CRC (N = 14 911) in the Netherlands between 2013 and 2015. An administrative database containing all in-hospital health-care activities was analyzed to investigate the association between the number of days patients spent in the emergency department (ED) or intensive care unit (ICU) and their exposure to chemotherapy or radiotherapy. Fewer patients received hospital care as death neared, but their intensity of care increased. In the last month of life, the average numbers of hospital bed days, ICU days, and ER contacts were 9.0, 5.5, and 1.2 for patients with CRC, and 8.9, 6.2 and 1.2 for patients with LC in 2015. On the other hand, the occurrence of palliative consultations ranged from 1% to 4%. Patients receiving chemotherapy 6 months before death spent fewer days in ICU than those who did not receive this treatment (odds ratios: CRC = 0.6 [95% confidence interval: 0.4-0.8] and LC = 0.7 [0.5-0.9]), while those receiving chemotherapy 1 month before death had more ED visits (odds ratios: CRC = 17.2 [11.8-25.0] and LC = 15.8 [12.0-20.9]). Our results showed that patients who were still receiving hospital care when death was near had a high intensity of care, yet palliative consultations were low. Receiving chemotherapy or radiotherapy in the final month of life was significantly associated with more ED and ICU contacts in patients with LC.