Indicators Of Health Care Utilization Research Articles

The Prediction of Healthcare Utilization by Frailty and Disability among Dutch Community-Dwelling People Aged 75 Years or Older.

Population aging is occurring worldwide. As a result, frailty and disability are in the full interest of practice, policy, and science. An increase in healthcare utilization is an adverse outcome of frailty and disability. The aim of the present study was the prediction of six indicators of healthcare utilization by frailty and disability measures. The six indicators of healthcare utilization of interest were: use of informal care, number of visits to a general practitioner, hospital admission, receiving nursing care, receiving personal care, and contacts with (health)care professionals. We used a sample of 484 people that was randomly drawn from the municipality of Roosendaal (the Netherlands), a municipality with 78,000 inhabitants. A subset of people who completed the Tilburg Frailty Indicator (TFI) at baseline and the Groningen Activity Restriction Scale (GARS) questionnaires was used with a nine-year followup. We used generalized estimation equations (GEE) to predict the six indicators with the frailty measures (physical, psychological, and social scores) and disability measures (ADL and IADL scores). We also performed GEE analyses adjusted for age, gender, and multimorbidity from part A of the TFI at baseline. The significant predictors were different for each indicator. However, the physical frailty score, the ADL score, and the IADL score often emerged as significant predictors. These three variables predicted several indicators of healthcare utilization: use of informal care, number of visits to a general practitioner, hospital admission, receiving nursing care, receiving personal care, and contacts with (health)care professionals. The social score was found to be significant for the indicator use of disciplines. In conclusion, our study showed that in particular physical frailty, and ADL and IADL disability predicted healthcare utilization in community-dwelling people aged 75 years or older. It is important that care and welfare professionals pay attention to physical frailty and both ADL and IADL disability aiming to diminish frailty and disability and preventing intensive healthcare utilization and related costs. Future research will have to focus on more representative Dutch municipalities in order to get a more reliable and accurate picture of the disciplines used by people with frailty and disability.

Referral, Genetic Counselling, and BRCA Testing in the Manitoba High-Grade Serous Ovarian Cancer Population, 2004–2019

(1) Background: The primary objective of this study was to examine the rate of genetic referral, BRCA testing, and BRCA positivity amongst all patients with high-grade serous ovarian cancers (HGSOC) from 2004-2019. The secondary objective was to analyze secondary factors that may affect the rates of referral and testing. (2) Methods: This population-based cohort study included all women diagnosed with HGSOC using the Manitoba Cancer Registry, CervixCheck registry, Medical Claims database at Manitoba Health, the Hospital Discharge abstract, the Population Registry, and Winnipeg Regional Health Authority genetics data. Data were examined for three different time cohorts (2004-2013, 2014-2016; 2017-2019) correlating to practice pattern changes. (3) Results: A total of 944 patients were diagnosed with HGSOC. The rate of genetic referrals changed over the three timeframes (20.0% → 56.7% → 36.6%) and rate of genetic testing increased over the entire timeframe. Factors found to increase rates of referral and testing included age, histology, history of oral contraceptive use, and family history of ovarian cancer. Prior health care utilization indicators did not affect genetic referral or testing. (4) Conclusion: The rate of genetic referral (2004-2016) and BRCA1/2 testing (2004-2019) for patients with a diagnosis of HGSOC increased over time. A minority of patients received a consultation for genetics counselling, and even fewer received testing for a BRCA1/2. Without a genetic result, it is difficult for clinicians to inform treatment decisions. Additional efforts are needed to increase genetics consultation and testing for Manitoban patients with HGSOC. Effects of routine tumour testing on rates of genetic referral will have to be examined in future studies.

Trends in inequality in maternal and child health and health care in Uganda: Analysis of the Uganda demographic and health surveys

BackgroundUganda has made great strides in improving maternal and child health. However, little is known about how this improvement has been distributed across different socioeconomic categories, and how the health inequalities have changed over time. This study analyses data from Demographic and Health Surveys (DHS) conducted in 2006, 2011, and 2016 in Uganda, to assess trends in inequality for a variety of mother and child health and health care indicators.MethodsThe indicators studied are acknowledged as critical for monitoring and evaluating maternal and child health status. These include infant and child mortality, underweight status, stunting, and prevalence of diarrhea. Antenatal care, skilled birth attendance, delivery in health facilities, contraception prevalence, full immunization coverage, and medical treatment for child diarrhea and Acute Respiratory tract infections (ARI) are all health care indicators. Two metrics of inequity were used: the quintile ratio, which evaluates discrepancies between the wealthiest and poorest quintiles, and the concentration index, which utilizes data from all five quintiles.ResultsThe study found extraordinary, universal improvement in population averages in most of the indices, ranging from the poorest to the wealthiest groups, between rural and urban areas. However, significant socioeconomic and rural-urban disparities persist. Under-five mortality, malnutrition in children (Stunting and Underweight), the prevalence of anaemia, mothers with low Body Mass Index (BMI), and the prevalence of ARI were found to have worsening inequities. Healthcare utilization measures such as skilled birth attendants, facility delivery, contraceptive prevalence rate, child immunization, and Insecticide Treated Mosquito Net (ITN) usage were found to be significantly lowering disparity levels towards a perfect equity stance. Three healthcare utilization indicators, namely medical treatment for diarrhea, medical treatment for ARI, and medical treatment for fever, demonstrated a perfect equitable situation.ConclusionIncreased use of health services among the poor and rural populations leads to improved health status and, as a result, the elimination of disparities between the poor and the wealthy, rural and urban people.RecommendationIntervention initiatives should prioritize the impoverished and rural communities while also considering the wealthier and urban groups.

District-level religious composition and child health in India

BackgroundCommunity characteristics are a significant social determinant of child health. Little is known about the effects of social heterogeneity as a specific factor that might impact health. This paper aims to fill the void in research on the health effects of India’s district-level religious heterogeneity.MethodsWeighted state fixed effects multivariate logistic regression was applied to India’s Third District Level Household Survey (2007–2008). The dependent variables were death of a child under five and indicators of healthcare utilization. The key independent variables were the proportions in the district who were Hindu, Muslim, Christian, Buddhist, and Sikh. The analysis controlled for generic community diversity, household religion, and socioeconomic status. Separate, sub-group analysis focused on Muslims only, Christians only, and Buddhists only.ResultsMultivariate fixed effects models show that a 1% point increase in the proportion of Muslim, Christian, or Buddhist households in a community is associated with respective odds ratios of child death of 1.008, 1.009, and 1.012 of experiencing the death of a child. The impact of a household’s own religious affiliation is statistically insignificant in these models. Higher proportions of Muslims and Christians in a community lower the odds of BCG (a vaccine for childhood tuberculosis) receipt and child healthcare-seeking.ConclusionsHouseholds residing where there are higher levels of religious minorities in India experience worse child survival. These effects are not mediated by the household’s own religious affiliation. There is evidence that health system performance and quality is systematically worse in communities with higher proportions of religious minorities. Our study can help policymakers identify communities where children may be at higher risk based on community heterogeneity and the potential for insufficient collective action. Policymakers might consider flagging these communities for special attention, because social heterogeneity is likely to be of long duration.

Real-world assessment of healthcare provided by the National Health Service: The network of regional Beaver research platforms


 Real-world evidence can provide answers on healthcare utilization and appropriateness, post-marketing drugs safety and comparative effectiveness, and cost-effectiveness profiles of healthcare pathways. Healthcare utilization databases, possibly integrated with drug and disease registries, electronic medical records, survey and cohort data (i.e. real-world data), allow to trace healthcare ‘footprints’ left from beneficiaries of National Health Service.
 Beaver is a research platform available on demand to Italian regions which we developed for computing indicators of healthcare utilization and clinical outcomes, as well as for generating evidence on effectiveness and cost-effectiveness profile. Two distinct solutions may be adopted. One, the so-called Beaver Light front-end allows to automatically compute health indicators of adherence to official guidelines. Two, the so-called Beaver Full front-end involves an eight-step procedure entirely driven by the study protocol.
 In order to fulfil the directives recently issued by the European Parliament and Council and the Italian Authority for the protection of individual data, the platform resides in each region’s infrastructure, so limiting the free movement of electronic health data. Indeed, regional authorities should be responsible for data safety and for allowing data accessibility. The use of standardized and validated algorithms enables to obtain regional estimates that, being obtained by employing regional platforms containing data extracted with standardized procedure, may be compared and possibly summarized by using common meta-analytic techniques.
 In conclusion, the Beaver regional platform is a promising tool which may contribute to stimulate healthcare research in Italy.

The effects of early pregnancy loss on health outcomes and health care utilization and costs.

ObjectiveTo evaluate the effects of early pregnancy loss on subsequent health care use and costs.Data SourcesLinked administrative health databases from Manitoba, Canada.Study DesignThis was a population‐based cohort study. The exposure of interest was first recorded ectopic pregnancy or miscarriage (EPM). Outcomes included visits to all ambulatory care providers, family physicians (FPs), specialists, and hospitals, as well as the costs associated with these visits. We also assessed the impact of EPM on a global measure of health service utilization and the incidence and costs of psychotropic medications.Data Collection/Extraction MethodsWe identified women who experienced their first recorded loss (EPM) from 2003–2012 and created a propensity score model to match these women to women who experienced a live birth, with outcome measures available through 31 December 2014. We used a difference in differences approach with multivariable negative binomial models and generalized estimating equations (GEE) to assess the impact of EPM on the aforementioned health care utilization indicators.Principal FindingsEPM was associated with a short‐term increase in visits to, and costs associated with, certain ambulatory care providers. These findings were driven in large part by increased visits/costs to FPs (rate difference [RD]: $19.92 [95% CI: $16.33, $23.51]) and obstetrician‐gynecologists (OB‐GYNs) (RD $9.41 [95% CI: $8.42, $10.40]) in the year immediately following the loss, excluding care associated with the loss itself. We also detected an increase in hospital stays and costs and a decrease in the use of psychotropic medications relative to matched controls.ConclusionPregnancy loss may lead to subsequent increases in certain types of health care utilization. While the absolute costs associated with post‐EPM care are relatively small, the observed patterns of service utilization are informative for providers and policy makers seeking to support women following a loss.

Sağlık Hizmetleri Kullanımında Hakkaniyet: Türkiye Sağlık Sisteminin Değerlendirilmesi: Kesitsel Araştırma

Objective: This study aims to analyse and evaluate the equity level of healthcare utilization by years in Türkiye by exploring the relationship between health services utilization and the factors that are predisposing, enabling and need factors in 'Behavioural Model' developed by Andersen. Material and Methods: The concentration index and regression analyses were used to estimate equity levels and to explore the effects of predisposing, enabling and need factors. Data of 5 Türkiye Health Surveys conducted in years of 2008, 2010, 2012, 2014 and 2016 was used to reach this study's purposes. Equity in healthcare utilization was investigated for four healthcare utilization indicators: 1) Services provided by family/practitioner physicians, 2) Services provided by specialized physicians, 3) Day care/outpatient care services, and 4) Inpatient care services provided by hospitals. Results: Estimated concentration index values for income level, education level, and number of diseases showed that health services utilization was concentrated among people having less income and education level as well as more diseases. Regression analyses also indicated that the variables of income and education level, and disease existence and number of diseases as well as some other socio-demographic characteristics of individuals had significant effects on health services utilization. Conclusion: Considering the effects of predisposing, enabling and need factors on the utilization of health services in Türkiye by years, it might be concluded that equity level in Turkish Healthcare System has been improved.

Influence of Admission Time on Health Care Quality and Utilization in Patients with Stroke: Analysis for a Possible July Effect and Weekend Effect.

(1) Purpose: Undesirable health care outcomes could conceivably increase as a result of the entry of new, less experienced health care personnel into patient care during the month of July (the July effect) or as a result of the less balanced allocation of health care resources on weekends (the weekend effect). Whether these two effects were present in Taiwan’s National Health Insurance (NHI) system was investigated. (2) Methods: The current study data were acquired from the NHI Research Database. The research sample comprised ≥18-year-old patients diagnosed as having a stroke for the first time from 1 January 2006 to 30 September 2012. The mortality rate within 30 days after hospitalization and readmission rate within 14 days after hospital discharge were used as health care quality indicators, whereas health care utilization indicators were the total length and cost of initial hospitalization. (3) Results: The results revealed no sample-wide July effect with regard to the four indicators among patients with stroke. However, an unexpected July effect was present among in-patients in regional and public hospitals, in which the total lengths and costs of initial hospitalization for non-July admissions were higher than those for July admissions. Furthermore, the total hospitalization length for weekend admissions was 1.06–1.07 times higher than that for non-weekend admissions; the total hospitalization length for weekend admissions was also higher than that for weekday admissions during non-July months. Thus, weekend admission did not affect the health care quality of patients with stroke but extended their total hospitalization length. (4) Conclusions: Consistent with the NHI’s general effectiveness in ensuring fair, universally accessible, and high-quality health care services in Taiwan, the health care quality of patients examined in this study did not vary significantly overall between July and non-July months. However, a longer hospitalization length was observed for weekend admissions, possibly due to limitations in personnel and resource allocations during weekends. These results highlight the health care efficiency of hospitals during weekends as an area for further improvement.

Analysis of Reported Health Care Use by Sexual Orientation Among Youth

In the United States, adolescents who are lesbian, gay, or bisexual (LGB) face disparities across physical and mental health outcomes compared with non-LGB youth, yet few studies have looked at patterns of health care utilization by sexual orientation. To compare health care utilization indicators for LGB and non-LGB youth. This cohort study analyzed wave 3 data from Healthy Passages, a longitudinal observational study of diverse public school students in Birmingham, Alabama; Houston, Texas; and Los Angeles County, California. Multivariable logistic regression models tested sexual-orientation differences in the past 12-month health care utilization measures, controlling for youth age, gender, race and ethnicity, household education, income, and marital status. Data collection began in 2010 when students were in the 5th grade (mean [SE] age, 11.13 [0.01] years) (wave 1) and continued 2 years later (wave 2, 7th grade) and 5 years later (wave 3, 10th grade). Permission to be contacted was provided for 6663 children, and 5147 (77%) participated in audio computer-assisted self-administered interviews. This study included 4256 youth (640 LGB, 3616 non-LGB) who completed interviews at wave 1 and wave 3 and answered key items used in this analysis. Analyses were completed in June 2021. Sexual orientation (LGB vs non-LGB). Health care utilization and communication difficulty with a physician in the past 12 months. Among 4256 youths included in the study at baseline in 5th grade (wave 1), 2171 (48.9%) were female; 1502 (44.5%) were Hispanic or Latino; 1479 (28.9%) were Black; the mean (SE) age was 11.19 (0.03) years; and 640 (14.5%) were LGB at wave 3. Compared with non-LGB youth, a higher proportion of LGB youth reported not receiving needed medical care in the last 12 months (adjusted odds ratio [aOR], 1.68; 95% CI,1.38-2.05), most commonly for sexually transmitted infections, contraception, and substance use. LGB youth more frequently reported difficulty communicating with their physician (aOR, 1.71; 95% CI, 1.27-2.30) than non-LGB youth. This study's results found that health care utilization differs by sexual orientation for youth. These findings suggest that clinician training is needed to address the health care needs of LGB youth. Routinely capturing sexual orientation data might enable tracking of health care utilization indicators for LGB youth.

COVID-19 PANDEMIC INDUCED DISRUPTIONS IN TROPONIN AND LOW-DENSITY LIPOPROTEIN CHOLESTEROL LABORATORY TEST VOLUMES ACROSS ALBERTA

BACKGROUNDAtherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality in Canada and worldwide. Laboratory tests, including troponin and low-density lipoprotein cholesterol (LDL-C), are important biomarkers of ASCVD risk. The objective of this study was to investigate patterns of testing for troponin and LDL-C test volumes among Alberta residents during the coronavirus disease 2019 (COVID-19) pandemic.METHODS AND RESULTSA repeated cross-sectional study design captured population-level laboratory test volumes between March 15, 2019 and December 14, 2020. Three-month cross-sections were derived to report laboratory test volumes by different COVID-19 restriction periods during 2020-2021 and using 2019-2020 as a preceding control period. Percent change for troponin and LDL-C test volumes were calculated for both control and COVID-19 periods among adult (≥18 years of age) Alberta residents, and stratified by age (18-49, 50-65, 66-79, and ≥80 years), sex, and geographic zones (urban, rural). This preliminary data is part of an ongoing study for which further troponin and LDL-C test volumes will be available up until March 14, 2021 (representing one year of data throughout the COVID-19 pandemic). Among the Alberta population, 292,836 troponin and 794,789 LDL-C tests were captured between March 15, 2020 and December 14, 2020 (Figure 1). Testing patterns during the COVID-19 restriction period showed marked reduction in test volumes from the previous year. The initial cross-section of the COVID-19 period (March-June 2020) was characterized by the largest overall reduction with troponin test volumes decreasing 18% and LDL-C test volumes decreasing 63%, compared to the year prior. As restrictions eased in the summer months of 2020, testing volumes rebounded to near pre-pandemic volumes for both tests. However, in the fall of 2020, troponin tests decreased again (-15%). Within these drops in utilization, slightly larger relative declines were observed for troponin test volumes in women (-20%) and patients ≥80 years-old (-25%) and for LDL-C test volumes among urban residents (-64%), women (-67%) and patients aged 18-49 (-66%) and 50-65 (-65%) years (Table 1).CONCLUSIONThis study describes declines in troponin and LDL-C test volumes in the initial and second COVID-19 lockdown periods. Women had overall smaller total troponin and LDL-C test volumes and larger relative declines during the pandemic compared to men. The decrease in these ASCVD-related laboratory test volumes during the pandemic may have been accompanied by other important changes in indicators of healthcare utilization and associated clinical outcomes. Ongoing analyses will further explore the impact of the pandemic.

Healthcare Resource Utilization in Autoimmune Hemolytic Anemia Patients: Analysis of 190 Cases from a Single Center

Autoimmune hemolytic anemia (AIHA) is a heterogeneous disease caused by autoantibody directed against erythrocyte antigens. It is usually considered a benign disease, easy to treat, and with low clinical impact. As a matter of fact, about 1/3 of cases present a severe onset and display a relapsing/refractory course that may lead to significant healthcare burden. However, data about healthcare direct and indirect costs and resource utilization are lacking, possibly due to the disease rarity and to the referral of difficult cases to 2ndary and 3rtiary centers.Here we retrospectively evaluated healthcare utilization in a single center cohort of primary AIHA patients, focusing on anemia severity, transfusion need, use of new highly expensive medications, splenectomy, and healthcare resource utilization (number of admissions and their length, outpatient visits). We studied 190 patients (72 M and 118 F, median age at diagnosis 57.7 yrs, range 2.2-94), followed-up for 4 yrs (0.1-45), classified in warm (W)AIHA (DAT positive for IgG and IgG+C), cold agglutinin disease, CAD (C), mixed (IgG+C with high titer cold agglutinins) and atypical (DAT-, IgA+, wIgM). In addition, hemoglobin levels at onset, hemolytic parameters (LDH, reticulocyte absolute counts, and bone marrow responsiveness index, BMRI), number of relapses, and of therapy lines were considered.Table 1 shows healthcare utilization indicators for AIHA patients divided according to AIHA type. On the whole, 121/190 (64%) required at least one hospital admission; the median number of hospital admissions was 1 (range 1-8), with 17/121 cases (9%) requiring 3 or more admissions. The higher frequency was observed in C+WAIHA, mixed and atypical cases (p=0.006). The median admission duration was 15 days, with 16 cases (13%) needing more than 30 days of admission. Concerning outpatients, median number of visits per year was 5, but 41/190 (22%) required more than a monthly visit. As regards therapeutic procedures, 103/190 (54%) required at least one transfusion; the median number of all transfusions received was 5, with 11/103 patients (11%) requiring more than 20 transfusions (the established threshold for chelation) and 6 more than 50. The distribution of transfusion need was significantly different among AIHA categories, with higher values observed in C+WAIHA, mixed and atypical cases (p=0.004). Considering transfusions as a function of follow-up length, the median was 2 per year, with 27 cases necessitating 4 or more (one subject about a weekly support). Highly expensive drugs were administered in 65/190 patients (34%), of whom 56 rituximab and 9 bortezomib, and splenectomy performed in 20/190 (11%) of patients. The administration of highly expensive drugs was significantly different among AIHA categories with higher rates observed in CAD and mixed cases (p=0.01). The analysis of hematologic parameters confirms the heterogeneity of the disease, with Hb values being particularly low in mixed and C+WAIHA (p=0.0001); the latter also showed lower absolute reticulocyte counts and BMRI (p=0.005 and p=0.008, respectively). As expected, admissions length and transfusions requirement were negatively correlated to Hb levels at onset (r=-0.26, p<0.001, and r=-0.18, p<0.01, respectively). Moreover transfusion requirement was positively correlated with a more severe hemolytic pattern (high LDH values r=0.21, p<0.01), and negatively with the bone marrow compensatory response (BMRI r=0.15, p<0.05).In conclusion, notwithstanding AIHA is usually considered a fairly benign disease, the clinical course of difficult cases (roughly 10-15%) require a reliable healthcare resource utilization representing a significant burden on the patient and the medical system. [Display omitted] DisclosuresBarcellini:Alexion: Honoraria; Agios: Honoraria, Research Funding; Novartis: Honoraria.

Assessing Frailty with the Tilburg Frailty Indicator (TFI): A Review of Reliability and Validity.

ObjectiveThe Tilburg Frailty Instrument (TFI) is an instrument for assessing frailty in community-dwelling older people. Since its development, many studies have been carried out examining the psychometric properties. The aim of this study was to provide a review of the main findings with regard to the reliability and validity of the TFI.MethodsWe conducted a literature search in the PubMed and CINAHL databases on May 30, 2020. An inclusion criterion was the use of the entire TFI, part B, referring to the 15 components. No restrictions were placed on language or year of publication.ResultsIn total, 27 studies reported about the psychometric properties of the TFI. By far, most of the studies (n = 25) were focused on community-dwelling older people. Many studies showed that the internal consistency and test–retest reliability are good, which also applies for the criterion and construct validity. In many studies, adverse outcomes of interest were disability, increased health-care utilization, lower quality of life, and mortality. Regarding disability, studies predominantly show results that are excellent, with an area under the curve (AUC) >0.80. In addition, the TFI showed good associations with lower quality of life and the findings concerning mortality were at least acceptable. However, the association of the TFI with some indicators of health-care utilization can be indicated as poor (eg, visits to a general practitioner, hospitalization).ConclusionSince population aging is occurring all over the world, it is important that the TFI is available and well known that it is a user-friendly instrument for assessing frailty and its psychometric properties being qualified as good. The findings of this assessment can support health-care professionals in selecting interventions to reduce frailty and delay its adverse outcomes, such as disability and lower quality of life.

Socioeconomic inequalities and determinants of health care utilization in Botswana: a decomposition analysis

In Botswana, healthcare services are more accessible to the more affluent, while healthcare benefits for the poor remain limited. The main aim of this study was to assess socioeconomic inequalities in health care utilization in Botswana. Using a multistage cross sectional design, 1178 male and female respondents aged 15 years and above were interviewed across three cities and towns, 15 urban villages and 15 rural villages. Health care utilization was measured using four indicators: health care needed, health care received, seeking health care for NCDs and use of health facilities. Multivariate analysis was performed using SPSS version 25, while decomposition of inequalities was carried out using ADePT (version 6). All comparisons were considered statistically significant at p < 0.05. Concentration indices show that poor people did not seek health care when sick (CI = −0.0084), did not receive health care when they needed it (CI = –0.0175) and often used public health facilities (CI = –0.0531). On the other hand, seeking health care for NCDs was slightly concentrated among the non-poor (CI = 0.0465). All observed inequalities were small and overlapped with the line of inequality except for receiving health care in public health facilities. Education and wealth status were key contributing factors to inequalities for all health care utilization indicators. Findings from this study indicate the need for improvements in education and economic well-being of poor people in Botswana in order to close the inequality gap for health care utilization.

Empowerment and health care access barriers among currently married women in Myanmar

BackgroundAlthough Myanmar is moving to attain UHC in 2030, health care utilization indicators are still low, especially among women. Women’s health outcomes are determined by the lack of access to health care, and many factors influence this condition. The objective of the present work was to identify the association between women’s empowerment and barriers to accessing health care among currently married women in Myanmar.MethodWe performed a secondary analysis using the Myanmar Demographic and Health Survey (2015–16), including 7759 currently married women aged 15–49 years. The outcome variable, barriers to accessing health care, were asked about in terms of whether the respondent faced barriers to getting permission to go, getting money to go, the distance to the health facility, and not wanting to go alone. The variables were recoded into zero, one, and more than one barrier. After performing the exploratory factor analysis for women’s empowerment indicators (decision-making power and disagreement to justification to wife-beating), a multinomial logistic regression was carried out.ResultsAmong currently married women, 48% experienced no barriers when accessing health care services, 21.9% had one barrier, and 30.1% had more than one barrier. After the exploratory factor analysis, scores were recoded into three levels. Women with low and middle empowerment had 1.5 odds (AOR 1.5, 95% CI: 1.2–1.8) and 1.5 odds (AOR 1.5, 95% CI: 1.3–1.9), respectively, to have barriers to accessing health care when compared to those with high empowerment for one barrier group. For the women who had more than one barrier, women with low empowerment were 1.4 times more likely (AOR 1.4, 95% CI: 1.1–1.7) to experience barriers in comparison to women with high empowerment. The barriers were seen to be reduced in the case of women who had a high level of education, had fewer children, came from rich households, and lived in urban areas.ConclusionWhen women are more empowered, they tend to face fewer barriers when accessing health care services. This finding could contribute to the policy formulation for reducing health inequity issues by increasing women’s empowerment.

Describing trends in the quality of health care and services for men and women living with dementia

AbstractBackgroundAs the Canadian population ages, challenges have emerged with the quality and healthcare utilization of services for persons living with dementia (PWD). These challenges may be exacerbated when we consider the sex inequalities. A disconcerting trend in sex differences has arisen among older adult women, where they are more disadvantaged compared to older men when seeking and receiving treatment. The aims of this study are to describe the quality of dementia care and healthcare utilization among PWD by sex.MethodsThe study will employ a repeated annual cross‐sectional cohort design over 15 years using linked administrative databases to examine health service use data. All incident cases of dementia in community‐dwelling persons aged 65 and over occurring between April 1st and March 31st for each year will be included. Dementia diagnosis will be ascertained using a validated algorithm. Quality of care indicators include: most regularly seen doctor (Overall UPC index), hospitalization for ambulatory care sensitive conditions, continuity of care (Bice‐Boxeman index), degree of coordination (30‐day hospital readmission). Healthcare utilization indicators include: emergency department visits, hospitalizations, alternate level of care, visits to primary care physicians and cognition specialists, long‐term care admission and mortality. Data will be stratified by sex.Results237,259 people (62.7% women) were included in the analyses. Variations over time and between men and women are observed in healthcare utilization indicators including emergency department visits, hospitalizations, alternate level of care, visits to primary care physicians and cognition specialists, long‐term care admission and mortality. For each indicator, graphs will be presented with an annual rate, adjusted for age and follow‐up time in the study.ConclusionAddressing the knowledge gap in the quality of care and healthcare utilization in PWD by sex is essential to inform decision‐makers for the implementation of adequate policies to promote equity in dementia care and ultimately improve the health among men and women living with dementia.

Health Care Utilization, Transition Readiness, and Quality of Life: A Latent Class Analysis.

To identify possible subgroups of health care utilization (HCU) patterns among adolescents and young adults (AYAs) with a chronic medical condition (CMC), and examine how these patterns relate to transition readiness and health-related quality of life (HRQoL). Undergraduates (N = 359; Mage=19.51 years, SD = 1.31) with a self-reported CMC (e.g., asthma, allergies, irritable bowel syndrome) completed measures of demographics, HCU (e.g., presence of specialty or adult providers, recent medical visits), transition readiness, and mental HRQoL (MHC) and physical HRQoL (PHC). Latent class analysis identified four distinct patterns of HCU. The BCH procedure evaluated how these patterns related to transition readiness and HRQoL outcomes. Based on seven indicators of HCU, a four-class model was found to have optimal fit. Classes were termed High Utilization (n = 95), Adult Primary Care Physician (PCP)-Moderate Utilization (n = 107), Family PCP-Moderate Utilization (n = 81), and Low Utilization (n = 76). Age, family income, and illness controllability predicted class membership. Class membership predicted transition readiness and PHC, but not MHC. The High Utilization group reported the highest transition readiness and the lowest HRQoL, while the Low Utilization group reported the lowest transition readiness and highest HRQoL. The present study characterizes the varying degrees to which AYAs with CMCs utilize health care. Our findings suggest poorer PHC may result in higher HCU, and that greater skills and health care engagement may not be sufficient for optimizing HRQoL. Future research should examine the High Utilization subgroup and their risk for poorer HRQoL.

Community Connector: The AHRQ Social Determinants of Health Data Viz Challenge Winner

Research ObjectiveClinical care accounts for a small part of the factors that affect population health. The rest is determined by social determinants of health (SDoH)—social, behavioral, and environmental factors that interact dynamically to keep people healthy. Many tools, such as the Opportunity Atlas, the City Health Dashboard, and the Robert Wood Johnson Foundation rankings, describe the social needs of populations but do not integrate a variety of federal, state, and local data sources and summarize only one community at a time, limiting the potential for peer‐to‐peer, comprehensive learning. Thus, we sought to build a common definition of local SDoH and a way to identify communities with similar needs and demographics, particularly those that have had success in addressing social needs and improving health and well‐being.Study DesignOur Community Connector tool (https://communityconnector.mathematica.org/) is designed to summarize a community’s social needs in one picture, or fingerprint; identify communities with similar fingerprints; and compare communities across key indicators of health care utilization and cost. This fingerprint is based on outcome‐agnostic county‐level scores for six domains of SDoH identified by the Kaiser Family Foundation. We used sparse principal component analysis to determine which variables would be used in the defined SDoH scores and assigned additional variables that were not selected by this approach based on prior knowledge and strong association with the health outcomes. Each of the domain scores is a weighted average of the selected, normalized variables. The tool also provides a comparison of a county’s fingerprint to other counties with similar demographic and nonmodifiable SDoH characteristics, where the similarity is determined using a Lasso regression model.Population StudiedWe collected open‐source federal, state, and local data for the state of Colorado and targeted health outcomes related to obesity, diabetes, and kidney disease for the prototype. We used data sources such as the Colorado Department of Public Health and Environment and the Centers for Disease Control and Prevention’s Diabetes Atlas. With additional time and funding, the tool can expand and scale nationally and present analyses on a larger set of health outcomes and utilization data.Principal FindingsThrough developing the tool, we learned there is vast heterogeneity across community needs, outcomes, and data availability. This tool can help users understand community differences and explore similarities. As we assessed the app’s usability, we incorporated feedback from a variety of stakeholders into the app. From this feedback, we learned how to display the graphics and instructions in the most comprehensible way. As a result, the Community Connector has had about 30 000 views since its launch in mid‐December.ConclusionsIn late January 2020, the Agency for Healthcare Research and Quality (AHRQ) announced this tool as the grand prize winner of the AHRQ’s Visualization Resources of Community‐Level Social Determinants of Health Challenge.Implications for Policy or PracticeThis tool provides further resources and opportunities for communities to use SDoH data when identifying intervention opportunities. In addition to expanding nationally and across health care outcomes, the Community Connector could potentially allow localities to customize their search for similar counties by uploading their own county‐level data to the tool.Primary Funding SourceAgency for Healthcare Research and Quality.

Bayesian latent multi-state modeling for nonequidistant longitudinal electronic health records.

Large amounts of longitudinal health records are now available for dynamic monitoring of the underlying processes governing the observations. However, the health status progression across time is not typically observed directly: records are observed only when a subject interacts with the system, yielding irregular and often sparse observations. This suggests that the observed trajectories should be modeled via a latent continuous-time process potentially as a function of time-varying covariates. We develop a continuous-time hidden Markov model to analyze longitudinal data accounting for irregular visits and different types of observations. By employing a specific missing data likelihood formulation, we can construct an efficient computational algorithm. We focus on Bayesian inference for the model: this is facilitated by an expectation-maximization algorithm and Markov chain Monte Carlo methods. Simulation studies demonstrate that these approaches can be implemented efficiently for large data sets in a fully Bayesian setting. We apply this model to a real cohort where patients suffer from chronic obstructive pulmonary disease with the outcome being the number of drugs taken, using health care utilization indicators and patient characteristics ascovariates.

The Tilburg Frailty Indicator (TFI): New Evidence for Its Validity.

ObjectiveThe Tilburg Frailty Indicator (TFI) is a self-report user-friendly questionnaire for assessing multidimensional frailty among community-dwelling older people. The main aim of this study is to re-evaluate the validity of the TFI, both cross-sectionally and longitudinally, focusing on the predictive value of the total TFI and its physical, psychological, and social domains for adverse outcomes disability, indicators of healthcare utilization, and falls.MethodsThe validity of the TFI was determined in a sample of 180 Dutch community-dwelling older people aged 70 years and older. The participants completed questionnaires including the TFI, the Groningen Activity Restriction Scale (GARS) for assessing disability, and questions with regard to health care utilization and falls in 2016 and again one year later.ResultsThe physical and psychological domains of the TFI were significantly correlated as expected with adverse outcomes disability, many indicators of healthcare utilization, and falls. Regression analyses showed that physical frailty was mostly responsible for the effect of frailty on the adverse outcomes. The cross-sectional and longitudinal predictive validity of total frailty with respect to disability and receiving personal care was excellent, evidenced by Areas Under the Curves (AUCs) >0.8. In most cases, using the cut-off point 5 for total frailty ensured the best values for sensitivity and specificity.ConclusionThe present study provided new, additional evidence for the validity of the TFI for assessing frailty in Dutch community-dwelling older people aiming to prevent or delay adverse outcomes, including disability.

The Validity of the SUNFRAIL Tool: A Cross-Sectional Study among Dutch Community-Dwelling Older People.

Early detection of frail older people is important. Timely intervention may allow health care professionals to prevent or delay the occurrence of adverse outcomes such as disability, increases in health care utilization, and premature death. We assessed the construct and criterion validity of the SUNFRAIL tool, a questionnaire for measuring frailty among older people. This cross-sectional study was carried out in a sample of Dutch citizens. A total of 195 community-dwelling persons aged 71 years and older completed the questionnaire. Construct validity was examined by determining the correlation between the SUNFRAIL tool and the Tilburg Frailty Indicator (TFI). Criterion validity for the SUNFRAIL tool was determined by establishing the correlations with chronic diseases and adverse outcomes of frailty (disability, falls, indicators of health care utilization). Disability was measured using the Groningen Activity Restriction Scale. Participants also answered questions regarding falls and health care utilization. The construct validity of this tool was good and showed significant correlations with the TFI. The correlation between SUNFRAIL total and TFI total was 0.624. The criterion validity of the SUNFRAIL tool was good for chronic diseases and good-to-excellent for adverse outcomes disability, receiving nursing care, and falls. The area under the curve for these outcomes was 0.840 (95% CI 0.781-0.899), 0.782 (95% CI 0.696-0.868), and 0.769 (95% CI 0.686-0.859), respectively. The results of our study suggest that the SUNFRAIL tool is a valid instrument for assessing frailty in community-dwelling older people. It is an attractive instrument for use in practice because it takes little time for health care professionals and older people to complete the questionnaire, and it expresses the integral functioning of human beings.