Intensity Of Health Care Utilization Research Articles

Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study

ObjectiveTo characterize types, duration, and intensity of health care utilization following pediatric concussion and to identify risk factors for increased post-concussion utilization. MethodsA retrospective cohort study of children 5 to 17 years old diagnosed with acute concussion at a quaternary center pediatric emergency department or network of associated primary care clinics. Index concussion visits were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We analyzed patterns of health care visits 6 months before and after the index visit using interrupted time-series analyses. The primary outcome was prolonged concussion-related utilization, defined as having ≥1 follow-up visits with a concussion diagnosis more than 28 days after the index visit. We used logistic regressions to identify predictors of prolonged concussion-related utilization. ResultsEight hundred nineteen index visits (median [interquartile range] age, 14 [11–16] years; 395 [48.2%] female) were included. There was a spike in utilization during the first 28 days after the index visit compared to the pre-injury period. Premorbid headache/migraine disorder (adjusted odds ratio (aOR) 2.05, 95% confidence interval [CI] 1.09–3.89) and top quartile pre-injury utilization (aOR 1.90, 95% CI 1.02–3.52) predicted prolonged concussion-related utilization. Premorbid depression/anxiety (aOR 1.55, 95% CI 1.31–1.83) and top quartile pre-injury utilization (aOR 2.29, 95% CI 1.95–2.69) predicted increased utilization intensity. ConclusionsHealth care utilization is increased during the first 28 days after pediatric concussion. Children with premorbid headache/migraine disorders, premorbid depression/anxiety, and high baseline utilization are more likely to have increased post-injury health care utilization. This study will inform patient-centered treatment but may be limited by incomplete capture of post-injury utilization and generalizability.

Health Care Use and System Costs Among Pediatric Refugees in Canada.

Resettled refugees land in Canada through 3 sponsorship models with similar health insurance and financial supports but differences in how resettlement is facilitated. We examined whether health system utilization, costs, and aggregate 1-year morbidity differed by resettlement model. Population-based matched cohort study in Ontario, 2008 to 2018, including pediatric (0-17 years) resettled refugees and matched Ontario-born peers and categorized refugees by resettlement model: (1) private sponsorship (PSRs), (2) Blended Visa Office-Referred program (BVORs), and (3) government-assisted refugee (GAR). Primary outcomes were health system utilization and costs in year 1 in Canada. Multivariable logistic regression was used to test the associations between sponsorship model and major illnesses. We included 23 287 resettled refugees (13 360 GARs, 1544 BVORs, 8383 PSRs) and 93 148 matched Ontario-born. Primary care visits were highest among GARs and lowest in PSRs (median visits [interquartile range], GARs 4[2-6]; BVORs 3[2-5]; PSRs 3[2-5]; P <.001). Emergency department visits and hospitalizations were more common among GARs and BVORs versus PSRs (emergency department: GARs 19.2%; BVORs 23.4%; PSRs 13.8%; hospitalizations: GARs 2.5%; BVORs 3.2%; PSRs 1.1%, P <.001). Mean 1-year health system costs were highest among GARs (mean [standard deviation] $1278 [$7475]) and lowest among PSRs ($555 [$2799]; Ontario-born $851 [9226]). Compared with PSRs, GARs (adjusted odds ratio 1.63, 95% confidence interval 1.47-1.81) and BVORs (adjusted odds ratio 1.52, 95% confidence interval 1.26-1.84) were more likely to have major illnesses. Health care use and morbidity of PSRs suggests they are healthier and less costly than GARs and BVOR model refugees. Despite a greater intensity of health care utilization than Ontario-born, overall excess demand on the health system for all resettled refugee children is low.

Population-Based Correlation of Regional Intensity of Health Care Utilization and Rates of Amputation Due Diabetes and Peripheral Arterial Disease

Population-Based Correlation of Regional Intensity of Health Care Utilization and Rates of Amputation Due Diabetes and Peripheral Arterial Disease

The Incremental Health Care Costs of Frailty Among Home Care Recipients With and Without Dementia in Ontario, Canada: A Cohort Study.

In this study, we investigated the incremental 1-year direct costs of health care associated with frailty among home care recipients in Ontario with and without dementia. We conducted a cohort study of 159,570 home care clients aged 50 years and older in Ontario, Canada in 2014/2015. At index home care assessment, we ascertained dementia status using a validated algorithm and frailty level (robust, prefrail, frail) based on the proportion of accumulated to potential health deficits. Clients were followed for 1-year during which we obtained direct overall and sector-specific publicly-funded health care costs (in 2015 Canadian dollars). We estimated the incremental effect of frailty level on costs using a 3-part survival- and covariate-adjusted estimator. All analyses were stratified by dementia status. Among those with dementia (n=42,828), frailty prevalence was 32.1% and the average 1-year cost was $30,472. The incremental cost of frailty (vs. robust) was $10,845 [95% confidence interval (CI): $10,112-$11,698]. Among those without dementia (n=116,742), frailty prevalence was 25.6% and the average 1-year cost was $28,969. Here, the incremental cost of frailty (vs. robust) was $12,360 (95% CI: $11,849-$12,981). Large differences in survival between frailty levels reduced incremental cost estimates, particularly for the dementia group (survival effect: -$2742; 95% CI: -$2914 to -$2554). Frailty was associated with greater 1-year health care costs for persons with and without dementia. This difference was driven by a greater intensity of health care utilization among frail clients. Mortality differences across the frailty levels mitigated the association especially among those with dementia.

Advance care planning and terminal intensive care unit admissions for cancer patients: We can do better.

e23000 Background: Terminal oncology intensive care unit (ICU) admissions are associated with high healthcare costs and decreased quality of life. Chemotherapy can be given in non-curative settings to optimize symptom control, but use of it at the end of life does not improve longevity. In addition, goals of care are too often not addressed for patients at high risk of death. Methods: We carried out a retrospective review identifying patients of a large academic cancer center who were admitted to and expired in an ICU between January 1, 2017 to December 31, 2018. Results: 120 patients met inclusion criteria. Median age was 58 years. Only 15.0% (n = 18) of all patients had advance directives. The majority of patients (94.1%, n = 113) were FULL CODE on admission. Median duration of admission was 10 days. Median time to death from ICU admission was 7.5 days. 65.0% (n = 78) of all patients were intubated, while 15.0% (n = 15) received CPR. 58.3% (n = 70) of the study population had solid malignancies; of note, 97.1% (n = 68) of these patients were metastatic at presentation and had a median ECOG performance status of 2. Patients with metastatic solid tumors typically have a more indolent course of progression compared to patients with hematologic malignancies. However, only 23.5% (n = 16) had discussed goals of care or code status with their outpatient oncologists, despite many seeing them within the last month prior to admission (83.8%, n = 57). Similarly, only 4.0% (n = 2) of patients with hematologic malignancies had advance care planning discussions with their oncologists prior to their terminal ICU admission. 27.5% (n = 33) of all patients had an inpatient palliative care consult. The inpatient pulmonary/critical care team had a high rate of inpatient code status transitions, with 85.6% (n = 97) of FULL CODE admissions transitioning to DNR/DNI. Conclusions: These findings reflect contemporary practice at a major academic cancer center. Despite most patients having regular contact with their outpatient oncologists, the intensity of health care utilization noted highlights a need to optimize recognition of patients at high risk of death and to engage patients in advance care planning discussions to avoid terminal ICU admissions.

Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation.

Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodysplastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, inpatient healthcare utilization of this population is unknown. Here we describe survival, intensity of healthcare utilization, and characteristics associated with high resource use at the end of life (EOL). Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We compared the distribution of demographic and clinical characteristics of patients as well as healthcare utilization over 2 years postrelapse and at EOL by postrelapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity by summing the presence of any of the following criteria: death in the hospital, use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense healthcare use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, postrelapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. One hundred fifty-four patients were included; median age at relapse was 56 years (interquartile range [IQR], 39 to 63), 55% were men, 79% had AL, and median time from HCT to relapse was 6 months (IQR, 3 to 10). After relapse, 28% received supportive care only, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion, second HCT, or donor lymphocyte infusion plus second HCT). With the exception of time until relapse and Karnofsky Performance Status, baseline characteristics (gender, age, race, graft-versus-host disease, year of treatment) did not significantly differ by postrelapse treatment group. One hundred thirty-six patients (88%) died within 2 years of relapse; survival differed significantly by postrelapse treatment group, with those receiving disease-directed treatment showing lower risk of death. Healthcare use in AL/MDS patients after post-HCT relapse was high overall, with 44% visiting the emergency department at least once (22% at least 2 times), 93% hospitalized (55% at least 2 times, 16% at least 5 times), and 38% using the intensive care unit (median length of stay 5, days; IQR, 3 to 10). Use was high even among those receiving only supportive care. For those patients who died, the mean intensity score for EOL healthcare use was 1.8 (standard deviation, 1.8). Most patients (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, an increase in age (estimate -.03 (95% CI, -.06 to -.003) and having AL versus MDS were significantly associated with a decreased EOL healthcare intensity score; no other variables were associated with intensity of EOL healthcare use. Healthcare utilization after post-HCT relapse is associated with receipt of disease-directed therapy but remains high across all groups despite known poor prognosis. Interventions are needed to minimize nonbeneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.

Health Care Utilization Is High Amongst Adults Who Relapse Following Allogeneic Hematopoietic Cell Transplantation

▪Background:Leukemia relapse is the leading cause of death for patients who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, the in-hospital health care utilization of this population is unknown. Using a cohort of patients who relapsed post-HCT for acute leukemia (AL) and myelodysplastic syndrome (MDS), we describe survival, intensity of health care utilization, and characteristics associated with high resource utilization at the end-of-life (EOL).Methods:Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We created a composite score for EOL health care utilization intensity summing the presence of any of the following criteria: death in the hospital, the use of chemotherapy, emergency department (ED), hospitalization, intensive care unit (ICU), intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense health care use at EOL. Chi-square and t-tests were used to assess differences in the distribution of health care utilization by post-relapse treatment. Log-rank test statistic and Kaplan Meier curves were used to evaluate differences in survival. Multivariable linear regression analysis was used to determine variables (demographic characteristics, advance directives documentation, palliative care referral, time to relapse) associated with EOL health care utilization intensity.Results:154 patients were included; median age was 55 years (IQR 38-62), 55% were male, 79% had AL. Following relapse, 28% did not undergo any treatment, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion (DLI), second HCT, or DLI plus second HCT). With the exception of age, baseline characteristics (gender, race, graft versus host disease, year of treatment) did not significantly differ by post-relapse treatment group. 140 (91%) patients died within two years of relapse; survival differed significantly by post-relapse treatment group (Figure 1). Health care utilization in AL/MDS patients following post-HCT relapse is described in Table 1. Overall utilization was high with 44% visiting the ED at least once (22% >= 2 times), 92% hospitalized (55% >= 2 times; 16% >= 5 times), and 38% using the ICU (median length of stay 5 days; IQR 3-10 days). Utilization was high even among those receiving no additional therapy (Table 1). For those patients who died, the median (range) intensity score for EOL health care use was 2 (0-8). Most (70%) had a marker of high-intensity health care utilization at the EOL or died in hospital. In multivariable analysis, post-relapse chemotherapy plus cell therapy (estimate (95% CI): 1.41 (0.45-2.37) compared to no treatment was associated with more intense EOL health care use; no other variables were associated with intensity of EOL health care use.Conclusions:Health care utilization following post-HCT relapse is associated with receipt of disease-directed therapy, but remains high across all groups despite known poor prognosis. Interventions are needed to minimize non-beneficial treatments and promote goal-concordant EOL care in this seriously ill patient population. DisclosuresMuffly:Adaptive Biotechnologies: Research Funding; Shire Pharmaceuticals: Research Funding.

Advance Directive Utilization Is Associated with Less Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Allogeneic hematopoietic cell transplantation (HCT) is associated with significant morbidity and mortality, making advance care planning (ACP) and management especially important in this patient population. A paucity of data exists on the utilization of ACP among allogeneic HCT recipients and the relationship between ACP and intensity of healthcare utilization in these patients. We performed a retrospective review of patients receiving allogeneic HCT at our institution from 2008 to 2015 who had subsequently died after HCT. Documentation and timing of advance directive (AD) completion were abstracted from the electronic medical record. Outcomes of interest included use of intensive care unit (ICU) level of care at any time point after HCT, within 30 days of death, and within 14 days of death; use of mechanical ventilation at any time after HCT; and location of death. Univariate logistic regression was performed to explore associations between AD completion and each outcome. Of the 1031 patients who received allogeneic HCT during the study period, 422 decedents (41%) were included in the analysis. Forty-four percent had AD documentation prior to death. Most patients (69%) indicated that if terminally ill, they did not wish to be subjected to life-prolonging treatment attempts. Race/ethnicity was significantly associated with AD documentation, with non-Hispanic white patients documenting ADs more frequently (51%) compared with Hispanic (22%) or Asian patients (35%; P = .0007). Patients with ADs were less likely to use the ICU during the transplant course (41% for patients with ADs versus 52% of patients without ADs; P = .03) and also were less likely to receive mechanical ventilation at any point after transplantation (21% versus 37%, P < .001). AD documentation was also associated with decreased ICU use at the end of life; relative to patients without ADs, patients with ADs were more likely to die at home or in hospital as opposed to in the ICU (odds ratio, .44; 95% confidence interval, .27 to .72). ACP remains underused in allogeneic HCT. Adoption of a systematic practice to standardize AD documentation as part of allogeneic HCT planning has the potential to significantly reduce ICU use and mechanical ventilation while improving quality of care at end of life in HCT recipients.

Health care utilization and end-of-life care for older patients with acute myeloid leukemia.

Health care utilization in older adults (age ≥60 years) with acute myeloid leukemia (AML) has not been well studied. We conducted a retrospective analysis of 330 consecutive older patients who were diagnosed with AML between May 1, 2005 and December 23, 2011, at 2 hospitals in Boston to examine their health care utilization and end-of-life care. Using multivariable logistic and linear regression models adjusting for covariates, we also compared health care utilization between patients who received intensive induction chemotherapy (n = 197; cytarabine/ anthracycline combination) versus nonintensive chemotherapy (n = 133; single-agent therapy). The median number of hospitalizations for the entire cohort was 4.2 (range, 1-18 hospitalizations). Patients who died spent a mean of 28.3% of their life after diagnosis in the hospital and 13.8% of their life attending outpatient clinic appointments. Although the majority of patients (87.9%) died during the 2-year follow-up period, a minority received palliative care (16.2%) or hospice (23.1%) services. Within 30 days of death, 84.5% of patients were hospitalized, and 61% died in the hospital. Among the patients who died, those who received intensive induction therapy (vs nonintensive therapy) spent 30% more of their life after diagnosis in the hospital (P < .0001) and were less likely to receive hospice services (odds ratio, 0.45; P = .05). The current findings highlight the intensity of health care utilization among older patients with AML, regardless of treatment modality. Despite the poor prognosis, palliative care and hospice services are rarely used. Future work should study novel health care delivery models to optimize care throughout the course of illness and at the end of life.

Women and irritable bowel syndrome: Is the gain in pain mainly in the brain?

It is by now common knowledge that, at least in the Western world, irritable bowel syndrome (IBS) is a disease predominantly of women. In fact, this appears to be true not only for IBS, but for most other functional bowel as well as somatic disorders characterized by chronic pain such as fibromyalgia and migraine. However, the underlying mechanisms responsible for this phenomenon remain to be understood although several theories abound, as reviewed extensively elsewhere. These can be classified as sociocultural, psychological or biological in nature, with perhaps considerable overlap amongst these categories. Sociocultural factors include issues such as sex-based differences in access to healthcare, rate of healthcare utilization and perhaps the proclivity to report physical discomfort. Such factors could for instance account for the differences in sex distribution of IBS patients in countries such as India. Psychological factors include the higher rates of somatization in women along with differences in the prevalence of conditions such as depression and coping responses to stress. Biological factors include cross-sensitization from neighboring organs such as the urinary bladder and genital tract, influence of sex hormones or other circulating factors, or intrinsic differences in the neuronal substrate of motility and/or pain perception. Finally, it should also be borne in mind that most commonly used criteria for diagnosing IBS in population surveys were distilled from symptoms reported mainly by women; it is therefore conceivable that these criteria may not necessarily be as sensitive or accurate in men. Irritable bowel syndrome is a multifaceted disease that appears to result in disturbances of both motility and sensation. Patients with IBS experience pain at distention pressures or volumes that produce, at best, normal internal sensation in healthy volunteers (allodynia); they also experience more severe discomfort at noxious distention pressures or volumes (hyperalgesia). Together these phenomena suggest sensitization (enhanced responsiveness to a stimulus) of the pain processing (nociceptive) circuitry. What causes sensitization in IBS is not known for certain but many of the factors described above may contribute to it. The question of whether the nociceptive system is more sensitized in women than in men (regardless of the pathogenesis of this difference) is therefore very important and was addressed in the study reported by Kim et al. in this issue of the Journal. Using a standardized barostat protocol, these investigators studied rectal sensation in men and women with IBS and in healthy controls. As expected, sensory thresholds were lower in the IBS population than in controls. However, no differences were found between men and women within the IBS population who appeared to be well matched for possible confounding factors such as psychological profiles. These findings are not particularly surprising. Despite data from animal studies to the contrary, several studies in the literature, with few exceptions, have previously failed to demonstrate a sex difference in colonic perception of painful stimuli in either healthy volunteers or in patients with IBS. What insight do these results provide us with respect to the female dominance of IBS? In keeping with other studies in the human literature cited, we may conclude that healthy men and women respond similarly to painful stimuli and that the nociception per se is similar in both male and female patients with IBS. However, these results do not mean that sex-based differences in nociceptive sensitization are not important. On the contrary, there is evidence that, while their response to single stimuli may not be different, women respond differently to repetitive noxious sigmoid stimuli with a significant reduction in discomfort threshold to subsequent testing, a phenomenon that is not observed in men. In the clinical context this means that the nociceptive system in women may be more vulnerable to sensitization after a period of intense frequent contractions such as that may occur after a bout of infectious colitis. Indeed, in postinfectious IBS, the same sex difference is perpetuated as in other forms of IBS. Thus, differences in susceptibility to nociceptive sensitization may explain why a greater proportion of women develop IBS. Once IBS has developed, however, their responses are expected to be similar to other patients including men. In this context, it is also important to understand that increased afferent signaling to the central nervous system is not by itself sufficient to make a patient with pain seek medical attention; that is, become a patient. For this to happen, pain perception needs to result in suffering (a combination of anxiety, fear, stress, uncertainty and loss of loved objects). Further, this suffering then leads to illness behavior, which reflects how pain is acted upon by an individual (such as rate and intensity of healthcare utilization) and Accepted for publication 10 October 2005.

Patient characteristics relevant to effective self-management: scales for assessing attitudes of adults toward asthma.

The Asthma Opinion Survey, a 33-item Likert-type instrument, was designed to measure attitudes relevant to self-management in adult outpatients. Items fall into eleven clusters; General Vulnerability, Specific Vulnerability, Attitudes Toward Patient Knowledge, Recognition of Airway Obstruction, Accessibility of Health Care, Panic-Fear, Belief in Treatment Efficacy, Staff-Patient Relationships, Sense of Control, Personal Impact, and Social Impact. Factor analysis of the clusters yielded three factors Vulnerability, Perceived Quality of Care, and Recognition and Control. The items, clusters, and factors all had adequate to good score spreads and internal consistencies. Asthma opinions covaried significantly with demographic characteristics, asthma severity, and intensity of health care utilization, and correlated with the Asthma Symptoms Checklist, an instrument developed at the National Jewish Hospital-National Asthma Center, in ways supporting construct validity. These results suggest the Asthma Opinion Survey is achieving its intended purpose.