Measures Of Health Service Utilization Research Articles

Community interventions for pandemic preparedness: A scoping review of pandemic preparedness lessons from HIV, COVID-19, and other public health emergencies of international concern.

Community action is broadly recognised as central to comprehensive and effective system responses to pandemics. However, there is uncertainty about how and where communities can be best supported to bolster long-term resilience and preparedness. We applied a typology of community interventions (Community Informing, Consulting, Involving, Collaborating or Empowering-or CICICE) to cover the diverse range of interventions identified across the literature and used this to structure a scoping review addressing three linked topics: (i) how CICICE interventions have been understood and applied in the literature on epidemic and pandemic preparedness; (ii) the spectrum of interventions that have been implemented to strengthen CICICE and (iii) what evidence is available on their effectiveness in influencing preparedness for current and future emergencies. We drew on peer-reviewed and grey literature from the HIV (from 2000) and COVID-19 pandemics and recent public health emergencies of international concern (from 2008), identified through systematic searches in MEDLINE, Scopus, the Cochrane Collaboration database, supplemented by keyword-structured searches in GoogleScholar and websites of relevant global health organisations. Following screening and extraction, key themes were identified using a combined inductive/deductive approach. 130 papers met the criteria for inclusion. Interventions for preparedness were identified across the spectrum of CICICE. Most work on COVID-19 focused on informing and consulting rather than capacity building and empowerment. The literature on HIV was more likely to report interventions emphasising human rights perspectives and empowerment. There was little robust evidence on the role of CICICE interventions in building preparedness. Evidence of effect was most robust for multi-component interventions for HIV prevention and control. Much of the reporting focused on intermediate outcomes, including measures of health service utilisation. We put forward a series of recommendations to help address evidence shortfalls, including clarifying definitions, organising and stratifying interventions by several parameters and strengthening evaluation methods for CICICE.

Evaluation of RuralkidsGPS; A Novel Integrated Paediatric Care Coordination Model of Care in Rural Australia - a Mixed-Methods Study Protocol.

The Kids Guided Personalised Service (KidsGPS) is an integrated model of care coordination for children and young people (CYP) living with medical complexity. After successful implementation in an urban setting, the model of care will be rolled-out at scale to four rural regions in New South Wales, Australia to establish RuralKidsGPS. This paper describes the approach and methods for the outcome and implementation evaluation of RuralKidsGPS. The evaluation aims to assess health, economic and implementation outcomes and processes whilst identifying barriers and enablers to inform future rollouts. Measures of health service utilisation (primary outcome), child health related quality of life and parent/carer experiences will be assessed. The implementation evaluation will occur alongside the outcomes evaluation and is underpinned by the Consolidated Framework for Implementation Research and informed by validated quantitative measures and qualitative interviews with patients, families, healthcare providers and service managers. An economic analysis will determine incremental cost effectiveness ratios for the new model of care using health service utilisation data. RuralKidsGPS, if effective, has the potential to improve equity of access to integrated care for CYP and their families and this protocol may inform other evaluations of similar models of care delivered at scale.

Development and validation of a dementia risk index for use with administrative healthcare data in Canada

AbstractBackgroundIdentification of individuals at high risk for dementia is important for planning health services and targeting prevention strategies. While dementia risk indices are available with clinical data, few have been created for use with population‐based administrative data in Canada. The purpose of this study was to establish a dementia risk index for people aged 50 years and older in Alberta, Canada, utilizing routinely gathered administrative healthcare databases. Using population‐based data, we can better understand the risk of dementia to identify individuals and populations at greatest risk.MethodThe study population included all individuals in Alberta, Canada, aged 50 years or older and free of diagnosed dementia on April 1, 2013. Participants were followed for up to 5 years to assess new diagnoses of dementia using a validated algorithm. A total of 59 known measurable dementia risk factors were assessed as potential predictors of dementia. At a 3:2 ratio, the sample was randomly divided into derivation and validation sets. The risk prediction model was created using a Cox proportional hazard model from a list of candidate variables in the derivation sample, and its performance to predict dementia was evaluated in the validation sample.ResultOne million participants aged 50 years and older without dementia were included in the study sample (mean age 62.95 years, 50.52% female), and 41,834 (3.86%) individuals developed dementia during follow‐up (mean duration 4.78 years). Out of 59 candidate variables, 17 variables were identified as independent risk factors for dementia, including advanced age, female gender, increased overall medical comorbidity, neighborhood measures of socioeconomic deprivation, specific medical conditions, mental health diagnoses, and measures of health service utilization. The final multivariate Cox proportional hazards model demonstrated good discriminative ability (Harrel’s C‐statistic = 0.87).ConclusionThis risk prediction index, derived using population‐based data, can reliably identify Canadian adults at increased risk of dementia. This risk index may assist clinicians, and the general public in assessing their risks for dementia and facilitate discussions on the most effective ways to reduce this risk. Understanding individual or population‐based dementia risk differences can help design dementia prevention and health promotion programs.

Predictors of Nursing Home Admission Among a Cohort of Homeless Older Adults Entering Emergency Shelter.

This study examined the extent and timing of nursing home admissions among older adults who had their first visit at an emergency shelter or re-entered after an extended absence. We assessed the relationships between demographic characteristics, health and behavioral health conditions, and health services utilization measures and the risk of nursing home admission. We linked administrative data from the emergency shelter system in Boston, MA to claims data from the Massachusetts Medicaid program. Using the linked data, we identified a cohort of 432 adults aged 55 and above who entered the shelter for the first time (or re-entered after an extended absence) between 2012 and 2015. We estimated Kaplan-Meier survival curves and hazard functions to describe the extent and timing of nursing home admissions in this population following the date of their initial shelter entry and Cox proportional hazards regression models to identify predictors of the risk of nursing home admission. Roughly 12% of the study cohort had a nursing home admission within 4 years of their initial shelter entry and risk of shelter admission was highest in the first few months following shelter entry. Older age, diagnoses indicating alcohol use disorder, greater overall disease burden, and a prior history of nursing home admission were all associated with a higher risk of nursing home admission following shelter entry. Amidst ongoing growth in the number of older homeless adults, our study findings have important implications for efforts to meet the housing and health needs of this population.

PGI12 - Burden of Illness of Chronic Hepatitis C in Medicaid

To estimate annual health services utilization and cost impacts of chronic hepatitis C virus (HCV) infection in Medicaid. Using 2012 Medicaid Analytic Extract data from 16 states, the cohort of 72,409 patients with HCV was drawn from the population of 5,035,716 individuals, ages 18-64 with continuous Medicaid coverage. HCV patients were stratified by liver disease severity (non-cirrhotic, compensated cirrhosis, or end-stage liver disease); eligibility (blind/disabled or other adults); and plan type (fee-for-service or managed care). Mean values of health services utilization measures were calculated. Healthcare costs were derived from fee-for-services claims. A control group of Medicaid recipients without HCV was constructed using coarsened exact matching on sociodemographic and clinical characteristics. Overall HCV prevalence was 1.4%. Blind/disabled HCV patients averaged 1.1-1.2 more hospitalizations and 3.3-4.6 more hospital days compared to non-HCV blind/disabled enrollees. Similarly, among other HCV-infected adults, hospitalizations were greater by 1.0 and hospital days were greater by 2.6-4.6. Other health services were also significantly higher for HCV patients, including emergency department visits, physician’s office/clinic visits, and prescription drug fills. Total healthcare costs were $53,159 ($35,280) for blind/disabled HCV (non-HCV) enrollees, and $26,788 ($9,610) for other adults with (and without) HCV. The difference in healthcare costs attributed to HCV ranged from $10,561 (99% CI: $7,272-$13,849) for non-cirrhotic blind/disabled adults to $46,264 (99% CI: $41,264-$51,263) for other adults with end-stage liver disease. The average incremental cost of HCV infection among adults in Medicaid was estimated at $17,671 per patient per year. These results were all highly statistically significant (p<0.001). The clinical and economic impacts of HCV among Medicaid beneficiaries in 2012 were considerable. Innovative direct-acting antiviral medicines with cure rates at or above 95% introduce the opportunity to greatly reduce or eliminate this burden.

Impact of Telephone-Based Problem-Solving Treatment on the Use of Medical and Psychological Services in the Military.

To explore the impact of problem-solving treatment (PST) for mild traumatic brain injury in active duty service members on the use of medical and psychological services. Service members who had a mild traumatic brain injury during their last deployment and enrolled in the CONcussion Treatment After Combat Trauma (CONTACT) study. Secondary analysis of a randomized clinical trial. Participants were assigned to telephone-based PST, or e-mailed or mailed education only over the course of 6 months. Self-reported health service utilization from months 4 through 6 and 10 through 12 after initiation of treatment, using the Cornell Service Index. In months 4 to 6, participants receiving PST had 6.17 times the odds of an emergency department visit or hospitalization than those receiving education only (95% confidence interval = 1.92-19.8; P value = .0023). These estimates, however, were not significant using a conservative Bonferroni correction (P value threshold < .0014). There were no other significant differences for other medical or psychological services received in months 4 to 6 or 10 to 12. Telephone-based PST was designed to complement clinical care, and this study showed that it may increase emergency department utilization. Future evaluations of PST with more accurate and complete measures of health service utilization are needed.

The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland

BackgroundSocial desirability response bias may lead to inaccurate self-reports and erroneous study conclusions. The present study examined the relationship between social desirability response bias and self-reports of mental health, substance use, and social network factors among a community sample of inner-city substance users. MethodsThe study was conducted in a sample of 591 opiate and cocaine users in Baltimore, Maryland from 2009 to 2013. Modified items from the Marlowe-Crowne Social Desirability Scale were included in the survey, which was conducted face-to-face and using Audio Computer Self Administering Interview (ACASI) methods. ResultsThere were highly statistically significant differences in levels of social desirability response bias by levels of depressive symptoms, drug use stigma, physical health status, recent opiate and cocaine use, Alcohol Use Disorders Identification Test (AUDIT) scores, and size of social networks. There were no associations between health service utilization measures and social desirability bias. In multiple logistic regression models, even after including the Center for Epidemiologic Studies Depression Scale (CES-D) as a measure of depressive symptomology, social desirability bias was associated with recent drug use and drug user stigma. Social desirability bias was not associated with enrollment in prior research studies. ConclusionsThese findings suggest that social desirability bias is associated with key health measures and that the associations are not primarily due to depressive symptoms. Methods are needed to reduce social desirability bias. Such methods may include the wording and prefacing of questions, clearly defining the role of “study participant,” and assessing and addressing motivations for socially desirable responses.

The impact of primary care reform on health system performance in Canada: a systematic review.

BackgroundWe aimed to synthesize the evidence of a causal effect and draw inferences about whether Canadian primary care reforms improved health system performance based on measures of health service utilization, processes of care, and physician productivity.MethodsWe searched the Embase, PubMed and Web of Science databases for records from 2000 to September 2015. We based our risk of bias assessment on the Grading of Recommendations Assessment, Development and Evaluation guidelines. Full-text studies were synthesized and organized according to the three outcome categories: health service utilization, processes of care, and physician costs and productivity.ResultsWe found moderate quality evidence that team-based models of care led to reductions in emergency department use, but the evidence was mixed for hospital admissions. We also found low quality evidence that team-based models, blended capitation models and pay-for-performance incentives led to small and sometimes non-significant improvements in processes of care. Studies examining new payment models on physician costs and productivity were of high methodological quality and provided a coherent body of evidence assessing enhanced fee-for-service and blended capitation payment models.ConclusionA small number of studies suggested that team-based models contributed to reductions in emergency department use in Quebec and Alberta. Regarding processes of diabetes care, studies found higher rates of testing for blood glucose levels, retinopathy and cholesterol in Alberta’s team-based primary care model and in practices eligible for pay-for-performance incentives in Ontario. However pay-for-performance in Ontario was found to have null to moderate effects on other prevention and screening activities. Although blended capitation payment in Ontario contributed to decreases in the number of services delivered and patients seen per day, the number of enrolled patients and number of days worked in a year was similar to that of enhanced fee-for-service practices.

Intervention types and outcomes of integrated care for diabetes mellitus type 2: a systematic review.

The delivery of integrated care is a priority in many countries' efforts to improve health outcomes for people at risk of or with diabetes. This study aims to provide an overview of the different types of integrated care interventions for type 2 diabetes and to report their outcomes. A systematic literature search was conducted in PubMed and Cochrane for the period 2003-2013. Article selection and data extraction were performed independently by three researchers and results were discussed together. The chronic care model (CCM) was used to describe intervention types. Forty-four articles met the inclusion criteria. Most interventions included all CCM components and a variety of sub-components. Most studies reported positive patient, process and health service utilization measures. The information on costs was limited and inconsistent. The low number of articles reporting comparable outcome measures made it difficult to make meaningful statements about an association between intervention type and outcomes. Future research would benefit from a more uniform understanding of integrated care as well as intermediate outcome measurements that allow for the establishment of a chain of evidence from specific intervention types to specific outcomes achieved. It is expected that such a comprehensive approach will reveal important insights as to which integrated care intervention types and settings are most conducive to successful implementation and would thereby be of relevance to policy makers and practitioners involved in the financing, management and delivery of integrated care.

Payment methods may influence behaviour of primary care dentists.

The Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, EconLit the NHS Economic Evaluation Database (EED) and the Health Economic Evaluations Database (HEED). Randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies were considered. Study selection was undertaken independently by three reviewers. Fee-for-service payments, fixed salary payments, capitation payments of combinations thereof included. Standard Cochrane methodological procedures were followed. Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. The risk of bias for the two studies was considered to be high and the overall quality of evidence for the outcomes was low/very low for all outcomes, as assessed using the GRADE approach.One study conducted in the four most deprived areas of Scotland used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. Measures of health service utilisation or patient outcomes were not reported. The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity, patient outcomes and healthcare costs. Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

The impact of insurance instability on health service utilization: does non-metropolitan residence make a difference?

Discontinuous and no health insurance are major barriers to health care utilization. This paper examines if nonmetropolitan versus metropolitan residence is associated with differences in health care utilization in the face of insurance instability. A cross-sectional analysis of adults aged 18-64 years was conducted using the 2006-2010 Medical Expenditure Panel Survey data set (N = 61,039). Negative binomial regression was used to model measures of health service utilization (emergency room [ER] visits, inpatient discharges, office-based visits, dental care visits, prescriptions filled, home health visits) as functions of insurance continuity, adjusted for sociodemographic and health-related covariates. Models were stratified by metropolitan versus nonmetropolitan residence. Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas. Insurance instability is associated with higher use of emergency services and reduced use of nonhospital health care services. Residents of nonmetropolitan areas with unstable or no insurance coverage may be at particular risk for reduced access and use of some health services relative to their counterparts living in metropolitan areas.

The effect of different methods of remuneration on the behaviour of primary care dentists

Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists' behaviour. To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes. We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies. Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments.Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration. Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures. Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

Health services utilization differences between patients with metastatic (M1) and nonmetastatic (M0) prostate cancer (PCa).

203 Background: Metastatic (M1) disease is diagnosed in up to 5% of PCa patients, but there is limited information about the differences in health services utilization between stage IV M1 and stage IV M0 patients in the one year leading up to and following diagnosis. Methods: We analyzed patients aged 66 or older from the linked Surveillance, Epidemiology, and End Results &amp; Medicare (SEER-Medicare) database. Patients with incident stage IV PCa diagnosed between 2005 and 2007 were identified and followed until one year post-diagnosis. Health services utilization measures included skilled nursing facility (SNF) stay, hospice stay, hospitalization, use of walking aid, wheelchair, and oxygen. We calculated the proportion of M1 and M0 patients utilizing each health service in the year before and after diagnosis. Results: Application of inclusion criteria resulted in 3,379 patients, of which 671 (19.9%) had M0 and 2,708 (80.1%) had M1 disease. The mean (median) age of the sample was 78 (77) years. The increase in the percentage of patients with SNF stay from the year prior to diagnosis to the year post-diagnosis was much larger in the M1 population (M0: 2.1% to 8.7%; M1: 5.2% to 23.6%). The proportion of M1 patients with hospice stay increased from 0.1% in the year prior to diagnosis to 21.1% in the year post-diagnosis, compared to an increase from 0% to 5.1% in the M0 population. Compared to M0 patients, M1 patients also exhibited greater increases in oxygen use (M0: 5.3% to 6.6%; M1: 6.5% to 12.6%), walking aid use (M0: 3.4% to 4.3%; M1: 3.5% to 10.6%), and wheelchair use (M0: 1.8% to 4.5%; M1: 4.1% to 11.4%) in the year following diagnosis. However, the increase in hospitalization in the year following diagnosis was lower in the M1 population (M0: 17.9% to 76.9%; M1: 24.4% to 66.6%). Conclusions: Among stage IV PCa patients, health services utilization is generally higher for M1 patients than M0 patients in the one year following diagnosis. However, hospitalization is lower among M1 patients compared to M0 patients in the one year following diagnosis. The finding that more than 20% of M1 patients had SNF and hospice stays in the one year following diagnosis suggests that M1 PCa is associated with substantial disease burden.

The Prevalence and Determinants of Chinese Medicine Use by Australian Women: Analysis of a Cohort of 10,287 Women Aged 56–61 Years

This study aimed to examine the factors associated with Chinese medicine use amongst a sample of 10,287 Australian women aged 56-61 years. Data was obtained from a cross-sectional postal questionnaire conducted in 2007, this being the fifth survey of the Australian Longitudinal Study on Women's Health. This representative sample of 10,287 women was randomly selected from the Health Insurance Commission (Medicare) database. The outcome measure was the use of Chinese medicine in the previous 12 months. The predictive factors included demographics, health status measures and health service utilization measures. Statistical analyses included univariate chi-square and ANOVA tests and backward stepwise multiple logistic regression modelling. The use of Chinese medicine amongst women aged 56-61 years appears to be strongly influenced by their country of birth, consultation with a range of CAM practitioners, and the use of some self-prescribed CAM. Interestingly, severe tiredness was the only symptom or diagnosis that predicted Chinese medicine use. Given the substantial prevalence of Chinese medicine use and the finding that the use of Chinese medicine is heavily integrated alongside the use of many other CAM and conventional treatments, it is imperative for the safety of patients that health professionals (across complementary and conventional healthcare) fully recognise the possible Chinese medicine use amongst their practice populations. In order to help inform relevant practice and policy development it is also important that future research further examining women's decision-making, motivations and evaluations regarding Chinese medicine use considers such issues within the context of broader CAM and conventional health care utilization.

Racial Disparities in Access to Care for Men in a Public Assistance Program for Prostate Cancer

California's IMPACT program provides all its enrollees with health insurance and social service resources. We hypothesized that racial/ethnic disparities in access to care might be attenuated among men served by this program. Our objective was to evaluate racial/ethnic differences in health services utilization and patient-reported health care outcomes among disadvantaged men in a prostate cancer public-assistance program, and to identify modifiable factors that might explain persistent disparities in this health care setting. We performed a retrospective cohort study of 357 low-income men enrolled in IMPACT from 2001 through 2005. We evaluated realized access to care with two health services utilization measures: (1) use of emergency department care without hospitalization and, (2) frequency of prostate-specific antigen testing. We also measured two patient-experience outcomes: (1) satisfaction with care received from IMPACT, and (2) confidence in IMPACT care providers. We observed significant bivariate associations between race/ethnicity and patient-experience outcomes (P<0.05), but not utilization measures. In multivariable models, Hispanic men were more likely than white men to report complete satisfaction with health care received in IMPACT (adjusted OR=5.15, 95% CI 1.17-22.6); however, the association between race/ethnicity and satisfaction was not statistically significant (P=0.11). Language preference and self-efficacy in patient-physician interactions are potentially-modifiable predictors of patient-experience outcomes. We observed no racial/ethnic disparities in health services utilization among disadvantaged men served by a disease-specific public assistance program. The greater satisfaction and confidence among Hispanic men are explained by modifiable variables that suggest avenues for improvement.

The UK Burden of Injury Study – a protocol. [National Research Register number: M0044160889

BackgroundGlobally and nationally large numbers of people are injured each year, yet there is little information on the impact of these injuries on people's lives, on society and on health and social care services. Measurement of the burden of injuries is needed at a global, national and regional level to be able to inform injured people of the likely duration of impairment; to guide policy makers in investing in preventative measures; to facilitate the evaluation and cost effectiveness of interventions and to contribute to international efforts to more accurately assess the global burden of injuries.Methods/DesignA prospective, longitudinal multi-centre study of 1333 injured individuals, atttending Emergency Departments or admitted to hospital in four UK areas: Swansea, Surrey, Bristol and Nottingham. Specified quotas of patients with defined injuries covering the whole spectrum will be recruited. Participants (or a proxy) will complete a baseline questionnaire regarding their injury and pre-injury quality of life. Follow up occurs at 1, 4, and 12 months post injury or until return to normal function within 12 months, with measures of health service utilisation, impairment, disability, and health related quality of life. National estimates of the burden of injuries will be calculated by extrapolation from the sample population to national and regional computerised hospital in-patient, emergency department and mortality data.DiscussionThis study will provide more detailed data on the national burden of injuries than has previously been available in any country and will contribute to international collaborative efforts to more accurately assess the global burden of injuries. The results will be used to advise policy makers on prioritisation of preventive measures, support the evaluation of interventions, and provide guidance on the likely impact and degree of impairment and disability following specific injuries.

A Comparison of HIV Health Services Utilization Measures in a Marginalized Population

In studies examining the use of human immunodeficiency virus (HIV) health services, researchers often use subjects' self-reported measures. Agreement between a subject's self-reports and medical records in marginalized populations is uncertain, yet important to understand, as this population is disproportionately affected by HIV. We sought to examine agreement between self-report and medical record health care utilization measures. Using a cross-sectional study, we studied 428 unstably housed HIV-infected adults in New York City. Self-reported data were collected from Audio Computer-Assisted Self-Interviews, and medical record data from health care providers' and facilities' ambulatory medical records. Agreement for a 6-month period was compared for ambulatory visits (0, 1, >or=2), HIV medications (antiretroviral therapy, opportunistic infection prophylaxis), whether CD4 counts and viral loads were performed and their values (CD4: <200, 200-500, >500 cells/mm; Viral load: undetectable, detected). Agreement between self-report and medical records was 55.2% (kappa=0.12) for visits, and 68.2-79.1% (kappa=0.27-0.48) for medications. Agreement on whether laboratory tests were performed was 62.3-65.7% (kappa=0.11-0.14), whereas agreement on laboratory values was 77.6-79.3% (kappa=0.52-0.70). Most disagreement resulted in greater number of self-reported visits, use of medications, and laboratory tests compared with medical record data. Among HIV-infected marginalized individuals, agreement between self-report and medical records was poor for ambulatory visits, poor to fair for medication use, and poor for laboratory tests performed. However, agreement for CD4 count value was substantially better. These findings have implications on health services research in marginalized populations that relies only on self-report or medical record data. This study underscores the importance of understanding how self-reported and medical record data are correlated in marginalized populations.

The impact of posttraumatic stress disorder on quality of life and health service utilization among veterans who have schizophrenia

The present study examined the impact of comorbid posttraumatic stress disorder (PTSD) on health-related quality of life and objective measures of health service utilization in 165 male veterans who have primary schizophrenia. Comorbid PTSD was assessed with the PTSD Checklist. Comorbid PTSD was significantly associated with decreased quality of life and increased medical service utilization, including increased psychiatric hospitalization and increased outpatient physical health visits, even after controlling for other clinical and demographic variables among this sample of patients who had primary schizophrenia. Veterans who have schizophrenia should be screened carefully for exposure to trauma and posttraumatic stress disorder.

Utilization and Financial Outcomes of an Asthma Disease Management Program Delivered to Medicaid Members

Background Although various studies have reported the financial outcomes of disease management programs for commercial populations, few have addressed the outcomes for Medicaid recipients. McKesson Heath Solutions (MHS) disease management programs support clients whose members have serious chronic illnesses including asthma, diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, and mental health conditions. This study describes financial outcomes of the MHS asthma disease management program by evaluating changes in health services utilization measures for Medicaid members who participated in the asthma disease management program.

Validity of a Modified Version of the Marks Asthma Quality of Life Questionnaire

To produce a scale useful for individual clinical decision making, the Marks Asthma Quality of Life Questionnaire (AQLQ-M) was modified to a 22-item scale using a 7-point Likert response scale, and the validity of the new instrument was assessed. Adult asthma subjects with moderate to severe disease, recruited from two hospitals in Adelaide, Australia, were surveyed at baseline (n = 293), and at 3-month follow-up (n = 234). Cronbach's a for the Total scale of the modified AQLQ-M (MAQLQ-M) was 0.97 and all subscale values exceeded 0.90. Test-retest reliability values for all scales were between 0.88 and 0.93. All correlations between disease reference measures were statistically significant to at least the p < 0.01 level. Stronger associations were seen with symptom and self-rating scales than for lung function, medication usage, and health service utilization measures of outcome. The MAQLQ-M showed good discriminative ability for all asthma symptom categories and for different FEV, values. Moderate, statistically significant associations were seen between changes in MAQLQ-M scores and clinical measures. Higher baseline MAQLQ-M scores were associated with lower risks over 12 months for hospital admissions (odds ratio, OR = 0.58) and repeated emergency department visits (OR = 0.47). The MAQLQ-M is a highly valid measure of asthma-related quality of life.