Medical Care Utilization Research Articles

Incremental health care costs for chronic pain in Ontario, Canada: a population-based matched cohort study of adolescents and adults using administrative data.

Little is known about the economic burden of chronic pain and how chronic pain affects health care utilization. We aimed to estimate the annual per-person incremental medical cost and health care utilization for chronic pain in the Ontario population from the perspective of the public payer. We performed a retrospective cohort study using Ontario health care databases and the electronically linked Canadian Community Health Survey (CCHS) from 2000 to 2011. We identified subjects aged ≥12 years from the CCHS with chronic pain and closely matched them to individuals without pain using propensity score matching methods. We used linked data to determine mean 1-year per-person health care costs and utilization for each group and mean incremental cost for chronic pain. All costs are reported in 2014 Canadian dollars. After matching, we had 19,138 pairs of CCHS respondents with and without chronic pain. The average age was 55 years (SD = 18) and 61% were female. The incremental cost to manage chronic pain was $1742 per person (95% confidence interval [CI], $1488-$2020), 51% more than the control group. The largest contributor to the incremental cost was hospitalization ($514; 95% CI, $364-$683). Incremental costs were the highest in those with severe pain ($3960; 95% CI, $3186-$4680) and in those with most activity limitation ($4365; 95% CI, $3631-$5147). The per-person cost to manage chronic pain is substantial and more than 50% higher than a comparable patient without chronic pain. Costs are higher in people with more severe pain and activity limitations.

STATE EARNED INCOME TAX CREDITS AND THE PRODUCTION OF CHILD HEALTH: INSURANCE COVERAGE, UTILIZATION, AND HEALTH STATUS

The Earned Income Tax Credit (EITC) has been credited with reductions in poverty and increases in the labor force participation of single mothers. The credit has the potential to affect the health of children in recipient families through three channels: family income, maternal employment, and health insurance coverage patterns. We exploit variation in state-level EITCs to estimate the effects of the credit on health insurance coverage, utilization of medical care, and health status. We find that the EITC is associated with significant changes in health insurance coverage patterns for children age 6–14, increasing rates of private health insurance but producing offsetting decreases in public coverage. State EITCs are also associated with significant improvements in health status for older children, an effect consistent with higher family income.

Risking Life and Limb: Estimating a Measure of Medical Care Economic Risk and Considering its Implications.

This paper considers the risk of incurring future medical expenditures in light of a family's resources available to pay for those expenditures as well as their choice of health insurance. We model non-premium medical out-of-pocket expenditures and use the estimates from our model to develop a prospective measure of medical care economic risk estimating the proportion of families who are at risk of incurring high non-premium out-of-pocket medical care expenses in relation to its resources. We further use the estimates from our model to compare the extent to which different types of insurance mitigate the risk of incurring non-premium expenditures by providing for increased utilization of medical care. We find that while 21.3% of families lack the resources to pay for the median expenditures for their insurance type, 42.4% lack the resources to pay for the 99th percentile of expenditures for their insurance type. We also find the mediating effect of insurance on non-premium expenditures to outweigh the associated premium expense for expenditures above $1804 for employer-sponsored insurance and $4337 for direct purchase insurance for those younger than age 65; and above $12118 of expenditures for Medicare supplementary plans for those aged 65 or older. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

User fees exemptions alone are not enough to increase indigent use of healthcare services.

The aim of this study was to assess whether user fees exemptions increased healthcare services use among indigents in the Ouargaye district in Burkina Faso. In this pre-post study, we surveyed 1224 indigents in 2010 about their healthcare services use over the preceding 6 months. Of these, 540 subsequently received a user fees exemption card. A follow-up survey was conducted 1 year later with a 55.3% retention rate. Analyses were performed in accordance with Andersen and Newman's model (Societal and individual determinants of medical care utilization in the United States. Milbank Q 1973;51:95-124) to explain healthcare services use by considering predisposing and facilitating factors and health needs indicators. Logistic regression analyses were performed.Among indigents exempted from user fees, 46.2% increased their healthcare services use in 2011, as opposed to 42.1% among the non-exempted. Being exempted was not associated with increased use of services (odds ratio, OR = 1.1, 95% confidence interval, CI [0.80-1.51]). Regardless of whether they were exempted or not, the indigents most likely to have increased their healthcare services use were older than 69 years of age (OR = 1.66, 95% CI [1.05-2.64]), male (OR = 1.44, 95% CI [0.99-2.08]), in low-income households (OR = 1.71, 95% CI [1.15-2.54]), and had received financial support from their families to obtain healthcare (OR = 1.59, 95% CI [1.1-2.28]). The indigents' increased healthcare services use was not attributable to user fees exemptions. Some contamination of the intervention is conceivable. Interventions combining user fees exemptions with actions targeting other obstacles to healthcare access would probably be more effective in increasing indigents' use of healthcare centres.

経済的理由による受診抑制に関する医師の認識と診療上の対応

目的：近年, 低所得層が増加し, 受診抑制による健康悪化が懸念されている．本研究では, 経済的理由による受診抑制に関する医師の認識ならびに, 受診抑制を防ぐ工夫をより多く行っている医師の特徴を明らかにすることを目的とした．方法：都内10区2市の全内科診療所1989箇所の医師各1名に郵送調査を実施し, 患者の受診抑制の経験, 受診抑制を防ぐ工夫, 基本属性などの約60項目を尋ねた．結果：回答の得られた617名のうち（回収率31％）, 550名（男性454名）を分析対象とした．約9割の医師が患者の受診抑制を認識しており, 「安価な薬を選択する」といった受診抑制を防ぐ工夫を行っていた．こうした工夫をより多く行う医師は40・50歳代, 総合診療の立場, 患者同意・参加型の治療の意思決定の実践, 受診抑制をより多く経験という特徴を持っていた．結論：総合的診療や患者参加型の治療の意思決定といったプライマリ・ケア機能を重視する医師ほど, 受診抑制を防ぐための診療上の工夫をより多く行っていることが示唆された．

Disability-adjusted Life Years (DALYs) for Mental and Substance Use Disorders in the Korean Burden of Disease Study 2012.

The purpose of this study was to estimate the national burden of mental substance disorders on medical care utilization in Korea using National Health Insurance System (NHIS) data and updated disability weight, in terms of disability-adjusted life years (DALYs). For each of the 24 disorders, the incident years lived with disability (YLDs) was calculated, using NHIS data to estimate prevalence and incidence rates. The DisMod-II software program was used to model duration and remission. The years of life lost (YLLs) due to premature death were calculated from causes of death statistics. DALYs were computed as the sum of YLDs and YLLs, and time discounting and age weighting were applied. The year examined was 2012, and the subjects were divided into 9 groups according to age. In 2012, the Korean burden of mental and substance use disorders was 945,391 DALYs. More than 98% of DALYs were from YLDs, and the burden in females was greater than that in males, though the burden in males aged less than 19 years old was greater than that in females. Unipolar depressive disorders, schizophrenia, and anxiety disorders were found to be major diseases that accounted for more than 70% of the burden, and most DALYs occurred in their 30–59. Mental and substance use disorders accounted for 6.2% of the total burden of disease and were found to be the 7th greatest burden of disease. Therefore, mental and substance use disorders need to be embraced by mainstream health care with resources commensurate with the burden.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review

Background. Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking “upstream” economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual’s control that affect housing and residential environments and the health resources or risk exposures such contexts provide. Objectives. We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. Search methods. We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. Selection criteria. We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. Data collection and analysis. Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. Results. Searches yielded 5528 references from which we included 152 studies, representing 139 757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. Conclusions. Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Long-term reduction of health care costs and utilization after epilepsy surgery.

To assess long-term direct medical costs, health care utilization, and mortality following resective surgery in persons with uncontrolled epilepsy. Retrospective longitudinal cohort study of Medicaid beneficiaries with epilepsy from 2000 to 2008. The study population included 7,835 persons with uncontrolled focal epilepsy ages 18-64 years, with an average follow-up time of 5 years. Of these, 135 received surgery during the study period. To account for selection bias, we used risk-set optimal pairwise matching on a time-varying propensity score, and inverse probability of treatment weighting. Repeated measures generalized linear models were used to model utilization and cost outcomes. Cox proportional hazard was used to model survival. The mean direct medical cost difference between the surgical group and control group was $6,806 after risk-set matching. The incidence rate ratio of inpatient, emergency room, and outpatient utilization was lower among the surgical group in both unadjusted and adjusted analyses. There was no significant difference in mortality after adjustment. Among surgical cases, mean annual costs per subject were on average $6,484 lower, and all utilization measures were lower after surgery compared to before. Subjects that underwent epilepsy surgery had lower direct medical care costs and health care utilization. These findings support that epilepsy surgery yields substantial health care cost savings.

Factors Affecting the Downward Mobility of Psychiatric Patients: A Korean Study of National Health Insurance Beneficiaries.

Objectives:The purpose of this study is to examine the magnitude of and the factors associated with the downward mobility of first-episode psychiatric patients.Methods:This study used the claims data from the Korean Health Insurance Review and Assessment Service. The study population included 19 293 first-episode psychiatric inpatients diagnosed with alcohol use disorder (International Classification of Diseases, 10th revision [ICD-10] code F10), schizophrenia and related disorders (ICD-10 codes F20-F29), and mood disorders (ICD-10 codes F30-F33) in the first half of 2005. This study included only National Health Insurance beneficiaries in 2005. The dependent variable was the occurrence of downward mobility, which was defined as a health insurance status change from National Health Insurance to Medical Aid. Logistic regression analysis was used to assess factors associated with downward drift of first-episode psychiatric patients.Results:About 10% of the study population who were National Health Insurance beneficiaries in 2005 became Medical Aid recipients in 2007. The logistic regression analysis showed that age, gender, primary diagnosis, type of hospital at first admission, regular use of outpatient clinic, and long-term hospitalization are significant predictors in determining downward drift in newly diagnosed psychiatric patients.Conclusions:This research showed that the downward mobility of psychiatric patients is affected by long-term hospitalization and medical care utilization. The findings suggest that early intensive intervention might reduce long-term hospitalization and the downward mobility of psychiatric patients.

Health care utilisation and costs in the general population in Germany

AimTo elicit reference values of medical and non-medical health care utilisation and costs in Germany from a societal perspective. Methods5007 telephone interviews were conducted in a representative sample of the German-speaking population above the age of 18. Participants were asked about medical and non-medical health care utilisation over the preceding six months. Participants were also asked about medical conditions, lifestyle, sociodemographic characteristics, employment status and sick leave. Resource utilisation was valued monetarily and analysed by means of descriptive and econometric tools (generalised linear models/two-part models). To obtain representative results, we weighted observations according to age, gender, education and state of residence. Results95% of the respondents had at least one contact with an outpatient physician. 12% of the respondents were hospitalised and 3% received rehabilitative care. Direct costs per respondent were €1475 on average. The mean cost of physician visits was €278. We found differences in average costs for physician visits between men (€232) and women (€321). Indirect costs were €1554 on average per full-time employee. Multivariate analysis showed significant associations between direct costs and morbidity, age and gender. Indirect costs appeared to be significantly associated with morbidity and age, but not with gender. ConclusionOur reference values can be regarded as representative reference values for health care utilisation and costs, and can be used for the calculation of disease-specific excess costs.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review.

Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide. We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

The effect of health insurance coverage on medical care utilization and health outcomes: Evidence from Medicaid adult vision benefits

Increasing the proportion of adults that have regular, comprehensive eye exams and reducing visual impairment due to uncorrected refractive error and other common eye health problems are federal health objectives. We examine the effect of vision insurance on eye care utilization and vision health outcomes by taking advantage of quasi-experimental variation in Medicaid coverage of adult vision care. Using a difference-in-difference-in-difference approach, we find that Medicaid beneficiaries with vision coverage are 4.4 percentage points (p<0.01) more likely to have seen an eye doctor in the past year, 5.3 percentage points (p<0.01) less likely to report needing but not purchasing eyeglasses or contacts due to cost, 2.0 percentage points (p<0.05) less likely to report difficulty seeing with usual vision correction, and 1.2 percentage points (p<0.01) less likely to have a functional limitation due to vision.

The Impacts of China's Urban Employee Basic Medical Insurance on Healthcare Expenditures and Health Outcomes.

At the end of 1998, China launched a government-run mandatory insurance program, the urban employee basic medical insurance (UEBMI), to replace the previous medical insurance system. Using the UEBMI reform in China as a natural experiment, this study identifies variations in patient cost sharing that were imposed by the UEBMI reform and examines their effects on the demand for healthcare services. Using data from the 1991-2006 waves of the China Health and Nutrition Survey, we find that increased cost sharing is associated with decreased outpatient medical care utilization and expenditures but not with decreased inpatient care utilization and expenditures. Patients from low-income and middle-income households or with less severe medical conditions are more sensitive to prices. We observe little impact on patient's health, as measured by self-reported health status. Copyright © 2015 John Wiley & Sons, Ltd.

Monitoring Resource Utilization in a Health Care Coordination Program.

This initial article describes the development of a health care coordination intervention and documentation system designed using the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Atlas framework for Centers for Medicare & Medicaid-funded innovation project, Leveraging Information Technology to Guide High-Tech, High-Touch Care (LIGHT). The study occurred at an academic medical center that serves 114 counties. Twenty-five registered nurse care managers (NCMs) were hired to work with 137 providers in 10 family community and internal medicine clinics. Patients were allocated into one of the four tiers on the basis of their chronic medical conditions and health care utilization. Using a documentation system on the basis of the AHRQ domains developed for this study, time and touch data were calculated for 8,593 Medicare, Medicaid, or dual-eligible patients. We discovered through the touch and time analysis that the majority of health care coordination activity occurred in the AHRQ domains of communication, assess needs and goals, and facilitate transitions, accounting for 79% of the NCM time and 61% of the touches. As expected, increasing tier levels resulted in increased use of NCM resources. Tier 3 accounted for roughly 16% of the patients and received 159 minutes/member (33% of total minutes), and Tier 4 accounted for 4% of patients and received 316 minutes/member (17% of all minutes). In contrast Tier 2, which did not require routine touches per protocol, had 5,507 patients (64%), and those patients received 5,246 hours of health care coordination, or 57 minutes/member, and took 48% of NCM time. 1. The AHRQ Care Coordination Atlas offered a systematic way to build a documentation system that allowed for the extraction of data that was used to calculate the amount of time and the number of touches that NCMs delivered per member. 2. Using a framework to systematically guide the work of health care coordination helped NCMs to think strategically about the care being delivered, and has implications for improving coordination of care. 3. For the purpose of reimbursement and communication with payers about quality metrics, it is vital that the type of touches and amount of time spent in delivering care coordination be documented in a manner that can be easily retrieved to guide practice decisions.

건강보험의 치석제거 급여 범위 확대에 대한 인식 및 만족도에 관한 연구

The purpose of this study was to identify the factors associated with medical care utilization, the level of recognition, satisfaction, revisit and recommendation after implementing the expanded health insurance coverage of dental scaling. A questionnaire survey was conducted and analyzed among 608 adults living in Seoul and Gyeonggi-do April 1st to 30th, 2014. The results of the survey are as follows: 76.9% of the respondents know the expanded health insurance coverage, which is influenced by educational background and monthly income. The level of satisfaction, revisit and recommendation intention is affected meaningfully by educational background. Two factors, high school graduate or less and dental hygienist, meaningfully affect patients' satisfaction with scaling, and recommendation from others and Internet searching contribute to revisit. High school graduate or less is also one of the factors affecting the intention of recommendation, along with recommendation from others, Internet searching, scaling by a dental hygienist, and oral hygiene education before scaling. Summing up the results, patient's satisfaction and intention to recommend are high when dental hygienists provide oral hygiene instruction prior to scaling. This study suggests that dental hygienists help patients feel comfortable before treatment by building rapport with them. In addition, it is required that consistent efforts for quality improvement in scaling be sustained, that the patient's needs be identified to increase their satisfaction with scaling, and that studies to verify relevant factors be conducted.

The Predictive Syndemic Effect of Multiple Psychosocial Problems on Health Care Costs and Utilization among Sexual Minority Women

Previous studies documenting sexual minority women's disproportionate risk for a range of medical, mental health, and substance use disorders have not provided a predictive framework for understanding their interrelations and outcomes. The present study aimed to address this gap by testing the syndemic effect of co-occurring psychosocial problems on 7-year health care costs and utilization among sexual minority women. The sample was comprised of sexual minority women (N = 341) who were seen at an urban LGBT-affirmative community health center. Medical and mental health care utilization and cost data were extracted from electronic medical records. Demographically adjusted regression models revealed that co-occurring psychosocial problems (i.e., childhood sexual abuse, partner violence, substance use, and mental health distress [history of suicide attempt]) were all strongly interrelated. The presence of these indicators had a syndemic (additive) effect on medical costs and utilization and mental health utilization over 7-year follow-up, but no effect on 7-year mental health costs. These results suggest that the presence and additive effect of these syndemic conditions may, in part, explain increased medical costs and utilization (and higher medical morbidity) among sexual minority women.

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

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

A comparison of the effectiveness of risperidone, haloperidol and flupentixol long-acting injections in patients with schizophrenia—A nationwide study

BackgroundRisperidone long-acting injection (RLAI), the first licensed, long-acting second-generation antipsychotic (SGA), has not yet been studied in terms of its effectiveness compared with first-generation antipsychotic (FGA) LAIs. MethodsThe differences in the effectiveness of RLAI and two other FGA LAIs, haloperidol and flupentixol, were assessed by conducting a one-year pre-post study based on the Taiwanese National Health Insurance Research Database. Effectiveness was defined as reduced medical care utilization and relapse prevention. ResultsA decreased number of relapses were identified in the haloperidol injection group in the post-LAI period than in the pre-LAI period (Wilcoxon signed rank test, p<0.05). The RLAI group had the largest number of acute admissions and relapses, the longest duration of admission (Wilcoxon signed rank test, p<0.005), and the lowest utilization of anticholinergic agents, such as benzodiazepine (BZD) and SGAs (except oral risperidone), among all of the LAI groups in the post-LAI period. ConclusionsAccording to the results of this observational study, we suggest that the effectiveness of RLAI is not superior to that of FGA (haloperidol or flupentixol) LAIs, but that RLAI might have fewer adverse effects.

Under regional characteristics of rural China: a clearer view on the performance of the New Rural Cooperative Medical Scheme.

The New Cooperative Medical Scheme (NCMS) was implemented in 2003 in response to the poor state of health care in rural China. Considering the substantial differences in regional socioeconomics, preferences for health care needs, and concurrent implementation of other health-related policies, the extent to which the impact of the NCMS differs in rural communities across China is unclear. The objective of this paper, therefore, was to explore the variation in the determinants of household enrolment and the impact of enrolment on health care utilization and medical expenditures in three large geographic regions in China. A quasi-experiment study was designed based on the panel data of the China Health and Nutrition Survey. The bounding approach was used to conduct a robust check of impact estimation under the assumption of unobserved bias. A major finding is that household income plays no significant role for enrolment, which indicates the equity of program coverage in income terms. However, regional circumstances matter. In the generally poorer western regions, households with a high ratio of migrant workers are less attracted to the NCMS program, and adoption of the program is related to the regional infrastructure environment variables in the eastern and western regions. The NCMS has improved medical care utilization for poor income groups and regions (western regions). The NCMS's impact on reducing the incidence of catastrophic expenditures is not shown for all regions.

Development of the Treatment Inventory of Costs in Psychiatric Patients: TIC-P Mini and Midi

BackgroundMedical costs of (psychiatric) illness can be validly measured with patient report questionnaires. These questionnaires comprise many detailed items resulting in lengthy administrations. ObjectivesWe set out to find the minimal number of items needed to retrieve 80% and 90% of the costs as measured by the Treatment Inventory of Costs in Patients with psychiatric disorders (TIC-P). MethodsThe TIC-P is a validated patient-reported outcome measure concerning the utilization of medical care and productivity losses. The present study focused on direct medical costs. We applied data of 7756 TIC-P administrations from three studies in patients with mental health care issues. Items that contribute least to the total cost were eliminated, providing that 80% and 90% of the total cost was retained. ResultsAverage medical costs per patient were €658 over the last 4 weeks. The distribution of cost was highly skewed, and 5 of the 14 items of the TIC-P accounted for less than 10% of the total costs. The 80% Mini version of the TIC-P required five items: ambulatory services, private practice, day care, general hospital, and psychiatric clinic. The TIC-P Midi 90% inventory required eight items. Both had variance between the three samples in the optimal choice of the items. ConclusionsThe number of items of the TIC-P can be reduced considerably while maintaining 80% and 90% of the medical costs estimated by the complete TIC-P. The reduced length makes the questionnaire more suitable for routine outcome monitoring.