Patterns Of Health Care Use Research Articles

What characterizes the eldercare debut? A registry-based study of pre-entry health care use

Abstract Introduction Timely identification of needs due to functional loss in old age is important. Policy guidelines requires local collaborative care action. Eldercare debut circumstances are poorly investigated from a collaborative perspective. This study explored the socio-demographic characteristics, functional status and patterns of health care use leading up to the first application for eldercare, and how older people’s intensity of primary care use was associated with their intensity of granted eldercare at debut. Methods Data on socio-demographics, functional status, and informal care in people ≥65 years (July ‘21 to June ‘22; n = 3,649) were combined with data on inpatient and outpatient care six months preceding debut in Stockholm, Sweden. Descriptive and regression statistics were used. Results Every second person debuted following a hospital stay and one in four had extensive functional limitations. The majority made one or two visits in primary care, but 13% had a high intensity of use and 20% made no visits at all. More than half received informal care weekly or daily. Non-use and high use of primary care were both significantly associated with increased probability of receiving high intensity of eldercare. Conclusions and implications The intensity of primary care use can provide an indication of people’s intensity of eldercare at debut, which is important for resource allocation. Deeper collaboration between eldercare and primary care actors can facilitate early identification of people in need of support, thereby alleviating individual suffering, enabling secondary and tertiary prevention, and optimizing the management of welfare resources. Key messages • The intensity of primary care use can provide an indication of people’s intensity of eldercare at debut. • Deeper collaboration between eldercare and primary care actors can facilitate early identification of older people with social support needs.

Care trajectories for musculoskeletal disorders following a new episode of low back pain

Abstract This study explored diverse care trajectories (CTs) for low back pain (LBP) and other musculoskeletal disorders (MSDs), over a 5-year period following a first episode of LBP. Based on Quebec's administrative health data from 2007 to 2011, this longitudinal cohort study involved 12,608 adults seeking health care for LBP. Using a new multidimensional state sequence analysis, we identified 6 distinct types of CTs. The most prevalent types 1, 2, and 3 (comprising 79.2%, 18.0%, and 21.7% of the cohort, respectively) exhibit rapid recovery and similar patterns of healthcare use over 5 years but differing in initial diagnoses: nonspecific LBP in type 1, trauma-related LBP in type 2 (mostly younger men and highest initial emergency consultation), and specific LBP in type 3. Types 4 to 6, representing smaller groups, show high healthcare utilization with comparable mixed LBP diagnoses at entry but distinctive subsequent care use patterns. Patients in types 4 and 6 (mainly older age groups and women) sought care for other MSDs from general practitioners or specialists, while middle-aged patients in type 5 experienced persistent nonspecific LBP with frequent general practitioner consultations over 5 years. The CTs typology revealed several key areas for improvement in nonpharmacological interventions, including the need to address possible inappropriate medical imaging and invasive interventions for older women with MSDs and the lack of ambulatory care access for younger patients with trauma-related LBP. Finally, results clearly highlighted poor access to rehabilitation physicians and rehabilitation services for all patients suffering from LBP and MSDs.

Reasons for Hospitalizations and Emergency Department Visits Among Patients with Essential Tremor.

Prior studies suggest that patients with essential tremor (ET) have increased rates of healthcare utilization, but the reason for this increased use is unknown. The objective of this study was to evaluate the reasons for healthcare use among ET patients. This was a retrospective cross-sectional study of ET patients with an admission or emergency department (ED) visit at a tertiary health system from 2018-2023. Patients were matched on an encounter level with control patients based on propensity scores incorporating age, sex, race, and co-morbid conditions. The primary outcome was the odds of an encounter for each diagnostic category comparing ET patients with matched controls. Only inpatient admissions for neurologic diagnoses were more likely for ET compared to control patients (odds ratio (OR) 3.73, 95% confidence interval (CI) 2.54 - 5.49, p < 0.001). Once admissions related to the surgical treatment of tremor were excluded, admissions for neurologic diagnoses were equally likely among ET and control patients (OR 0.96, 95% CI 0.59 - 1.57, p = 0.88). Surgical treatment of tremor appears to be a key driver of healthcare use among ET patients. Future investigations should examine the pattern of healthcare use of ET patients before and after surgery. Prior studies have shown increased healthcare use among essential tremor (ET) patients. The objective of this study was to evaluate the reasons for healthcare use among ET patients compared to matched control patients. Surgical treatment of tremor was found to be a key driver of healthcare use among ET patients.

Health Care Use Among Cancer Patients With Diabetes, National Health and Nutrition Examination Survey, 2017-2020.

Diabetes is a common comorbidity among people with cancer. The objective of our study was to examine patterns of health care use among patients with cancer and either type 2 diabetes or prediabetes. We used data from the National Health and Nutrition Examination Survey (NHANES) for 2017-2020. The study population included US adults aged 18 years or older who were diagnosed with any cancer and type 2 diabetes or prediabetes (established by self-report and/or hemoglobin A1c measurement). We used Poisson and multivariate logistic regression models to determine the effect of comorbidity on health care use, defined as health care visits and overnight stays in a hospital. Of 905 cancer patients representing 27,180,715 people in the US, 24.4% had a type 2 diabetes diagnosis, and 25.8% had a prediabetes diagnosis. Patients with cancer and prediabetes had a significantly higher rate of health care visits (incidence rate ratio = 1.11; 95% CI, 1.01-1.22; P = .03) than patients with cancer only. We found no significant association between having cancer and type 2 diabetes and the number of health care visits or overnight hospital stays compared with patients with cancer only. More emphasis should be placed on optimal care coordination among people with cancer and other conditions, such as diabetes and prediabetes, to reduce the impact of comorbidity on health care use. Interventions integrated with technology to provide timely access to education on preventing or managing diabetes and prediabetes among cancer patients are warranted.

Healthcare Use and Costs in Children Receiving Home Mechanical Ventilation in Ontario: A 14-Year Cohort Study.

Rationale: Home mechanical ventilation (HMV) is an advanced medical therapy offered to children with medical complexity. Despite the growing pediatric HMV population in North America, there are limited studies describing healthcare use and predictors of highest costs using robust health administrative data. Objectives: To describe patterns of healthcare use and costs in children receiving HMV over a 14-year period in Ontario, Canada. Methods: We conducted a retrospective population-based cohort study (April 1, 2003, to March 31, 2017) of children aged 0-18 years receiving HMV via invasive mechanical ventilation or noninvasive ventilation. Paired t tests compared healthcare system use and costs 2 years before and 2 years after HMV approval. We developed linear models to analyze variables associated with children in the top quartile of health service use and costs. Results: We identified 835 children receiving HMV. In the 2 years after HMV approval compared with the 2 years prior, children had decreased hospitalization days (median, 9 [interquartile range, 3-30] vs. 29 [6-99]; P < 0.0001) and intensive care unit admission days (6.6 [1.9-18.0] vs. 17.1 [3.3-70.9]; P < 0.0001) but had increased homecare service approvals (195 [24-522] vs. 40 [12-225]; P < 0.0001) and outpatient pulmonology visits (3 [1-4] vs. 2 [1-3]; P < 0.0001). Total healthcare costs were higher in the 2 years after HMV approval (mean, CAD$164,892 [standard deviation, CAD$214,187] vs. CAD$128,941 [CAD$194,199]; P < 0.0001). However, all-cause hospital admission costs were reduced (CAD$66,546 [CAD$142,401] vs. CAD$81,578 [CAD$164,672]; P < 0.0001). The highest total 2-year costs were associated with invasive mechanical ventilation (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.24-5.31; reference noninvasive ventilation), number of medical devices at home (OR, 1.63; 95% CI, 1.35-1.96; reference no technology), and increased healthcare costs in the year before HMV initiation (OR, 2.23; 95% CI, 1.84-2.69). Conclusions: Children progressing to the need for HMV represent a worsening in their respiratory status that will undoubtedly increase healthcare use and costs. We found that the initiation of HMV in these children can reduce inpatient healthcare use and costs but can still increase overall healthcare expenditures, especially in the outpatient setting.

The effect of dementia on patterns of healthcare use in older adults with diabetes.

For persons with diabetes, incidence of dementia has been associated with increased hospitalization; however, little is known about healthcare use preceding and following incident dementia. We describe healthcare utilization in the 3 years pre- and post-incident dementia among older adults with diabetes. We used the National Health and Aging Trends Study (NHATS) linked to Medicare fee-for-service claims from 2011 to 2018. We included community-dwelling adults ≥65 years who had diabetes without dementia. We matched older adults with dementia (identified with validated NHATS algorithm) at the year of incident dementia to controls using coarsened exact matching. We examined annual outpatient visits, emergency department (ED) visits, hospitalization, and post-acute skilled nursing facility (SNF) use 3 years preceding and 3 years following dementia onset. We included 195 older adults with diabetes with incident dementia and 1107 controls. Groups had a similar age (81.6 vs 81.7 years) and were 56.4% female. Persons with dementia were more likely to be of minority racial and ethnic groups (26.7% vs 21.3% Black, non-Hispanic, 15.3% vs 6.7% other race or Hispanic). We observed a larger decrease in outpatient visits among persons with dementia, primarily due to decreasing specialty visits (mean outpatient visits: 3 years pre-dementia/matching 6.8 (SD 2.6) dementia vs 6.4 (SD 2.6) controls, p < 0.01 to 3 years post-dementia/matching 4.6 (SD 2.3) dementia vs 5.5 (SD 2.7) controls, p < 0.01). Hospitalization, ED visits, and post-acute SNF use were higher for persons with dementia and rose in both groups (e.g., ED visits 3 years pre-dementia/matching 3.9 (SD 5.4) dementia vs 2.2 (SD 4.8) controls, p < 0.001; 3 years post-dementia/matching 4.5 (SD 4.7) dementia vs 3.5 (SD 6.1) controls, p = 0.04). Older adults with diabetes with incident dementia have higher rates of acute and post-acute care use, but decreasing outpatient use over time, primarily due to a decrease in specialty visits.

Care trajectories around a first dementia diagnosis in patients with serious mental illness.

To develop a typology of care trajectories (CTs) 1 year before and after a first dementia diagnosis in individuals aged ≥65 years, with prevalent schizophrenia or bipolar disorder. This was a longitudinal, retrospective cohort study using health administrative data (1996-2016) from Quebec (Canada). We selected patients aged ≥65 years with an incident diagnosis of dementia between 1 January 2014 and 31 December 2016, and a diagnosis of schizophrenia and/or or bipolar disorder. A CT typology was generated by a multidimensional state sequence analysis based on the "6 W" model of CTs. Three dimensions were considered: the care setting ("where"), the reason for consultation ("why") and the specialty of care providers ("which"). In total, 3868 patients were categorized into seven distinct types of CTs, with varying patterns of healthcare use and comorbidities. Healthcare use differed in terms of intensity, but also in its distribution around the diagnosis. For instance, whereas one group showed low healthcare use, healthcare use abruptly increased or decreased after the diagnosis in other groups, or was equally distributed. Other significant differences between CTs included mortality rates and use of long-term care after the diagnosis. Most patients (67%) received their first dementia diagnosis during hospitalization. Our innovative approach provides a unique insight into the complex healthcare patterns of people living with serious mental illness and dementia, and provides an avenue to support data-driven decision-making by highlighting fragility areas in allocating care resources. Geriatr Gerontol Int 2024; 24: 577-586.

Associations between prior healthcare use, time to diagnosis, and clinical outcomes in inflammatory bowel disease: a nationally representative population-based cohort study

BackgroundTimely diagnosis and treatment of inflammatory bowel disease (IBD) may improve clinical outcomes.ObjectiveExamine associations between time to diagnosis, patterns of prior healthcare use, and clinical outcomes in IBD.DesignUsing the Clinical...

Investigating characteristics of patients and healthcare Visits Prior to Out-of-Hospital Cardiac Arrest in Two Tertiary Hospitals in Oman

Introduction The high incidence of out of hospital cardiac arrest (OHCA) as well as its low survival rates are contributing to the burden on public health. Emerging evidence have recognized prodromal symptoms and patterns of healthcare use suggesting the possibility of predicting these cardiac events despite the general belief that they are merely sudden. Our study aimed to identify the characteristics of patients who present in OHCA and the utilization pattern of healthcare facilities by these patients in the period preceding the cardiac arrest. Methods This is a retrospective study which included adult OHCA patients who presented at two emergency departments (ED) in Muscat, Oman between 2016 and 2020. The ED visits that occurred within the six months preceding the arrest were investigated. Descriptive statistics and frequency tables were used to report the baseline characteristics of all patients. Associations were tested using chi-square test. Results The final cohort consisted of 822 patients with mean age of 60.2 years. The male and female percentages were 65.7% and 34.3% respectively. Less than 10% survived to hospital discharge. About two thirds of all recorded ED visits occurred in the three months immediately before the arrest. A significant association was observed between the frequency of pre-OHCA visits and cardiopulmonary resuscitation (CPR) outcome among patients (P-value = 0.000004). Conclusion Over a quarter of the cohort subjects have approached ED prior to the arrest. Patients are more likely to seek medical attention before the arrest complaining mainly of cardiac and respiratory symptoms. The chances of survival after receiving CPR were higher for those with higher number of visits prior to the arrest. Having a unified system to document and monitor frequent emergency presentations as well as demographics of the patients concerned will aid in the pattern recognition and prevention of OHCA in many subjects.

Patterns of healthcare use among children with immigrant and non-immigrant backgrounds in 2019 and 2020: evidence from the CRIAS cohort study in the metropolitan area of Lisbon, Portugal

BackgroundInternational migrant families may face various barriers in the access and use of health services. Evidence on immigrant children’s health care or prevention facilities’ utilisation patterns is scarce in Portugal. Therefore, the objectives of this study were to compare health services use between immigrant and non-immigrant children in the Metropolitan Area of Lisbon in 2019–2020 with the aim of informing public policies towards equitable access to, and use of health services.MethodsThe CRIAS (Health Trajectories of Immigrant Children) prospective cohort study enrolled 420 children (51.6% immigrant) born in 2015 and attending primary health care (PHC) services in 2019. We compared primary health care facilities and hospital paediatric emergency department (ED) utilisation patterns in the public National Health Service, together with reported private practitioners use, between immigrant and non-immigrant children in 2019 and 2020. The Pearson chi-squared test, Fisher-Freeman-Halton Exact test, two-proportion z-test and Mann‒Whitney U test were used to examine the differences between the two groups.ResultsIn 2019, no significant differences in PHC consultations attendance between the two groups were observed. However, first-generation immigrant children (children residing in Portugal born in a non-European Union country) accessed fewer routine health assessments compared to non-immigrant children (63.4% vs. 79.2%). When children were acutely ill, 136 parents, of whom 55.9% were parents of non-immigrant children, reported not attending PHC as the first point of contact. Among those, nearly four times more non-immigrant children sought healthcare in the private sector than immigrant children (p < 0.001). Throughout 2019, immigrant children used ED more often than non-immigrant children (53.5% vs. 40.4%, p = 0.010), as their parents reported difficulties in accessing PHC. In 2020, during the COVID-19 pandemic, fewer immigrant children accessed PHC compared to non-immigrant children (70% vs. 80%, p = 0.018). Both non-immigrant and immigrant children reduced ED use by 2.5 times, with a higher decrease among immigrant children (46% vs. 34%). In both 2019 and 2020, over 80% of immigrant and non-immigrant children used ED for conditions classified as having low clinical priority.ConclusionBeyond identifying health care use inequalities between immigrant and non-immigrant children, the study points to urgent needs for public policy and economic investments to strengthen PHC for all children rather than for some.

Postpartum healthcare expenditures for commercially insured deliveries with and without severe maternal morbidity

Although severe maternal morbidity is associated with adverse health outcomes in the year after delivery, patterns of healthcare use beyond the 6-week postpartum period have not been well documented. This study aimed to estimate healthcare utilization and expenditures for deliveries with and without severe maternal morbidity in the 12 months following delivery among commercially insured patients. Using data from the 2016 to 2018 IBM Marketscan Commercial Claims and Encounters Research Databases, we identified deliveries to individuals 15 to 49 years of age who were continuously enrolled in noncapitated health plans for 12 months after delivery discharge. We used multivariable generalized linear models to estimate adjusted mean 12-month medical expenditures and 95% confidence intervals for deliveries with and without severe maternal morbidity, accounting for region, health plan type, delivery method, and obstetrical comorbidities. We estimated expenditures associated with inpatient admissions, nonemergency outpatient visits, outpatient emergency department visits, and outpatient pharmaceutical claims. We identified 366,282 deliveries without severe maternal morbidity and 3976 deliveries (10.7 per 1000) with severe maternal morbidity. Adjusted mean total medical expenditures for deliveries with severe maternal morbidity were 43% higher in the 12 months after discharge than deliveries without severe maternal morbidity ($5320 vs $3041; difference $2278; 95% confidence interval, $1591-$2965). Adjusted mean expenditures for readmissions and nonemergency outpatient visits during the 12-month postpartum period were 61% and 39% higher, respectively, for deliveries with severe maternal morbidity compared with deliveries without severe maternal morbidity. Among deliveries with severe maternal morbidity, adjusted mean total costs were highest for patients living in the western region ($7831; 95% confidence interval, $5518-$10,144) and those having a primary cesarean ($7647; 95% confidence interval, $6323-$8970). Severe maternal morbidity at delivery is associated with increased healthcare use and expenditures in the year after delivery. These estimates can inform planning of severe maternal morbidity prevention efforts.

Association of opioid or other substance use disorders with health care use among patients with suicidal symptoms

IntroductionPrior literature establishes noteworthy relationships between suicidal symptoms and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, engagement with health care services among this vulnerable population remains underinvestigated. This study sought to examine patterns of health care use, identify risk factors in seeking treatment, and assess associations between outpatient service use and emergency department (ED) visits. MethodsUsing electronic health records (EHRs) derived from five health systems across New York City, the study selected 7881 adults with suicidal symptoms (including suicidal ideation, suicide attempt, or self-harm) and SUDs between 2010 and 2019. To examine the association between SUDs (including OUD) and all-cause service use (outpatient, inpatient, and ED), we performed quasi-Poisson regressions adjusted for age, gender, and chronic disease burden, and we estimated the relative risks (RR) of associated factors. Next, the study evaluated cause-specific utilization within each resource category (SUD-related, suicide-related, and other-psychiatric) and compared them using Mann-Whitney U tests. Finally, we used adjusted quasi-Poisson regression models to analyze the association between outpatient and ED utilization among different risk groups. ResultsAmong patients with suicidal symptoms and SUD diagnoses, relative to other SUDs, a diagnosis of OUD was associated with higher all-cause outpatient visits (RR: 1.22), ED visits (RR: 1.54), and inpatient hospitalizations (RR: 1.67) (ps < 0.001). Men had a lower risk of having outpatient visits (RR: 0.80) and inpatient hospitalizations (RR: 0.90), and older age protected against ED visits (RR range: 0.59–0.69) (ps < 0.001). OUD was associated with increased SUD-related encounters across all settings, and increased suicide-related ED visits and inpatient hospitalizations (p < 0.001). Individuals with more mental health outpatient visits were less likely to have suicide-related ED visits (RR: 0.86, p < 0.01), however this association was not found among younger and male patients with OUD. Although few OUD patients received medications for OUD (MOUD) treatment (9.9 %), methadone composed the majority of MOUD prescriptions (77.7 %), of which over 70 % were prescribed during an ED encounter. ConclusionsThis study reinforces the importance of tailoring SUD and suicide risk interventions to different age groups and types of SUDs, and highlights missed opportunities for deploying screening and prevention resources among the male and OUD populations. Redressing underutilization of MOUD remains a priority to reduce acute health outcomes among younger patients with OUD.

Patient emergency health-care use before hospital admission for COVID-19 and long-term outcomes in Scotland: a national cohort study

It is unclear what effect the pattern of health-care use before admission to hospital with COVID-19 (index admission) has on the long-term outcomes for patients. We sought to describe mortality and emergency readmission to hospital after discharge following the index admission (index discharge), and to assess associations between these outcomes and patterns of health-care use before such admissions. We did a national, retrospective, complete cohort study by extracting data from several national databases and linking the databases for all adult patients admitted to hospital in Scotland with COVID-19. We used latent class trajectory modelling to identify distinct clusters of patients on the basis of their emergency admissions to hospital in the 2 years before the index admission. The primary outcomes were mortality and emergency readmission up to 1 year after index admission. We used multivariable regression models to explore associations between these outcomes and patient demographics, vaccination status, level of care received in hospital, and previous emergency hospital use. Between March 1, 2020, and Oct 25, 2021, 33 580 patients were admitted to hospital with COVID-19 in Scotland. Overall, the Kaplan-Meier estimate of mortality within 1 year of index admission was 29·6% (95% CI 29·1-30·2). The cumulative incidence of emergency hospital readmission within 30 days of index discharge was 14·4% (95% CI 14·0-14·8), with the number increasing to 35·6% (34·9-36·3) patients at 1 year. Among the 33 580 patients, we identified four distinct patterns of previous emergency hospital use: no admissions (n=18 772 [55·9%]); minimal admissions (n=12 057 [35·9%]); recently high admissions (n=1931 [5·8%]), and persistently high admissions (n=820 [2·4%]). Patients with recently or persistently high admissions were older, more multimorbid, and more likely to have hospital-acquired COVID-19 than patients with no or minimal admissions. People in the minimal, recently high, and persistently high admissions groups had an increased risk of mortality and hospital readmission compared with those in the no admissions group. Compared with the no admissions group, mortality was highest in the recently high admissions group (post-hospital mortality HR 2·70 [95% CI 2·35-2·81]; p<0·0001) and the risk of readmission was highest in the persistently high admissions group (3·23 [2·89-3·61]; p<0·0001). Long-term mortality and readmission rates for patients hospitalised with COVID-19 were high; within 1 year, one in three patients had died and a third had been readmitted as an emergency. Patterns of hospital use before index admission were strongly predictive of mortality and readmission risk, independent of age, pre-existing comorbidities, and COVID-19 vaccination status. This increasingly precise identification of individuals at high risk of poor outcomes from COVID-19 will enable targeted support. Chief Scientist Office Scotland, UK National Institute for Health Research, and UK Research and Innovation.

Hospital-service use in the last year of life by patients aged ⩾60 years who died of heart failure or cardiomyopathy: A retrospective linked data study

Background: Understanding patterns of health care use in the last year of life is critical in health services planning. Aim: To describe hospital-based service and palliative care use in hospital in the year preceding death for patients who died of heart failure or cardiomyopathy in Queensland from 2008 to 2018 and had at least one hospitalisation in the year preceding death. Design: A retrospective data linkage study was conducted using administrative health data relating to hospitalisations, emergency department visits and deaths. Participants and setting: Participants included were those aged ⩾60 years, had a hospitalisation in their last year of life and died of heart failure or cardiomyopathy in Queensland, Australia. Results: Of the 4697 participants, there were 25,583 hospital admissions. Three quarters (n = 3420, 73%) of participants were aged ⩾80 years and over half died in hospital (n = 2886, 61%). The median number of hospital admissions in the last year of life was 3 (interquartile range [IQR] 2–5). The care type was recorded as ‘acute’ for 89% (n = 22,729) of hospital admissions, and few (n = 853, 3%) hospital admissions had a care type recorded as ‘palliative.’ Of the 4697 participants, 3458 had emergency department visit(s), presenting 10,330 times collectively. Conclusion: In this study, patients who died of heart failure or cardiomyopathy were predominantly aged ⩾80 years and over half died in hospital. These patients experienced repeat acute hospitalisations in the year preceding death. Improving timely access to palliative care services in the outpatient or community setting is needed for patients with heart failure.

Remote consultations in London – a comparison between mental health and cardiology pathways

AbstractAs a response to the COVID-19 pandemic, in March 2020 a shift to remote consulting for routine primary care and outpatient appointments was instructed. With the aim to inform whether and how remote consultations should continue post-pandemic, the London NIHR Applied Research Collaborations (ARCs) conducted a research-grade evaluation of the impact of this shift in London, focusing on cardiology and mental health as exemplar pathways.Quantitative methodology aimed to explore patterns of healthcare use, efficiency, and clinical outcomes using de-identified patient-level health records datasets in North-West London and South London.Qualitative interviews with clinicians and patients with experience in remote consultations sought to develop a more in-depth understanding of the experience of the move to remote consulting.Disclosure of InterestNone Declared

Emergency department outcomes for patients experiencing homelessness in England: retrospective cross-sectional study.

Emergency departments (EDs) are an important point of access to health care for people experiencing homelessness. Evidence suggests that ED attendances by homeless people are more likely to result in leaving the ED without treatment, or dying in the ED. We investigate which diagnoses and patterns of health care use are associated with these (and other) discharge destinations and re-attendance within 7 days among homeless patients. We used national hospital data to analyze attendances of all 109254 people experiencing homelessness who presented at any Type 1 ED in England over 2013-18. We used logistic regression to estimate the association of each outcome with primary diagnosis and patterns of healthcare use. Compared with patients with no past ED use, patients with a high frequency of past ED use were more likely to leave without treatment and re-attend within 7 days. Patients not registered at a general practice were likelier to leave without treatment or die in the ED and had lower odds of unplanned re-attendance. A primary diagnosis of 'social problems' was associated with being discharged without follow-up. Patients with a psychiatric primary diagnosis were disproportionately likely to be referred to another health care professional/provider or an outpatient clinic. Further research is needed to understand why some homeless patients leave the ED without treatment and whether their healthcare needs are being met. Some patients may be attending the ED frequently due to poor access to other services, such as primary care and social welfare.

Patterns of Health Care Use 5 Years After an Intervention Linking Patients in Addiction Treatment With a Primary Care Practitioner

Substance use disorders are associated with high rates of emergency department (ED) use and challenges engaging with primary care services. To examine 5-year health care engagement and utilization outcomes for participants in the LINKAGE trial, given previously reported associations of LINKAGE with improved care engagement in the short term. In this post hoc analysis of a nonrandomized controlled trial, participants were assigned to the LINKAGE or usual care (UC) groups using a nonrandomized 3-month alternating off and on strategy over 30 months. Baseline through 5-year follow-up data were collected from April 2011 to October 2018. The trial was conducted at an urban outpatient addiction treatment clinic within a large health system among patients newly enrolled in addiction treatment. Data analysis was conducted from April 2021 to February 2022. The LINKAGE intervention included 6 group-based sessions emphasizing patient agency, skill, and motivation in navigating health care services as well as a facilitated telephone or email connection with a primary care practitioner. The UC group received medical education. Substance use problem discussions with primary care practitioners (by patient self-report at 1-, 2-, and 5-year follow-up interview) and annual use of the electronic patient portal, primary care, and ED based on electronic health records. A total of 503 participants, with a mean (SD) age of 42 (12) years, 346 (69%) male participants and 37 (7%) African American, 34 (7%) Asian, and 101 (20%) Hispanic participants, were assigned to LINKAGE (252 participants) or UC (251 participants). Compared with UC participants, LINKAGE participants were significantly more likely to discuss substance use problems with a primary care practitioner at 1-year follow-up (risk ratio [RR], 1.30; 95% CI, 1.03-1.65; P = .03) and use the electronic patient portal at 1- and 2-year follow-up (eg, messaging clinicians at 2 years: RR, 1.24; 95% CI, 1.04-1.47; P = .02). The LINKAGE group had small, statistically significant 5-year annual increases in primary care use (RR, 1.03; 95% CI, 1.003-1.07; P = .03) and significant annual decreases in substance-related ED use (RR, 0.79; 95% CI, 0.64-0.97; P = .03), relative to UC. The LINKAGE group did not significantly differ from the UC group on other types of ED utilization. In this study, a patient activation intervention embedded in outpatient addiction treatment was associated with sustained improvements in health care engagement beyond previously reported 6-month outcomes and with long-term improvements in health care use patterns. ClinicalTrials.gov Identifier: NCT01621711.

Studying the Long-term Impact of COVID-19 in Kids (SLICK). Healthcare use and costs in children and young people following community-acquired SARS-CoV-2 infection: protocol for an observational study using linked primary and secondary routinely collected healthcare data from England, Scotland and Wales

IntroductionSARS-CoV-2 infection rarely causes hospitalisation in children and young people (CYP), but mild or asymptomatic infections are common. Persistent symptoms following infection have been reported in CYP but subsequent healthcare...

Patterns of Healthcare Use and Mortality After Alzheimer's Disease or Related Dementia Diagnosis Among Alaska Native Patients: Results of a Cluster Analysis in a Tribal Healthcare Setting.

Background:Alaska Native and American Indian (AN/AI) people represent a rapidly aging population with disproportionate burdens of Alzheimer’s disease and related dementias (ADRD) risk factors.Objective:To characterize healthcare service use patterns and mortality in the years following ADRD diagnosis for patients in an Alaska Native Tribal health system.Methods:The study sample included all AN/AI patients aged 55 or older with an ADRD diagnosis who were seen between 2012–2018 (n = 407). We used cluster analysis to identify distinct patterns of healthcare use for primary care, emergency and urgent care, inpatient hospital stays, and selected specialty care. We compared demographic and clinical factors between clusters and used regression to compare mortality.Results:We identified five clusters of healthcare service use patterns after ADRD diagnosis: 1) people who use a low amount of all services (n = 107), 2) people who use a high amount of all services (n = 60), 3) people who use a high amount of primary and specialty care (n = 105), 4) people who use a high amount of specialty care (n = 65), and 5) people who use a high amount of emergency and urgent care (n = 70). The cluster with the highest use had the greatest proportion of comorbidities and had a 2.3-fold increased risk of mortality compared to the cluster with the lowest healthcare service use.Conclusion:Results indicate that those receiving the most services had the greatest healthcare-related needs and increased mortality. Future research could isolate factors that predict service use following ADRD diagnosis and identify other differential health risks.

Multidimensional analysis of adult patients’ care trajectories before a first diagnosis of schizophrenia

For patients at high-risk for developing schizophrenia, a delayed diagnosis could be affected, among many reasons, by their patterns of healthcare use. This study aims to describe and generate a typology of patients’ care trajectories (CTs) in the 2 years preceding a first diagnosis of schizophrenia, over a medico-administrative database of 3712 adults with a first diagnosis between April 2014 and March 2015 in Quebec, Canada. This study applied a multidimensional approach of State Sequence Analysis, considering together sequences of patients’ diagnoses, care settings and care providers. Five types of distinct CTs have emerged from this data-driven analysis: The type 1, shared by 77.6% of patients, predominantly younger men, shows that this group sought little healthcare, among which 17.5% had no healthcare contact for mental disorders. These individuals might benefit from improved promotion and prevention of mental healthcare at the community level. The types 2, 3 and 4, with higher occurrence of mental disorder diagnoses, represent together 19.5% of the study cohort, mostly middle-aged and women. These CTs, although displaying roughly similar profiles of mental disorders, revealed very dissimilar sequences and levels of care providers encounters, primary and specialized care use, and hospitalizations. Surprisingly, patients of these CTs had few consultations with general practitioners. An increased attentiveness for middle-aged patients and women with high healthcare use for mental disorders could help to reduce delayed diagnosis of schizophrenia. This calls for further consideration of healthcare services for severe mental illness beyond those offered to young adults.