Health Service Utilization Patterns Research Articles

When patients have to pay a share of drug costs: effects on frequency of physician visits, hospital admissions and filling of prescriptions

Previous research has shown that patient cost-sharing leads to a reduction in overall health resource utilization. However, in Canada, where health care is provided free of charge except for prescription drugs, the converse may be true. We investigated the effect of prescription drug cost-sharing on overall health care utilization among elderly patients with rheumatoid arthritis. Elderly patients (> or = 65 years) were selected from a population-based cohort with rheumatoid arthritis. Those who had paid the maximum amount of dispensing fees (200 dollars) for the calendar year (from 1997 to 2000) were included in the analysis for that year. We defined the period during which the annual maximum co-payment had not been reached as the "cost-sharing period" and the one beyond which the annual maximum co-payment had been reached as the "free period." We compared health services utilization patterns between these periods during the 4 study years, including the number of hospital admissions, the number of physician visits, the number of prescriptions filled and the number of prescriptions per physician visit. Overall, 2968 elderly patients reached the annual maximum cost-sharing amount at least once during the study periods. Across the 4 years, there were 0.38 more physician visits per month (p < 0.001), 0.50 fewer prescriptions filled per month (p = 0.001) and 0.52 fewer prescriptions filled per physician visit (p < 0.001) during the cost-sharing period than during the free period. Among patients who were admitted to the hospital at least once, there were 0.013 more admissions per month during the cost-sharing period than during the free period (p = 0.03). In a predominantly publicly funded health care system, the implementation of cost-containment policies such as prescription drug cost-sharing may have the unintended effect of increasing overall health utilization among elderly patients with rheumatoid arthritis.

Health Care Access and Utilization Patterns in Unstably Housed HIV-Infected Individuals in New York City

As part of a multisite initiative to evaluate outreach targeting underserved HIV-infected individuals, we describe baseline characteristics of unstably housed HIV-infected individuals from New York City, and their health care access and utilization patterns. Interviews with 150 HIV-infected single room occupancy (SRO) hotel residents on health care access and utilization, barriers to accessing health care, demographic characteristics, history of incarceration, severity of HIV disease, depressive symptoms, substance use, and exposure to violence were conducted. Most participants were 40 years of age or older, male, black or Latino, had public insurance, a history of substance use, depressive symptoms, and a CD4(+) count above 200 cells/mm(3). Access to and utilization of care was high with 91% reporting having a regular provider, 95% identifying a non-emergency department (ED) clinic or office as their usual location of care, 89% reporting at least one ambulatory visit, and 82% reporting optimal (>/=2) ambulatory visits during the previous 6 months. Additionally, 45% reported at least one ED visit, and 30% at least one hospitalization within the previous 6 months. Among black and Latino marginalized SRO hotel residents in New York City, this study found surprisingly high measures of access to and utilization of ambulatory care services, along with high use of acute care services. Understanding HIV-related health services access and utilization patterns among marginalized populations is essential to improve their HIV care. These patterns of high levels of access to and utilization of health care services contradict clinical experiences and other studies, and require further exploration.

Attenuation of Racial Differences in Health Service Utilization Patterns for Previously Uninsured Children in the Delta

A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers. The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs. General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed. Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services. Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Chapter 2. Mental Health in the Hispanic Immigrant Community

Abstract This chapter addresses the mental health status of Hispanics in the United States. The prevalence and incidence of mental health disorders among different Hispanic ethnic subgroups is examined. Patterns of mental health services utilization and barriers to mental health care are also reviewed. Research specific to best mental health practices with Hispanics is stressed.

Preferences for Mental Health Care: A Comparison of Older African Americans and Older Caucasians

Research on mental health service utilization patterns has shown that older adults underutilize outpatient services, particularly in minority populations. Greater reliance on inpatient services may result when a mental health problem can no longer be ignored. The goal of this study was to compare the attitudes and beliefs of African American and Caucasian older adults about mental health care and preferred providers. A 47-item survey was administered to a convenience sample of 1,598 primarily African Americans, recruited at 40 sites, including the study sample of 726 people older than age 50. Results showed that respondents of both races preferred advice from their family doctor, clergy, or a family member. African Americans preferred services in their doctor’s or clergy’s office, whereas Caucasians preferred a professional service provider’s office. Findings suggest that providers and policy makers consider the impact of age, culture, and ethnicity on mental health services provision.

Patterns of health service utilization and perceptions of needs and services in rural Orissa

Despite emphasis on strengthening local health care provision, concern remains regarding the rates of utilization of state-provided services within Orissa. The reported study examined patterns of service utilization across the rural population of four districts of Orissa, with special reference to perceptions of the availability and quality of state services at the primary care level. Within the selected districts, 219 interviews were conducted across 66 villages. Households reported utilizing a wide range of health care providers, although hospitals constituted the most frequently--and primary health care centres (PHCs) the least frequently--accessed services. Private practitioners (qualified and unqualified) represented a major sector of provision. This included high rates of access by scheduled tribes and castes (running at approximately twice the rate of access to both local and PHC provision). Key factors guiding patterns of utilization were reputation of the provider, cost and physical accessibility. Local health provision through assistant nurse midwives and male health workers was generally perceived of poor quality, with the lowest rates of resolution of health problems of all service providers. The location of a sub-centre base for assistant nurse midwives within a village had no demonstrable impact on access to services. Acknowledging constraints on broader generalization, the implications of the findings for informing health policy and programming within Orissa are noted. This includes support for current efforts to strengthen the capacity of PHC and sub-centre level provision within the state, and acknowledgement of the potentially growing role of effectively regulated private provision in meeting the needs of the rural poor.

The ecology of health care in Hong Kong

To better understand the distribution of resources and health care consumption patterns in different geo-ethnic and socio-economic settings, we sought to describe the patterns of illness, care-seeking behavior and health services utilization in Hong Kong compared to the US and UK. Data were derived from the 2002 Hong Kong Thematic Household Survey covering 31,762 non-institutional and institutional residents, representing 6,504,255 persons after applying population weights. Of 1000 individuals during a 1-month period, 567 reported symptoms, 512 of whom considered seeking health care. Four hundred and forty persons visited western allopathic medical practitioners, with 372 (84.5%) in primary care and 68 (15.5%) in specialty care. There were 54 visits to traditional Chinese medical practitioners and 16 emergency room episodes. Seven individuals were hospitalized in community hospitals and on average one in 1000 were admitted to a tertiary medical center. Ninety out of the 567 who experienced symptoms undertook self-management strategies, which included over-the-counter western allopathic medications ( n = 54 ) or traditional Chinese remedies ( n = 14 ) or both ( n = 2 ), dietary modification ( n = 1 ) and rest ( n = 15 ). We have mapped the ecology of health care in Hong Kong. Monthly prevalence estimates were remarkably similar to US figures for hospital-based events, whereas there was evidence of apparent, substantial “over-consumption” of ambulatory, community-based care. Our results also indicate that the local community's care-seeking orientation still very much favors western allopathic medicine over traditional Chinese therapy, at least for acute illness episodes.

Treatment of osteoporosis in an older home care population

BackgroundPrevious research indicates that many patients with fractures indicative of underlying osteoporosis are not receiving appropriate diagnostic follow-up and therapy. We assessed osteoporosis treatment coverage in older home care clients with a diagnosis of osteoporosis and/or prevalent fracture.MethodsSubjects included 330 home care clients, aged 65+, participating in a longitudinal study of medication adherence and health-related outcomes. Data on clients' demographic, health and functional status and service utilization patterns were collected using the Minimum Data Set for Home Care (MDS-HC). A medication review included prescribed and over-the-counter medications taken in the past 7 days. Criteria for indications for osteoporosis therapy included diagnosis of osteoporosis or a recent fracture. Coverage for treatment was examined for anti-osteoporotic therapies approved for use in 2000.ResultsOf the 330 home care clients, 78 (24%) had a diagnosis of osteoporosis (n = 47) and/or had sustained a recent fracture (n = 34). Drug data were available for 77/78 subjects. Among the subjects with osteoporosis or a recent fracture, 45.5% were receiving treatment for osteoporosis; 14% were receiving only calcium and vitamin D, and an additional 31% were receiving drug therapy (bisphosphonate or hormone replacement therapy). The remaining 54.5% of subjects were not receiving any approved osteoporosis therapy.ConclusionsThe high prevalence of undertreatment among a population of older adults with relatively high access to health care services raises concern regarding the adequacy of diagnosis and treatment of osteoporosis in the community.

Patterns of mental health service utilisation in Italy and Spain

Methods for comparing local mental health service systems are needed to allow identification of different patterns of service provision and of inequities within and between countries. The aim of this study was to describe and compare mental health service systems in 13 catchment areas in Spain and Italy. Within each country, a range of area characteristics was represented. The European Service Mapping Schedule (ESMS) and European Socio-Demographic Schedule (ESDS) were used to describe: (i) socio-demographic and geographical area characteristics; (ii) services provided; and (iii) service utilisation in each area. Great differences emerged in patterns of service provision and use between and within countries. In contrast to Northern Europe, high unemployment rates were not associated with high service utilisation rates, but areas with large numbers of single-person households tended to have high service use. Most service utilisation rates were substantially below those reported from Northern European studies. Spanish centres tended to have low rates of hospital service utilisation despite limited development of community-based services. Trieste, where there has been a strong emphasis on developing innovative community services, showed a distinctive pattern with low hospital bed use and high rates of day service use and of contacts in the community. This methodology yielded useful data, which raise significant questions regarding equity and the implementation of mental health policy. The very large variations indicate that underlying local patterns of service provision must be investigated and taken into account in the interpretation of research evaluations of interventions.

Frequency and patterns of mental health services utilization among adolescents with anxiety and depressive disorders

The main aim of this study was to examine the frequency and patterns of mental health services utilization among 12- to 17-year-old adolescents with anxiety and depressive disorders. Another aim was to examine the factors associated with the use of mental health services. The study population comprised 1,035 adolescents randomly recruited from 36 schools. Anxiety and depressive disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Only 18.2% of the adolescents who met DSM-IV criteria for anxiety disorders, and 23% of those with depressive disorders, used mental health services. Among adolescents with anxiety disorders, mental health services utilization was associated with past suicide attempt, older age, the presence of comorbid disorders, as well as parental anxiety and depression. The only factor that predicts the use of mental health service among adolescents with depressive disorder was a history of suicide attempt. The implication of the results in terms of tailoring services for children and adolescents with anxiety and depressive disorders are discussed.

Use of health care among adults with chronic and complex physical disabilities of childhood

Purpose. The purpose of this study was to explore the patterns of health services utilization among adults with chronic and complex physical disabilities of childhood, specifically cerebral palsy, spina bifida, and acquired brain injuries.Methods. A cohort of 345 young adults who had graduated from the Bloorview MacMillan Children's Centre was identified. Their health care records were extracted from Ontario Health Insurance Plan (OHIP) and Canadian Institute for Health Information (CIHI) databases, for a four-year period. These data were analysed to estimate the frequency of out-patient physician visits and admissions to hospital.Results. The mean age of the sample was 21.9 years (range 19.0–26.9 years). The results show that 95% of the sample visited a physician at least once per year, and 24% had a primary care physician. On average, these adults visited physicians 11.5 times per year (approximately once per month) and were admitted to hospital once every 6.8 years.Conclusions. These results suggest that adults with complex physical disabling conditions from childhood have ongoing health issues that require frequent service. Their admission rate is 9.0 times that of the general population, and few have a primary care physician. A new model of service may be necessary for this high-needs group.

Researching culture and health: Variables used to identify culturally diverse groups in New South Wales

NSW is one of Australia's most multicultural states, with 29 per cent of residents having been born overseas and 24 per cent speaking a language other than English at home. Given that rates of death and disease and patterns of health service utilisation differ across cultural variables such as region or country of birth, a better understanding of the interactions between culture and health may enable public health programs and clinical services to be more sensitive to community needs.

Impact of APOE in mild cognitive impairment

The authors aimed to use baseline data of an ongoing large, prospective study in subjects with mild cognitive impairment (MCI) to investigate the impact of APOE genotype on the symptom profile of the condition. Cognitive assessments included the AD Assessment Scale cognitive subscale (ADAS-cog), the Mini-Mental State Examination (MMSE), and a cognitive battery for assessment of memory, attention, and executive function. Behavioral assessments included the Neuropsychiatric Inventory and Beck Depression Inventory. Activities of daily living were assessed by the AD Cooperative Study Activities of Daily Living (ADCS-ADL) scale. Hippocampal volumes were measured with MRI. A total of 494 of 1,018 study subjects provided APOE data. Approximately 40% of the subjects were APOE epsilon4 carriers. APOE epsilon4 carriers had lower MMSE (p = 0.01) and higher ADAS-cog (p < 0.0001) scores than noncarriers, indicating worse cognitive impairment. APOE epsilon4 carriers also had greater deficits on New York University delayed paragraph recall and Buschke free and cued selective reminding tests, and on the ADCS-ADL scale (p < 0.001). They also had smaller hippocampal volumes (p = 0.002). Behavioral scores were similar across the subgroups. MCI subjects carrying the APOE epsilon4 allele showed distinct cognitive and imaging profiles, which appeared to resemble those of early Alzheimer patients. APOE epsilon4 genotype was associated with greater impairments in memory and functional activities as well as hippocampal atrophy.

Perception of Severity of Acute Respiratory Tract Infections and Diarrhoea in Children under the Age of Five in Rural India: Utilization Pattern of Health Services

A cross-sectional survey of 970 children under the age of 5 in 870 households showed a biweekly incidence of acute respiratory tract infections (ARIs) and diarrhoea of 9 and 8.7%, respectively. Ninety per cent of the mothers, irrespective of their educational status, could identify correctly the severe forms of the illness. When perceived as severe the majority (75%) of them went to unqualified indigenous practitioners and only when perceived as mild did they use the government services. This shows that the user preferences for acute healthcare services vary with their perception of the illness and unqualified practitioners are the main source of healthcare providers especially in the rural areas.

Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes.This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries.The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.

Long-term survival patterns of a large nationwide cohort of elderly veterans with colorectal cancer

3708 Background: Administrative databases have generally not been designed to permit cancer researchers to readily follow patients forward from the period pre-diagnosis through initial curative intent treatment, adjuvant therapy, post-treatment follow-up, to the final endpoint of either death or loss to follow-up. One major hurdle to cancer research using such databases has been the lack of data such as stage at diagnosis, and histopathologic type and grade. A second major hurdle is that many patients use more than one system of care, in this instance, Department of Veterans Affairs (VA) and Medicare-reimbursed care. These dual users would be inaccurately represented in the analysis if only one source of data were analyzed. Methods: A retrospective analysis of 13 years of nationwide Medicare and VA inpatient and institutional outpatient data beginning with the three years pre-diagnosis (1986–1990) through a minimum of five years post-diagnosis (1994–1998) was conducted. Death data were available through December 2003. Data were also extracted from tumor registry files, Computerized Patient Record System Files, and paper medical records at each VA. The population studied included all VA patients diagnosed with colorectal cancer and surgically treated for cure during the five-year period 1989–1993, who were Medicare-eligible at diagnosis, and survived the index admission. Results: Of the 6612 patients treated with curative intent during the five-year period, 4902 (74%) could be staged. Of these, 4535 (93%) were deemed eligible for the study. Of the eligible patients, 77% were diagnosed with colon cancer and 23 percent with rectal cancer. The majority (88%) had adenocarcinoma. The histopathologic grade was moderately differentiated for 54% and well differentiated for 19%. As of December 2003, 74% had died. Including all stages (0- IV), the average survival in months after treatment was 75 (median=61). Conclusions: This rich database provides a wealth of data for subgroup analyses of survival, recurrence patterns, and particularly, of health services utilization patterns within and across systems of care. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Heartland Division, Department of Veteran's Affairs Medical Center

Long-term survival patterns of a large nationwide cohort of elderly veterans with colorectal cancer

3708 Background: Administrative databases have generally not been designed to permit cancer researchers to readily follow patients forward from the period pre-diagnosis through initial curative intent treatment, adjuvant therapy, post-treatment follow-up, to the final endpoint of either death or loss to follow-up. One major hurdle to cancer research using such databases has been the lack of data such as stage at diagnosis, and histopathologic type and grade. A second major hurdle is that many patients use more than one system of care, in this instance, Department of Veterans Affairs (VA) and Medicare-reimbursed care. These dual users would be inaccurately represented in the analysis if only one source of data were analyzed. Methods: A retrospective analysis of 13 years of nationwide Medicare and VA inpatient and institutional outpatient data beginning with the three years pre-diagnosis (1986–1990) through a minimum of five years post-diagnosis (1994–1998) was conducted. Death data were available through December 2003. Data were also extracted from tumor registry files, Computerized Patient Record System Files, and paper medical records at each VA. The population studied included all VA patients diagnosed with colorectal cancer and surgically treated for cure during the five-year period 1989–1993, who were Medicare-eligible at diagnosis, and survived the index admission. Results: Of the 6612 patients treated with curative intent during the five-year period, 4902 (74%) could be staged. Of these, 4535 (93%) were deemed eligible for the study. Of the eligible patients, 77% were diagnosed with colon cancer and 23 percent with rectal cancer. The majority (88%) had adenocarcinoma. The histopathologic grade was moderately differentiated for 54% and well differentiated for 19%. As of December 2003, 74% had died. Including all stages (0- IV), the average survival in months after treatment was 75 (median=61). Conclusions: This rich database provides a wealth of data for subgroup analyses of survival, recurrence patterns, and particularly, of health services utilization patterns within and across systems of care. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Heartland Division, Department of Veteran's Affairs Medical Center

Identified Problems and Service Utilization Patterns Among Kinship Families Accessing Mental Health Services

This study examined the mental health problems and service utilization patterns of kinship families who accessed services in an urban outpatient child psychiatry clinic. A random sample of children who completed the intake process during a calendar year yielded 47 children, or 19% of the sample, whose primary caregiver was a relative, other than a biological parent; approximately half of those families were involved with the child welfare system. Data from an administrative database and from medical records describe the diagnoses, identified problems, and services used by the kinship families. Academic or school-related problems emerged as an identified problem in approximately half of the kinship cases, but school intervention was not a primary target for clinicians. The kinship sample was also compared with a random stratified sample of children who were living with primary caregivers other than kin. Kinship families were more likely to be African-American, but few differences were found between kin and non-kin cases on diagnoses and frequency, duration, or type of services received. The findings suggest that collaboration with schools might increase the engagement and retention of kinship families in mental health services.

Children of migratory agricultural workers: the ecological context of acute care for a mobile population of immigrant children

Migratory and seasonal agricultural workers fill the labor needs of United States farmers. Although migrant workers are a culturally and ethnically diverse population, presently, they are predominantly immigrants of Hispanic ethnicity. Migrant farm workers are increasingly young, financially impoverished, male, undocumented immigrants from Mexico. Families with children constitute 45% of this population. The ecological context of migrant children’s lives is characterized by poverty, social isolation, heightened inter- and intra-national mobility, limited protections from occupational safety and health legislation, and health access barriers. Moreover, the linkage of citizenship and immigration status to the receipt of public insurance and selected social services benefits has the potential to increase access barriers for migrant workers and their families. Despite these obvious vulnerabilities, few health services research studies address this population. Most of what is known relates to adults, with very little known about migrant children’s health services utilization patterns or health morbidities. In the emergency department setting, the differential approach required to care for children, as compared to adults, must be modified further in order to address the unique needs of this vulnerable population. The effective delivery of acute care to the children of migratory agricultural workers requires awareness of and attention to their unique health access barriers, issues of continuity and compliance with care, and their unique health and injury risks.

New Approaches to Immigrant Health Assessment

While immigrant subgroups may present vulnerabilities in terms of health status, health service use, and social determinants, comprehensive information on their health is lacking. To examine mortality (1980-1998) and health service utilization (1985-2002) patterns in Canadian immigrants, a record linkage pan-Canadian research initiative using immigration and health databases has been undertaken. Preliminary results indicate that overall mortality is low among Canadian immigrants as compared to the general population for most leading causes (thus supporting the notion of "healthy immigrant effect"), with cause-specific exceptions. Moreover, results from British Columbia show that overall physician visits are low for immigrants, but not for all subgroups. Results from Ontario demonstrate a sharp increase in physician claims approximately three months following landing. Future analyses will address the short- and long-term health outcomes of immigrant subgroups, including less common diseases. Results are pertinent to practitioners working with immigrants and can inform immigrant health policy.