Predictors Of Resource Use Research Articles

Professional versus personal resource utilization in survivors of intimate partner violence.

Although many women are affected by intimate partner violence (IPV) across the life span, rates of help seeking for IPV-related concerns are low. The current project examined predictors of personal and professional resource use in a sample of female IPV survivors, with the purpose of identifying engagement strategies for IPV services and resources. The study is notable for is concurrent examination of demographic variables, abuse characteristics, beliefs about cause of violence, beliefs about helpfulness of resources, coping style, and PTSD symptoms as predictors of resource use. Interviews and self-report measures were completed by 372 women recruited from community agencies. The average age was 34.41 years (SD = 8.09), and 66% of the sample was African American, followed by 28% Caucasian, 1.4% Latino, and 1.4% Native American. Results indicated that professional help seeking was significantly related to psychological aggression, age, controllability of cause of violence, engaged coping, helpfulness of resource, and PTSD severity (p < .001), and that personal resource use was related to relationship length, stability of cause of violence, disengaged coping, and helpfulness of resource (p < .001). These findings point to the importance of cognitions and coping style in the decision to seek help for IPV. In particular, beliefs about the helpfulness of potential resources as well as beliefs about the controllability and stability of the violence appear to be important targets for increasing engagement of IPV survivors in available services. (PsycINFO Database Record

Capturing patients' needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems.

BackgroundContemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients’ needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay.MethodsA systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological s using keywords related to functioning (‘Functioning’, ‘Functional status’, ‘Function*, ‘ICF’, ‘International Classification of Functioning, Disability and Health’, ‘Activities of Daily Living’ or ‘ADL’) and casemix systems (‘Casemix’, ‘case mix’, ‘Diagnosis Related Groups’, ‘Function Related Groups’, ‘Resource Utilization Groups’ or ‘AN-SNAP’). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors’ discussion of results, study limitations and implications was extracted.ResultsTen included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients.ConclusionFurther exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient’s needs for services and to better predict resource use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1277-x) contains supplementary material, which is available to authorized users.

Development of a framework for prospective payment for child mental health services.

There is a need to develop a payment system for services for children with mental health problems that allows more targeted commissioning based on fairness and need. This is currently constrained by lack of clinical consensus on the best way forward, wide variation in practice, and lack of data about activity and outcomes. In the context of a national initiative in England our aim was to develop a basis for an improved payment system. Three inter-related studies: a qualitative consultation with child and adolescent mental health services (CAMHS) stakeholders on what the key principles for establishing a payment system should be, via online survey (n = 180) and two participatory workshops (n = 91); review of relevant national clinical guidelines (n = 15); and a quantitative study of the relationship between disorders and resource use (n = 1774 children from 23 teams). CAMHS stakeholders stressed the need for a broader definition of need than only diagnosis, including the measurement of indirect service activities and appropriate outcome measurement. National clinical guidance suggested key aspects of best practice for care packages but did not include consideration of contextual factors such as complexity. Modelling data on cases found that problem type and degree of impairment independently predicted resource use, alongside evidence for substantial service variation in the allocation of resources for similar problems. A framework for an episode-based payment system for CAMHS should include consideration of: complexity and indirect service activities; evidence-based care packages; different needs in terms of impairment and symptoms; and outcome measurement as a core component.

Cardiac MR-derived indices are stronger predictors of resource use and risk than jugular venous pressure, in paediatric patients with functionally single ventricles, prior to completion of total cavopulmonary connection (TCPC)

Methods Outcome data for all patients undergoing inter-stage pre-TCPC CMR between 2007-2014 was analysed. Predetermined outcome measures included survival, duration of peri-TCPC hospitalisation and TCPC fenestration. MRI was performed under general anaesthetic with simultaneous transduction of jugular venous pressure (JVP), as per our Unit protocol. CMR-derived data included volumes and function of single ventricle, through-plane phase contrast flow volumes, contrast-enhanced angiography and 3D SSFP images. Flow was measured in ascending aorta, SVC, IVC, pulmonary arteries and pulmonary veins bilaterally. Thus systemic to pulmonary (S-P) collateral flow, net PA flow and SVC:IVC flow was quantified. 3D images allowed quantitative scoring of systemic veins off-loading the SVC system into IVC : 0= no SVC-IVC offloading veins seen, 1= few, small, low calibre veins, 2= large, obvious veins.

High Resource Use among Adult Congenital Heart Surgery Admissions in Adult Hospitals: Risk Factors and Association with Death and Comorbidities

Adult hospitals are a common location of adult congenital heart disease (ACHD) admissions, including cardiac surgical admissions. Understanding the patterns and predictors of resource use could aid these institutions by identifying and targeting potentially modifiable determinants of high resource use (HRU). Our objectives were to examine resource use during adult congenital heart surgical admissions in adult hospitals, determine the association of HRU with mortality, and identify risk factors for HRU. Population-based retrospective study We obtained data from the Nationwide Inpatient Sample 2005-2009 and examined ACHD surgical admissions ages 18-49 years (n = 16 231). We defined HRU as admissions with >90th percentile for total hospital charges. Despite representing 10% of admissions, HRU admissions accounted for 32% of total charges. HRU admissions had a higher mortality rate (9.7% vs. 1.8%, P < .001). Multivariable analysis demonstrated that HRU is associated with government insurance adjusted odds ratio (AOR) 2.0 (95% confidence interval [CI] 1.6,2.4), emergency admissions AOR 3.9 (95% CI 3.1,4.8), complications AOR 4.2 (95% CI 3.3,5.2), renal failure AOR 1.8 (95% CI 1.4,2.2), congestive heart failure AOR 1.2 (95% CI 1,1.4), surgical complexity risk category-2 AOR 2.0 (95% CI 1.0,3.6), and category-3+ AOR 2.3 (95% CI 1.4,3.8). HRU admissions for adult congenital heart surgery consumed a disproportionate amount of resources and were associated with higher mortality. HRU risk factors included nonelective admissions, government insurance, heart failure, surgical complexity, renal failure, and complications. Complications, if preventable, may be a target for improvement strategies to decrease resource use. Other risk factors may require a broader patient care approach.

Direct and indirect cost of urge urinary incontinence with and without pharmacotherapy

To evaluate the impact of treating urge urinary incontinence (UUI), including mixed urinary incontinence (MUI), on healthcare resource utilisation, productivity, activity impairment and associated costs. The study used data from the 2011 U.S. National Health and Wellness Survey, an Internet-based questionnaire of a nationwide sample of adults. UUI or MUI respondents were identified via three Incontinence Questions. Respondents with stress urinary incontinence only, prostate cancer or (medication for) benign prostatic hyperplasia were excluded. UUI/MUI respondents were categorised as Rx users for overactive bladder (OAB) and non-Rx users (who never used Rx and whose condition reportedly interfered with life activities or was difficult to manage). Outcome measures included healthcare utilisation and Work Productivity and Activity Impairment questionnaire-based scores. Direct and indirect costs were estimated using 2010 labour and 2008 medical expenditure data sources. Generalised linear models predicted resource use and productivity as a function of treatment status, adjusting for covariates (e.g. sociodemographics, OAB severity, comorbid status) that may also predict impairment. Rx (vs. non-Rx) users were more likely to be female (80.7% vs. 70.0%), older (mean=62.7 vs. 53.1) and reporting more moderate-to-severe OAB (70.9% vs. 52.6%; all p<0.05). Adjusting for covariates, Rx (vs. non-Rx) users had significantly lower activity impairment (41.1% vs. 46.8%), more provider visits (7.42 vs. 5.60) and costs ($18,175 vs. $13,679), and higher total direct costs ($27,291 vs. $21,493), all p<0.01. Urge urinary incontinence patients using, vs. never using, prescription medication reported lower activity impairment but higher direct costs. These findings may inform the degree to which UUI pharmacotherapy affects health outcomes.

Socio-economic position and childhood multimorbidity: a study using linkage between the Avon Longitudinal Study of Parents and Children and the General Practice Research Database.

IntroductionIn adults, multimorbidity is associated with social position. Socially disadvantaged adults typically experience more chronic illness at a younger age than comparable individuals who are more advantaged. The relation between social position and multimorbidity amongst children and adolescents has not been as widely studied and is less clear.MethodsThe NHS Information Centre (NHS IC) linked participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) to the General Practice Research Database (GPRD). Multimorbidity was measured in three different ways: using a count of the number of drugs prescribed, a count of chronic diseases, and a person’s predicted resource use score; the latter two measures were derived using the Johns Hopkins ACG system. A number of different socio-economic position variables measured as part of ALSPAC during pregnancy and early childhood were considered. Ordered logistic and negative binomial regression models were used to investigate associations between socio-economic variables and multimorbidity.ResultsAfter mutually adjusting for the different markers of socio-economic position, there was evidence, albeit weak, that chronic condition counts among children aged from 0 to 9 years were higher among those whose mothers were less well educated (OR = 0.44; 95% confidence interval 0.18-1.10; p = 0.08). Conversely, children whose mothers were better educated had higher rates of chronic illness between 10 and 18 years (OR = 1.94; 95% CI 1.14-3.30). However, living in a more deprived area, as indicated by the Townsend score, was associated with a higher odds of chronic illness between 10 and 18 years (OR for each increasing decile of Townsend score = 1.09; 95% CI 1.00-1.19; p = 0.06).ConclusionsWe have found some evidence that, in younger children, multimorbidity may be higher amongst children whose parents are less well educated. In older children and adolescents this association is less clear. We have also demonstrated that linkage between prospective observational studies and electronic patient records can provide an effective way of obtaining objectively measured outcome variables.

Does psychopathology at admission predict the length of inpatient stay in psychiatry? Implications for financing psychiatric services

BackgroundThe debate on appropriate financing systems in inpatient psychiatry is ongoing. In this context, it is important to control resource use in terms of length of stay (LOS), which is the most costly factor in inpatient care and the one that can be influenced most easily. Previous studies have shown that psychiatric diagnoses provide only limited justification for explaining variation in LOS, and it has been suggested that measures such as psychopathology might be more appropriate to predict resource use. Therefore, we investigated the relationship between LOS and psychopathological syndromes or symptoms at admission as well as other characteristics such as sociodemographic and clinical variables.MethodsWe considered routine medical data of patients admitted to the Psychiatric University Hospital Zurich in the years 2008 and 2009. Complete data on psychopathology at hospital admission were available in 3,220 inpatient episodes. A subsample of 2,939 inpatient episodes was considered in final statistical models, including psychopathology as well as complete datasets of further measures (e.g. sociodemographic, clinical, treatment-related and psychosocial variables). We used multivariate linear as well as logistic regression analysis with forward selection procedure to determine the predictors of LOS.ResultsAll but two syndrome scores (mania, hostility) were positively related to the length of stay. Final statistical models showed that syndromes or symptoms explained about 5% of the variation in length of stay. The inclusion of syndromes or symptoms as well as basic treatment variables and other factors led to an explained variation of up to 25%.ConclusionsPsychopathological syndromes and symptoms at admission and further characteristics only explained a small proportion of the length of inpatient stay. Thus, according to our sample, psychopathology might not be suitable as a primary indicator for estimating LOS and contingent costs. This might be considered in the development of future costing systems in psychiatry.

Relationships of age, cholecystectomy approach and timing with the surgical and functional outcomes of elderly patients with cholecystitis

Background Safety confirmation has led to calls for laparoscopic cholecystectomy (LC) to prevail in elderly patients, but the functional changes after LC have not been sufficiently compared with open cholecystectomy (OC). Using an administrative database, we reassessed the quality of cholecystectomy approach and timing of cholecystectomy for elderly patients with cholecystitis. Methods A total of 2552 patients aged ≥60 years who underwent cholecystectomy for cholecystitis were enrolled. Variables included demographics, comorbidities, complications, preoperative bile duct scrutiny, cholecystectomy timing (<48, 48–96, >96 h), functional status estimated by the Barthel index, teaching status, postoperative length of stay (LOS) and total charges (TC). The impacts of age, OC and timing on LOS, TC, complications and functional changes were assessed by mixed linear regression analyses using propensity score-matched cohorts for LC and OC. Results The patients comprised 1742 LC and 810 OC patients across 122 hospitals. The mean ages and octogenarian proportions were 70.1 years and 10.6% for LC and 72.9 years and 20.5% for OC. Advancing age, males and acute inflammation were more frequently associated with OC. Longer LOS, higher TC and more complications were observed for OC. Age was a predictor of functional changes but not complications. Octogenarians and complications were associated with longer LOS, higher TC and more functional deterioration. Earlier cholecystectomy was only associated with lower TC. Conclusions Octogenarians were likely to have OC and functional deterioration. Since OC was a predictor of resource use and complications, strategies to complete earlier LC and prevent complications are required for octogenarians.

Vascular complications predict resource use in T2DM

Vascular complications predict resource use in T2DM

The prevalence of shunt-treated hydrocephalus: a mathematical model

Background The aim of the study was to create a mathematical model that reproduces the prevalence of shunt-treated hydrocephalus in the United States over the years and predicts trends in the near future. Methods A structured search was performed of the English language literature for case series reporting rates of shunt insertion and revision, shunt removal, and patient mortality. A meta-analytic model was constructed to pool data from multiple studies and to calculate these rates at various time intervals. Separate Markov models were used to predict numbers of shunts at any one time for children (<17 years old) and adults. The models analyze the number of shunts inserted every year since 1955 and follow the likely fates of those patients as time passes. Results Prevalence rates predicted by the model agree closely with those reported in the literature. However, the model's structure creates considerable variability around point estimates. Conclusions The model gives a comprehensive view of the prevalence of shunt-treated hydrocephalus in both children and adults from 1955 to the present. This model may prove useful in predicting resource use and needs for patients with hydrocephalus.

Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS)

To estimate diabetes-related resource use and investigate its predictors among individuals with type 2 diabetes in 24 countries in Asia, Latin America, the Middle East and Africa. Cross-sectional observational data on diabetes-related resource use were collected from 15,016 individuals with type 2 diabetes within the second wave of International Diabetes Management Practices Study. Mean (SD) annual quantities were determined and predictors of diabetes-related hospitalisations, inpatient days, emergency room visits and absenteeism were investigated using negative binomial regression. Patients in Asia (n = 4678), Latin America (n = 6090) and the Middle East and Africa (n = 4248) made a mean (SD) of 3.4 (6.9), 5.4 (6.7) and 2.5 (4.4) General Practitioner visits per year. The mean (SD) number of inpatient days amounted to 3.8 (18.1), 2.2 (13.9) and 2.6 (13.5) per year. Results of the regression analysis showed the major influence of diabetes-related complications and inadequate glycaemic control on resource use. The expected annual rate of hospitalisation of patients with macrovascular complications compared with those without was 4.7 times greater in Asia [incidence rate ratio (IRR) = 4.7, 95% CI: 2.8-7.8, n = 2551], 5.4 times greater in Latin America (IRR = 5.4, 95% CI: 3.0-9.8, n = 3228) and 4.4 times greater in the Middle East and Africa (IRR = 4.4, 95% CI: 2.8-6.9, n = 2630). Micro- and macrovascular complications and inadequate glycaemic control are significant predictors of resource use in people with type 2 diabetes of developing countries. This knowledge confirms the health economic importance of early diagnosis of diabetes, education of patients and glycaemic control.

Predicting resource use at mass gatherings using a simplified stratification scoring model

Introduction Mass gathering events require varying types and amounts of medical resources to deal with patient presentations. The needs of various events have so far been difficult to predict with precision, yet likely are impacted by several factors which may be used in a predictive fashion. Hypothesis Medical needs at mass gathering events can be predicted based on a combination of weather, number in attendance, presence of alcohol, demographic of the participants in attendance, and crowd intentions. Furthermore, each of these factors can be assigned a score and events can be stratified based on that score. Methods Fifty-five mass gathering events of varying type occurring in proximity to a large mid-Atlantic university were analyzed retrospectively. Based on a scoring system using the factors described, the events were categorized as “minor,” “intermediate,” or “major.” The actual medical needs at each event were then analyzed. Results Twelve events were classified a priori as “minor,” 20 events were classified as “intermediate,” and 23 received a classification of “major.” These events had averages of 2.3, 6.3, and 71 total contacts, respectively. These trends were consistent for minor encounters, major encounters, and transports. The classification system correctly predicted the resource demand for the 3 classes of events. Conclusion A classification system that stratifies events based on weather, number in attendance, presence of alcohol, demographic in attendance, and crowd intentions can effectively predict medical needs at mass gatherings. This system is most accurate in the description of minor- and intermediate-type events; major events were less well described by this classification system.

Patient Health Status and Costs in Heart Failure

Although a variety of prognostic tools have been shown to predict rehospitalization and mortality in heart failure patients, their utility in assessing future costs is less clear. We assessed whether health status assessment with the Kansas City Cardiomyopathy Questionnaire (KCCQ) predicts future costs in stable heart failure outpatients with left ventricular dysfunction after myocardial infarction. We evaluated 12-month cost utilization data from 1516 heart failure outpatients enrolled in the Quality-of-Life Substudy of the Eplerenone Post-Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS). Multivariable hierarchical models assessed whether the KCCQ (categorized as 0 to <25, 25 to <50, 50 to <75, and 75 to 100) was an independent predictor of future resource use. At baseline, 685 patients (45.2%) had good health status (KCCQ scores > or =75), whereas 510 (33.6%), 262 (17.3%), and 59 (3.9%) had fair (KCCQ, 50 to 74), poor (KCCQ, 25 to 49), and the worst (KCCQ <25) health status, respectively. After multivariable adjustment, compared with patients with good health status, patients with fair health status incurred incremental 1-year costs of $1520 (cost ratio, 1.23; 95% confidence interval, 1.05 to 1.43), whereas patients with poor and the worst health status incurred incremental 1-year costs of $4265 (cost ratio, 1.63; 95% confidence interval, 1.34 to 1.99) and $8999 (cost ratio, 2.34; 95% confidence interval, 1.62 to 3.38), respectively (P<0.0001 for association with KCCQ). Further adjustment for New York Heart Association class led to only partial attenuation of this relationship (P=0.0002). Health status assessment predicts resource use and costs over the next year in stable heart failure outpatients with left ventricular dysfunction after myocardial infarction.

An Analysis of Medicare Payment Policy for Total Joint Arthroplasty

Medicare facility payment policy for lower extremity total joint arthroplasty (TJA) has undergone extensive changes since 2005. The purpose of this study was to compare patient and procedure characteristics and resource use among TJA procedures and to identify predictors of resource use in TJA. Clinical, demographic, and economic data were analyzed from 6483 primary or revision TJA patients from 4 high-volume centers between October 2005 and June 2006. Descriptive analyses were conducted to evaluate differences between procedure types, and multivariable linear regression analyses were undertaken to identify predictors of resource use. Both patient severity of illness and surgical complexity influenced resource use associated with TJA procedures. As the primary goal of Medicare payment policy is to set payment rates proportional to relative resource use, both severity of illness and surgical complexity should be incorporated for payment equity and to minimize incentives for selection bias among hospitals that perform TJA procedures.

An Economic Evaluation from Randomized Trial Data Comparing ERCP to MRCP in Suspected Biliary Obstruction

Background: MRCP can prevent unnecessary ERCPs and their complications in patients with biliary obstruction (BO). Aim: To determine differences in costs between MRCP and ERCP-first strategies in patients with an intermittent probability of BO, and to identify predictors of resource use. Methods: Patients with an intermediate probability of BO based on clinical and ultrasound (US) findings were randomized to MRCP or ERCP, and followed for a year. The number of procedures, and medical direct and indirect Canadian costs (in CDN $) were analyzed per intention-to-treat. Multivariate linear regression models identified independent predictors of resource utilization. Results: 131 patients were randomized to MRCP and 126 to ERCP. Groups were similar in age (55.8 ± 17.7 yrs vs 52.3 ± 18.4 yrs), gender (60% vs 65% female), symptoms, and post-cholecystectomy status (44% vs 34%). Mean follow-ups were 10.3 ± 3.0 mos for MRCP and 10.1 ± 3.3 mos for ERCP. The proportion of additional procedures (58.8% vs 21.4%, CI on difference [0.26; 0.48]) and their total numbers (151 vs 202, CI on difference [14.2, 87.8]) were greater in the MRCP group. No clinically relevant difference was observed in days away from usual activities (268.5d, mean = 2.05d, SE [4.85d] for MRCP, and 431d, mean = 3.42d, SE [7.66d] for ERCP, CI on mean difference [-0.92; 1.55d]). Except for those related to diagnostic ERCP, all other direct medical costs were greater in the MRCP group (average (per patient) and total opportunity loss of CDN$579.55 and CDN$ 79,745.90). In contrast, indirect costs were greater in the ERCP group (average and total savings of CDN$ 36.43 and CDN$ 9,911.29). When summing direct and indirect costs, an ERCP-first strategy resulted in net total and average savings of CDN$ 69,830.37 and CDN$ 543.17 respectively. Multivariate linear regression showed that, in the ERCP group, pre-randomization US findings of CBD (beta = 1.66) and intrahepatic duct dilation (beta = 3.08) were associated with a greater number of post-ERCP procedures, while suspected CBD stone (beta = −2.10) or chronic pancreatitis (beta = −3.39) were negative predictors. In the MRCP group, an elevated serum bilirubin (beta = 0.017), pre-randomization US suspicion of a CBD stone (beta = 2.68), or of an ampullary lesion (beta = 13.6) were associated with a greater likelihood of additional tests. Conclusion: This economic analysis of a medical effectiveness randomized trial suggests that ERCP-first is a preferred strategy for the management of patients with an intermediate probability of biliary obstruction. Initial abdominal US findings provide valuable prognostic information which can improve downstream resource utilization.

Payment by volume (not results)

Payment by results, a system for paying healthcare trusts, is intended as a fair and consistent basis for hospital funding. It relies on a national tariff structured around a case-mix measure known as healthcare resource groups. It is often argued that if payment by results works as planned, the National Health Service will become more efficient and productive. However, the use of a case-mix measure, the healthcare resource group, which derives from the diagnostic related (or diagnosis-related) group, has attendant problems. These include the risk that the payment structure will be inaccurate, unfair and liable to cause the financial destabilisation of trusts. There is also the risk that healthcare institutions will falsify patient classifications (‘up-coding’) to ensure higher remuneration. It has been argued that payment by results may be particularly unsuited to psychiatry. The ability of healthcare resource groups to accurately predict resource use in psychiatry is doubtful. In conclusion, mental health trusts will need to adapt to payment by results but there will inevitably be losers.

Population-Based Study of Determinants of Initial Secondary Care Costs of Acute Stroke in the United Kingdom

To determine the cost-effectiveness of specific interventions to prevent or treat acute stroke, it is necessary to know the costs of stroke according to patient characteristics and stroke subtype and etiology. However, very few such data are available and none from population-based studies. We determined the predictors of resource use and acute care costs of stroke using data from a population-based study. Data were obtained from the Oxford Vascular study, a population-based cohort of all individuals in nine general practices in Oxfordshire, UK, which identified 346 patients with a first or recurrent stroke during April 1, 2002, to March 31, 2004. Univariate and multivariate analyses were performed to identify the main predictors of resource use and costs. Acute care costs ranged from 326 pounds sterling (lower decile) to 19,901 pounds sterling (upper decile). There were multiple important univariate interrelations of patient characteristics, stroke subtype, and stroke etiology with hospital admission, length of stay, and 30-day case-fatality. For example, patients with primary intracerebral hemorrhage were more likely to be admitted than patients with partial anterior circulation ischemic stroke and less likely to survive without disability, but length of stay was reduced as a result of high early case-fatality such that cost was substantially less. However, the majority of univariate predictors of resource use, cost, and outcome were confounded by initial stroke severity as measured by the National Institutes of Health Stroke Scale score, which accounted for approximately half of the predicted variance in cost. Cost increased approximately linearly up to an National Institutes of Health Stroke Scale score of 18 and then fell steeply at higher scores as a result of rising early case-fatality. Several patient and event-related characteristics explained the wide range of initial secondary care costs of acute stroke, but stroke severity was by far the most important independent predictor.

Review: Use of Health Care Services Among Persons Living with HIV Infection: State of the Science and Future Directions

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.

Care needs of residents in community‐based long‐term care facilities in Taiwan

The purpose of this study is to gain an understanding both of the characteristics of residents who receive the services of nursing assistants and the service intensity (service tasks, service time and cost) of nursing assistants as a means of developing a patient classification based upon resource consumption. Most people in Taiwan send their disabled older family members to community-based long-term care facilities instead of nursing homes because they are much cheaper, and because they are generally closer to their homes, making visits more convenient. Nursing assistants make up the largest group of personnel in long-term care facilities. To determine resource use, both the service time and the actual activities performed for a resident by nursing assistants need to be assessed and this will help to develop a patient classification system to predict resource use and patient outcomes. A descriptive survey method was used to identify the tasks performed by nursing assistants in community-based long-term care facilities in Taiwan. Nursing assistants were recruited from 10 long-term care facilities in the Shihlin and Peitou Districts of Taipei City. Thirty-four nursing assistants and 112 residents participated in this study. Findings showed that each nursing assistant spent 5.05 hours per day doing direct service care, which is much higher than the 2.08 hours for nursing assistants in the United States. Among service tasks provided by nursing assistants, personal care consumed 35.1% of their time. Non-complex treatments were second (33.3%). Skilled nursing and medical services were third (31.6%). The service intensity required of nursing assistants was strongly related to the residents' activities of daily living and their needs. Complex nursing procedures are normally provided by Registered Nurses in nursing homes and consumed almost as much of the nursing assistants' time as did personal care activities in this study. It is suggested that a training program for nursing assistants, especially for foreigners in community-based long-term care facilities, should be mandated to assure the quality of service.