Proportion Of Healthcare Services Research Articles

Assessing the Value of Unsupervised Clustering in Predicting Persistent High Health Care Utilizers: Retrospective Analysis of Insurance Claims Data.

BackgroundA high proportion of health care services are persistently utilized by a small subpopulation of patients. To improve clinical outcomes while reducing costs and utilization, population health management programs often provide targeted interventions to patients who may become persistent high users/utilizers (PHUs). Enhanced prediction and management of PHUs can improve health care system efficiencies and improve the overall quality of patient care.ObjectiveThe aim of this study was to detect key classes of diseases and medications among the study population and to assess the predictive value of these classes in identifying PHUs.MethodsThis study was a retrospective analysis of insurance claims data of patients from the Johns Hopkins Health Care system. We defined a PHU as a patient incurring health care costs in the top 20% of all patients’ costs for 4 consecutive 6-month periods. We used 2013 claims data to predict PHU status in 2014-2015. We applied latent class analysis (LCA), an unsupervised clustering approach, to identify patient subgroups with similar diagnostic and medication patterns to differentiate variations in health care utilization across PHUs. Logistic regression models were then built to predict PHUs in the full population and in select subpopulations. Predictors included LCA membership probabilities, demographic covariates, and health utilization covariates. Predictive powers of the regression models were assessed and compared using standard metrics.ResultsWe identified 164,221 patients with continuous enrollment between 2013 and 2015. The mean study population age was 19.7 years, 55.9% were women, 3.3% had ≥1 hospitalization, and 19.1% had 10+ outpatient visits in 2013. A total of 8359 (5.09%) patients were identified as PHUs in both 2014 and 2015. The LCA performed optimally when assigning patients to four probability disease/medication classes. Given the feedback provided by clinical experts, we further divided the population into four diagnostic groups for sensitivity analysis: acute upper respiratory infection (URI) (n=53,232; 4.6% PHUs), mental health (n=34,456; 12.8% PHUs), otitis media (n=24,992; 4.5% PHUs), and musculoskeletal (n=24,799; 15.5% PHUs). For the regression models predicting PHUs in the full population, the F1-score classification metric was lower using a parsimonious model that included LCA categories (F1=38.62%) compared to that of a complex risk stratification model with a full set of predictors (F1=48.20%). However, the LCA-enabled simple models were comparable to the complex model when predicting PHUs in the mental health and musculoskeletal subpopulations (F1-scores of 48.69% and 48.15%, respectively). F1-scores were lower than that of the complex model when the LCA-enabled models were limited to the otitis media and acute URI subpopulations (45.77% and 43.05%, respectively).ConclusionsOur study illustrates the value of LCA in identifying subgroups of patients with similar patterns of diagnoses and medications. Our results show that LCA-derived classes can simplify predictive models of PHUs without compromising predictive accuracy. Future studies should investigate the value of LCA-derived classes for predicting PHUs in other health care settings.

A nurse practitioner-led care bundle approach for primary care of patients with complex health needs.

Often developed for acute care and less frequently for primary care, care bundles are clusters of evidence-based practices for improving care delivery and patient outcomes. Care bundles usually arise when ineffective or costly outcomes are identified, are meant to make care more reliable, and require superb teamwork and communication. Patients using the highest proportion of health care services are those living with complex health conditions and challenging sociocultural lives, statistics corroborated within our primary care clinic. In our nurse practitioner (NP)-led, interprofessional, team-based primary care program serving mainly low-income patients, we noted that many patients with multiple chronic conditions had an excess of clinic encounters, emergency department visits, and hospitalizations. To improve health status for these patients and reduce costly care inefficiencies, we developed a unique bundle of care practices for embedding within our NP-led complex care program. Our goals were to improve patient efficacy for self-management of chronic conditions and promote appropriate use of health care resources and services. Using AEIØOU as a mnemonic, the derived care bundle better focused our team efforts and provided us with a planning, communication, and documentation schema for quality improvement. It was particularly useful for team-based care because tasks could be documented or communicated by letter or number and easily reviewed by team members or others involved in patients' care. Use of the AEIØOU bundle within our program resulted in better coordination of team-based comprehensive care for our high-needs patients, seen anecdotally in fewer unnecessary contacts and missed appointments and in patient appreciation comments. Emergency department visits and hospitalization data for the six months before compared with 6 months after enrollment in the program showed significant reductions. To improve the primary care of complex patient populations, we recommend further use and testing of the AEIØOU bundle within other care models.

Preliminary validation of the insomnia severity index in Danish outpatients with a medical condition

PurposeInsomnia is a frequent sleeping disorder in the general and clinical population. With an increasing proportion of health care services being provided as outpatient care, a short, valid and reliable tool is needed to identify insomnia in medical patients under outpatient care in Denmark. The Insomnia Severity Index (ISI) could be the needed tool if found valid and reliable. Hence, the aim of this study is to evaluate elements of the psychometric properties of the Danish version of ISI (ISI-DK).MethodsOutpatients from three hospital wards and one rehabilitation center were asked to complete the ISI-DK twice, 2 weeks apart. Internal consistency, discriminative validity, test-retest reliability, and measurement error was assessed.ResultsThe ISI-DK was completed by 249 (79.0%) participants the first time, and 163 (65.5%) the second time. Respondents had a mean age of 58.2 years (SD 13.5) and 63.5% were women. All but one of the discriminative hypotheses was accepted. Internal consistency was high in the global scale at 0.90 and good with Cronbach’s alpha at 0.75–0.88 in the proposed subscales. The test-retest reliability was good, as the intraclass correlation was 0.90 (95% CI: 0.87; 0.93). Ceiling and floor effects were low < 4.4%. Standard error of measurement was 2.52 and smallest detectable change 6.99.ConclusionThis preliminary assessment showed encouraging results supporting the ISI-DK as a valid and reliable tool for screening insomnia severity in Danish outpatients with a medical condition, but further assessments are needed.

Resource Use and costs of End-Of-Life/Palliative Care: Ontario Adult Cancer Patients Dying during 2002 and 2003

The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.

Alcohol Use and Reported Physician Visits in Older Adults

Background. In general, older adults use a greater proportion of health care services than other age segments of the population. Alcohol abusers also use a greater proportion of health care services than alcohol nonabusers. Therefore we expected that among older adults, alcohol consumption would be positively related to health service use. In a sample of older adults, this study examined the relationship between alcohol consumption and an indicator of health service use-the self-reported number of physician visits. Methods. Data obtained on adult participants in the 1990 National Health Interview Survey, age 60 and older (n = 10,522), were examined. The number of physician visits was regressed on health status and alcohol consumption measures. Results. Counter to a priori expectations, alcohol consumption was negatively associated with physician visits. This finding was obtained after adjusting for respondent sex and health status measures. Conclusions. Other research suggests that the rates of alcohol-related hospital admissions among older adults are on par with those of myocardial infarctions-an indication that harmful use of alcohol in older adults is going undetected. We found heavier alcohol consumption associated with fewer physician visits. This underscores the need for a better understanding of the role alcohol serves in the health perceptions of older adults. Broadening our knowledge in this area would be of benefit not only to the well-being of individuals also for health services policy considerations.