Hospital Utilization Rates Research Articles

Accuracy of Administrative Data (AD) Verses Expert Review (ER) To Identify and Classify Selected Care-Associated Adverse Outcomes

BACKGROUND/OBJECTIVES: In November of 2005, Florida became the first state to publicly report performance outcome measures on hospitals, including the rates of care-associated post-operative sepsis (POS) and decubitus ulcer (DU). Those rates are determined by the state authority having jurisdiction (AHJ) using Agency for Healthcare Research and Quality (AHRQ) data that provides 30 measures reflecting hospital volumes, mortality rates, utilization rates and patient safety. This study compares the POS and DU findings for one of our system hospitals as initially reported by the AHJ with our own ER.

Closure of a home hospital program: Impact on hospitalization rates

Home hospitalization (HH), as a substitute to in-patient care, is an area of growing interest, particularly amongst the elderly. Debate nonetheless exists concerning its economic justification. This study describes a natural experiment that arose following spending cuts and closure of the 400 patient Jerusalem HH program. It examines the hypothesis that HH closure would cause increasing geriatric and general medical hospital utilization amongst the 45,000 beneficiaries of the Jerusalem Clalit Health Fund (HMO) aged 65 years and over. Hospitalization rates were measured prior to and following HH closure, and analysis of variance confirmed the significance of the differences in both geriatric ( p < 0.0001) and general medical hospitalization rates ( p = 0.02) over the study period. Linear regression analyses of the hospitalization rates prior to HH closure were performed to determine the expected trajectory of hospitalization rates following HH closure. The observed hospital utilization in the year following HH closure cost US$ 6.2 million in excess of predicted expenditure; closure of the HH resulted in the saving of US$ 1.3 million. The ratio of direct increased costs to savings was 5:1 thus confirming the hypothesis that HH closure would result in increased hospital utilization rates among the local elderly population.

The Efficacy of Asthma Case Management in an Urban School District in Reducing School Absences and Hospitalizations for Asthma

Pediatric asthma rates are reaching epidemic proportions, adversely affecting children's quality of life, educational potential, and health care costs, especially those in the inner city. This study evaluated the effectiveness of a school-based asthma case management (CM) approach with medically underserved inner-city children attending Memphis City schools. Fourteen elementary schools with high rates of asthma-related hospital utilization were grouped according to school size, percentage of children with asthma enrolled, and percentage of children eligible for free or reduced-price lunch. Schools were randomized to either a nurse CM intervention or a usual care (UC) condition. The CM group included 115 students; 128 students were in the UC group. A longitudinal design was used to follow students' progress. Students were primarily African-American children diagnosed with asthma. In CM schools, nurse case managers conducted weekly group sessions incorporating the Open Airways curriculum, followed up on students' school absences, and coordinated students' asthma care with families, school personnel, and medical providers. In UC schools, students received routine school nursing services. CM students had fewer school absences than their counterparts in UC schools (mean 4.38 vs 8.18 days, respectively) and experienced significantly fewer emergency department visits (p < .0001) and fewer hospital days (p < .05) than UC students. No such differences existed before program initiation. Replication and follow-up in year 2 showed continued significant improvements. School-based nurse CM can achieve significant improvements in school attendance and medical utilization.

Carcinoma of he stomach, colon, and rectum. A survey of 772 surgical biopsies from Malaya.

Abstract A survey of surgical biopsy material from carcinoma of the stomach, colon, and rectum in Malaya with its multiracial population was carried out. The difficulty of interpretation of local frequency figures, owing to differences in rates of hospital utilization in the various races, is discussed. The frequency of occurrence of carcinoma of the stomach would seem to be the same for all three races, Chinese, Indian, and Malay. Carcinoma of the colon and rectum are not the uncommon diseases they had previously been thought to be in the region. The incidence of carcinoma of the colon and rectum is lower in Indians compared with the Chinese and Malays.

Endometriosis: What is the risk of hospital admission, readmission, and major surgical intervention?

Study objective To describe trends in hospital utilization and surgical rates for endometriosis and to estimate the probability of hospital readmission over 4 years among women with early-stage disease. Design Population-based, retrospective cross-sectional and longitudinal analysis of 53 385 hospital admissions for same-day surgery or inpatient treatment of endometriosis from fiscal years 1994/95 through 2001/02 (Canadian Task Force classification III). Setting All hospital discharge records that listed endometriosis as the most-responsible diagnosis in the province of Ontario, Canada, from fiscal years 1994–1995 through 2001–2002. Patients Ontario female patients 15 years of age or older admitted to the hospital for treatment of endometriosis. Interventions Surgical treatments were classified as minor, intermediate, or major depending on the extent of the surgery. Measurements and main results Age-standardized annual discharge rates were calculated and trends in surgical treatment described. The records of 7993 women who received minor or intermediate surgery on their index hospital visit were linked, and the likelihood and predictors of readmission were calculated using survival analysis and logistic regression. During the observation period, the standardized discharge rates fell significantly from 172.9 per 100 000 women aged 15 to 70 to 137.1 per 100 000 (p < .05). Age-specific rates were highest for women aged 15 to 39 (approximately 200 per 100 000). The proportion of hospitalizations involving minor surgeries dropped (from 27% to 17%), and the proportion involving intermediate surgeries increased (from 40% to 53%). The likelihood of hospital readmission within 4 years for additional surgical treatment was 27% and of having a hysterectomy was 12%. Conclusion Fewer women are being hospitalized for minor surgical procedures for endometriosis with hospital-based care being reserved for more extensive procedures. Nonetheless, about a quarter of women hospitalized for initial surgical treatment for endometriosis will undergo additional surgical treatment within 4 years, and one in 10 will have a hysterectomy.

Use of Multisystemic Therapy to Improve Regimen Adherence Among Adolescents With Type 1 Diabetes in Chronic Poor Metabolic Control

The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes. A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA(1c) [A1C] > or =8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for approximately 6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed. In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] = 16.75, P = 0.001) and 24-h recall interviews (F[1,125] = 6.70, P = 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] = 6.25, P = 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] = 4.03, P = 0.047). Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes.

Multisystemic Treatment of Poorly Controlled Type 1 Diabetes: Effects on Medical Resource Utilization

To determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease rates of hospital utilization and related costs of care among adolescents with poorly controlled type diabetes. Thirty-one adolescents were randomly assigned to receive either MST or standard care. MST lasted approximately 6 months, and all participants were followed for 9 months. Rates of inpatient admissions and emergency room (ER) visits were calculated for a 9-month prestudy period and during the 9 months of study participation. The relationship between changes in inpatient admissions and changes in metabolic control was also investigated. Intervention participants had a decreasing number of inpatient admissions from the baseline period to the end of the study, whereas the number of inpatient admissions increased for controls. Use of the emergency room did not differ. Related medical charges and direct care costs were significantly lower for adolescents receiving MST. Correlational analyses conducted with a subset of participants indicated that decreases in inpatient admissions were associated with improved metabolic control for MST but not control participants. Findings suggest that MST has the potential to decrease inpatient admissions among adolescents with poorly controlled type 1 diabetes.

SARS in Teaching Hospital, Taiwan

To the Editor: During the global epidemic of severe acute respiratory syndrome (SARS), the illness was transmitted rapidly within hospitals, which created pools of persons who became infected and through whom the disease was spread. Intrahospital transmission amplified regional outbreaks and augmented spread of the illness into the community (1–3). Healthcare workers, hospital patients, and hospital visitors accounted for 18%–58% of all cases of SARS in the five countries with the largest outbreaks (1,2). The concentration of SARS among hospital staff strained hospital facilities, personnel, and finances. National Taiwan University Hospital, established more than 100 years ago, is the first teaching hospital and the best resource in Taiwan for managing patients with illnesses that are difficult to treat. The hospital has 2,400 beds and provides primary and tertiary care services in Taipei. Taipei City was among the hardest hit areas by SARS in the world (3). From March 10 to July 23, 2003, the hospital reported 270 patients with SARS, many of whom were severely ill. The hospital treated 180 of the 665 patients with SARS reported in Taiwan, even though it was staffed by 4,450 of the country's 178,000 healthcare workers. SARS had an impact on this hospital for three likely reasons. First, the hospital identified and treated the first SARS patients in Taiwan (4,5). Second, it provided easy access through the emergency room and outpatient clinics. Febrile persons with a travel history to SARS-affected areas or other risk of SARS exposure came directly to this hospital for care. Third, many hospitals, particularly private facilities, were reluctant to report and admit patients with SARS during the early stage of the epidemic because of financial considerations and fear. The hospital felt the brunt of the epidemic in Taiwan during early May 2003, which paralleled the severity of the SARS epidemic in Taipei (3,4,6). The maximal number of SARS patients admitted to the hospital within 24 hours was 12 on May 3. The maximal number of SARS patients reported within 24 hours was 15 on May 6; 8 patients were transferred to other hospitals on May 7. However, 18 patients stayed overnight in the emergency room on May 7. Subsequently, SARS developed in 12 emergency room healthcare workers (6,7). Our preliminary studies showed that the average inpatient cost for patients with SARS was not higher than for patients with pneumonia, after adjustment for age, sex, and length of stay (MF Chen, unpub. data). However, SARS caused financial and operational disruptions in the hospital. During this period, hospital utilization rates decreased. Compared with the previous year's rates, outpatient and emergency visits fell to 37%, inpatient admissions fell to 29%, and surgical procedures fell to 15%. Bed occupancy decreased from 86% in May 2002 to 38% in May 2003. SARS also imposed physical and psychological concerns on the healthcare workers. During the later stage of the SARS epidemic, the Taiwan government offered special financial assistance to hospitals and healthcare workers as an incentive to help fight SARS. The country's National Health Insurance program compensated hospitals for the decrease in revenues, based on the hospital's reimbursement amount before the SARS epidemic. This measure was effective in motivating other hospitals to accept patients with SARS. The proportion of inpatients with SARS at the hospital dropped from 79.5% during March 10 to April 23, to 46.2% during April 24 to May 1, to 11.6% during May 2 to July 23. This financial assistance program remarkably reduced the impact on the hospital as other hospitals began treating patients with SARS. Preparations for a medical emergency must address the availability and quality of medical care as well as the implications for public health policy, including political, legal, social, financial, and ethical issues (1). The importance of a sound financial policy cannot be overemphasized. Since the 1980s, healthcare systems have become free market enterprises. Laws and regulations are needed to allow governments to mobilize the resources of all hospitals and compensate them during health crises. Government agencies need to work together with the healthcare system, including health insurance systems and social services, well in advance of epidemic emergencies to maximize limited resources and distribute them equitably. Democratic societies must preserve human rights (including the right to medical care and freedom from fear), while respecting and protecting the rights and safety of hospitals and healthcare workers. We now face the potential resurgence of SARS, other emerging and reemerging infectious diseases, and the threat of bioterrorism. Careful consideration of the financial issues of hospital management should be an important part of social policy. The emergence of SARS provides a reminder of the potential threat to the entire healthcare system when a new disease suddenly appears. A major lesson from the SARS experience is that government planning and intervention are required.

Association between Antihypertensive Agent Use and Hospital Admissions in a Managed Care Population

Utilization of medical care services has been used as a surrogate for outcome of patient compliance with treatment regimens. Antihypertensive treatment status and selection of drug agents may influence medical utilization. The purpose of this study was to determine the association between medically untreated hypertension and treated hypertension according to class of antihypertensive agent with the rate of hospitalization. This is a retrospective, observational study on adult hypertensive patients based on claim data from a network-model HMO. The 12,548 patients were identified by ICD-9-CM hypertensive codes over a 3-year period. The hospital admission rate was the outcome measurement. The exploratory variables included antihypertensive treatment status and drug class. Patients' age, gender, and coexisting medical conditions were treated as confounding factors. Descriptive analyses and multivariate regression analyses were performed. Coexisting medical conditions were significant factors in hospital admission rates. Compared with diuretic treatment, there were no differences in hospital admission rates among hypertensive patients treated with an angiotensin II antagonist or angiotensin-converting enzyme inhibitor. Untreated patients or those treated with beta-blockers or calcium channel blockers experienced higher hospitalization rates (95% CI, 1.25-1.90, 1.03-1.44, and 1.08-1.46, respectively). Compared with the major antihypertensive agents or no therapy for hypertension, diuretic or angiotensin-converting enzyme inhibitor therapy may result in a reduced rate of hospital utilization.

Relationships between pediatric asthma and socioeconomic/urban variables in Baltimore, Maryland

Spatial relationships between clinical data for pediatric asthmatics (hospital and emergency department utilization rates), and socioeconomic and urban characteristics in Baltimore City were analyzed with the aim of identifying factors that contribute to increased asthma rates. Socioeconomic variables and urban characteristics derived from satellite data explained 95% of the spatial variation in hospital rates. The proportion of families headed by a single female was the most important variable accounting for 89% of the spatial variation. Evidence suggests that the high rates of hospital admissions and emergency department (ED) visits may partially be due to the difficulty of single parents with limited resources managing their child's asthma condition properly. This knowledge can be used for education towards mitigating ED and hospital events in Baltimore City.

Analysis of healthcare utilization patterns and adherence in patients receiving typical and atypical antipsychotic medications

SUMMARYObjective: To examine the effects of typical and atypical antipsychotics on medication adherence and healthcare resource utilization.Research design and methods: This was a retrospective observational cohort analysis of pharmacy and medical health insurance reimbursement data of patients from a southeastern United States health plan. Pharmacy data of subjects between 6 and 65 years of age were identified. Inclusion criteria included initiation of a single antipsychotic agent between July 1, 1999 and September 30, 2000; no antipsychotic medication usage 6 months prior to the index prescription date; and continuous health plan enrollment for the 18-month study period. Multivariable methods were utilized to analyze healthcare resource utilizations between groups.Outcome measures: Primary outcome measures included: (1) adherence and persistence with antipsychotic therapy; (2) healthcare utilization for outpatient office and hospital visits, inpatient hospital visits, and emergency room visits; and (3) therapy modifications and concomitant medications.Results: A total of 469 patients met initial study criteria. Atypical and typical antipsychotics were prescribed to 384 and 85 patients, respectively. Length of therapy (days) for the atypical cohort was significantly longer (136 vs 80; p < 0.001). As defined using medication possession ratio (MPR), the atypical cohort was significantly more adherent to therapy than the typical cohort (mean MPR, 0.53 vs 0.24; p < 0.001). After adjusting for differences in demographics, baseline utilization, MPR, and length of therapy (n = 377), the atypical cohort experienced significantly fewer office visits (2,635 vs 4,249 per 1000 patients per month [P1000PPM]; p = 0.005), fewer inpatient admissions (197 vs 511 P1000PPM; p = 0.032), and fewer emergency room visits (125vs354 P1000PPM; p = 0.002).Conclusions: Atypical antipsychotic users were significantly more adherent to therapy, and had lower rates of office, hospital and emergency room utilization. Within the context of inherent limitations associated with health insurance claims databases, this study suggests that a relationship exists across cohorts between medication adherence and use of healthcare resources.

Health Service Utilization by Manitoba Children

To compare physician and hospital utilization rates by children across subregions of Manitoba. 1998/99 data for physician visits and hospitalizations for children aged 0 to 19 were extracted from the Population Health Research Data Repository. Rates of utilization were compared across 12 regions (RHAs) within Manitoba, and 12 community areas within Winnipeg. Rates were also compared across premature mortality rates (PMR) and area income levels. Substantial regional variation was found for utilization rates. The hospitalization rate for children from the three northern RHAs (highest PMRs) (114/1000) was almost four times the Winnipeg rate (30/1000) and almost double the rate for the rural south RHAs (lowest PMRs) (59/1000). The variation among regions in physician visits ranged from under 2 visits in 2 of the northern RHAs to almost 4 visits in urban areas. However, the low visit rates in rural RHAs are offset somewhat by greater use of nurses. Hospitalizations and physician visits were also related to area income level. Findings are discussed in terms of health care need.

Hospitalization of homeless persons with tuberculosis in the United States.

This study assessed whether homeless patients are hospitalized for tuberculosis (TB) more frequently and longer than other patients and possible reasons for this. We prospectively studied hospitalizations of a cohort of TB patients. HIV-infected homeless patients were hospitalized more frequently than other patients, while homeless patients who had no insurance or whose insurance status was unknown were hospitalized longer. Hospitalization cost $2000 more per homeless patient than for other patients. The public sector paid nearly all costs. Homeless people may be hospitalized less if given access to medical care that provides early detection and treatment of TB infection and disease and HIV infection. Providing housing and social services may also reduce hospital utilization and increase therapy completion rates.

Socioeconomic risk factors and population-based regional allocation of healthcare funds.

Using the notion of professional uncertainty a population-based proxy need measure for hospital services was developed. Its relationship with socioeconomic variables and Standardized Mortality Ratios (SMR) was investigated in an attempt to develop an adjustment factor for socioeconomic risk factors beyond age-sex adjustment to be used for a population-based healthcare funding formula for Alberta. The data used are 1990, 1991, 1992 vital statistics and hospital separation abstracts, 1991 census data and Refined Diagnosis Related Group (RDRG) case weights. Geographic units studied were the 26 federal electoral districts in Alberta using postal codes as a linkage geo-code between census and hospital utilization and death data. SMRs, age-sex standardized per capita hospital utilization and proxy need rates were derived and correlated with socioeconomic variables derived from the census files. It appears that the poor, the less educated and aboriginals need more hospital services than the affluent, employed and educated, confirming previous findings. The unemployed tend to need more but use fewer services while immigrants and non-white ethnics tend to need and use fewer services. The unemployed, less educated and non-white ethnics are associated with positive correlation with premature mortality (SMR based on deaths under age 75 years), while the employed, highly educated tend to live longer. In general SMRs have positive but very low correlations with utilization and need rates suggesting that SMRs should not be used for resource allocation. Stepwise multiple regression analyses showed that the percentages of unemployed, immigrants, non-whites, aboriginals and those with education less than grade 9 explain about 90% of the variation in age-sex standardized hospital utilization rates. Percentages of unemployed, non-white ethnics, residents with education less than grade 9 and aboriginals explained 71% of variations in age-sex standardized per capita proxy hospital service need measures. Based on the results of regression analyses, a SEAM (Socio-Economic Adjustment Multiplier) scale was developed for utilization (SEAM-U) and proxy needs (SEAM-N). In essence a SEAM is a set of relative value (RV) multipliers applicable to a provincial common per age-sex adjusted capita allocation value to account for the impact of socioeconomic risk factors on hospital service needs or utilization. Finally, the resulting regression equations derived from the 26 Federal electoral district data were applied to Alberta's health regions, regional SEAMs were derived, and the impact of such adjustment was assessed.

A Hierarchical Bayesian Model for Predicting the Rate of Nonacceptable In-Patient Hospital Utilization

A Hierarchical Bayesian Model for Predicting the Rate of Nonacceptable In-Patient Hospital Utilization

A Hierarchical Bayesian Model for Predicting the Rate of Nonacceptable In-Patient Hospital Utilization

A nonacceptable claim (NAC) is an insurance claim for an unnecessary hospital stay. This study establishes a statistical model that predicts the NAC rate. The model supplements current insurer programs that rely on detailed audits of patient medical records. Hospital discharge claim records are used as inputs in the statistical model to predict retrospectively the probability that a hospital admission is nonacceptable. A full Bayesian hierarchical logistic regression model is used with regression coefficients that are random across the primary diagnosis codes. The model provides better fits and predictions than standard methods that pool across primary diagnosis codes.

Cost of health care for a community of older adults in an urban academic healthcare system.

Urban academic medical centers provide care for large populations of vulnerable older adults. These patients often suffer a disproportionate share of chronic illnesses, disabilities, and social stressors that may increase health care costs. To describe the distribution and content of total healthcare costs accrued over a 4-year period by a community of older adults cared for in an urban academic healthcare system and to describe high-cost patients and utilization patterns. A cohort study. A tax-supported public healthcare system consisting of a 450-bed hospital and seven community-based ambulatory care centers. 12,581 patients aged 60 years and older who had at least two ambulatory visits and/or one hospitalization within the healthcare system from 1993 through 1995. Patient demographic and clinical characteristics, hospital and ambulatory utilization rates, and all healthcare costs accrued from 1993 through 1996 were determined. Costs were estimated from the perspective of the healthcare system using cost to charge ratios. The mean patient age was 70 years, 60% were women, 44% were Black, and 83% were covered by Medicare and/or Medicaid. Nearly 25% of patients were obese, 15.8% had a history of smoking, and 15.5% had evidence of malnutrition. The mean number of ambulatory visits per year was 4.3 (+/-7.2), and 38.1% of patients had been hospitalized one or more times. Within the 4-year window, 24.1% of patients had missed five or more appointments with their primary care physicians, 32.7% of patients had five or more unscheduled clinic visits, and 12.5% had five or more emergency room visits. Total health care costs for 4 years for this cohort of older adults was $125.2 million dollars, with per capita annual mean costs of $3893. Expenditures associated with hospitalizations accounted for 63.6% of healthcare costs. Total inpatient and outpatient costs for the 38% of patients hospitalized at least once accounted for 85.3% of all health care expenditures. Patients who died in the hospital did not accrue significantly greater costs than patients who died out of the hospital. Simulations of a random 5% adverse selection of high-cost patients among two capitated systems resulted in cost shifts of $11.1 million. Recorded smoking history, obesity, and low serum albumin were significantly associated with excess costs. Healthcare costs are concentrated in a significant minority of older adults. Costs accrued in conjunction with hospital stays dominate healthcare expenditures for this cohort of older adults. However, most older adults (83%) have one or fewer hospital episodes in a 4-year period. Although patients who died accrued greater healthcare costs, these costs were not higher when the death occurred in the hospital. Self-care behaviors are an important target for interventions to reduce costs.

Sex differences in the factors related to hospital utilization: results from the 1990 Ontario Health Survey.

We assessed the factors associated with hospital admission in Ontario, Canada, across age-specific and sex-specific groups. Data from the cross-sectional, population-based 1990 Ontario Health Survey (OHS) were used to examine the relationships between hospital admission and sociodemographic, health care need, psychosocial, and lifestyle factors. The OHS sample of 42,698 adults aged > or = 16 years, weighted to represent more than 7 million Ontarians, was used. Hospitalization rates per 1000 in the prior year were 130 for men and 203 for women. The higher rates for women are attributed in part to admissions related to childbearing. Women who delivered a child in the year before the OHS were excluded from subsequent analyses. Multivariate logistic regression models revealed that health care need (increasing number of health problems, fair/poor health status, older age) was the most important factor associated with higher hospitalization rates for men. For women, in addition to health care need, psychosocial (low/average well-being) and sociodemographic factors (married, low income, unemployed, English/French spoken in the home) were related to higher hospital utilization. Health care need is the most important factor for describing hospital use in men and women. However, rates of hospital utilization for women are more sensitive to sociodemographic factors even in a setting with universal health insurance. This suggests that among women, societal factors may exist that relate to potential disparities in access to health services. Efforts to assess how these factors operate are necessary to aid the development of interventions to minimize disparities that may exist.

Variations in hospitalization rates for asthma among Black and minority ethnic communities

In response to the introduction of ethnic monitoring within the U.K. hospital inpatient data set, this study investigates the variations in secondary healthcare utilization by Black and minority ethnic communities whose cause of admission is related to asthma. The study examines all residents of the West Midlands: over 5 million people, of whom 8·5% are from Black and minority ethnic groups. A retrospective study of 15 921 asthma-related hospital admissions, from 1 April 1995 to 31 March 1996, was carried out. Age-standardized admission rates were higher in all Black and minority ethnic groups studied than in the White group. There were elevated rates in Black children aged 5–14 years, and particular differences were observed for Indian and Bangladeshi men and women aged 65 years or over. Emergency admissions to hospital for asthma were strongly associated with patients' socioeconomic background but this was largely observed for Black and minority ethnic groups that also generally experience high levels of deprivation. The findings support previous studies which suggest that hospital utilization rates for asthma among people from Black and minority ethnic groups are high compared with the White group, despite little evidence in measured prevalence. This study suggests that ethnic background is more important in asthma admissions than deprivation, which raises serious concerns on the appropriateness and quality of asthma care for these patient groups within our society. Future studies need to examine pathways to care, that is the health-seeking behaviour of Black and minority ethnic groups, the type of treatment received at the primary care level and referral patterns to secondary care.

Hospital utilization and personality characteristics of veterans with psychiatric problems.

The relationship between hospital utilization and psychometric, demographic, and diagnostic data was examined among veterans with psychiatric problems. Data were obtained from the records of 500 psychiatric inpatients admitted to a Veterans Affairs medical center between 1984 and 1987 and followed for four years. All patients completed the Minnesota Multiphasic Personality Inventory, the California Personality Inventory, the Millon Clinical Multiaxial Inventory, and the Psychological Inventory of Personality and Symptoms. Stepwise linear regression analysis was used to predict the number and length of inpatient stays, and Cox and logistic regression analyses predicted rehospitalization. Higher rates of psychiatric hospital utilization were found among patients who were unmarried, who had disabilities connected with their military service, who had lower levels of adaptive functioning, and who were diagnosed as having posttraumatic stress disorder, drug or alcohol use disorder, or passive-aggressive or antisocial personality disorder. Higher utilization was also found among those whom psychometric data characterized as less responsible and more compulsive. The data also predicted the length of subsequent medical hospitalization and identified patients who stayed out of the hospital longer and who were not rehospitalized. Hospital utilization was found to be a function of psychiatric diagnosis, marital status, and various personality factors. Factors relating to social disadvantage also played a role. Axis I diagnoses, particularly substance use disorders, were as important as, if not more important than, axis II diagnoses in predicting utilization.