Risk Of Healthcare Utilization Research Articles

Evaluating fluvoxamine for the outpatient treatment of COVID-19: A systematic review and meta-analysis.

This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to evaluate the efficacy, safety, and tolerability of fluvoxamine for the outpatient management of COVID-19. We conducted this review in accordance with the PRISMA 2020 guidelines. Literature searches were conducted in MEDLINE, EMBASE, International Pharmaceutical Abstracts, CINAHL, Web of Science, and CENTRAL up to 14 September 2023. Outcomes included incidence of hospitalisation, healthcare utilization (emergency room visits and/or hospitalisation), mortality, supplemental oxygen and mechanical ventilation requirements, serious adverse events (SAEs) and non-adherence. Fluvoxamine 100mgtwice a day was associated with reductions in the risk of hospitalisation (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.58-0.97; I 2 =0%) and reductions in the risk of healthcare utilization (RR 0.68, 95% CI 0.53-0.86; I 2 =0%). While no increased SAEs were observed, fluvoxamine 100mgtwice a day was associated with higher treatment non-adherence compared to placebo (RR 1.61, 95% CI 1.22-2.14; I 2 =53%). In subgroup analyses, fluvoxamine reduced healthcare utilization in outpatients with BMI ≥30kg/m2 , but not in those with lower BMIs. While fluvoxamine offers potential benefits in reducing healthcare utilization, its efficacy may be most pronounced in high-risk patient populations. The observed non-adherence rates highlight the need for better patient education and counselling. Future investigations should reassess trial endpoints to include outcomes relating to post-COVID sequelaes. Registration: This review was prospectively registered on PROSPERO (CRD42023463829).

Impact of air pollution on healthcare utilization in patients with bronchiectasis.

Air pollutants are increasingly recognized to affect long-term outcomes in patients with bronchiectasis. We aimed to figure out the association between air pollutants and the risk of healthcare utilization in patients with bronchiectasis. Data for 1,029 subjects with bronchiectasis in Seoul were extracted. The air pollutants included particulate matter of 10 μm or less in diameter (PM10), particulate matter of 2.5 μm or less in diameter (PM2.5), sulfur dioxide (SO2), carbon monoxide (CO), ozone (O3), and nitrogen dioxide (NO2). The outcome was all-cause healthcare uses, defined as outpatient visit, emergency department visit, or hospitalization. The concentration-response curves between each air pollutant and relative risks for healthcare utilization were obtained. There were significant correlations between air pollutant concentrations and the risk of healthcare utilization, particularly for PM10, NO2, SO2, and CO. This risk was observed even at concentrations below the recommended safe thresholds for the general population. The slopes for the association between PM10 and NO2 and the risk of healthcare use showed a logarithmic growth pattern, with the steepest increase up to 30 μg/m3 and 0.030 parts per million (ppm), respectively. The curves for SO2 and CO showed an inverted U-shaped pattern, with a peak at 0.0045 ppm and a slow upward curve, respectively. No specific trends were observed for PM2.5 and O3 and the risk of healthcare use. Increased concentrations of PM10, NO2, SO2, and CO were associated with increased healthcare utilization in patients with bronchiectasis. For patients with bronchiectasis, there were no safety thresholds for those air pollutants, and even low levels of air pollutant exposure can negatively impact bronchiectasis outcomes.

Multimorbidity, Frailty and Diabetes in Older People-Identifying Interrelationships and Outcomes.

Multimorbidity and frailty are highly prevalent in older people with diabetes. This high prevalence is likely due to a combination of ageing and diabetes-related complications and other diabetes-associated comorbidities. Both multimorbidity and frailty are associated with a wide range of adverse outcomes in older people with diabetes, which are proportionally related to the number of morbidities and to the severity of frailty. Although, the multimorbidity pattern or cluster of morbidities that have the most adverse effect are not yet well defined, it appears that mental health disorders enhance the multimorbidity-related adverse outcomes. Therefore, comprehensive diabetes guidelines that incorporate a holistic approach that includes screening and management of mental health disorders such as depression is required. The adverse outcomes predicted by multimorbidity and frailty appear to be similar and include an increased risk of health care utilisation, disability and mortality. The differential effect of one condition on outcomes, independent of the other, still needs future exploration. In addition, prospective clinical trials are required to investigate whether interventions to reduce multimorbidity and frailty both separately and in combination would improve clinical outcomes.

The relationship between patient-reported distress and healthcare utilization in mNSCLC.

e24138 Background: Distress has a negative impact on the patient experience of cancer. We previously demonstrated that patients with metastatic non-small cell lung cancer (mNSCLC) face significant and sustained distress during first-line treatment. However, the association between distress and unplanned healthcare utilization (HCRU) is not well understood. Here we examine this association. Methods: We conducted secondary analyses of data from 152 adult patients with mNSCLC treated at Duke Cancer Institute who were part of a retrospective chart review study (3/15-6/20). For the original investigation, demographic, clinical, and distress data were abstracted. NCCN Distress Thermometer (DT) scores were recorded at each clinic visit from start of first-line therapy to end of first year, change in therapy or death. The DT is an 11-point ordinal scale, with a 39-item Problem List, assessing overall distress. DT scores of > = 4 indicate actionable distress. Further HCRU data were analyzed, including unplanned hospitalizations, 30-day readmissions, length of stay, clinic visits, infusion center visits, emergency department (ED) visits, and death. Descriptive statistical analyses were performed for sources of distress and HCRU. To examine the association between distress and HCRU, we utilized an adjusted frailty model (for baseline demographics, metastatic site, and National Cancer Institute Index). This Cox proportional hazards model allowed for multiple HCRU events per patient and included actionable distress as a time-dependent covariate. Results: First, the proportion of actionable DT scores (423/1652, 25.6%) was strikingly high. Most DTs included report of at least one physical problem (n = 1593, 96.4%), regardless of distress level. However, emotional problems (e.g., worry, nervousness, depression) were reported much more frequently when the DT score was actionable (61.9% vs. 20.8%). At the patient level (n = 152), actionable distress was associated with increased HCRU. For example, a larger proportion of those with an average DT score > = 4 had at least one hospitalization (n = 22, 53.7%), infusion center visit (n = 11, 26.8%) or ED visit (n = 28, 68.3%) compared to patients with a non-actionable average DT score. Furthermore, HCRU was 54% more likely to occur after a patient reporting actionable distress compared to a patient reporting lower distress levels any time during treatment (adjusted HR 1.54; CI 1.20, 1.97). A one-point increase in distress was associated with an 8% increase in risk of HCRU (HR 1.08; CI 1.03, 1.13) at any point during treatment. Conclusions: Patients with mNSCLC experience high levels of distress, with actionable distress appearing to be driven significantly by emotional problems. Patient-reported distress is also associated with HCRU. Intervention development and testing is needed to address the unmet psychological needs in lung cancer care and their potential impact on unplanned HCRU.

Prevalence of co-occurring serious illness diagnoses and association with health care utilization at the end of life.

End-of-life care differs by serious illness diagnosis. Cancer and dementia are serious illnesses that have been associated with less intensive end-of-life health care use. It is not known how health care utilization varies in the presence of >1 serious illness. We used the Rochester Epidemiology Project to identify persons living in a midwestern area who died on July 1, 2017-June 30, 2018 at age ≥65 years, and were seriously ill. We examined the number of emergency department (ED), hospital, and intensive care unit (ICU) stays in the last 6 months and the last 30 days of life. We used Poisson regression to determine the incidence rate ratio for ED, hospital, and ICU stay in the last 6 months and 30 days of life by number of serious illness diagnoses. For cancer and dementia, we examined the effect of an additional serious illness. We included a population of 1372 adults who were, on average, 84 years, 52% female, and 96% white. Approximately 41% had multiple serious illnesses. Compared to older adults with 1 serious illness diagnosis, rates of hospitalization, and ICU stay for adults with 2 or ≥3 serious illness diagnoses were at least 1.5 times higher in the last 6 months and the last 30 days of life. Rates of ED visits were significantly higher for older adults with 2 or ≥3 serious illness diagnoses in the last 6 months of life, but only higher for those with ≥3 versus 1 serious illness diagnosis in the last 30 days of life. For both cancer and dementia, rates of ED visits, hospitalization and ICU stay were lower for the condition alone than when an additional serious illness diagnosis was present. Having multiple serious illnesses increases the risk of health care utilization at the end of life.

Impact of Physical and Social Frailty on the Utilization of Nursing Care Services in Very Old Adults

Frailty, characterized by increased vulnerability to external stressors, has been found to increase the risk of healthcare utilization and nursing home admission. As the age group of 80 years or older remains frequently underrepresented in previous research, this study examined the impact of physical and social frailty on the utilization of nursing care services in very old population of North Rhine-Westphalia. Using data from a representative cross-sectional study, 1,577 community-dwelling and institutionalized individuals aged ≥80 years were included. Physical frailty was defined according to Fried’s criteria (exhaustion, weight loss, low handgrip strength, low physical activity). Social frailty was measured with self-reported loneliness, social isolation, and time spent with others. The use of outpatient care services, day care, informal and inpatient care were considered. Multinomial regression was applied to investigate the impact of physical and social frailty on the use of outpatient and inpatient care services, controlling for relevant sociodemographic and health related characteristics. Compared to very old adults who did not use any care services, no association was found between frailty and the use of outpatient or informal care. Comparing nonusers of care services with institutionalized individuals, nursing home residents were less likely to experience physical frailty and pre-frailty, but were more likely to be socially isolated and to feel lonely. These findings suggest that physical frailty might have been successfully prevented in the context of institutional inpatient care. However, early identification and intervention focused on social inclusion of the institutionalized very old individuals are needed to reverse social frailty.

Effect of COVID-19 on demand for healthcare in Togo

BackgroundDemand-side barriers to health care are as important as supply-side factors in deterring patients from obtaining effective treatment during COVID-19. Developing countries, including Togo, have focused on reducing the risk of health care utilization during this period by ensuring basic health care services as an important policy to improve health outcomes and meet international obligations to make health services accessible.MethodsThe data used to cover all 44 districts in the six (6) health regions of Togo, are from a national home survey. They are collected from July 8th to 17th, 2020. In each district chief town, a minimum of thirty (30) households were included by a systematic two-stage random draw (neighborhood and then home). Based on these data, the multinomial regression model was used to identify risk factors for the request for health care services during COVID-19.ResultsA total of 1946 (with a response rate of 98.3%) participants were addressed in the study. The finding on households with age above 60 years indicated that the relative risk ratio (RRR = 23.97; 95% CI = 0.93; 615.38) allowed them to practice self-medication in lieu of modern healthcare facilities. The multinomial model revealed that the relative risk ratio of pre-COVID-19 activities (RRR = 4.87; 95% CI = 1.018; 23.38) permits households to rely on their self-medication choice and (RRR = 3.14; 95% CI = 0.91; 0.83) prefer public health facilities. Given that the head of the households (RRR = 0.19; 95% CI = 0.017, 2.11) is educated, he prefers the choice of private health centers during COVID-19 pandemic to public health facilities.ConclusionThis study has demonstrated that the majority (30.49%) of patients sought health care. The analysis shows that the loss of employment, activities before COVID-19 in households and areas not infected by the pandemics allow them to ask for health care (self-medication and public hospitals) despite the COVID-19 impacts. However, higher education and age determine a different choice of health care delivery by households. Thus, policy makers need to cast special emphasis on social policies to address home health shocks.

Association of Childhood Atopic Dermatitis With a Higher Risk of Health Care Utilization and Drug Use for Asthma: A Nationwide Cohort Study

Overwhelming evidence supports a causal relationship between occurrence of asthma and atopic dermatitis (AD). The aims of the study were to determine the incidence of asthma in children with AD and to examine the health care utilization and drug use for asthma in children with AD. Children with hospital-diagnosed AD (cases) were matched with individuals from the background population (controls) in a 1:4 ratio. In the final cohort (18,625 cases and 74,500 controls), the incident cases of asthma were 4203 among AD cases and 5298 in controls, corresponding to incidence rates of 34 and 9 in cases and controls per 1000 person-years, respectively (hazard ratio [HR] = 3.82, 95% confidence interval [CI] = 3.65-4.00). During the 1-year follow-up period from asthma diagnosis, children with concomitant AD had a significantly higher risk of hospital admission (HR = 1.97, 95% CI = 1.63-2.37), emergency department visits (HR = 1.62, 95% CI = 1.22-2.14), outpatient visits (HR = 1.97, 95% CI = 1.74-2.23), asthma medication (HR = 1.31, 95% CI = 1.27-1.35), and rescue course corticosteroids (HR = 1.74, 95% CI = 1.13-2.69) compared with children with asthma only. The risk of being diagnosed with asthma was higher in children with AD. Risk of health care utilization and drug use for asthma was higher in children with both AD and asthma compared with asthma only.

Frailty Predicts Increased Health Care Utilization Among Community-Dwelling Older Adults: A Longitudinal Study in China

ObjectivesFrailty, a multidimensional syndrome characterized by vulnerability to stressors, is an emerging public health priority with high prevalence in older adults. Frailty has been identified to predictive negative health outcomes, yet quantified evidence regarding its effect on health care systems is scarce. This study examines how frailty affects health care utilization, and explores whether these associations varied by gender. DesignCohort study with a 2-year follow-up. Settingand Participants: Data were derived from 2 waves (2011 and 2013) of the China Health and Retirement Longitudinal Study, and 3119 community-dwelling participants aged ≥60 years were analyzed. MethodsFrailty was assessed by a validated frailty phenotype scale, and measures for health care utilization were self-reported. Panel data approach of mixed-effects regression models was used to examine the associations. ResultsLongitudinal results demonstrated that compared with robustness, prefrailty and frailty were both significantly associated with increased likelihood of outpatient visit, inpatient visit, and inpatient length of stay, even after adjusting for multimorbidity in multivariate analyses (all P < .05). Every 1-component increase in frailty was also found to significantly increase the risk for health care utilization [any outpatient visit: adjusted odds ratio (OR) 1.30, 95% confidence interval (CI) 1.14–1.48; number of outpatient visits: adjusted incident rate ratio (IRR) 1.34, 95% CI 1.18–1.53; any inpatient visit: adjusted OR 1.44, 95% CI 1.22–1.71; number of inpatient visits: adjusted IRR 1.40, 95% CI 1.20–1.62; inpatient length of stay: adjusted IRR 1.50, 95% CI 1.18–1.92]. The preceding associations were similarly observed irrespective of gender. Conclusions and ImplicationsFrailty is a significant predictor for increased health care utilization among community-dwelling older adults. These findings have important implications for routine clinical practice and public health investment. Early screening and intervention for potentially modifiable frailty could translate into considerable savings for households and health care systems.

Physical Frailty, Cognitive Impairment, and Healthcare Utilization in Linked Cohort and Claims Data

Accurate prediction of healthcare utilization is an important issue for Medicare managed care organizations. We hypothesized that physical frailty and cognitive impairment increase the risk of healthcare utilization in older adults receiving Medicare coverage, independent of age and multimorbidity. We used the marginal means/rates model to investigate the association between baseline cognitive impairment with/without frailty (using the physical frailty phenotype), vs. frailty alone, in NHATS and the number of incident non-ER-related hospitalizations and emergency room (ER) visits within 12 months in linked Medicare claims data (N=3,915). After covariate adjustment, physical frailty alone was predictive of both non-ER-related hospitalizations (HR=1.77; p=0.012) and ER visits (HR=1.75; p<0.001). Cognitive impairment with or without frailty was only associated with ER visits (HR=1.53, p=0.002; HR=1.30, p=0.001). Our findings support the value of physical frailty and cognitive impairment assessment above and beyond multimorbidity to improve the prediction of care utilization for vulnerable subgroups of Medicare beneficiaries.

Specialist psychiatric health care utilization among older people with intellectual disability \u2013 predictors and comparisons with the general population: a national register study

BackgroundPeople with intellectual disability (ID) face considerable barriers to accessing psychiatric health care, thus there is a risk for health disparity. The aims of the present study were 1) to compare specialist psychiatric health care utilization among older people with ID to that with their age peers in the general population, taking into account demographic factors and co-morbidities associated with specialist psychiatric health care utilization and 2) to determine a model for prediction of specialist psychiatric health care utilization among older people with ID.Material and methodsWe identified a national cohort of people with ID (ID cohort), aged 55+ years and alive at the end of 2012 (n = 7936), and a referent cohort from the general population (gPop cohort) one-to-one matched by year of birth and sex. Data on utilization of inpatient and outpatient specialist psychiatric health care, as well as on co-morbidities identified in either psychiatric or somatic specialist health care, were collected from the National Patient Register for the time period 2002–2012.ResultsAfter adjusting for sex, age, specialist psychiatric health care utilization the previous year, and co-morbidities, people in the ID cohort still had an increased risk of visits to unplanned inpatient (relative risk [RR] 1.95), unplanned outpatient (RR 1.59), planned inpatient (RR 2.02), and planned outpatient (RR 1.93) specialist psychiatric health care compared with the general population. Within the ID cohort, increasing age was a predictor for less health care, whereas psychiatric health care the previous year predicted increased risk of health care utilization the current year. As expected, mental and behavioral disorders predicted increased risk for psychiatric health care. Furthermore, episodic and paroxysmal disorders increased the risk of planned psychiatric health care.ConclusionsOlder people with ID have a high need for psychiatric specialist health care due to a complex pattern of diagnoses. Further research needs to investigate the conditions that can explain the lesser psychiatric care in higher age groups. There is also a need of research on health care utilization among people with ID in the primary health care context. This knowledge is critical for policymakers’ plans of resources to meet the needs of these people.

The Association Between Neighborhood Socioeconomic and Housing Characteristics with Hospitalization: Results of a National Study of Veterans.

Social determinants of health (SDOH) have an inextricable impact on health. If remained unaddressed, poor SDOH can contribute to increased health care utilization and costs. We aimed to determine if geographically derived neighborhood level SDOH had an impact on hospitalization rates of patients receiving care at the Veterans Health Administration's (VHA) primary care clinics. In a 1-year observational cohort of veterans enrolled in VHA's primary care medical home program during 2015, we abstracted data on individual veterans (age, sex, race, Gagne comorbidity score) from the VHA Corporate Data Warehouse and linked those data to data on neighborhood socioeconomic status (NSES) and housing characteristics from the US Census Bureau on census tract level. We used generalized estimating equation modeling and spatial-based analysis to assess the potential impact of patient-level demographic and clinical factors, NSES, and local housing stock (ie, housing instability, home vacancy rate, percentage of houses with no plumbing, and percentage of houses with no heating) on hospitalization. We defined hospitalization as an overnight stay in a VHA hospital only and reported the risk of hospitalization for veterans enrolled in the VHA's primary care medical home clinics, both across the nation and within 1 specific case study region of the country: King County, WA. Nationally, 6.63% of our veteran population was hospitalized within the VHA system. After accounting for patient-level characteristics, veterans residing in census tracts with a higher NSES index had decreased odds of hospitalization. After controlling all other factors, veterans residing in census tracts with higher percentage of houses without heating had 9% (Odds Ratio, 1.09%; 95% CI, 1.04 to 1.14) increase in the likelihood of hospitalization in our regional Washington State analysis, though not our national level analyses. Our results present the impact of neighborhood characteristics such as NSES and lack of proper heating system on the likelihood of hospitalization. The application of placed-based data at the geographic level is a powerful tool for identification of patients at high risk of health care utilization.

Expenditure variations analysis using residuals for identifying high health care utilizers in a state Medicaid program

BackgroundHigh utilizers receive great attention in health care research because they have a largely disproportionate spending. Existing analyses usually identify high utilizers with an empirical threshold on the number of health care visits or associated expenditures. However, such count-and-cost based criteria might not be best for identifying impactable high utilizers.MethodsWe propose an approach to identify impactable high utilizers using residuals from regression-based health care utilization risk adjustment models to analyze the variations in health care expenditures. We develop linear and tree-based models to best adjust per-member per-month health care cost by clinical and socioeconomic risk factors using a large administrative claims dataset from a state public insurance program.ResultsThe risk adjustment models identify a group of patients with high residuals whose demographics and categorization of comorbidities are similar to other patients but who have a significant amount of unexplained health care utilization. Deeper analysis of the essential hypertension cohort and chronic kidney disease cohort shows these variations in expenditures could be within individual ICD-9-CM codes and from different mixtures of ICD-9-CM codes. Additionally, correlation analysis with 3M™ Potentially Preventable Events (PPE) software shows that a portion of this utilization may be preventable. In addition, the high utilizers persist from year to year.ConclusionsAfter risk adjustment, patients with higher than expected expenditures (high residuals) are associated with more potentially preventable events. These residuals are temporally consistent and hence may be useful in identifying and intervening impactable high utilizers.

CACHEXIO: Evaluation of body composition changes and immunotherapy in patients with metastatic cancer.

209 Background: Given body composition predicts toxicity for patients receiving cytotoxic chemotherapy, we explored changes in body composition and biomarkers as predictors of immune-related adverse events (irAEs) and health care utilization. Methods: We conducted a longitudinal study of patients with metastatic solid tumor receiving immunotherapy (07/2014-10/2017). Eligible patients had a computed tomography (CT) scan prior to first-line immunotherapy with at least two additional CT scans at three, six or nine months after immunotherapy initiation. We analyzed body composition using cross-sectional CT scans at the third lumbar vertebra. We utilized mixed effect linear regression models to assess longitudinal changes in body composition (weight, skeletal muscle, total adipose). We examined associations of baseline body composition and biomarkers (albumin, neutrophil-lymphocyte ratio (NLR)) with the incidence of irAEs and healthcare utilization (hospitalizations/ED visits) using logistic regression. Results: Of 140 patients treated with immunotherapy, 61 met inclusion criteria. The majority (80%) received prior chemotherapy and the most common malignancies included lung (26%), head and neck (20%), and melanoma (20%). We found that one-third (n=19) experienced an irAE and colitis (53%) was the most common irAE. Patients experienced substantial weight loss over time (B= -1.88, p&lt;0.001) with a decrease both in skeletal muscle (B= -3.08, p=0.001) and total adipose tissue (B =-50.44, p&lt;0.001). We found greater skeletal muscle at baseline was associated with lower risk of health care utilization (OR 0.98, 95% CI: 0.965-0.998, p=0.03). We observed no association with biomarkers and/or body composition variables with irAEs or health care utilization. Conclusions: Patients with metastatic cancer receiving immunotherapy lose weight including skeletal muscle and adipose tissue. Aside from higher baseline skeletal muscle predicting less health care utilization, we did not observe any other associations between body composition changes and irAEs or health care utilization.

Ambient Air Pollution and Variation in Multiple Domains of Asthma Morbidity among Peruvian Children.

A large portion of asthma morbidity occurs in low- and middle-income countries, and Peru suffers particularly high asthma prevalence. Ambient air exposures are also high, and likely play a role. Most studies of environmental exposures focus on understanding contributors to health care utilization or mortality risk; however, less severe outcomes may still impact quality of life (QOL). To study the association between multiple pollutants and several asthma domains in Peruvian children. A total of 484 children aged 9-19 years with asthma were followed for 6-9 months, and evaluated for asthma control, asthma-related QOL, missed school days, and health care utilization. We used geographically distributed monitors to estimate air pollutant concentrations and multivariable generalized linear mixed models to model asthma outcomes as a function of pollutants. A total of 67% of children had moderate to severe persistent asthma. In multipollutant models, higher particulate matter less than 2.5 μm in aerodynamic diameter (PM2.5), black carbon, and nitrogen dioxide concentrations were independently associated with worse asthma control. For each interquartile range increase in PM2.5 or nitrogen dioxide concentration, there was a 59% or 34% higher odds of uncontrolled asthma, respectively. If the proportion of PM2.5 that was black carbon increased, there were increased odds of uncontrolled asthma. Similarly, pollutants were independently associated with worse asthma-related QOL, and PM exposure was associated with increased risk of health care utilization. Our study highlights the importance of pollutant exposures on multiple domains of asthma morbidity among Peruvian children, including not only acute exacerbations, but also on general asthma burden, such as worse asthma symptom control and QOL.

In a Longevity Society, Loss and Grief Are Emerging Risk Factors for Health Care Use: Findings From the Health and Retirement Survey Cohort Aged 50 to 70 Years.

In a society of long lives, parent and child life can overlap by as much as 50 years. Most children now experience the death of their parents as adults. Many of the 2.5 million deaths each year in the United States are parents. Parental loss is a risk factor for subsequent illness. The Health and Retirement Survey is a representative cohort of persons aged 50 to 70 years. Using the 2010 cohort data, we estimate risk for use of health care after the death of a parent. Loss is a near universal experience in the cohort (87%). A report of any loss increases risk of health care utilization by 20% to 30%. For a longevity society, preventing loss-related hospitalization is a measurable outcome for bereavement care.

Who Participates in Chronic Disease Self-management (CDSM) Programs? Differences Between Participants and Nonparticipants in a Population of Multimorbid Older Adults

Self-care management is recognized as a key component of care for multimorbid older adults; however, the characteristics of those most likely to participate in Chronic Disease Self-Management (CDSM) programs and strategies to maximize participation in such programs are unknown. To identify individual factors associated with attending CDSM programs in a sample of multimorbid older adults. Participants in the intervention arm of a matched-pair cluster-randomized controlled trial of the Guided Care model were invited to attend a 6-session CDSM course. Logistic regression was used to identify factors independently associated with attendance. All subjects (N = 241) were aged 65 years or older, were at high risk for health care utilization, and were not homebound. Baseline information on demographics, health status, health activities, and quality of care was available for CDSM participants and nonparticipants. Participation was defined as attendance at 5 or more CDSM sessions. A total of 22.8% of multimorbid older adults who were invited to CDSM courses participated in 5 or more sessions. Having better physical health (odds ratio [95% confidence interval] = 2.3 [1.1-4.8]) and rating one's physician poorly on support for patient activation (odds ratio [95% confidence interval] = 2.8 [1.3-6.0]) were independently associated with attendance. Multimorbid older adults who are in better physical health and who are dissatisfied with their physicians' support for patient activation are more likely to participate in CDSM courses.

Cost of anxiety disorders: Impact of comorbidity

The aim of this study was to assess the relative impact of co-mobidity and of symptom severity on the costs of caring for patients with generalized anxiety disorders (GAD). One thousand and fortytwo patients with GAD according to DSM III-R were observed by psychiatrists using a cross-sectional methodology. Demographic, clinical, therapeutic as well as health care utilization data were collected at a single point in time. Patients were stratified according to prevalence of co-morbidity. An economic analysis was performed based on a societal perspective. Hospitalizations and losses of productivity were the two major components of costs both in patients with and without co-morbidity. On the other hand costs of pharmaceuticals remain a marginal component of costs associated with GAD in the two groups. Controlling for confounding variables, the prevalence of health care utilisation was found to be significantly higher in patients with co-morbidity for hospitalization, laboratory tests, medications and absenteeism from work. Most of cost components were found to be significantly higher in patients with co-morbidity. The relative risk of health care utilization was higher in patients with co-morbidity, past history of anxiety, high level of anxiety as well as in older patients. Overall our findings suggest that both co-morbidity and symptom severity play a role in cost generation in GAD patients.