Secondary Care Utilisation Research Articles

PP30 Primary Care Utilisation and its Socio-Economic Determinants: findings from the Lifeways Cross-Generation Cohort Study During the Recession Period in the Republic of Ireland

BackgroundWorldwide there is a well-established association between rates of primary and secondary health care utilisation and socio-economic deprivation. The collapse of the Celtic Tiger economy and recession in 2006/7 may...

Analysis of the Impact of the Birmingham OwnHealth Program on Secondary Care Utilization and Cost: A Retrospective Cohort Study

This study aimed to assess the impact of the Birmingham OwnHealth(®) program (a partnership among the National Health Service [NHS] Birmingham East and North, formerly Birmingham East and North PCT, as the commissioner, Pfizer Health Solutions [Tadworth, United Kingdom] as the primary contractor, and NHS Direct as a subcontractor) on the number of unscheduled secondary care spells and the cost of care for patients with long-term conditions. This article reports a retrospective cohort study conducted at the NHS Birmingham East and North. Adults with at least 1 of 10 defined long-term conditions were eligible for inclusion. Patients in the OwnHealth program were compared with those in a matched comparison group from a population who were eligible but did not enroll in the program. The main outcome measures were the difference in the number of secondary care spells (defined as the experience between hospital admission and discharge) between the OwnHealth group and the comparison group and the difference in the cost of care (calculated from the cost of activities during secondary care spells). The mean number of secondary care spells per person per year in the OwnHealth group was 0.61 (standard deviation [SD] 1.35) compared with 0.84 (SD 1.49) in the comparison group (p<0.0005). This constituted a 27% reduction in secondary care spells per person per year. The mean cost of secondary care spells per person per year in the OwnHealth group was $1,305 (SD $3,138) compared with $1,678 (SD $3,485) in the comparison group (p<0.0005). This difference in costs constituted a 27% reduction in utilization and 22% reduction in cost of secondary care with the OwnHealth program. Telehealth intervention can reduce the cost of secondary care of some patients with long-term conditions.

High referral rates to secondary care by general practitioners in Norway are associated with GPs’ gender and specialist qualifications in family medicine, a study of 4350 consultations

BackgroundReferral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation.MethodsThe probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics.ResultsOf the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36).In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively).The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced.ConclusionsThe main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself.

Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation.

In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner's Chronic Care Model. Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation. Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes. Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience, case management approaches need to be introduced in a way which respects patients' wishes, for example the ability to see a familiar doctor or nurse.

Morbidity figures from general practice: sex differences in traumatology

Trauma prevention starts with to find out the extent of the problem and who it affects. Insight into morbidity figures is therefore necessary. To explore sex differences in traumatology and secondary medical care utilization in primary care related to age and socio-economic status (SES). Data were obtained from an academic continuous morbidity registration project in the Netherlands in the period from 1996 to 2006, in which 13,000 patients were followed in 10 successive years. Sex differences showed a male excess from childhood to 45 years and women showing almost double trauma rates in the elderly. Low SES was associated with the greatest incidence of traumas. The largest sex difference in incidence above 65 years appeared in the high SES with more traumas in women compared with men. From this age on, female morbidity in traumatology outnumbered male morbidity regardless of SES. Considering use of referrals, we found that in the age group 15-45 years men made a greater use of secondary medical care. However, the vastest gender influence in medical care utilization was noticed in the age group over 65 years, outnumbered with women. Young men and old women are the most at risk for traumatic health problems: men presenting with traumata of the skull, the tibia and ocular trauma's and women with fractures of the femur, humerus and wrist. For both men and women the greatest incidence is in the low SES. Family physicians can play a pivotal role in prevention to focus on their patients with high risks.

Do Secondary Conditions Explain the Relationship Between Depression and Health Care Cost in Women With Physical Disabilities?

Morgan RO, Byrne MM, Hughes RB, Petersen NJ, Taylor HB, Robinson-Whelen S, Hasche JC, Nosek MA. Do secondary conditions explain the relationship between depression and health care cost in women with physical disabilities? Objective To examine the influence of depression on health care utilization and costs among women with disabilities and to determine whether the severity of other secondary health conditions affects this association. Design A time series of 7 interviews over a 1-year period. Setting Large, southern metropolitan area. Participants Community-dwelling women (N=349) with a self-identified diagnosis of a physical disability. Interventions Not applicable. Main Outcome Measures Primary disability, secondary health conditions (Health Conditions Checklist), depressive symptoms (Beck Depression Inventory–Second Edition), and health care utilization (based on the Health and Social Service Utilization Questionnaire and the Stanford Health Assessment Questionnaire). We estimated health care costs using standardized criteria and published average costs. Results Outpatient and emergency department health care utilization and overall costs were higher in women with depressive symptoms and increased with the frequency and severity of the symptoms. Depressive symptoms were highly correlated with the severity of secondary health conditions. Adjusting for demographics and primary disability, both the presence and severity of depressive symptoms were associated with significantly higher health care costs. However, secondary health condition severity explained the association between depressive symptoms and cost; it also substantially increased the variance in cost that was explained by the multivariate models. Conclusions Secondary health conditions are significantly associated with depressive symptoms and higher health care costs, with secondary health conditions accounting for the association between depressive symptoms and costs. This association suggests that effective management of secondary health conditions may help reduce both depressive symptomatology and health care costs.

Understanding secondary databases: a commentary on “Sources of bias for health state characteristics in secondary databases”

Understanding secondary databases: a commentary on “Sources of bias for health state characteristics in secondary databases”

Health promotion for people with disabilities: development and evaluation of the Living Well with a Disability program

People with disabilities can benefit from health promotion opportunities to reduce the incidence and severity of secondary conditions that further limit their participation in society. This paper describes participatory action research (PAR) methods we used to develop, implement and evaluate the Living Well with a Disability program. Community-based agencies that provide information and referral services to people with disabilities (independent living centers funded under Title VII, Rehabilitation Act) recruited a convenience sample of 246 people with mobility impairments to participate in a randomly assigned, wait-list control health promotion intervention study. Paper-and-pencil outcome measures included the secondary conditions surveillance instrument, unhealthy days and health care utilization. Logistic regression on outcomes controlling for demographic variables and pre-test measures indicated reductions in all three outcome variables. People with mobility impairments who participated in the Living Well with a Disability program reported less limitation from secondary conditions, fewer unhealthy days and less health care utilization. PAR methods are particularly important to design useful interventions for this population.

Living Well With a Disability Health Promotion Intervention: Improved Health Status for Consumers and Lower Costs for Health Care Policymakers.

Objective: Investigate effectiveness of a health promotion intervention for adults with mobility impairments. Study Design: Interrupted time series, staggered baseline quasi-experimental with random assignment to treatment start date. Setting: 9 Centers for Independent Living in 8 states. Participants: Adults with mobility impairments living independently (N 188). Intervention: Living Well With a Disability: Facilitated group health promotion (16 hr over 8 weeks). Main Outcomes Measures: Secondary conditions, symptom days, health care utilization. Results: Reductions in limitation from secondary conditions, symptom days, and health care utilization over the intervention period. Effects on secondary conditions maintained for 12 months. Overall cost savings of $807 per person (total for sample $151,716) projected from reductions in health care utilization of study sample. Conclusions: Health promotion interventions can increase quality of life while helping to control health care costs.

Rehabilitation of COPD patients: which training modality

Non pharmacological therapy has been gaining more interest and has been evolving rapidly over the last decade as an essential part of therapy for COPD patients. Pulmonary Rehabilitation (PR), the most important non pharmacological treatment in patients with COPD, has a primary goal: to achieve the highest possible level of individual exercise tolerance, thus reducing the primary and/or secondary health care utilisation. The aim of the present review is to focus the role of exercise training in these patients as well as to address the question on which training methods are the most beneficial. We have therefore undertaken a MEDLINE-based search including the terms: pulmonary rehabilitation, exercise, lung disease/obstructive. Several strategies based on endurance or strength training are nowadays implemented during PR programmes in order to maximise the benefits for each patient. The impaired function of ambulation muscles causing breathlessness as one of the more frequent symptoms in many COPD, suggests that training the lower extremities is the most important goal to achieve during pulmonary rehabilitation of these patients. On the other hand, as muscle strength appears to be an independent contributor to survival and utilisation of health care resources, it seems largely justified also to include this further modality in the PR program of these patients. In conclusion, both modalities are effective and useful for COPD patients. However, whether resistance training should be administered to all COPD and which is the optimal length of strength training still needs to be elucidated.

The Cost of Childhood Respiratory Illness: The Primary and Secondary Care Interface

Introduction:Although the prevalence of asthma has increased over the past two decades, there is no comprehensive method for calculating the financial cost of the condition to include both primary and secondary sectors.Objective:To quantify the cost of healthcare provision in primary and secondary care in relation to respiratory illness.Methods:A sample of children (n=713) was randomly selected from respondents to a postal respiratory questionnaire sent out to two general practice populations in 1993. The selected children were stratified according to responses to five key questions on the questionnaire. An increasing number of positive responses to the key questions indicated an increasing likelihood of asthma. Details of all the children's primary and secondary care utilisation over a two-year period were obtained from general practice records. A method was then established to calculate unit costs for all aspects of primary and secondary care, which were then applied to the utilisation data.Results:The cost of healthcare provision in both primary and secondary care increased as the children's likelihood of asthma increased, with a statistically significant linear trend (p<0.05). The majority of care was provided in primary care for both respiratory and non-respiratory illness, however, the majority of cost was located in secondary care. The ‘likely asthmatics’ accounted for a greater proportion of the total cost of care (61%) than the ‘unlikely asthmatics’.Conclusions/Recommendations:The findings of this study have relevance for both primary and secondary care, as have the established unit costs; in providing information for resource allocation decisions.

Hospital utilization as a function of social deprivation: diabetes vs non-diabetes.

We tested the hypothesis that a relationship between ill health and deprivation exists for patients with diabetes, distinct from that experienced by the non-diabetic population. Age standardized admission and appointment rates and proportion of total activity for patients with and without diabetes were determined by electoral ward and correlated with the Townsend index of social deprivation for the health district of South Glamorgan (population 408,000). Both diabetic (r = 0.78, p < 0.001) and non-diabetic (r = 0.74, p < 0.001) in-patient admissions were positively correlated with social deprivation. This relationship also existed for attended out-patient appointments (r = 0.67, p < 0.001 and r = 0.45, p < 0.01, respectively). The proportion of diabetic to non-diabetic admissions by ward also showed a positive correlation for in-patients (r = 0.47, p < 0.001). This remained true for IDDM (r = 0.23, not significant) and NIDDM (r = 0.62, p < 0.001) diabetes, for admissions for coronary heart disease (r = 0.50, p < 0.001) and cerebrovascular disease (r = 0.29, p < 0.05), elective admissions (r = 0.30, p > 0.05), and emergency admissions (0.46, p < 0.001). Our results suggest that secondary care utilization is positively correlated with social deprivation and that this relationship is stronger in the diabetic population. This may be due to different prevalence rates or increased complications requiring hospital treatment in different social circumstances. Further research is required to examine these factors more closely.

New oxide of nitrogen : R.^Leonard Hasche, of the University of California ( Jour. Am. Chem. Soc., 1925, 47, 2143–2148)

Morgan RO, Byrne MM, Hughes RB, Petersen NJ, Taylor HB, Robinson-Whelen S, Hasche JC, Nosek MA. Do secondary conditions explain the relationship between depression and health care cost in women with physical disabilities?To examine the influence of depression on health care utilization and costs among women with disabilities and to determine whether the severity of other secondary health conditions affects this association.A time series of 7 interviews over a 1-year period.Large, southern metropolitan area.Community-dwelling women (N=349) with a self-identified diagnosis of a physical disability.Not applicable.Primary disability, secondary health conditions (Health Conditions Checklist), depressive symptoms (Beck Depression Inventory–Second Edition), and health care utilization (based on the Health and Social Service Utilization Questionnaire and the Stanford Health Assessment Questionnaire). We estimated health care costs using standardized criteria and published average costs.Outpatient and emergency department health care utilization and overall costs were higher in women with depressive symptoms and increased with the frequency and severity of the symptoms. Depressive symptoms were highly correlated with the severity of secondary health conditions. Adjusting for demographics and primary disability, both the presence and severity of depressive symptoms were associated with significantly higher health care costs. However, secondary health condition severity explained the association between depressive symptoms and cost; it also substantially increased the variance in cost that was explained by the multivariate models.Secondary health conditions are significantly associated with depressive symptoms and higher health care costs, with secondary health conditions accounting for the association between depressive symptoms and costs. This association suggests that effective management of secondary health conditions may help reduce both depressive symptomatology and health care costs.

Germanium glass : L.M. Dennis and A. W. Laubengayer, of Cornell University ( Jour. Am. Chem. Soc., 1925, 47, 1945–1947)

Morgan RO, Byrne MM, Hughes RB, Petersen NJ, Taylor HB, Robinson-Whelen S, Hasche JC, Nosek MA. Do secondary conditions explain the relationship between depression and health care cost in women with physical disabilities?To examine the influence of depression on health care utilization and costs among women with disabilities and to determine whether the severity of other secondary health conditions affects this association.A time series of 7 interviews over a 1-year period.Large, southern metropolitan area.Community-dwelling women (N=349) with a self-identified diagnosis of a physical disability.Not applicable.Primary disability, secondary health conditions (Health Conditions Checklist), depressive symptoms (Beck Depression Inventory–Second Edition), and health care utilization (based on the Health and Social Service Utilization Questionnaire and the Stanford Health Assessment Questionnaire). We estimated health care costs using standardized criteria and published average costs.Outpatient and emergency department health care utilization and overall costs were higher in women with depressive symptoms and increased with the frequency and severity of the symptoms. Depressive symptoms were highly correlated with the severity of secondary health conditions. Adjusting for demographics and primary disability, both the presence and severity of depressive symptoms were associated with significantly higher health care costs. However, secondary health condition severity explained the association between depressive symptoms and cost; it also substantially increased the variance in cost that was explained by the multivariate models.Secondary health conditions are significantly associated with depressive symptoms and higher health care costs, with secondary health conditions accounting for the association between depressive symptoms and costs. This association suggests that effective management of secondary health conditions may help reduce both depressive symptomatology and health care costs.