Self-reported Healthcare Utilization Research Articles

Population-level trends in self-reported healthcare utilization among older adults in Mexico with and without cognitive impairment

BackgroundOlder adults with cognitive impairment exhibit different patterns of healthcare utilization compared to their cognitively healthy counterparts. Despite extensive research in high-income countries, similar studies in low- and middle-income countries are lacking. This study aims to investigate the population-level patterns in healthcare utilization among older adults with and without cognitive impairment in Mexico.MethodsData came from five waves (2001–2018) of the Mexican Health and Aging Study. We used self-reported measures for one or more over-night hospital stays, doctor visits, visits to homeopathic doctors, and dental visits in the past year; seeing a pharmacist in the past year; and being screened for cholesterol, diabetes, and hypertension in the past two years. Cognitive impairment was defined using a modified version of the Cross Cultural Cognitive Examination that assessed verbal memory, visuospatial and visual scanning. Total sample included 5,673 participants with cognitive impairment and 34,497 without cognitive impairment interviewed between 2001 and 2018. Generalized Estimating Equation models that adjusted for time-varying demographic and health characteristics and included an interaction term between time and cognitive status were used.ResultsFor all participants, the risk for one or more overnight hospital stays, doctor visits, and dental visits in the past year, and being screened for diabetes, hypertension, and high cholesterol increased from 2001 to 2012 and leveled off or decreased in 2015 and 2018. Conversely, seeing a homeopathic doctor decreased. Cognitive impairment was associated with higher risk of hospitalization (RR = 1.13, 1.03–1.23) but lower risk of outpatient services (RR = 0.95, 0.93–0.97), cholesterol screening (RR = 0.93, 0.91–0.96), and diabetes screening (RR = 0.95, 0.92–0.97).No significant difference was observed in the use of pharmacists, homeopathic doctors, or folk healers based on cognitive status. Interaction effects indicated participants with cognitive impairment had lower risk for dental visits and hypertension screening but that these trajectories differed over time compared to participants without cognitive impairment.ConclusionsWe identified distinct population-level trends in self-reported healthcare utilization and differences according to cognitive status, particularly for elective and screening services. These findings highlight the necessity for policy interventions to ensure older adults with cognitive impairment have their healthcare needs met.

Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care.

The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone. A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with musculoskeletal conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or musculoskeletal presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. Patients with musculoskeletal conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care. Patients with musculoskeletal conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care.

Healthcare use and out-of-pocket costs for rural family caregivers and care recipients in a randomized controlled trial.

Rural family caregivers (FCGs) in the United States often experience high economic costs. This randomized controlled trial compared a transitional palliative care intervention (TPC) to support FCGs of seriously ill care recipients (CRs) to an attention control condition. We evaluated the TPC's effect on healthcare use and out-of-pocket spending for both FCGs and CRs. TPC FCGs received teaching, guidance, and counseling via video calls for 8 weeks following CR discharge from the hospital. After discharge, a research assistant called all FCGs once a month for up to 6 months or CR death to collect self-reported healthcare utilization (e.g., outpatient, emergency department, and hospital), out-of-pocket healthcare spending (e.g., deductibles and coinsurance), and health-related travel costs (e.g., transportation, lodging, food) for FCGs and CRs. Incidence rate ratios (IRRs) were estimated using negative binomial regressions. The study included 282 FCG-CR dyads across three U.S. states. Follow-up over the 6-month period was shortened by high CR mortality rates across both arms (29%), but was similar across arms. TPC reduced nights in the hospital for CR (IRR = 0.75; 95% confidence interval [CI] = 0.56-0. 99). Total out-of-pocket spending was not significantly different for TPC versus control. Across both groups, mean out-of-pocket spending for dyads was $1401.85, with healthcare payments contributing $1048.58 and transportation expenses contributing $136.79. TPC dyads reported lower lodging costs (IRR = 0.71; 95% CI = 0.56-0.89). This study contributes to evidence that palliative care interventions reduce the number of nights in the hospital for seriously ill patients. Yet, overall rural FCGs and seriously ill CRs experience substantial out-of-pocket economic costs in the 6 months following hospitalization. Transitional care intervention design should consider impacts on patient and caregiver spending. gov # is NCT03339271.

The unique vulnerabilities of nighttime smartphone use: a commentary on "tracked and self-reported nighttime smartphone use, general health, and healthcare utilization: results from the SmartSleep Study" by Drews et al.

The unique vulnerabilities of nighttime smartphone use: a commentary on "tracked and self-reported nighttime smartphone use, general health, and healthcare utilization: results from the SmartSleep Study" by Drews et al.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist’s geriatric assessment

Pharmacist’s geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist’s geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

Association of integration with oral health among Indian migrants living in the Netherlands.

Limited data exist about the relationship between acculturation and oral health. Hence, the aim of this study was to assess the association of integration with self-reported oral health, behaviours, and oral healthcare utilization among Indian migrants living in the Netherlands, a cross sectional survey study. Between February and April 2021, a random sample from Dutch municipalities was obtained for the Indian migrants living in the Netherlands (n = 147). A validated questionnaire was used to collect information on independent variables, namely socio-demographic, integration assessment tool: Immigration Policy Lab (IPL-12) and everyday discrimination scale (EDS). The outcome variables were self-reported oral health, oral health behaviours, and oral healthcare utilization. Multiple regression analysis was used to assess the associations. Higher integration among Indian migrants was associated with longer stay in the Netherlands, having a Dutch passport, intention to settle in the Netherlands, and having a permanent residence. After adjusting for covariates such as age, gender, marital status, education, income, occupation, and dental insurance, regression analysis showed that Indians with higher integration had lower odds of reporting their oral health as fair to poor [OR = 0.92(95%CI:0.0.85;0.99)] than the Indians with low integration scores. Also, Indians with higher integration had lower odds of using a manual toothbrush as compared to an electric toothbrush or use of both [OR = 0.86(95%CI:0.76;0.97)]. Highly integrated Indians had lower odds of consuming Indian sweets than lower integrated Indians (OR = 0.91; 95%CI:0.86;0.97). Indians with higher integration had 1.15 times (95% CI:1.03;1.29) higher odds of visiting a Dutch dental professional than visiting a dentist in both places (India and the Netherlands). No significant association was found between discrimination and the three outcome variables. Integration is positively association with self-reported oral health outcomes among the Indian migrants. Measure to improve integration among Indian migrants may help to promote healthy oral health behaviours and improve their oral health care utilization.

Access to Care and Health Care Utilization Among Patients With Nephrolithiasis

ObjectiveTo characterize the impact of nephrolithiasis diagnosis and treatment on healthcare utilization and identify predictors of barriers to care in the patient population. MethodsWe conducted a retrospective cohort study using the All of Us Database, an NIH database targeting recruitment of underrepresented populations. Patients with a diagnosis of kidney stones were included and matched to a control group. Primary outcomes were patients’ self-reported healthcare access and utilization. Univariable and multivariable regression analyses were performed. Results9,173 patients with a diagnosis of nephrolithiasis were included and matched to 9,173 controls without a diagnosis of nephrolithiasis. Patients with kidney stones were less likely to have had >1 year since last provider visit (1.7% vs. 3.8%, p<.001), but did not report increased delays obtaining care (31%), inability to afford care (11.4%), or higher likelihood of skipping medications (12.9%). Among patients with stones, 1,208 (13.2%) had been treated surgically. On multivariable analysis, younger age, female sex, lower income, lower education, non-insured status, and lower physical and mental health were all associated with delays obtaining care, difficulty affording care, skipping medications, and/or prolonged time since seeing a provider. ConclusionA diagnosis of nephrolithiasis and subsequent surgical intervention were not associated with an increase in patient-reported barriers to care. However, among patients with nephrolithiasis, younger, comorbid, female patients from lower socioeconomic status are at significant risk of being unable to access and utilize treatment.

Tracked and self-reported nighttime smartphone use, general health, and healthcare utilization: results from the SmartSleep Study.

Nighttime smartphone use is an increasing public health concern. We investigated whether nighttime smartphone use is associated with general health and primary healthcare utilization. Four thousand five hundred and twenty individuals (age 35.6 ± 9.7 years, 35% male) provided self-reported information on smartphone use frequency, symptoms of depression, and general health (one-item perceived health and cross-symptom composite score). A subset of the study sample (n = 3221) tracked their nighttime smartphone use. Primary healthcare utilization, i.e. the number of weeks in which at least one service from the patient's general practitioner (GP) was billed in 2020, was extracted from Danish population registries. Statistical analysis comprised logistic and multiple linear regression, controlling for sociodemographics. Three hundred and nineteen individuals (7%) reported using their smartphone almost every night or more. More frequent self-reported nighttime smartphone use was associated with poor general health across all measures. Using the smartphone almost every night or more was associated with 2.8 [95% CI: 1.9, 4.1] fold higher odds of reporting poor health and with an average of 1.4 [95% CI: 0.7, 2.1] additional GP utilizations per year compared to no use. Associations were also found for the cross-symptom composite score across all symptoms. Further adjustment for symptoms of depression attenuated some associations. Smartphone use towards the end of the sleep period (sleep-offset use) was associated with poorer self-reported general health, but not with healthcare utilization. Nighttime smartphone use frequency is associated with poor general health and healthcare utilization. Further studies should investigate the underlying causal structure and nighttime smartphone use as a transdiagnostic intervention target.

Healthcare utilization and associated factors during the first wave of COVID-19 pandemic in Ghana: A cross-sectional survey.

Understanding healthcare utilization during the coronavirus disease 2019 (COVID-19) pandemic is crucial to inform policy and to prepare health systems for future pandemics. We examined self-reported healthcare utilization and associated factors, including public health preventive practices, perceptions, and coping strategies among the general public in Ghana during the first wave of the COVID-19 pandemic. We adopted a cross-sectional study design using a public survey to recruit 643 respondents between May 23, and July 11, 2020 during the first wave of confirmed COVID-19 cases and after the fifth week of a partial lockdown in Ghana. Descriptive, bivariate, and binary logistic regression analyses were carried out in Stata version 15. Overall, there was a high level of compliance with COVID-19 public health preventive measures. In terms of perception, 357 (55.5%) of respondents stated unnecessary worry was created about the disease. In relation to coping strategies, 376 (58.5%) of respondents stayed home for more than 6 h, while 35 (5%) reported drinking alcohol to overcome the fear created by the disease. The results showed that 176 (27.4%) of the respondents utilized healthcare while 44 (9.4%) did not utilized healthcare for fear of contracting the disease at the health facility. Marital status (adjusted odds ratio [aOR] = 0.63; 95% confidence interval [CI] = 0.409, 0.963), religion (aOR = 2.34; 95% CI = 1.10, 4.98), and possession of valid health insurance (aOR = 1.51; 95% CI = 1.020, 2.235) were associated with healthcare utilization. There was low healthcare utilization coupled with fear of contracting the COVID-19 disease at the health facilities among the respondents. The findings suggest the need for effective public education that ensures that future pandemics' prevention information and recommendations are easily understandable by the general public. Additionally, investment in health insurance coverage may contribute to healthcare utilization during future pandemics.

ASSOCIATIONS BETWEEN HEARING LOSS AND HEALTH CARE UTILIZATION: EVIDENCE FROM NHATS

Abstract We investigated the association between self-reported hearing loss and healthcare utilization among community dwelling older Medicare beneficiaries (age ≥65) who were enrolled in the 2011 cycle of the National Health and Aging Trends Study (NHATS). Participants’ survey data were linked to fee-for-service Medicare claims data during the 2011-2016 period. Hearing loss was ascertained using based on participants’ hearing aid use, and difficulty hearing in various noisy situations. Those who reported any difficulty hearing or reported hearing aid use were categorized as having hearing loss. Healthcare utilization included: (1) number of inpatient hospitalizations, (2) number of Emergency Department visits, and (3) total number of days spent during hospitalizations per calendar year. Each participant with hearing loss was matched to a participant without hearing loss using a one-to-one propensity score matching to minimize confounding bias. Using generalized estimating equations, we found that among our matched sample those with hearing loss had 21% (Incidence Rate [IR]=1.21; 95% Confidence Interval [CI]= 1.06,1.37) higher rates of emergency department visits, and 48% (IR = 1.48; 95% CI: 1.20,1.82) higher number of days spent in a hospital over the 6-year period from 2011-2016. No association was found between hearing loss and the number of hospitalizations. These finding suggest that older adults with hearing loss may be at risk for increased healthcare utilization. Interventions for hearing loss, such as the use of hearing aids, might reduce healthcare utilization and associated expenditures among older adults in the U.S. Medicare program.

Usability and Feasibility Testing of an Atrial Fibrillation Educational Website with Patients Referred to an Atrial Fibrillation Specialty Clinic.

The purpose of this study was to design, usability test, and explore the feasibility of a web-based educational platform/intervention for patients with atrial fibrillation (AF) as part of their virtual AF care. Participants were patients attending a specialized AF clinic. The multiple mixed-methods design included website design, think-aloud usability test, 1-month unstructured pre-testing analysis using Google Analytics, follow-up interviews, and a non-randomized one-group feasibility test using pre/post online surveys and Google Analytics. Usability testing participants (n = 2) guided adjustments for improving navigation. Pre-testing participants' (n = 9) website activity averaged four sessions (SD = 2.6) at 10 (SD 8) minutes per session during a 1-month study period. In the feasibility test, 30 patients referred to AF specialty clinic care completed the baseline survey, and 20 of these completed the 6-month follow-up survey. A total of 19 patients accessed the website over the 6 months, and all 30 participants were sent email prompts containing information from the website. Health-related quality of life, treatment satisfaction, household activity, and AF knowledge scores were higher at follow-up than baseline. There was an overall downward trend in self-reported healthcare utilization at follow-up. Access to a credible education website for patients with AF has great potential to complement virtual and hybrid models of care.

The Relationship Between Pediatric Attention-Deficit/Hyperactivity Disorder Symptoms and Asthma Management

PurposeChildren with comorbid Attention-Deficit/Hyperactivity Disorder (ADHD) and asthma are at an increased risk for adverse health outcomes and reduced quality of life. The objective of these analyses was to examine if self-reported ADHD symptoms in children with asthma are associated with asthma control, asthma controller medication adherence, quick relief medication use, pulmonary function, and acute healthcare utilization. MethodsWe analyzed data from a larger study testing a behavioral intervention for Black and Latinx children with asthma aged 10–17 years and their caregivers. Participants completed the Conners-3AI self-report assessment for ADHD symptoms. Asthma medication usage data were collected for 3 weeks following baseline via electronic devices fitted to participants' asthma medications. Other outcome measures included the Asthma Control Test, self-reported healthcare utilization, and pulmonary function measured by spirometry testing. ResultsThe study sample consisted of 302 pediatric participants with an average age of 12.8 years. Increased ADHD symptoms were directly associated with reduced adherence to controller medications, but no evidence of mediation was observed. Direct effects of ADHD symptoms on quick-relief medication use, health care utilization, asthma control, or pulmonary function were not observed. However, the effect of ADHD symptoms on emergency room visits was mediated by controller medication adherence. DiscussionADHD symptoms were associated with significantly reduced asthma controller medication adherence and indirectly with emergency room visits. There are significant potential clinical implications to these findings, including the need for the development of interventions for pediatric asthma patients with ADHD.

An examination of health care utilization during the COVID-19 pandemic among women with early-stage hormone receptor-positive breast cancer

BackgroundWomen undergoing treatment for breast cancer require frequent clinic visits for maintenance of therapy. With COVID-19 causing health care disruptions, it is important to learn about how this population’s access to health care has changed. This study compares self-reported health care utilization and changes in factors related to health care access among women treated at a cancer center in the mid-South US before and during the pandemic.MethodsParticipants (N = 306) part of a longitudinal study to improve adjuvant endocrine therapy (AET) adherence completed pre-intervention baseline surveys about their health care utilization prior to AET initiation. Questions about the impact of COVID-19 were added after the pandemic started assessing financial loss and factors related to care. Participants were categorized into three time periods based on the survey completion date: (1) pre-COVID (December 2018 to March 2020), (2) early COVID (April 2020 – December 2020), and later COVID (January 2021 to June 2021). Negative binomial regression analyses used to compare health care utilization at different phases of the pandemic controlling for patient characteristics.ResultsAdjusted analyses indicated office visits declined from pre-COVID, with an adjusted average of 17.7 visits, to 12.1 visits during the early COVID period (p = 0.01) and 9.9 visits during the later COVID period (p < 0.01). Hospitalizations declined from an adjusted average 0.45 admissions during early COVID to 0.21 during later COVID, after vaccines became available (p = 0.05). Among COVID period participants, the proportion reporting changes/gaps in health insurance coverage increased from 9.5% participants during early-COVID to 14.8% in the later-COVID period (p = 0.05). The proportion reporting financial loss due to the pandemic was similar during both COVID periods (34.3% early- and 37.7% later-COVID, p = 0.72). The proportion of participants reporting delaying care or refilling prescriptions decreased from 15.2% in early-COVID to 4.9% in the later-COVID period (p = 0.04).ConclusionCOVID-19 caused disruptions to routine health care for women with breast cancer. Patients reported having fewer office visits at the start of the pandemic that continued to decrease even after vaccines were available. Fewer patients reported delaying in-person care as the pandemic progressed.

Impact of Social Determinants of Health on Disease-Related Outcomes in Pediatric Sickle Cell Patients

Background: Social Determinants of Health (SDoH) are socioeconomic factors that influence health and well-being and are largely responsible for health inequities. Research has shown that economic, housing, food and medical insecurities are associated with lower quality of life, poor mental health, and worse outcomes for people living with chronic illness. Individuals with Sickle Cell Disease (SCD) are at increased risk of mortality, poor health-related quality of life, functional disability and high health care utilization. Furthermore, SCD primarily affects populations of African descent, who also tend to be disproportionately burdened by poverty and systemic racism. Prior studies have shown that children with SCD from lower income families have worse health-related quality of life, and higher healthcare utilization rates. However, there is paucity of data investigating links between SDoHs with quality of life and disease-related outcomes in this population. Thus, it is important to gain a better understanding of how these factors affect the well-being of children living with SCD. In this study, we attempt to identify the unmet social needs of patients in one pediatric sickle cell clinic and their association with self-reported health care utilization and disease complications. Methods: We approached pediatric patients (aged 1-18 years) and their guardians attending routine visits at the Children's Hospital of Richmond Comprehensive Sickle Cell Clinic. Those coming for a newborn visit or having acute crises were excluded. After consenting, parents completed a demographic and patient-reported outcome questionnaire followed by the Boston Medical Center's WECARE survey that screens for SDoH, such as housing, food, utility, transportation and medical insecurities. We defined an unmet social need as any positive answer to the WECARE survey. Counts, percentages and exact tests were used to examine the relationship between unmet needs and demographic factors and disease outcome variables. Results: To date, 50 children with SCD aged 1-17 years and their parents were screened, consented, assented (children >7) and completed the surveys. There was incomplete data on social needs from 5 subjects, thus 45 total are included here. 53% of subjects indicated an unmet need in at least one of the categories in the WECARE survey: 41% had food insecurity, 4% had housing insecurity, 13% had problems paying for medication, 11% had problems with transportation, 24% had trouble paying utility bills, 9% had difficulty taking care of family members and 13% were unemployed. Children with at least one unmet social need were more likely (p<0.05) to have a lower household income (Table 1), report one or more hospitalizations in the past six months and report missing a scheduled activity or school in the previous month compared to children without an unmet need (Table 2). Those with an unmet need also reported higher Emergency Department visits, acute SCD complications, and lower grades than those without an unmet need, but these findings were not statistically significant. Conclusion: This preliminary data demonstrates that SDoH, represented by unmet social needs, have an association with increased healthcare utilization and disease-related complications for children with SCD. A larger sample size is needed to characterize these relationships more fully. Ongoing research includes investigating the relationships between SDoH with Quality of Life and disease indicators gathered from medical charts of children with SCD. By identifying which unmet socioeconomic needs exist in our clinics, we can provide more equitable and holistic care to children with SCD and ultimately improve their health outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Medical, dental, and optical care utilization among community-living people with spinal cord injury in the United States

Context/Objective Information about patterns of healthcare utilization for people living with spinal cord injury (SCI) is currently limited, and this is needed to understand independent community living after SCI. This study investigates self-reported healthcare utilization among community-living people with SCI and assesses disparities across demographic, socioeconomic, and injury-related subgroups. Design Secondary analysis of cross-sectional survey data administered via telephone interview. Setting 6 SCI Model Systems centers in the United States (California, Colorado, New Jersey, New York, Ohio, and Pennsylvania). Participants Adults with chronic, traumatic SCI who were community-living for at least one year after the completion of an inpatient rehabilitation program (N = 617). Interventions Not applicable. Outcome Measures Utilization of a usual source of 4 types of health care in the past 12 months: primary, SCI, dental, and optical. Results 84% of participants reported utilizing primary care in the past year. More than half reported utilizing SCI (54%) and dental (57%) care, and 36% reported utilizing optical care. There were no significant differences across key subgroups in the utilization of primary care. Participants who had been injured for 5 years or less and participants with greater educational attainment were more likely to report utilizing SCI care. Participants with higher household income levels were more likely to report using dental care. Female participants and older age groups were more likely to report using optical care. Conclusion Rates of healthcare utilization among people with SCI are below recommended rates and vary across demographic, socioeconomic, and injury-related subgroups. This information can inform future research to target barriers to using healthcare services among community-living people with SCI.

Neighborhood disadvantage, health status, and health care utilization after blood or marrow transplant: BMTSS report

AbstractLiving in a disadvantaged neighborhood is associated with poor health outcomes. Blood or Marrow Transplant (BMT) survivors remain at risk of chronic health conditions requiring anticipatory management. We hypothesized that among BMT survivors, neighborhood disadvantage was associated with poor self-reported routine health care utilization and health. We leveraged data from BMTSS – a retrospective cohort study examining long-term outcomes among individuals surviving ≥2 y following BMT at three institutions between 1974 and 2014. Participants in this analysis completed the BMTSS survey (sociodemographics; chronic health conditions; time since routine check-up; self-reported health). The Area Deprivation Index (ADI) represented neighborhood disadvantage; this composite indicator of 17 census measures is a percentile rank (0 = least deprived to 100 = most deprived). Multivariable ordered logit regression adjusted for clinical factors and individual-level sociodemographics, modeling associations between ADI, time since routine check-up, and self-reported health. Among 2,857 survivors, median ADI was 24 (interquartile range: 10-46). Adjusting for self-reported individual-level socioeconomic indicators and chronic health conditions, patients in more disadvantaged neighborhoods had higher odds of reporting longer intervals since routine check-up (ORADI_continuous = 1.007, P < .001) and poorer health status (controlling for time since check-up; ORADI_continuous = 1.005, P = .003). Compared with patients living in the least disadvantaged neighborhood (ADI = 1), patients in the most disadvantaged neighborhood (ADI = 100), had twice the odds (ORADI = 1.007^99 = 2.06) of reporting no routine visits and 1.65-times the odds of reporting poor health (ORADI = 1.005^99 = 1.65). In BMT survivors, access to health care and health status are associated with area disadvantage. These findings may inform strategies to address long-term care coordination and retention for vulnerable survivors.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Perceived discrimination when using health-care services, health outcomes, and health-care utilisation among Romani people in Europe: evidence from the Second European Union Minorities and Discrimination Survey

BackgroundThe global COVID-19 pandemic has highlighted substantial health inequities in Europe. Minorities and immigrants are the populations most likely to experience disparities related to health-care access and health outcomes. We aimed to link self-reports of health conditions with experiences of discrimination when using health-care services among Romani ethnic minorities in the European Union (EU). MethodsThe Second EU Minorities and Discrimination Survey was disseminated in 2016 to ethnic minorities, immigrants, and descendants of immigrants in 19 member states of the EU (Austria, Belgium, Cyprus, Germany, Denmark, Greece, Spain, Finland, France, Ireland, Italy, Luxembourg, Malta, Netherlands, Poland, Portugal, Sweden, Slovenia, and the UK). The primary outcomes were self-reported health status (subjective assessment of own health conditions), health-care utilisation, and unmet health-care need. Experiences of discrimination when using health-care services in the past 5 years was the key explanatory variable. Anonymised data relating to perceived discrimination, self-reported good health, health-care utilisation, and socioeconomic status were available for individuals who identify as Romani ethnic minorities in nine EU member states—Bulgaria, Croatia, Czech Republic, Greece, Hungary, Portugal, Romania, Slovakia, and Spain. We used multivariate logistic regression analyses to examine the association between perceived discrimination and self-reported health status, health-care utilisation, and unmet health-care needs, controlled for sex, age, income level, education level, health insurance coverage, and residential location. Adjusted odds ratios (ORs) and 95% CIs of self-perceived discrimination are reported. FindingsUsing data on perceived discrimination when using health care, self-reported health status, health-care access, and socioeconomic status for 7942 Romani individuals (aged 16–90 years), including 4046 Romani individuals who have used health-care services during the past 5 years, we found that perceived discrimination when utilising health care is more prevalent for Romani people than other ethnic minorities in Europe (OR 2·19, 95% CI 1·96–2·44). After controlling for sex, age, income level, education level, health insurance coverage, and residential location, our multivariate logistic regression analyses showed that the perceived discrimination of Romani people is negatively associated with self-reported good health (adjusted OR 0·84, 0·69–1·03), and health-care utilisation (adjusted OR 0·34, 0·25–0·44). Furthermore, Romani people's perceived discrimination is associated with an increased risk of unmet health-care needs (adjusted OR 3·01, 2·27–3·98). The results were robust across sexes. InterpretationA multifaceted strategy might be needed to eliminate the disparities in health outcomes and health-care access between the Romani ethnic group and other ethnic minority groups in the EU, including expanding access to health care, addressing social determinants of health, and advancing anti-discrimination regulations in the EU. FundingNone.

Prevalence and burden of COPD misclassification in the Canadian Longitudinal Study on Aging (CLSA)

IntroductionTo examine the prevalence of chronic obstructive pulmonary disease (COPD) misclassification and the associated burden of symptoms, healthcare utilisation and physical performance status in the Canadian general population. This information...

How Healthcare Utilization Due to Dizziness and Vertigo Differs Between Older and Younger Adults

BackgroundVertigo and dizziness are common in older adults. We describe self-reported healthcare utilization because of dizziness and vertigo in older adults attending a tertiary care specialized vertigo center.MethodsData from 765 patients (45% were ≥60 years old) with chronic dizziness and vertigo who attended a daycare multimodal treatment program were recorded. Data included sociodemographic parameters, dizziness-related characteristics, the Body Sensations Questionnaire (BSQ), the Agoraphobic Cognitions Questionnaire (ACQ), and the Hospital Anxiety and Depression Scale (HADS). Also, healthcare utilization, including (1) physician and clinical services, (2) hospitalizations in the year before consulting the vertigo center, (3) prescription of drugs and other professional services were included. Descriptive statistics, exploratory data analysis, and regression models were used.ResultsIntensity of dizziness was similar in both age groups, however, distress due to dizziness was more severe in younger persons. Dizziness symptoms lasted longer in older adults than in younger persons. Older adults had a somatic diagnosis (74.6 vs. 35.0%) more frequently and reported more falls (37.2 vs. 28.5%) than younger individuals. Anxiety about bodily sensations was higher in younger patients (mean BSQ1 = 9.33 ± 5.6) than in older patients (mean BSQ1 = 6.72 ± 5.4). Older persons had fewer depressive symptoms (mean HADS depression = 5.8 ± 3.6 vs. 6.5 ± 4.1) and less anxiety (mean HADS anxiety = 5.7 ± 3.7 vs. 7.8 ± 4.1) than younger individuals. Younger people were more frequently hospitalized (24.4%) than older adults (16.3%) in the year before consulting the vertigo center. Also, younger patients and patients with non-somatic etiologies had considerably more consultations with healthcare providers than older patients. Older adults received less medication (50.3%), less physiotherapy (41%), and less psychological therapy (11.6%) for vertigo than younger people (59.7, 52.2, 20.4%, respectively).ConclusionAge-associated differences in healthcare utilization were defined in selected patients attending a specialized vertigo center. Since dizziness is frequently a heterogeneous disorder requiring interdisciplinary care, its diagnostic and therapeutic work-up must be improved for older patients with dizziness.