Subsequent Service Use Research Articles

Drinking patterns, gender and health III: Avoiding versus seeking health care

Background: Inability to predict most health services use and costs using demographics and health status suggests that other factors affect use, including attitudes and practices that influence health and willingness to seek care. Alcohol consumption has generated interest because heavy, chronic consumption causes adverse health consequences, acute consumption increases injury, and moderate drinking is linked to better health while hazardous drinking and alcohol-related problems are stigmatized and may affect willingness to seek care.Methods: A stratified random sample of health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). We linked survey data to 24 months of health-plan records to examine relationships between alcohol use, gender, health-related attitudes, practices, health, and service use. In-depth interviews with a stratified 150-respondent subsample explored individuals’ reasons for seeking or avoiding care.Results: Quantitative results suggest health-related practices and attitudes predict subsequent service use. Consistent predictors of care were having quit drinking, current at-risk consumption, cigarette smoking, higher body mass index, disliking visiting doctors, and strong religious/spiritual beliefs. Qualitative analyses suggest embarrassment and shame are strong motivators for avoiding care.Conclusions: Although models included numerous health, functional status, attitudinal and behavioral predictors, variance explained was similar to previous reports, suggesting more complex relationships than expected. Qualitative analyses suggest several potential predictive factors not typically measured in service-use studies: embarrassment and shame, fear, faith that the body will heal, expectations about likelihood of becoming seriously ill, disliking the care process, the need to understand health problems, and the effects of self-assessments of health-related functional limitations.

The Effectiveness of Home Care Reablement — Developing the Evidence Base

Adult social care services are increasingly establishing reablement services as part of their range of home care provision, sometimes alone, sometimes jointly with NHS partners. Typically, home care reablement is a short‐term intervention, often free of charge, that aims to maximise independent living skills. This paper describes two small studies examining the impact of home care reablement on subsequent service use. The evidence so far strongly suggests that a period of home care reablement can reduce the subsequent use of home care services and that, for some people, these benefits may last for a year or more. However, a number of organisational and cultural factors can limit the immediate and longer‐term benefits of home care reablement.

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Social disadvantage and schizophrenia

To study, in a geographically defined area, associations between the neighbourhood social environment and individual socioeconomic status on the one hand, and treated incidence of schizophrenia and level of subsequent service use on the other. A combined data set of (i) patients with a case register diagnosis of schizophrenia and (ii) population controls was subjected to multilevel analyses, including neighbourhood exposures (neighbourhood socioeconomic disadvantage and social capital) and individual level confounders. Separate analyses were conducted for inpatient and outpatient psychiatric service consumption as indexed by the case register. Neighbourhood socioeconomic disadvantage and neighbourhood social capital did not impact on the treated incidence of schizophrenia, but quantity of inpatient service consumption was higher in neighbourhoods with higher level of social control (i.e. where it is more likely that neighbours intervene in neighbourhood-threatening situations). In addition, most indicators of lower individual socioeconomic status were associated with higher treated incidence, while treated incidence was lower when individual educational status was low. Residents of high social control neighbourhoods may seek greater levels of resolution of psychiatric disorder in patient-residents, and by consequence may induce greater levels of inpatient service consumption in patients diagnosed with schizophrenia. Individual-level indicators of social disadvantage are associated with higher risk of treated psychotic disorder, with the exception of lower educational status, which may confer a lower probability of treatment given the presence of psychotic disorder.

Health service utilisation of a regional cohort of very preterm infants over the first 2 years of life

Very preterm infants represent major consumers of health services following neonatal discharge. We examined the health service utilisation of a regional cohort of very preterm infants over the first 2 years of life, including the association with neurodevelopmental outcome. A regionally based 2-year cohort of 100 very preterm infants along with a comparison sample of 104 full term control infants matched for sex, time and place of birth were recruited. Perinatal and social background factors that predispose very preterm infants to increased risk of subsequent general practitioner (GP) and hospital service use were identified. At 2 years, all children underwent a neurodevelopmental assessment, Bayley Scales of Infant Development (BSID-II). Details of children's medical contacts obtained by parent interview were cross-checked against GP and hospital records/databases. Very preterm infants had a similar number of GP visits to term infants but more outpatient hospital visits. Fifty-three (55%) very preterm infants were admitted to hospital on 131 occasions compared with 26 (26%) term infants on 37 occasions (p<0.001). The main reason for hospitalisation in the preterm cohort was respiratory disorder. The frequency of hospital admissions was significantly related to birthweight (P=0.01), gestational age (P<0.001) and the number of people living in the family household (P=0.02). No associations were found between hospital admission and neurodevelopment at 2 years. Very preterm infants had higher rates of hospital admissions and visits than term infants unrelated to neurodevelopmental outcome at 2 years of age. These findings highlight that very preterm birth is associated with ongoing health morbidity.

Experiences of and Attitudes Toward Mental Health Services Among Older Youths in Foster Care

Experiences of and Attitudes Toward Mental Health Services Among Older Youths in Foster Care

Predictors of Medication Adherence and Associated Health Care Costs in an Older Population With Overactive Bladder Syndrome: A Longitudinal Cohort Study

We examined the relationship between self-reported health status data, subsequent antimuscarinic medication adherence and health care service use in older adults with OAB syndrome in a managed care setting. This was a longitudinal cohort study of older adults in the southeastern United States with OAB who completed a health status assessment, used antimuscarinic medications and were enrolled in an HMO continuously for 1 to 3 years. Demographic, clinical and use related economic variables were also retrieved from the administrative claims data of patient HMOs. Prescription refill patterns were used to measure medication adherence. Associations were examined with a sequential, mixed model regression approach. A total of 275 patients were included. The severity of comorbidity (Charlson index), patient perception of quality of life (Short Form-12 scores) and total number of prescribed medications during the year prior to enrollment in a Medicare HMO were independently associated with decreased antimuscarinic MPRs after enrollment. After controlling for other variables increased antimuscarinic MPR remained the strongest predictor of decreased total annual health care costs (5.6% decrease in annual costs with every 10% increase in MPR, p < 0.001). We found strong associations between decreased antimuscarinic medication adherence and increased health care service use in older adults with OAB in a managed care setting. Health status assessments completed at enrollment had the potential to identify enrollees at higher risk for nonadherent behaviors and poor health related outcomes.

Determinants of receipt of ambulatory medical care in a national sample of mentally ill homeless veterans.

This study used the Behavioral Model for Vulnerable Populations to identify determinants of receipt of outpatient medical care within 6 months of initial contact with a national homeless veterans outreach program. Prospective study. Homeless veterans contacted through the program in 1999 (n = 26,926). Data from structured interviews conducted at the time of program intake were merged with Veterans Affairs administrative data to determine subsequent medical service use. Logistic regression modeling was used to identify predisposing, enabling, and need factors from traditional and vulnerable domains predictive of receiving medical care. Overall, 41.8% of subjects received at least one medical visit in the 6 months after program intake; of these, 48.7% had three or more visits. In multivariate analyses, the likelihood of receiving medical care was, among other things, positively associated with age, female gender, and placement in residential treatment and negatively associated with duration of homelessness and being contacted through outreach versus referred or self-referred into the homeless program. Mental illness did not appear to be an additional barrier to initiating medical care; however, a diagnosis of substance abuse or schizophrenia was associated with a decreased likelihood of receiving three or more visits. A majority of homeless veterans contacted through a national outreach program failed to receive medical services within 6 months of program entry. Vulnerable-domain factors were important supplements to traditional variables in predicting use of medical services in the homeless population. Greater efforts are needed to ensure that mentally ill homeless persons are successfully linked with and engaged in medical treatment.

Case finding and referral model for emergency department elders: A randomized clinical trial

Study objective: Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. Methods: A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. Results: The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. Conclusion: An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients. [Ann Emerg Med. 2003;41:57-68.]

Attack context: an important mediator of the relationship between psychological status and asthma outcomes

Background: The importance of psychosocial variables in asthma is increasingly recognised, although attempts to relate these to asthma outcomes often produce only weak relationships. This study aimed to identify whether...

Let's ask the homeless people themselves: a needs assessment based on a probability sample of adults.

A probability sample of 301 homeless adults from Buffalo, NY, was followed over 6 months to document the utilization of a variety of community services, examine services desired, and identify factors associated with service utilization, preference, and satisfaction. The following needs were all rated as at least equally important as the need for affordable housing: safety, education, transportation, medical/dental treatment, and job training/placement (most of these needs were also rated as difficult to obtain). Needs for formal mental health and substance abuse services were rated as relatively unimportant and easy to obtain, and for those who actually used them, respondents were often dissatisfied with them. Of 16 predictor variables examined in multivariate analyses, several showed consistent relationships with subsequent service use, preference, and satisfaction. Younger adults, persons of color, those with dependent children, and persons having fewer social supports reported less service utilization, less satisfaction with services received, different perceived needs for particular services, and/or greater difficulty obtaining services.

Counselling in primary care: A randomised controlled trial

A randomised controlled trial of the effectiveness of counselling (In-House Counselled (IHC) group) compared to routine advice from General Practitioners (Routine Treatment (RT) group) was conducted with three practices and a total of 188 patients in East Sussex. Changes in interpersonal problems using the 32 item Inventory of Interpersonal Problems, symptoms of psychological distress using the Symptom Index and self esteem using Repertory Grids were compared between groups at four months and after a further four month follow-up. A questionnaire monitoring patient service satisfaction was given to those who had received In-House counselling. The number of counselling sessions, early withdrawals and refusers was also monitored. In order to facilitate interprofessional communication, the three counsellors and a GP representative from each practice met monthly for an Action Learning group, led by an external facilitator to provide a forum to discuss working practices. The group met six times for two and a half hours. An audit of the participants' medical notes was carried out at the end of the study to establish any changes in subsequent use of medical services and prescribing patterns. The results show that patients within both groups improved considerably, in line with similar studies. The IHC group was significantly less likely to be referred out to mental health services. However, there was no statistical difference between the groups on any of the measures or in changes in subsequent service use or prescribing patterns. This may have been a result of Action Learning Group producing more psychologically minded GPs. Patients in the IHC group were overwhelmingly in favour of counselling and stated that it had helped them with a variety of psychological problems.