Subsequent Health Service Use Research Articles

Fatalism or vigilance? Exposure to infant and maternal deaths and subsequent use of maternal health services in Malawi

In developing contexts, where formal health services are still expanding, understanding what factors discourage individuals from using health services is critical to advance population health. A long theorized, but rarely investigated, conjecture is that in high-mortality contexts, exposure to death can beget fatalism, or even foster distrust of formal healthcare, locking families into cycles of low use of health services. A counter perspective, however, suggests exposure to death can encourage individuals’ health vigilance, corresponding with their higher use of health services. We test these competing ideas by analyzing the associations between women’s intimate exposure to death in the context of pregnancy and delivery via (1) a sister’s maternal death and (2) an infant child’s neonatal death, and their subsequent use of maternal health services. We focus on the context of Malawi, a setting that features high maternal and infant mortality rates, similar to those observed across much of sub-Saharan Africa, as well as persistent gaps in service use. Specifically, we use Malawi Demographic and Health Survey (2015–16) data to examine if a sister’s maternal death or a child’s neonatal death corresponds with a woman’s odds of attending full antenatal care during a subsequent pregnancy or delivering the pregnancy at a formal health facility. Given the qualitatively distinct nature of losing one’s only or first child, we also assess if the effect of a child’s neonatal death varies by birth order. The results show that maternal and neonate death exposures correspond generally with women’s higher use of maternal health services, challenging the notion that exposure to death fosters fatalism or distrust. Although the results vary in significance, the nuanced findings highlight women’s vigilance in the face of health threats, emphasizing their resilience amid a high burden of familial loss.

Thresholds in PROMIS Scores Anchored to Subsequent Unscheduled Health Service Use Among People Diagnosed With Cancer.

To establish thresholds in the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, physical function, fatigue, and depression scores on the basis of their association with subsequent use of the emergency department (ED) or urgent care by people diagnosed with cancer. Retrospective data from 952 people seen at Henry Ford Cancer and insured through the Health Alliance Plan were analyzed using generalized linear mixed-effects models. The log odds of ED or urgent care use during 14 or 30 days after each patient-reported outcome (PRO) assessment were related to PRO scores, while adjusting for comorbidity, sociodemographic, and tumor characteristics. Pain interference and physical function were associated with subsequent ED or urgent care visits, but fatigue and depression were not, and the results for 14- and 30-day visits were similar. Thresholds anchored in the likelihood of these visits differed according to cancer stage. For people with advanced cancer, a pain interference score of 60 or higher (odds ratio [OR] 3.75, [95% CI, 1.53 to 7.87]) and a physical function score lower than 40 (OR 2.94, [95% CI, 1.22 to 7.06]) produced the largest ORs with narrowest CIs for 30-day visits. For people with nonadvanced cancer, the thresholds of 65 for pain interference (OR 2.64, [95% CI, 1.40 to 5.01]) and 35 for physical function (OR 1.87, [95% CI, 1.01 to 3.45]) produced largest ORs with narrowest CIs for 30-day visits. These anchor-based thresholds in PROMIS scores can inform clinicians' actions with the goal of preventing ED or urgent care visits.

Youth cannabis use and subsequent health service use for mood and anxiety disorders: A population-based cohort study

Epidemiologic research suggests a modest association between youth cannabis use and mood and anxiety disorders (MADs). However, current evidence is based mostly on cohort studies using data from the 20th century when cannabis was significantly less potent than today. We linked population-based survey data from 2009 to 2012 with administrative records of health services covered under universal healthcare up to 2017. The cohort included youth aged 12 to 24 years at baseline living in Ontario, Canada with no prior MAD health service use (n = 8,252). We conducted a multivariable Cox model to estimate the association between cannabis use frequency (never, <weekly, weekly+) and MAD health service use (hospitalization, ED visit, or outpatient physician visit) in the following 3 years, adjusting for sociodemographic factors and other substance use. Compared to no cannabis use, <weekly use was significantly associated with subsequent MAD health service use (aHR=1.48; 95 % CI: 1.10–1.99) while weekly+ use was not (aHR=0.92; 95 % CI: 0.63–1.34). Sex and age interactions were not significant on the multiplicative or additive scales. This study found a modest longitudinal association between youth cannabis use and MAD health service use but no evidence of a linear dose-response relationship. Further research is needed to clarify these findings.

Concordance between 8-1-1 HealthLink BC Emergency iDoctor-in-assistance (HEiDi) virtual physician advice and subsequent health service utilization for callers to a nurse-managed provincial health information telephone service

BackgroundBritish Columbia 8–1-1 callers who are advised by a nurse to seek urgent medical care can be referred to virtual physicians (VPs) for supplemental assessment and advice. Prior research indicates callers’ subsequent health service use may diverge from VP advice. We sought to 1) estimate concordance between VP advice and subsequent health service use, and 2) identify factors associated with concordance to understand potential drivers of discordant cases.MethodsWe linked relevant provincial administrative databases to obtain inpatient, outpatient, and emergency service use by callers. We developed operational definitions of concordance collaboratively with researcher, patient, VP, and management perspectives. We used Kaplan–Meier curves to describe health service use post-VP consultation and Cox regression to estimate the association of caller factors (rurality, demography, attachment to primary care) and call factors (reason, triage level, time of day) with concordance as hazard ratios.ResultsWe analyzed 17,188 calls from November 16, 2020 to April 30, 2021. Callers advised to attend an emergency department (ED) immediately were the most concordant (73%) while concordance was lowest for those advised to seek Family Physician (FP) care either immediately (41%) or within 7 days (47%). Callers unattached to FPs were less likely to schedule an FP visit (hazard ratio = 0.76 [95%CI: 0.68–0.85]). Rural callers were less likely to attend an ED within 48 h when advised to go immediately (0.53 [95%CI:0.46–0.61]) compared to urban callers. Rural callers advised to see an FP, either immediately (1.28 [95%CI:1.01–1.62]) or within 7 days (1.23 [95%CI: 1.11–1.37]), were more likely to do so than urban callers.InterpretationConcordance between VP advice and subsequent caller health service use varies substantially by category of advice and caller rurality. Concordance with advice to “Go to ED” is high overall but to access primary care is below 50%, suggesting potential issues with timely access to FP care. Future research from a patient/caller centered perspective may reveal additional barriers and facilitators to concordance.

Linking health service utilisation and mortality data-unravelling what happens after fall-related paramedic care.

A randomised controlled trial implemented and evaluated a new model of care for non-transported older fallers to prevent future falls and unplanned health service use. This current study uses linked data to evaluate the effects of the intervention beyond the initial 12-month study period. Study data from an established cohort of 221 adults were linked to administrative data from NSW Ambulance, Emergency Department Data Collection, Admitted Patient Data Collection and Registry of Births, Deaths and Marriages evaluating health service use at 12, 24 and 36months following randomisation including time to event (health service utilisation) and mortality. Negative binomial and Cox's proportional hazard regression were performed to capture the impact of the study between groups and adherence status. At 36months follow-up, 89% of participants called an ambulance, 87% attended the Emergency Department and 91% were admitted to hospital. There were no significant differences in all-cause health service utilisation between the control and intervention group (IG) at 12, 24 and 36months follow-up. Fall-related health service use was significantly higher within the IG at 12 (IRR:1.40 (95%CI:1.01-1.94) and 24months (IRR:1.43 (95%CI:1.05-1.95)). Medication use, impaired balance and previous falls were associated with subsequent health service use. Over 40% of participants died by the follow-up period with risk of death lower in the IG at 36months (HR:0.64, 95%CI:0.45-0.91). Non-transported fallers have a high risk of future health service use for fall and other medical-related reasons. Interventions which address this risk need to be further explored.

Disease-modifying drugs for multiple sclerosis and subsequent health service use

Objective: We assessed the relationship between the multiple sclerosis (MS) disease-modifying drugs (DMDs) and healthcare use. Methods: Persons with MS (aged ⩾18 years) were identified using linked population-based health administrative data in four Canadian provinces and were followed from the most recent of their first MS/demyelinating event or 1 January 1996 until the earliest of death, emigration, or study end (31 December 2017 or 31 March 2018). Prescription records captured DMD exposure, examined as any DMD, then by generation (first-generation (the injectables) or second-generation (orals/infusions)) and individual DMD. The associations with subsequent all-cause hospitalizations and physician visits were examined using proportional means model and negative binomial regression. Results: Of 35,894 MS cases (72% female), mean follow-up was 12.0 years, with person-years of DMD exposure for any, or any first- or second-generation DMD being 63,290, 54,605 and 8685, respectively. Any DMD or any first-generation DMD exposure (versus non-exposure) was associated with a 24% lower hazard of hospitalization (adjusted hazard ratio, aHR: 0.76; 95% confidence intervals (CIs): 0.71–0.82), rising to 29% for the second-generation DMDs (aHR: 0.71; 95% CI: 0.58–0.88). This ranged from 18% for teriflunomide (aHR: 0.82; 95% CI: 0.67–1.00) to 44% for fingolimod (aHR: 0.56; 95% CI: 0.36–0.87). In contrast, DMD exposure was generally not associated with substantial differences in physician visits. Conclusion: Findings provide real-world evidence of a beneficial relationship between DMD exposure and hospitalizations.

The Influence of Social Support, Help-Seeking Attitudes and Help-Seeking Intentions on Older Australians' use of Mental Health Services for Depression and Anxiety Symptoms.

This study investigated the influence of predisposing factors (social support, help-seeking attitudes and help-seeking intentions) on older Australian adults' use of mental health services for depression and/or anxiety symptoms. Participants were 214 older Australian adults (61% female; aged between 60 and 96 years; M = 75.15 years, SD = 8.40 years) who completed a self-report questionnaire that measured predisposing factors and lifetime mental health service use for depression and/or anxiety symptoms. Higher levels of social support predicted non-use of mental health services. When this relationship was serially mediated by help-seeking attitudes and help-seeking intentions, it predicted mental health service use for depression and/or anxiety. Older adults are less likely to seek help for depression and/or anxiety symptoms unless members of their social support network encourage positive help-seeking attitudes, which lead to positive help-seeking intentions and the subsequent use of mental health services.

The association between mistreatment of women during childbirth and postnatal maternal and child health care: Findings from “Birth in Brazil”

BackgroundThe mistreatment of women during pregnancy, childbirth, and the puerperium is a global public health problem besides being a violation of human rights. However, research exploring the consequences of mistreatment of women and newborns is scarce. QuestionTo shed light on this issue, we investigated the association between the mistreatment of women during childbirth and the subsequent use of postnatal health services by women and their newborns. MethodsWe used data from the study “Birth in Brazil”, a national hospital-based survey of puerperal women and their newborns, carried out in 2011/2012. This analysis involved 19,644 women. Mistreatment was a latent variable composed of seven indicators. We assessed the attendance of women and newborns to a review consultation following birth, and the timing of this appointment. We applied multigroup structural equation modeling (based on childbirth payment source) and considered separate analysis for women (vaginal births and0 caesarean-sections) and newborns. FindingsWe found a causal association between mistreatment during childbirth and decreased and/or delayed use of postnatal health services, for both women and their newborns. These results also revealed that women who use the public sector are affected more than those who pay for private healthcare. ConclusionMistreatment during childbirth has broader implications than “maternal mental health”, and it would be useful to understand that experience of care has vast implications for families. In Brazil, the mistreatment must be mitigated via the implementation of public policy. This is part of the path to dignified and respectful childbirth care for all women.

Mental Health Consequences and Service Use of Older Adults at Risk of Financial Exploitation

Abstract This study examines whether the experience of financial exploitation is associated with increased likelihood of mental health consequences and subsequent use of mental health services. Interviews were conducted with 99 participants, age 60 and older, at risk for elder abuse. The authors and research team administered standardized measures of elder mistreatment, depression, trauma, social support, and service use. Older adults who experienced financial exploitation reported worse trauma symptoms and depression than those who did not experience financial exploitation. Those with increased functional impairment were least likely to rely on mental health services. The findings highlight the importance of interventions to address and enhance response to depression, trauma, and social support in older adults who are victims of financial exploitation.

Associations of insomnia symptoms with subsequent health services use among community-dwelling U.S. older adults.

Determine the association of insomnia symptoms with subsequent health services use, in a representative sample of U.S. older adults. Participants were 4,289 community-dwelling Medicare beneficiaries who had continuous fee-for-service Medicare coverage 30 days before, and 1 year after the National Health and Aging Trends Study (NHATS) Round 1 interview. Participants reported past-month insomnia symptoms (i.e. sleep onset latency >30 min, difficulty returning to sleep) which we categorized as 0, 1, or 2 symptoms. Outcomes were health services use within 1 year of interviews from linked Medicare claims: emergency department (ED) visits, hospitalizations, 30-day readmissions, home health care (all measured as yes/no), and number of hospitalizations and ED visits. Overall, 18.5% of participants were hospitalized, 28.7% visited the ED, 2.5% had a 30-day readmission, and 11.3% used home health care. After adjustment for demographics, depressive and anxiety symptoms, medical comorbidities, and BMI, compared to participants with no insomnia symptoms, those with two insomnia symptoms had a higher odds of ED visits (odds ratio [OR) = 1.60, 95% confidence interval [CI] = 1.24-2.07, p < 0.001), hospitalizations (OR = 1.29, 95% CI = 1.01-1.65, p < 0.05), and 30-day readmissions (OR = 1.88, 95% CI = 1.88-3.29, p < 0.05). Reporting 2 insomnia symptoms, versus no insomnia symptoms, was associated with a greater number of ED visits and hospitalizations (incidence rate ratio (IRR) = 1.52, 95% CI = 1.23-1.87, p < 0.001; IRR = 1.21, 95% CI = 1.02-1.44, p < 0.05, respectively) after adjusting for demographic and health characteristics. Among older adults, insomnia symptoms are associated with greater health services use, including emergency department use, hospitalization, and 30-day readmission. Targeting insomnia may lower health services use.

General health status in young people with intellectual disabilities with and without Down syndrome in, and transitioning from, special education: findings from the National Longitudinal Transitions Study-2.

There has been little prior investigation of the general health of young people with intellectual disabilities across transition, nor separately for youth with intellectual disabilities with or without Down syndrome, despite general health being a strong predictor of subsequent health service use, hospital admissions and mortality in the general population. We aimed to investigate general health status in youth with intellectual disabilities with and without Down syndrome over the transitional period and quantify the extent to which personal characteristics, parental relationship and household income are associated with general health status. The National Longitudinal Transitions Study-2 includes a nationally representative sample of youth receiving special education services aged 13-17years at wave 1, followed up over 10years in five waves of data collection. Data on general health status of youth with intellectual disabilities with and without Down syndrome were obtained from parent reports. We summarised overall demographics and general health status and plotted general health status for those who had health data available for all five waves. We then used random-effects ordered logistic regression to investigate whether wave of data collection, age, sex, Down syndrome, ethnicity, parental relationship status and household income are associated with general health status. At wave 1, data on intellectual disabilities were available on 9008/9576 (94.1%) young people, and 871/9008 (9.7%) of them had intellectual disabilities, of whom 125/871 (14.4%) had Down syndrome. Youth with intellectual disabilities with or without Down syndrome had low rates of excellent or very good health. Across waves 1-5, there was a shallow gradient in the proportion of youth with intellectual disabilities reporting excellent/very good health, from 57.7% at 13-17years to 52.6% at 21-25years, being more marked for those without Down syndrome (57.8% at 13-17years to 51.8% at 21-25years). However, contrary to our expectations, an ordinal measure of general health status did not decline over this transitional period and did not differ between youth with and without Down syndrome. There was a gradient with higher income associated with better health, significantly so over $50001 (odds ratio=0.559, 95% confidence interval 0.366-0.854). Poorer health was experienced by youth with Hispanic, Latino or Spanish ethnicity (odds ratio=1.790, 95% confidence interval 1.051-3.048). Female sex and parental relationship status were not associated with health status. Young people with intellectual disabilities have bad health, and require support across all ages, including transition. Schools, teachers and staff in transitional services should consider health, and health care and support during transitional planning due to change in service provision and be aware of ethnicity and the stressful effects of low household income. This is important as interventions based on provision of greater support can prevent adverse consequences.

Loss of Enjoyment, Autonomy, Dignity: Top Reasons for Seeking PAD

Loss of Enjoyment, Autonomy, Dignity: Top Reasons for Seeking PAD

The predictive effect of medical illnesses for mental health care in adolescence: a register-based study.

BackgroundAdolescence is a developmentally sensitive stage, during which a medical illness may have an effect on individual development, and vice versa. Chronic medical illnesses in adolescents have been associated with psychiatric symptoms. The aim of the present register-based pilot study was to assess whether, and to what extent, different medical diagnoses predict subsequent use of mental health services among adolescents.MethodsThe study material comprised data on visits to a pediatric clinic by 12- to 16-year-old adolescent patients over a period of 5 years. Altogether, 10,154 visits by 1,781 patients were identified. The associations of the medical diagnoses with a subsequent visit to the adolescent psychiatry clinic were analyzed using logistic regression.ResultsDuring the follow-up period, 299 patients (16.8%) visited or contacted the adolescent psychiatry clinic at least once. Of various diagnoses, the highest odds ratios (ORs) were observed for diabetes mellitus (OR=4.07, p<0.001) and neoplasms (OR=3.29, p=0.047). An association was found between adolescent psychiatry clinic visits and female gender.ConclusionMedical symptoms and illnesses that require a referral to a pediatrician are a marked risk factor for later use of mental health services. The results call for screening for psychological distress among patients with somatic illnesses and prompt referrals to mental health services if required.

The effect of a celebrity health disclosure on demand for health care: trends in BRCA testing and subsequent health services use.

In May 2013, an internationally renowned celebrity-Angelina Jolie-disclosed her receipt of BRCA1/BRCA2 (BRCA) testing and subsequent double mastectomy in a highly publicized editorial. Publicity surrounding celebrity health services use increases awareness of important health issues and demand for health services. We aimed to describe BRCA testing trends before and after Jolie's disclosure, breast cancer-related services use following testing, and test reimbursement trends. MarketScan Commercial Claims data were used to compare trends in BRCA testing before and after Jolie's health disclosure using an interrupted time series model among women aged 18-64. We used modified Poisson regression to estimate risks for health services use (surgical consult, mastectomy, mammography, magnetic resonance imaging, genetic counseling) following BRCA testing. BRCA testing rates increased from 12.5 to 19.0 tests/100,000 women between January 2013 and October 2014. Immediately following Jolie's disclosure, testing increased by approximately 37% (p<0.001). Although BRCA testing increased, use of post-testing follow-up services declined after Jolie's disclosure. Mean insurance reimbursement and patient out-of-pocket spending on the test decreased by 3 and 36%, respectively. While genetic testing uptake increased following Jolie's disclosure, subsequent health services use associated with BRCA mutations declined, suggesting that celebrity disclosures may be associated with potential genetic testing overuse.

The new frontier in health services research: a behavioural paradigm guided by genetics.

The incorporation of genetics into health services research has largely floundered, despite the rapidly accelerating availability of, and access to, such data. This is expected given the ethical questions involved. However, using these new resources robustly to examine population choices when it comes to health insurer selection, coverage therein and especially the subsequent use of health services is a necessary step forward, especially given the increasing prevalence of multimorbidity. Such a novel advancement in health services research may eventually propel public and private insurers to redesign their infrastructure to more accurately reflect the behavioural inclinations of their beneficiary populations. Using this resource will likely provide equally important insight for countries with extensive mixed insurer systems (like the United States) or nations with a greater emphasis on single-payer systems (such as various European models).

Motivational aftercare planning to better care: Applying the principles of advanced directives and motivational interviewing to discharge planning for people with mental illness.

Improving the input of people with mental illness into their recovery plans can potentially lead to better outcomes. In the present study, we evaluated the introduction of motivational aftercare planning (MAP) into the discharge planning of psychiatric inpatients. MAP is a manualized intervention combining motivational interviewing with advance directives. We measured changes in the level of patient input into discharge planning following training staff in the use of MAP. This included the following: (i) documentation of early relapse signs along with successful past responses; (ii) evidence of aftercare planning; and (iii) the use of the patients' own words in the plan. We used a ward-level controlled before-and-after design comparing one intervention ward with two control wards. We used anonymized recovery plans, with a goal of 50 plans per ward before and after the intervention, to look for evidence of patient input into care planning with a standardized checklist. There were also qualitative interviews with individuals discharged from the unit. We reviewed 100 intervention ward plans and 197 control ones (total n=297). There were no significant differences in recovery plans from intervention and control wards at baseline. Following MAP training, the intervention ward improved significantly (e.g. identification of triggers increased from 52 to 94%, χ2 =23.3, d.f.=1, P<0.001). This did not occur in the control wards. The qualitative data (n=20 interviews) showed improvements in participants' experiences of discharge planning. MAP increased inpatient input into discharge planning and was valued by participants. The effect on subsequent health service use needs evaluation.

Patterns of community follow-up, subsequent health service use and survival among young and mid-life adults discharged from chronic care hospitals: a retrospective cohort study.

BackgroundDespite the demand for rehabilitation and chronic care services across the life course, policy and care strategies tend to focus on older adults and overlook medically complex younger adult populations. This study examined young and mid-life adults discharged from tertiary chronic care hospitals in order to describe their health service use and to examine the association between patterns of timely community follow-up, and subsequent health outcomes.MethodsThis population-based retrospective cohort study used linked administrative data to identify 1,906 individuals aged 18–64 years and discharged alive from tertiary chronic care hospitals in Ontario, Canada between April 1, 2005 and March 31, 2006. Multivariate Cox proportional hazard models were used to examine the effect of community follow-up within 7 days of discharge (home care and/or a primary care physician visit or neither) on time to first hospitalization and emergency department (ED) visit. Five-year survival was examined using Kaplan-Meier survival curves.ResultsThe cohort had a high prevalence of multi-morbidity and use of hospital, emergency services and physician services was high in the year following discharge. Most individuals received follow-up care from a primary care physician and/or home care within 7 days of discharge while 30 % received neither. Within 1 year of discharge, 18 % of individuals died. Among those who survived, time to acute care hospitalization in the year following discharge was significantly longer among those who received both a home care and a physician follow-up visit compared to those who received neither. No significant associations were found between community follow-up and ED visits within 1 year.ConclusionsImmediate community follow-up may reduce subsequent use of acute care services. Future research should determine why some individuals, who would likely benefit from services, are not receiving them including barriers to access.

The effect of celebrity health disclosures on demand for health care: Trends in BRCA testing in 2013 and subsequent health services use.

e13106Background: Celebrity health disclosures through the media increase awareness of important health issues and may increase health services use. In May 2013 an internationally-renowned celebrit...

Interventions to improve patient access to and utilisation of genetic and genomic counselling services.

The primary objective is to assess the effectiveness of interventions to improve patient identification, access to and utilisation of genetic and genomic counselling services when compared to: No intervention;Usual or current practice; andOther active intervention. The secondary objective is to explore the resource use and costs associated with interventions aimed at improving patient identification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. We will report on factors that may explain variation in the effectiveness of interventions aimed at improving patient identification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. Another secondary objective is to explore how interventions which target improved patient identification, access to and utilisation of genetic and genomic counselling services affect the subsequent appropriate use of health services for the prevention or early detection of disease. It is also possible that the genetic counselling interaction itself will contribute to the possible use of preventative services.

Comorbid antisocial and substance misuse proclivity and mental health service utilization by female inmates: testing the worst of both worlds hypothesis with the PAI.

The primary purpose of this study was to establish whether female inmates with comorbid proclivity for antisocial behavior and substance misuse, as measured by the Personality Assessment Inventory (PAI; Morey, 2007), use more mental health-related services than female inmates with either antisocial or substance misuse proclivity alone. A second purpose was to determine whether the effect of comorbid antisocial and substance misuse proclivity on mental health service utilization is cumulative or interactive. In a survey of 421 female federal prison inmates, it was noted that proclivity for both antisocial behavior and substance misuse was associated with significantly greater subsequent use of mental health services in female inmates than either proclivity alone, even after preexisting mental health diagnoses and treatment were controlled. In addition, the effect was additive rather than interactive. These findings provide further support for the "worst of both worlds" hypothesis, which holds that comorbid antisocial and substance involvement/proclivity portend poorer future outcomes than either antisocial or substance involvement/proclivity alone. The implications of these results for development of a comprehensive training model that provides mental health professionals with the skills to properly screen and effectively treat female inmates are discussed, along with the need to clarify the theory behind the "worst of both worlds" hypothesis.