Transitions In Health Status Research Articles

Calculation of Life Insurance Premiums with Markov Chain Applications for Patients with Pulmonary Tuberculosis Disease in Indonesia

This study aims to calculate the premium for Long Term Care (LTC) insurance on Annuity as A Rider Benefit products with a multi-status model. Pulmonary Tuberculosis is one of the major infectious diseases that contribute significantly to morbidity and mortality rates. Therefore, it is necessary to calculate insurance premiums that consider the health risks of sufferers. In this study, Markov chains are used to model the health status transition of individuals with Pulmonary Tuberculosis over time, considering several health states, such as healthy, sick, and dead. Tuberculosis epidemiological data in Indonesia is used to estimate the transition probabilities between health states. The case study used in this research is a 35-year-old man who participates in LTC insurance with a coverage period of 5 years. It is known that the value of compensation when a person dies is IDR 100,000,000. The interest rate used is 5%. The calculation results obtained annual premium for LTC insurance on Annuity as A Rider Benefit product is Rp294,333. Then the calculation of the annual net premium of this insurance is also calculated based on age and gender. When age increases, the premium will be greater, this is influenced by the greater chance of death when age increases. In addition, based on gender, it is found that the male premium is more expensive than the female gender. This is influenced by the chance of death of men is greater than women.

Data-Driven Analysis for Detecting Transitions in Health Status in Traumatic Brain Injury: Implications For Prevention

<h3>Research Objectives</h3> To apply computational and data visualization techniques to categorize health records of patients with traumatic brain injury (TBI) in Ontario Canada, from preceding injury to the injury event. <h3>Design</h3> Big data reduction techniques, conditional logistic regression modeling, correlation matrices, and hierarchical clustering. <h3>Setting</h3> Health administrative data on publicly funded services provided to residents of Ontario, Canada, including information on acute care hospitalizations and emergency department (ED) visits. <h3>Participants</h3> Data from 235,003 unique patients with TBI and the same number of reference patients discharged from the ED or acute care hospitals during the same study period for a reason other than TBI, individually matched by sex, age, place of residence, and income quintile. <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> We identified main and associated diagnoses according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision that were associated with a TBI event. To understand health status transitions from the time preceding TBI to the TBI event, we clustered all factors from each period into a single heatmap. <h3>Results</h3> Data-driven analysis revealed a remarkable extent of meaningful associations and health status transitions as they concern external causes of injury and injury severity. The strongest associations between health status preceding TBI and health status at the injury event were between clusters of multiple body system pathology and advanced age-related brain pathology. <h3>Conclusions</h3> Application of a health status transitions perspective to contextual injury event, and recognition that health status preceding injury makes a person more or less susceptible to TBI due to specific external cause of injury and developing a more or less severe TBI, entails new approaches to injury taxonomy, treatment and rehabilitation, and predictive classifications. <h3>Author(s) Disclosures</h3> The research reported in this presentation was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award R21HD089106 and the National Institute Of Neurological Disorders And Stroke of the National Institutes of Health under Award R01NS117921, and in part, by the Canada Research Chairs Program.

Functional Limitations among European Older Adults: Cross-Country Differences in Health Improvements and Social Environment Influence

This study explores differences on health status transitions based on functional health and dead records among older population in Europe. We also study the influence of residence pattern on health changes over time. Method: Data used came from EU-SILC registers on individuals aged 50 + from 19 countries. Fixed and Mixed effect Cox Proportional Hazards Models are used to ascertain any country differences on health outcomes and then by co-residence pattern. Results: There are remarkable country heterogeneity among older people to experience changes on their health status, specially, for health improvements and mortality risk. As expected, Baltic and Eastern European countries have a higher propensity for health deterioration and Southern European countries for health improvements on their functional capacities. However, there are exceptions as Bulgaria and Romania, which have a lower risk of deterioration and death transition than average. Overall, living with partner and adult children-rather than living only with a couple shown positive effects for older European to experience health improvements with notably differences in Southern countries as in Italy and Spain. Discussion: country framework differences play a fundamental role to understand changes on health status at older ages, in particular, how health care support toward older people is managed by health systems within European countries and the availability of close relatives among older adult population.

Decoding health status transitions of over 200 000 patients with traumatic brain injury from preceding injury to the injury event

For centuries, the study of traumatic brain injury (TBI) has been centred on historical observation and analyses of personal, social, and environmental processes, which have been examined separately. Today, computation implementation and vast patient data repositories can enable a concurrent analysis of personal, social, and environmental processes, providing insight into changes in health status transitions over time. We applied computational and data visualization techniques to categorize decade-long health records of 235,003 patients with TBI in Canada, from preceding injury to the injury event itself. Our results highlighted that health status transition patterns in TBI emerged along with the projection of comorbidity where many disorders, social and environmental adversities preceding injury are reflected in external causes of injury and injury severity. The strongest associations between health status preceding TBI and health status at the injury event were between multiple body system pathology and advanced age-related brain pathology networks. The interwoven aspects of health status on a time continuum can influence post-injury trajectories and should be considered in TBI risk analysis to improve prevention, diagnosis, and care.

A Research on the Different Financing Models of Long-term Care Insurance in China

Establishing a long-term care insurance (LTCI) system covering the whole people and balancing urban and rural areas is an important strategic plan for China to deal with the aging and disability of the population. Since the establishment of the LTCI system at the national level in 2016, China has 49 pilot areas for LTCI by 2020. Each pilot area is seriously fragmented, and the financing model of LTCI has not yet been finalized. So what is the financing model of LTCI that suits China’s national conditions? In addition, different financing models have their own advantages and disadvantages. The optimal financing model may depend on economic, social and demographic factors. Since the fund funded system does not have the function of mutual assistance in social insurance, this paper limits the financing model of LTCI between the pay-as-you-go system and the mixed system. Which one is optimal for the long-term sustainable development of China’s LTCI? Starting from the evolutionary law of the health status of elderly individuals, this paper explores the operation of China’s LTCI system under different financing models.This paper uses multi-period micro-tracking survey data, through the continuous time homogeneous Markov process and the generalized linear model, to describe the movement law of the health status transition of the elderly in China, and combines the seven census data and the age shift algorithm to calculate the size and structure of the disabled elderly population from 2020 to 2040. Further, based on the social insurance actuarial balance theory, a dynamic actuarial model under the pay-as-you-go system and three mixed systems is constructed to simulate the equilibrium premium rate and payment amount of LTCI for urban employees and urban and rural residents in the next 20 years. The study finds that, in terms of the size of disabled population, the female elderly are the main body of disabled population; the scale of disabled population in urban areas is significantly higher than that in rural areas. The main reason is that rural-urban migration has made urban elderly population larger, and the urban disability rate is higher than that in rural areas. In addition, in terms of funding pressure, the study shows that at any time and under any financing model, the relative payment pressure of LTCI for urban employees is significantly lower than that of urban and rural residents, but the absolute payment pressure is slightly higher than that of urban and rural residents. Finally, in terms of the selection of financing models, this paper believes that LTCI for urban employees should adopt a mixed system, and LTCI for urban and rural residents should adopt a pay-as-you-go system.The contribution of this paper is mainly reflected in two aspects: First, at the level of empirical research, it combines macro and micro data to describe the evolution of the health status of the elderly from the micro level, predicts the size of disabled population in China from the macro level, and finally establishes a LTCI system that covers the entire population. This not only deepens the research on individual health, but also enriches the research results in the social insurance actuarial field. Second, at the policy level, based on the results of the research, it provides an optimal financing model for LTCI for urban employees and LTCI for urban and rural residents. This optimal model can alleviate the payment burden of financing entities and enhance the stability of the LTCI system. It has important practical significance for the work focus and further promotion of China’s LTCI system.

The Health Status Transition and Medical Expenditure Evaluation of Elderly Population in China.

(1) Background: Because of the rapid expansion of the aging population in China, their health status transition and future medical expenditure have received increasing attention. This paper analyzes the health transition of the elderly and how their health transition impacts medical expenditures. At the same time, feasible policy suggestions are provided to respond to the rising medical expenditure and the demand for social care. (2) Methods: The data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2015 and analyzed using the Markov model and the Two-Part model (TPM) to forecast the size of the elderly population and their medical expenditures for the period 2020–2060. (3) Results: The study indicates that: (1) for the elderly with a mild disability, the probability of their health improvement is high; in contrast, for the elderly with a moderate or severe disability, their health deterioration is almost certain; (2) the frequency of the diagnosis and treatments of the elderly is closely related to their health status and medical expenditure; alternatively, as the health status deteriorates, the intensity of the elderly individuals’ acceptance of their diagnosis and treatment increases, and so does the medical expense; (3) the population of the elderly with mild and moderate disability demonstrates an inverted “U”-shape, which reaches a peak around 2048, whereas the elderly with severe disability show linear growth, being the target group for health care; (4) with the population increase of the elderly who have severe disability, the medical expenditure increases significantly and poses a huge threat to medical service supply. Conclusions: It is necessary to provide classified and targeted health care according to the health status of the elderly. In addition, improving the level of medical insurance, establishing a mechanism for sharing medical expenditure, and adjusting the basic demographic structure are all important policy choices.

A Social Media Study on Mental Health Status Transitions Surrounding Psychiatric Hospitalizations.

For people diagnosed with a mental illness, psychiatric hospitalization is one step in a long journey, consisting of clinical recovery such as removal of symptoms, and social reintegration involving resuming social roles and responsibilities, overcoming stigma and self-maintenance of the condition. Both clinical recovery and social reintegration need to go hand-in-hand for the overall well-being of individuals. However, research exploring social media for mental health has considered narrower, disjoint conceptualizations of people with mental illness - either as a patient or as a support-seeker. In this paper, we combine medical records with social media data of 254 consented individuals who have experienced a psychiatric hospitalization to address this gap. Adopting a theory-driven, Gaussian Mixture modeling approach, we provide a taxonomy of six heterogeneous behavioral patterns characterizing peoples' mental health status transitions around hospitalizations. Then we present an empirically derived framework, based on feedback from clinical researchers, to understand peoples' trajectories around clinical recovery and social reintegration. Finally, to demonstrate the utility of this taxonomy and the empirical framework, we assess social media signals that are indicative of individuals' reintegration trajectories post-hospitalization. We discuss the implications of combining peoples' clinical and social experiences in mental health care and the opportunities this intersection presents to post-discharge support and technology-based interventions for mental health.

Income and education are associated with transitions in health status among community-dwelling older people in Japan: the JAGES cohort study.

Health inequalities are an emerging issue in ageing societies, but inequalities in pre-frailty, which is suffered by almost half of older people, are mostly unknown. This study aimed to determine the association between the socio-economic status (SES) and changes across pre-frailty, frailty, disability and all-cause mortality. We conducted a prospective cohort study across 23 Japanese municipalities between 2010 and 2013. Functionally independent community-dwelling older adults aged ≥65 years (n = 65 952) in 2010 were eligible for the study. The baseline survey was conducted from 2010 to 2012, and the self-reporting questionnaires were mailed to 126 438 community-dwelling older adults [64.8% (81 980/126 438) response rate]. The follow-up survey was conducted in 2013. Overall, 65 952 individuals were followed up [80.4% (65 952/81 980) follow-up rate]. The health status was classified into five groups: robust; pre-frailty; frailty; disability and death. We conducted three multinomial logistic regression models stratified by the initial disability status. Educational attainment and equivalized household income were separately added to the models as exposures after adjusting for covariates. Participants with the lowest educational level were less likely to recover from pre-frailty to robust compared with those with the highest level [odds ratio (OR) (95% confidence interval (CI)) = 0.84 (0.76-0.93)]. The participants with the lowest income level were also less likely to recover from pre-frailty to robust compared with those with the highest level [OR (95% CI) = 0.80 (0.69-0.91)]. Older individuals with a lower SES were less likely to recover from a pre-frailty status.

The relationship and mechanism between education and functional health status transition among older persons in China

BackgroundDespite decades of study, debates exist surrounding the relationship between education and functional health status transition among elderly populations. This study aims to add evidence to the debates using China as a case study. Specifically, this study analysed the association of education with functional health status transition and then the mechanism behind that association using the budget constraint relax hypothesis and the efficiency improvement hypothesis among elderly population in China.MethodsBased on data from the Chinese Longitudinal Healthy Longevity Surveys from 2008 and 2011, this study focussed on adults aged 65 years and above, with a final sample size of 12,112. A generalised structural equation model was used to analyse the relationship between education and functional health status transition and the mechanism behind that association.ResultsDuring the three examined years, among elderly adults who were nondisabled at baseline, 53.1% stayed nondisabled, 14.6% became disabled, and 32.3% died; among those disabled in 2008, 8.1% recovered, 21.6% stayed disabled, and 70.3% died. Compared with older adults without any education, those who had attended primary schools had both lower mortality and disability, whereas those who had attended high schools and above only had a lower mortality rate. The budget constraint relax hypothesis and the efficiency improvement hypothesis explained the majority of the relationship between education and transition from non-disability to death, but hardly explained the transition from non-disability to disability. Furthermore, once a person was disabled, education had no significant relationship with functional ability recovery or mortality.ConclusionsAttending primary school seems to provide the highest benefit to functional health status transition among older and nondisabled persons in China. Those who attended high schools and above are expected to live a longer life with disability. The mechanism between education and the onset of disability needs more discussion.

Development and validation of a new instrument to measure health-related quality of life in patients with psoriatic arthritis: the VITACORA-19.

To develop/validate an instrument to measure health-related quality of life (HRQoL) in patients with psoriatic arthritis (PsA), for use in clinical studies. An item pool of 35 items was generated following standardized procedures. Item reduction was performed using clinimetric and psychometric approaches after administration to 66 patients with PsA. The resulting instrument, the VITACORA-19, consists of 19 items. Its validity content, internal consistency, test-retest reliability, known groups/convergent validity, and sensitivity to change were tested in a longitudinal and multicenter study conducted in 10 hospitals in Spain, with 323 patients who also completed the EuroQol 5-dimensional questionnaire (EQ-5D) and a health status transition item. There were 3 study groups: group A (n = 209, patients with PsA), group B (n = 71, patients with arthritis without psoriatic aspect, patients with arthrosis, and patients with dermatitis), and group C (n = 43, healthy controls). The questionnaire was considered easy/very easy to answer by 94.7% of the patients with PsA. The factorial analysis clearly identified only 1 factor. Cronbach's alpha coefficient and interclass correlation coefficients exceeded 0.90. Statistically significant differences (p < 0.001) were observed between groups: subjects from group C had better HRQoL, followed by group B, and finally group A had the worst HRQoL. The VITACORA-19 scores showed significant correlations (p < 0.001) to PsA disease activity, EQ-5D, and perceived health state, scoring the patients with better health state higher. The minimum important difference was established as an 8-point change in the global score. The Spanish-developed VITACORA-19, designed to measure HRQoL in patients with PsA, has good validity, reliability, and sensitivity to change.

Two separated effects of employer-provided health insurance on job mobility

We estimate the effect of employer-provided health insurance (EPHI) on job mobility via a dynamic model of joint employment and health insurance decision in the presence of uncertainty about wage rate and health status transitions. The model is based on a Markov decision process in which a hedonic wage approach provides an economic rationale for the different choices and health insurance serves as an input to the health production process. Including health transitions in the model helps us to understand how the availability of EPHI (positive job characteristic) and holding EPHI (the wage-health insurance trade-off) enter into the individuals’ decisions. The model is estimated using the 1999–2000 Medical Expenditure Panel Survey panel 4, and the results show that the ‘pure’ effects of holding EPHI are negligible, the ‘full’ effects of EPHI are significant and the degrees of the inefficiency vary between 14% and 25% across different states.

Effect of Health Protective Factors on Health Deficit Accumulation and Mortality Risk in Older Adults in the Beijing Longitudinal Study of Aging

To evaluate transitions in health status and risk of death in older adults in relation to baseline health deficits and protective factors. Prospective cohort study with reassessments at 5, 8, and 15 years. Secondary analysis of data from the Beijing Longitudinal Study on Aging. Urban and rural community-dwelling people aged 55 and older at baseline (n = 3,275), followed from 1992 to 2007, during which time 51% died. Health status was quantified using the deficit accumulation-based frailty index (FI), constructed from 30 intrinsic health measures. A protection index was constructed using 14 extrinsic items (e.g., exercise, education). The probabilities of health changes, including death, were evaluated using a multistate transition model. Women had more health deficits (mean baseline FI 0.13 ± 0.11) than did men (mean baseline FI 0.11 ± 0.10). Although health declined on average (mean FIs increased), improvement and stability were common. Baseline health significantly affected health transitions and survival over various follow-up durations (odds ratio (OR) = 1.27, 95% confidence interval (CI) = 1.17-1.37 for men; OR = 1.24, 95% CI = 1.16-1.33 for women for each increment of deficits). Each protective factor reduced the risk of health decline and the risk of death in men and women by 13% to 25%. Deficit accumulation-based transition modeling demonstrates persisting effects of baseline health status on age-related health outcomes. Some mitigation by protective factors can be demonstrated, suggesting that improving physical and social conditions might be beneficial.

Vitamin K antagonists and time in the therapeutic range: implications, challenges, and strategies for improvement

Oral vitamin K antagonists are highly efficacious in the prevention and treatment of thromboembolic disease. Optimal use of these agents in clinical practice is challenged by their narrow therapeutic window. The proportion of time spent in the International Normalized Ratio (INR) range of 2.0-3.0 [time in the therapeutic range (TTR)] has been closely associated with adverse outcomes, i.e., stroke, hemorrhage, mortality. Although TTR is a validated marker, it has several limitations. TTR does not capture short-term risks associated with highly variable periods or periods characterized by extreme deviations in INR. Because TTR measurement is limited to consecutive periods of warfarin exposure, it does not inform the risks associated with gap periods of 56 days or greater as these time intervals are excluded from end-point rate calculations. Because individuals with gaps in monitoring represent a different patient population than those without gaps, e.g., less adherent, more acutely ill, more frequent transitions in health status, TTR analyses are likely most valid and informative for individuals with uninterrupted monitoring of the INR. Duration of warfarin therapy and patient-specific factors have also been shown to influence TTR. Younger age, female sex, lower income, black race, frequent hospitalizations, polypharmacy, active cancer, decompensated heart failure, substance abuse, psychiatric disorders, dementia, and chronic liver disease have all been associated with lower TTR. Targeted strategies to improve TTR are urgently needed.

Health Status Transitions

present the policy implications of research carried out by member institutes of the European Network of Economic Policy Research Institutes. Initiated by CEPS in 1999, ENEPRI conducts research on welfare and employment issues with the aim of diffusing existing research, coordinating research plans and increasing the awareness of the European dimension in national problems. The research presented in this Policy Brief was conducted under the AHEAD project (Ageing, Health Status and the Determinants of Health Expenditure), which was funded for a three-year period by the European Commission under the 6

Percutaneous Tibial Nerve Stimulation Twice a Week in Female Patients with Refractory Urinary Frequency: A Preliminary Study

Introduction: To determine whether percutaneous tibial nerve stimulation (PTNS) applied twice a week is effective in female patients with refractory urinary frequency. Patients and Methods: Twenty-two patients with increased daytime urinary frequency and bladder sensation were enrolled in the prospective study undergoing a total of 10 times of PTNS. The response was assessed using a voiding diary, the 36-item short-form health survey (SF-36) quality-of-life questionnaire and the patient’s self-evaluation table. Results: A statistically significant improvement was found in daytime and nighttime voiding frequency, daytime voiding volume and nighttime lowest voiding volume variables. The self-reported health status transition in SF-36 was statistically lower after the treatment. Ten patients, who evaluated the trial as having had some effect, had more significant improvement statistically in nocturia than did the other 12 patients, who evaluated the trial as having had no effect. Conclusions: Intermittent PTNS twice a week might be an alternative treatment for patients with refractory urinary frequency. However, these preliminary impressions should be further confirmed.

Disability incidence and official health status transitions in Russia

This paper examines determinants of being disabled in Russia, along with the probability of moving from one disability status to another, using data from 1994 through 2005 from the Russian Longitudinal Monitoring Survey. Results from multinomial probit regressions indicate that disability risk rises sharply with age, declines with income and self-reported good health, and is lower for women. Neither smoking nor drinking alcohol increases either the risk of being or becoming disabled. Recovery – health status improvement – improves with household size. Misclassification or measurement error is important: a surprisingly large proportion of “incurably” disabled Russians do in fact recover. This study has been funded in part by National Institute of Aging grant #2P30 AG17248-02 through the Population Aging Center at the University of Colorado at Boulder. We are grateful to Aleksandr Andreev for outstanding research assistance. Jeanine Braithwaite, John Komlos, Cem Mete, Mieke Meurs, Daniel Mont, Frank Sloan, and five anonymous referees contributed valuable comments. We acknowledge our appreciation without implicating them in remaining errors and misinterpretations.

Self-rated health status transition and long-term care need, of the oldest Chinese

The objectives of this paper are: (1) to estimate the transition probabilities among self-rated health status for the oldest Chinese aged 80 and above; (2) to project the future need of long-term care due to changes in demography and health status among the oldest Chinese. Self-rated health data collected in Chinese Longitudinal Healthy Longevity Survey conducted in 1998, 2000 and 2002 were used to estimate the self-rated health status transition probabilities, and to project future long-term care need by calculating the number of unhealthy person-years. The majority of the oldest Chinese's health status remains unchanged or worsens within 2 years. The number of unhealthy person-years rises regardless of gender, and the absolute number and increase rate of females are higher than those of males. Under the assumption that average care expenditure is 15 US dollars per hour in 2010, the long-term care expenditure will increase from 8352 million dollars in 2010 to 42,530 million dollars in 2050, a growth of more than 400% over the next 40 years. Long-term care need for the oldest Chinese will rise rapidly in the next decades, which should stimulate increased governmental and public awareness of their need.

A multi-level analysis of urban/rural and socioeconomic differences in functional health status transition among older Chinese

The main purpose of the study is to assess urban versus rural differences in functional status transitions among older Chinese, aged 55+, and to examine how individual and community level socioeconomic indicators alter the rural/urban effects and themselves influence transitions. The study uses a hierarchical linear modeling approach that considers individual responses to be embedded within communities. Data come from the 2004 and 2006 rounds of the Chinese Health and Nutrition Survey. The study considers the functional transitions of 2944 individuals living across 209 communities in nine Chinese provinces. Functioning is measured at baseline as being able or not being able to conduct all of the following: walking, standing, climbing stairs, lifting, kneeling. Outcomes include having or not having a functional limitation, measured the same way, dying, or not responding. Outcomes are modeled adjusted for baseline functional status. Findings indicate urbanites have substantial advantages. They are less likely to have a limitation at follow-up and less likely to die over the study period. Some of this is explained by socioeconomic indicators measured at two levels. Cross-level interactions suggest education and having insurance operate differently in urban and rural areas. Community-level indicators are somewhat less predictive, and much of the urban advantage is unexplained. In conclusion, the study suggests differences in the influences of socioeconomic indicators in China versus what has been found in the past, and that place of residence in China is a particularly robust predictor of functional health transitions.

Health status transitions in community-living elderly with complex care needs: a latent class approach

BackgroundFor older persons with complex care needs, accounting for the variability and interdependency in how health dimensions manifest themselves is necessary to understand the dynamic of health status. Our objective is to test the hypothesis that a latent classification can capture this heterogeneity in a population of frail elderly persons living in the community. Based on a person-centered approach, the classification corresponds to substantively meaningful groups of individuals who present with a comparable constellation of health problems.MethodsUsing data collected for the SIPA project, a system of integrated care for frail older people (n = 1164), we performed latent class analyses to identify homogenous categories of health status (i.e. health profiles) based on 17 indicators of prevalent health problems (chronic conditions; depression; cognition; functional and sensory limitations; instrumental, mobility and personal care disability) Then, we conducted latent transition analyses to study change in profile membership over 2 consecutive periods of 12 and 10 months, respectively. We modeled competing risks for mortality and lost to follow-up as absorbing states to avoid attrition biases.ResultsWe identified four health profiles that distinguish the physical and cognitive dimensions of health and capture severity along the disability dimension. The profiles are stable over time and robust to mortality and lost to follow-up attrition. The differentiated and gender-specific patterns of transition probabilities demonstrate the profiles' sensitivity to change in health status and unmasked the differential relationship of physical and cognitive domains with progression in disability.ConclusionOur approach may prove useful at organization and policy levels where many issues call for classification of individuals into pragmatically meaningful groups. In dealing with attrition biases, our analytical strategy could provide critical information for the planning of longitudinal studies of aging. Combined, these findings address a central challenge in geriatrics by making the multidimensional and dynamic nature of health computationally tractable.

Association Between Hospitalization and Discontinuity of Medication Therapy Used in the Community Setting in the Netherlands

Transitions from one healthcare setting to another often parallel transitions in health status and can be associated with intentional as well as unintentional changes in patient care. Hospitalization may put patients at increased risk of discontinuity of medication use. To assess the association between hospitalization and medication therapy discontinuities. A retrospective follow-up study was conducted using data obtained from the PHARMO Record Linkage System. We randomly selected patients who had been hospitalized (index date) between July 1, 1998, and June 30, 2000. For each hospitalized patient, one nonhospitalized patient was matched for age, sex, and geographic area, and was assigned the same index date as the corresponding hospitalized patient. The primary study outcome was the incidence of one or more medication therapy discontinuities at the index date and at several control moments during a period of 18 months before and 18 months after hospital admission. We defined 4 mutually exclusive types of discontinuities: generic-brand substitution, product substitution, therapeutic switch, and stop. The study population comprised 8681 hospitalized patients and an equal number of age/sex-matched nonhospitalized patients. Of all hospitalized patients on drug therapy at the index date (n = 5265) 3322 (63.1%) had one or more medication therapy discontinuities at the index date, compared with 1390 (33.5%) of the nonhospitalized patients taking medication at the index date (n = 4147; RR 1.82; 95% CI 1.71 to 1.94). The highest risk estimate was found for therapeutic switch (RR 5.34; 95% CI 3.93 to 7.26), followed by product substitution (RR 2.32; 95% CI 1.88 to 2.86) and stop (RR 1.98; 95% CI 1.85 to 2.13). There was no significantly increased risk for generic-brand name substitution (RR 0.87; 95% CI 0.72 to 1.06). Hospitalization is associated with discontinuity of drugs used in the community setting. Medication stops were observed most frequently. Hospital safety programs should focus attention on medication therapy discontinuities at times of transition to ensure continuity of care in relation to drug therapy.