Trends In Health Care Use Research Articles

When the smoke gets in your lungs: short-term effects of Indonesia’s 2015 forest fires on health care use

BackgroundThe forest fires that ravaged parts of Indonesia in 2015 were the most severely polluting of this century but little is known about their effects on health care utilization of the affected population. We estimate their short-term impact on visit rates to primary and hospital care with particular focus on visits for specific smoke-related conditions (respiratory disease, acute respiratory tract infection (ARTI) and common cold).MethodWe estimate the short-term impact of the 2015 forest fire on visit rates to primary and hospital care by combining satellite data on Aerosol Optical Depth (AOD) with administrative records from Indonesian National Health Insurance Agency (BPJS Kesehatan) from January 2015–April 2016. The 16 months of panel data cover 203 districts in the islands of Sumatra and Kalimantan before, during and after the forest fires. We use the (more efficient) ANCOVA version adaptation of a fixed effects model to compare the trends in healthcare use of affected districts (with AOD value above 0.75) with control districts (AOD value below 0.75). Considering the higher vulnerability of children’s lungs, we do this separately for children under 5 and the rest of the population adults (> 5), and for both urban and rural areas, and for both the period during and after the forest fires.ResultsWe find little effects for adults. For young children we estimate positive effects for care related to respiratory problems in primary health care facilities in urban areas. Hospital care visits in general, on the other hand, are negatively affected in rural areas. We argue that these patterns arise because accessibility of care during fires is more restricted for rural than for urban areas.ConclusionThe severity of the fires and the absence of positive impact on health care utilization for adults and children in rural areas indicate large missed opportunities for receiving necessary care. This is particularly worrisome for children, whose lungs are most vulnerable to the effects. Our findings underscore the need to ensure ongoing access to medical services during forest fires and emphasize the necessity of catching up with essential care for children after the fires, particularly in rural areas.

The Impact of Visual Impairment on Healthcare Use among Four Medical Institution Types: A Nationwide Retrospective Cohort Study in Korea.

The aim of this study was to determine the effect of visual impairment (VI) onset on the use of healthcare services across four types of institutions in South Korea. We utilized data from the National Health Insurance Service database from 2006 to 2015 for 714 persons who experienced VI onset in 2009-2012 and for 2856 matched persons for a 1:4 ratio of matching controls. We compared trends in healthcare use and expenditures for eye diseases at clinics, hospitals, general hospitals, and tertiary teaching hospitals using 3 years of data prior to and after the onset of VI. The inpatient and outpatient healthcare expenditures of individuals with VI were higher than those without VI, peaking at the pre-VI onset period in tertiary teaching hospitals. During the pre-VI onset period, the proportion of healthcare expenditures attributed to eye diseases ranged 11%-40.8% among individuals with VI, but 1.9%-11% among individuals without VI at the four types of institutions. The differences in healthcare use between the pre- and post-VI periods were primarily observed in tertiary teaching hospitals for inpatient care. There was a peak in utilization of outpatient care in the year preceding VI onset at tertiary teaching hospitals, clinics, and hospitals, but there was a decrease in outpatient care over time during the post-VI period. Our findings suggest economic burden of healthcare in tertiary teaching hospitals during pre-VI onset period and a potential lack of regular management and continuity of care in post-VI periods.

Healthcare use and medical cost before and after diagnosis of nontuberculous mycobacterial infection in Korea: the National Health Insurance Service-National Sample Cohort Study.

The global prevalence and incidence of nontuberculous mycobacterial (NTM) infections are increasing; however, population-level data on healthcare use and medical costs for people with NTM infections are limited. Thus, we investigated the rates of healthcare use and medical costs of people with NTM infections in South Korea using the National Health Insurance Service-National Sample Cohort from 2002 to 2015. In this cohort study, people with and without NTM infection aged 20-89 years were matched 1 to 4 by sex, age, Charlson comorbidity index, and year of diagnosis. The overall and annual average healthcare use and medical costs were calculated. In addition, trends in healthcare use and medical costs for each of the 3 years before and after NTM diagnosis were investigated for people diagnosed with NTM infection. A total of 798 individuals (336 men and 462 women) diagnosed with NTM infection and 3192 controls were included in the study. NTM-infected patients had significantly higher rates of healthcare use and medical costs than those in the control group (p < 0.05). NTM-infected patients showed 1.5 times the medical cost and 4.5 times the respiratory disease cost of the control group. People diagnosed with NTM infection incurred the highest medical costs in the 6 months before diagnosis. NTM infection increases the economic burden on Korean adults. Appropriate diagnostic tests and treatment plans for NTM infections are needed to reduce the burden of the disease caused by such infection.

Impact of COVID-19 Pandemic on Military Medical Encounters and Musculoskeletal Injuries

Background and Aim: Musculoskeletal injuries (MSKI) are the leading cause of outpatient medical encounters in the U.S. Army, and trends have remained stable over the past decade. The COVID-19 pandemic has altered healthcare use and workplace and lifestyle patterns, potentially affecting injury trends. We investigated the impact of the pandemic on healthcare use and injuries within the Army. Methods: We quantified medical encounters (all, in-person only, telephone consults only) and incident MSKI from electronic medical records among active duty soldiers from April 2016 through March 2021. We compared weekly counts before and after the COVID-19 national emergency declaration on March 13, 2020 in an interrupted time-series analysis using autoregressive integrated moving average models accounting for time and seasonal trends. Results: From April 2016 to March 2020, the mean (SD) weekly count was 125,953 (20,782) for all medical encounters [in-person: 113,249 (19,139); telephone consults: 17,053 (2,536)] and 11,016 (1,907) for MSKI. Weekly counts for all and in-person medical encounters and MSKI decreased and telephone consults increased in the month following the declaration. All medical encounters gradually returned to levels predicted in the absence of the pandemic, yet the reductions for in-person medical encounters [-13,405 (95% CI: -21,516, -5,294)] and MSKI [-1,933 (95% CI: -2,812, -1,056)] and increases in telephone consults [1,530 (95% CI: 566, 2,496)] were sustained through March 2021. Conclusions: Observed trends in healthcare use during the pandemic differed from previous years. All medical encounters appeared to have returned to predicted levels. While activities in the Army have largely resumed, the sustained reduction in MSKI is likely multifactorial and may be due to shifts in healthcare access and use. The views expressed are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or the U.S. Government. Keywords: COVID-19, occupational epidemiology

Trends in Health Care Use Among Black and White Persons in the US, 1963-2019

In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking. To assess trends in Black-White disparities in health care use since 1963. This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians. Self-reported race and ethnicity. Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures. Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods. This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.

Change in Disease Dynamics and Health Care Utilisation in Children during COVID 19 in a Tertiary Care Hospital of Eastern India

This retrospective, observational study was conducted by collecting data from medical records during COVID 19 pandemic from March 2020 till August 2020. This was compared with the data of 2019 during similar months. The impact of COVID 19 on use of preventive and curative paediatric health care service units like outpatient department, casualty, intensive care and immunization clinic were assessed. Data from 2019 to 2020 were compared using standard parametric and nonparametric tests. There was a significant decline in routine OPD (68%) attendance during the COVID 19 period as compared to pre-COVID period. Paediatric ward admissions and PICU admissions were decreased by 55% and 42% respectively. We also observed a significant 43% decline in the number of children attending immunization clinic in the year 2020. The fear of COVID 19 pandemic and the measures taken to control the pandemic has affected the health seeking behaviour of patients. This evaluation of trends in healthcare use may help in planning the delivery of healthcare service delivery in future.

Pandemic trends in health care use: From the hospital bed to self-care with COVID-19.

To explore whether the acute 30-day burden of COVID-19 on health care use has changed from February 2020 to February 2022. In all Norwegians (N = 493 520) who tested positive for SARS-CoV-2 in four pandemic waves (February 26th, 2020 -February 16th, 2021 (1st wave dominated by the Wuhan strain), February 17th-July 10th, 2021 (2nd wave dominated by the Alpha variant), July 11th-December 27th, 2021 (3rd wave dominated by the Delta variant), and December 28th, 2021 -January 14th, 2022 (4th wave dominated by the Omicron variant)), we studied the age- and sex-specific share of patients (by age groups 1-19, 20-67, and 68 or more) who had: 1) Relied on self-care, 2) used outpatient care (visiting general practitioners or emergency ward for COVID-19), and 3) used inpatient care (hospitalized ≥24 hours with COVID-19). We find a remarkable decline in the use of health care services among COVID-19 patients for all age/sex groups throughout the pandemic. From 83% [95%CI = 83%-84%] visiting outpatient care in the first wave, to 80% [81%-81%], 69% [69%-69%], and 59% [59%-59%] in the second, third, and fourth wave. Similarly, from 4.9% [95%CI = 4.7%-5.0%] visiting inpatient care in the first wave, to 3.6% [3.4%-3.7%], 1.4% [1.3%-1.4%], and 0.5% [0.4%-0.5%]. Of persons testing positive for SARS-CoV-2, 41% [41%-41%] relied on self-care in the 30 days after testing positive in the fourth wave, compared to 16% [15%-16%] in the first wave. From 2020 to 2022, the use of COVID-19 related outpatient care services decreased with 29%, whereas the use of COVID-19 related inpatient care services decreased with 80%.

Trends in Health Care Use and Spending for Young Children With Neurologic Impairment.

Children with neurologic impairment (NI) are a growing subset of children who frequently use health care. We examined health care use and spending trends across services for children with NI during their first 5 years of life. This was a retrospective study of 13 947 children with NI in the multistate IBM Medicaid MarketScan Database (2009-2017). We established birth cohorts of children with NI and analyzed claims from birth to 5 years. NI, identified by using International Classification of Diseases, 9th Revision, diagnosis codes, was defined as ≥1 neurologic diagnosis that was associated with functional and/or intellectual impairment. We measured annual health care use and per-member-per-year spending by inpatient, emergency department (ED), and outpatient services. Population trends in use and spending were assessed with logistic and linear regression, respectively. During their first versus fifth year, 66.8% vs 5.8% of children with NI used inpatient services, and 67.8% vs 44.4% used ED services. Annual use in both categories decreased over 0-5 years (inpatient odds ratio: 0.35, 95% confidence interval: 0.34 to 0.36; ED odds ratio: 0.78, 95% confidence interval: 0.77 to 0.79). The use of outpatient services (primary care, specialty care, home health) decreased gradually. Per-member-per-year spending on inpatient services remained the largest spending category: $83 352 (90.2% of annual spending) in the first year and $1944 (25.5%) in the fifth year. For children with early-onset NI from 0-5 years, use and spending on inpatient services decreased dramatically; ED and outpatient service use decreased more gradually. These findings may help systems, clinicians, and families optimize care by anticipating and adjusting for shifting use of health care services.

Effects of the COVID-19 pandemic on the mental health of shielded children and children living in shielded households in Wales: a data linkage study

BackgroundThe COVID-19 pandemic has had a detrimental effect on children's mental health. Shielded children or those living with a shielded person might be particularly susceptible to mental health difficulties arising as a result of strict public health restrictions. However, studies examining mental health outcomes in these children are scarce. We aimed to address this evidence gap. MethodsWe linked the COVID-19 Shielded Patient List to demographic and health-care datasets within the Secure Anonymised Information Linkage (SAIL) databank. We constructed three cohorts of children aged 2–17 years who were living in Wales and registered with a general practitioner that provides data to SAIL when shielding was introduced on March 23, 2020: shielded children, children living with a shielded person, a general population group of registered children who were neither shielding or living with a shielded person. We used published Read codes to identify children with primary care diagnoses or prescriptions relating to anxiety or depression, before and during the pandemic. We compared the difference in proportions of new diagnoses or prescriptions during COVID-19 between groups. FindingsBefore the COVID-19 pandemic (March 23, 2019, to March 23, 2020), 155 (4·2%) of 3721 shielded children received diagnoses or prescriptions for anxiety or depression, compared with 128 (3·4%) of 3721 children during the pandemic (March 23, 2020, to Jan 31, 2021); 71 (2·0%) of 3566 had new diagnoses or prescriptions during the pandemic. For children in shielded households, these values were 489 (2·5%) of 19 954 children before COVID-19 and 301 (1·5%) of 19 954 children during COVID-19, with 218 (1·1%) of 19 456 having new diagnoses or prescriptions during the pandemic. For the general population, these values were 8001 (2·0%) of 411 680 children before COVID-19 and 5420 (1·3%) of 411 680 children during COVID-19, with 4070 (1·0%) of 403 679 having new diagnoses or prescriptions during the pandemic. The difference in the proportion of new diagnoses or prescriptions between shielded children and the general population was significant (χ2 35·40 [95% CI 0·59–1·51], p<0·0001). InterpretationOur findings show a decrease in diagnoses or prescriptions for anxiety or depression during COVID-19, which could be partly attributed to a reluctance to seek health care during this time. The prevalence of anxiety or depression was highest in shielded children, and the rate of new diagnoses or prescriptions during COVID-19 was significantly higher among shielded children. Future work could involve longitudinal follow-up of these children to assess future trends in health-care use for mental health-related conditions and longer-term health and education outcomes among these groups. FundingHealth and Care Research Wales.

Variability in end-of-life healthcare use in patients with osteoarthritis: a population-based matched cohort study

To investigate the patterns of healthcare use (HCU) at the last year of life in persons with osteoarthritis (OA). Using linked registers, we identified persons aged≥ 65 years who died during 2003-2014 and were resided in the Skåne region during 5-year prior to death. Among these, we randomly matched decedents with a principal OA diagnosis prior to the last year of life (OA cohort, n=17,993) with up to 4 comparators without OA by sex, age at death, and year of death (n=59,945). We measured monthly HCU for each decedent during last year of life and applied two-part regression models to estimate HCU attributable to OA. Group-based trajectory modelling (GBTM) was used to detect distinct trajectories of HCU within the OA cohort. During last 12-month of life, each person with OA had, on average, 2.5 (95% CI 2.2, 2.7) excess healthcare consultations and 1.8 (95% CI 1.3, 2.2) more inpatient days than those without OA. While both cohorts observed increasing trends in HCU towards death, excess healthcare consultations attributable to OA declined and inpatient days increased as death approached. For both healthcare consultations and inpatient days, GBTM identified four distinct trajectory classes. While underlying cause of death and age were the most important predictors of class membership, the overall predictive accuracy was poor. OA was associated with excess HCU especially hospital-based care during the last year of life. However, there seem to be distinct trajectory classes within the OA patient population.

Mycosis fungoides and S\xe9zary syndrome: a population-wide study on prevalence and health care use in Finland in 1998\u20132016

BackgroundInformation about health care use and costs of cutaneous T-cell lymphoma (CTCL) patients is limited, particularly in a European setting.MethodsIn this population-wide study we set out to investigate prevalence, and trends in health care use in two CTCL subtypes, mycosis fungoides (MF) and Sézary syndrome (SS) over a time period of 19 years in 1998–2016 by using a nation-wide patient register containing data on all diagnosed MF and SS cases in Finland.ResultsThe prevalence of diagnosed MF and SS rose from 2.04 to 5.38/100000, and from 0.16 to 0.36/100000 for MF and SS respectively during 1998–2016. We found a substantial decrease in inpatient treatment of MF/SS in the past two decades with a mean of 2 inpatient days/patient/year due to MF/SS in 2016, while the mean numbers of MF/SS related outpatient visits remained stable at 8 visits/year/patient. Most MF/SS-related outpatient visits occurred in the medical specialty of dermatology. In a ten-year follow-up after MF/SS diagnosis, the main causes for outpatient visits and inpatient stays were MF/SS itself, other cancers, and other skin conditions. Also cardiovascular disease and infections contributed to the number of inpatient days. Mean total hospital costs decreased from 11,600 eur/patient/year to 3600 eur/patient/year by year 4 of the follow-up, and remained at that level for the remainder of the 10-year follow-up. MF/SS accounted for approximately half of the hospital costs of these patients throughout the follow-up.ConclusionsThe nearly 3-fold increase in prevalence of diagnosed MF/SS during 1998–2016 puts pressure on the health care system, as this is a high-cost patient group with a heavy burden of comorbidities. The challenge can be in part answered by shifting the treatment of MF/SS to a more outpatient-based practice, and by adapting new pharmacotherapy, as has been done in Finland.

Trends in healthcare use in children aged less than 15 years: a population-based cohort study in England from 2007 to 2017

ObjectiveTo describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade...

Socioeconomic differences in health-care use and outcomes for stroke and ischaemic heart disease in China during 2009–16: a prospective cohort study of 0·5 million adults

SummaryBackgroundChina initiated major health-care reforms in 2009 aiming to provide universal health care for all by 2020. However, little is known about trends in health-care use and health outcomes across different socioeconomic groups in the past decade.MethodsWe used data from the China Kadoorie Biobank (CKB), a nationwide prospective cohort study of adults aged 30–79 years in 2004–08, in ten regions (five urban, five rural) in China. Individuals who were alive in 2009 were included in the present study. Data for all admissions were obtained by linkage to electronic hospital records from the health insurance system, and to region-specific disease and death registers. Generalised linear models were used to estimate trends in annual hospital admission rates, 28-day case fatality rates, and mean length of stay for stroke, ischaemic heart disease, and any cause in all relevant individuals.Findings512 715 participants were recruited to the CKB between June 25, 2004, and July 15, 2008, 505 995 of whom were still alive on Jan 1, 2009, and contributed to the present study. Among them, we recorded 794 824 hospital admissions (74 313 for stroke, 69 446 for ischaemic heart disease) between 2009 and 2016. After adjustment for demographic, socioeconomic, lifestyle, and morbidity factors, hospitalisation rates increased annually by 3·6% for stroke, 5·4% for ischaemic heart disease, and 4·2% for any cause, between 2009 and 2016. Higher socioeconomic groups had higher hospitalisation rates, but the annual proportional increases were higher in those with lower education or income levels, those enrolled in the urban or rural resident health insurance scheme, and for those in rural areas. Lower socioeconomic groups had higher case fatality rates for stroke and ischaemic heart disease, but greater reductions in case fatality rates than higher socioeconomic groups. By contrast, mean length of stay decreased by around 2% annually for stroke, ischaemic heart disease, and any cause, but decreased to a greater extent in higher than lower socioeconomic groups for stroke and ischaemic heart disease.InterpretationBetween 2009 and 2016, lower socioeconomic groups in China had greater increases in hospital admission rates and greater reductions in case fatality rates for stroke and ischaemic heart disease. Additional strategies are needed to further reduce socioeconomic differences in health-care use and disease outcomes.FundingWellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and Chinese National Natural Science Foundation.

대장암 치료유형별 거주지역내 의료기관 이용 추이분석

대장암 치료유형별 거주지역내 의료기관 이용 추이분석

Diverging trends in health care use between 2010 and 2016: Evidence from three groups of transition countries

This paper investigates changes in health care use in 28 transition countries using data on more than 60,000 households from the “Life in Transition” surveys II and III conducted in 2010 and 2016. Following the literature, the transition countries are divided into three groups – Eastern Europe, Southern Europe and the non-Baltic states of the former Soviet Union with Mongolia – based on the speed of their transformation. Regressions based on Andersen’s conceptual framework show no difference in public health care use between the three groups in 2010. By 2016, however, the share of households using the public health care system dropped by remarkable 17.1–22.2% points in Southern Europe and 13.5–27.1% points in the former Soviet Union with Mongolia compared to Eastern Europe. Moreover, by 2016, the probability of a household using the private health care system (with no use of public health care) in Southern Europe and the former Soviet Union was 7.5–18.7% points higher than in Eastern Europe, whereas it was 2.9–6.8% points lower than in Eastern Europe back in 2010. The analyses indicate that differences in household characteristics, as well as perceived corruption and quality of public health care, help to understand these diverging trends in health care use in the three groups of transition countries between 2010 and 2016.

Hospitalization Trends and Comorbidities Among People With HIV/AIDS Compared With the Overall Hospitalized Population, Illinois, 2008-2014.

To understand trends in health care use among people living with HIV/AIDS (PLWHA), this study compared trends in hospitalization rates, comorbidities, and hospital death rates of hospitalized PLWHA with the overall hospitalized population in Illinois during 2008-2014. This study identified principal hospitalizations (the principal discharge diagnosis coded with an HIV-related billing code) and secondary HIV hospitalizations (a non-principal discharge diagnosis coded with an HIV-related billing code) from 2008-2014 Illinois hospital discharge data. Hospitalization rates among PLWHA were calculated using prevalence data from the Illinois Electronic HIV/AIDS Registry; US Census population estimates were used to calculate overall Illinois hospitalization rates. Joinpoint regression analysis was used to assess trends overall and among demographic subgroups. Comorbidities and discharge status for all hospitalizations were identified. In 2014, the hospitalization rate was 2.2 times higher among PLWHA than among the overall Illinois hospitalized population. From 2008 to 2014, principal HIV hospitalization rates per 1000 PLWHA decreased by 48% (from 71 to 37) and secondary HIV hospitalization rates declined by 26% (from 296 to 218). The decline in the principal HIV hospitalization rate was steepest from 2008 to 2011 (annual percentage change = -16.0%; P = .003). Mood disorders, substance-related diagnoses, and schizophrenia accounted for 18% to 22% of principal hospitalizations among PLWHA compared with 7% to 8% of overall Illinois hospitalizations. Hepatitis as a comorbidity was more common among hospitalized PLWHA (18%-22%) than among the overall Illinois hospitalized population (1.4%-1.5%). Hospitalized PLWHA were 3 times more likely than the overall Illinois hospitalized population to die while hospitalized. HIV hospitalizations are largely preventable with appropriate treatment and adherence. Additional efforts to improve retention in HIV care that address comorbidities of PLWHA are needed.

BEFORE-AND-AFTER STUDY: DOES BARIATRIC SURGERY REDUCE HEALTHCARE UTILIZATION AND RELATED COSTS AMONG OPERATED PATIENTS?

Healthcare use and costs are about 81% higher for morbidly obese individuals compared to non-obese persons, and 47% higher compared to the non-morbidly obese population. The benefits of bariatric surgery for health are well established, but its mid-term impact on healthcare use and costs remains controversial. This study examines the trends in healthcare use and costs in a Brazilian cohort during a 4-year period before and after surgery. Healthcare use and direct costs related to inpatients and outpatients were retrieved from a healthcare insurance company database from which all cohort members were selected. Between 2004 and 2010, 4,006 individuals underwent bariatric surgery. Most patients were female (80%) with a mean age of 36.2 years and a mean body mass index of 42.8 kg/m2. Elevated blood pressure was present in 38% of cases and diabetes was found in 12.5% of subjects. Hospital admissions increased consistently after surgery, even after excluding hospitalizations for esthetic surgery and pregnancy-related care. The most prevalent conditions in this group were gastrointestinal diseases. Emergency department visits increased after bariatric procedures, in particular for genitourinary and hematologic problems. Adjusted costs were higher after surgery as assessed during a 4-year follow-up period. Results indicate that costs and hospital admissions after bariatric surgery increase following this procedure, even when elective interventions are excluded. Healthcare providers and policy makers need to be aware that a decrease in obesity-related diseases following bariatric surgery does not reduce healthcare use and costs.

Changing use of traditional healthcare amongst those dying of HIV related disease and TB in rural South Africa from 2003 - 2011: a retrospective cohort study.

BackgroundIn 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period.MethodsData was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use.ResultsThere were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008–2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003–2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated.ConclusionsThere were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6882-14-504) contains supplementary material, which is available to authorized users.

Patient-Centered Medical Home Initiative Produced Modest Economic Results For Veterans Health Administration, 2010–12

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.

The Impact of Overweight and Obesity on Pediatric Medical Expenditures

Published studies do not consistently find overweight and obesity to be associated with higher medical expenditures for US children. Previous analyses use varying samples and methods, making results difficult to compare. To examine whether methodological choices or temporal trends are driving differences in estimates of the association between weight and pediatric medical expenditures. We analyzed the medical expenditures and use of 6- to 17-year-old individuals in the 2006-2010 US Medical Expenditure Panel Surveys. The impact of overweight and obesity on annual medical expenditures and use was assessed, controlling for age, income, race, sex, geographic region, urban/rural residency, insurance status, and survey year. A two-part regression model, in which part one estimated the likelihood of incurring any expenditure and part two estimated non-zero expenditures, was used to predict total expenditures. Expenditures were inflated to 2012 dollars using the medical care component of the Consumer Price Index. Poisson and logistic regression models were used to predict differences in healthcare use between normal weight, overweight, and obese youth. We found that overweight and obese youth have higher, but not significantly higher medical expenditures than normal weight youth. Conclusions were robust to various methodological assumptions. We found that obese adolescents have a higher use of prescriptions drugs and healthcare visits compared with normal weight youth (0.04-1.3 visits), but differences in use only translated into marginally higher expenditures. These findings may reflect new trends in healthcare use among obese youth. Future research should assess whether services are being underused by obese youth and the impact of persistent obesity on long-term medical expenditures.