Trends In Health Care Utilization Research Articles

Healthcare Utilization Among Justice‐Involved Individuals Enrolled in Medicaid: Lessons from a Midwestern State

Research ObjectiveJustice‐involved individuals have historically faced numerous barriers to accessing timely healthcare, especially after release from incarceration. This population disproportionately needs behavioral health services, for which continuity of care is crucial to prevent poor outcomes. To address this need, several states including Indiana have implemented policies to facilitate Medicaid enrollment for justice‐involved adults. Specifically, Indiana implemented policies and procedures, including Medicaid eligibility expansion through an 1115 waiver, the ability of the Indiana Department of Corrections (IDOC) to submit applications for coverage on behalf of the individuals prior to release, and allowing for coverage to be suspended rather than terminated during incarceration. Increased Medicaid coverage after release followed, but healthcare utilization patterns after release are not yet well understood. The purpose of this study is to describe healthcare utilization for individuals released from state prisons and enrolled in the Healthy Indiana Plan, Indiana's Medicaid coverage for adults.Study DesignIn this retrospective, observational study, we linked IDOC release data to Medicaid enrollment, claims data, and other state program data. We described trends in healthcare utilization in the four months following Medicaid coverage and further explore trends by time between release and Medicaid coverage.Population StudiedJustice‐involved adults released from IDOC state correctional facilities and subsequently enrolled in Medicaid between 2013‐2018 (n=19,636).Principal FindingsApproximately 80% of individuals received some sort of healthcare within the first 4 months of becoming enrolled in Medicaid, with the highest utilization occurring in the emergency department (ED, 44.1%) and office visits (41.2%). The average time to first service was approximately 55 days (SD: 37.4). The ED was the most common first setting for care (30.8%) and 20.3% of first encounters were for mental health and substance use‐related services. Those who were enrolled in Medicaid shortly after their release (within 7 days) were more likely to utilize any care compared to those who were enrolled later (89.5% vs 77.0%, p <0.0001) and received care an average of 27 days quicker (p<0.0001). In addition, those who were enrolled quickly were more likely to receive any care in almost all settings, receive substance use and mental health services, and seek care faster than those who were enrolled later.ConclusionsWe identify high healthcare utilization in this population after release from prison, largely higher than among the general population. In addition, we find that individuals who receive Medicaid coverage shortly after release are more likely to seek care in most settings and faster. While this may be indicative of better access to care, this may also be driven by selection or individuals becoming enrolled presumptively at the time of an acute encounter.Implications for Policy or PracticeThe transition that occurs when individuals are released from prison represents an important opportunity to fill gaps in coverage and facilitate continuous access to needed services. Findings from this study provide a better understanding of the patterns of healthcare utilized after release from prison, including the settings and types of care received. Further research is needed to understand of the extent to which Medicaid coverage improves behavioral health outcomes and chronic disease management.Primary Funding SourceState of Indiana

Population-based Trends in Healthcare Utilization and National Healthcare Spending on Pancreatitis in North America

It is estimated that the global incidence of pancreatitis has increased from ∼1.0 million new cases per year in 1990 to ∼1.6 million new cases annually in 2017.1 In the United States, pancreatitis is the third most common gastrointestinal diagnosis requiring hospitalization.2 With rising rates of alcohol consumption and obesity, the incidence of pancreatitis is anticipated to continue to increase. Furthermore, the management of pancreatitis is highly resource intensive and often requires hospitalization, close monitoring, and therapeutic interventions or surgery to manage either the underlying etiology or pancreatitis-related complications.

Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study.

To evaluate the trend of healthcare utilization among patients with dementia (PwD) in different post-diagnosis periods, Taiwan’s nationwide population database was used in this study. PwD were identified on the basis of dementia diagnoses during 2002–2011. We further subdivided the cases into 10 groups from the index year to the 10th year after diagnosis. The frequency of emergency department visits and hospitalizations, the length of stay, outpatient and department visits, and the number of medications used were retrieved. The Joinpoint regression approach was used to estimate the annual percent change (APC) of healthcare utilization. The overall trend of healthcare utilization increased with the progression of dementia, with a significant APC during the first to second year after diagnosis (p < 0.01), except that the frequency of outpatient visits showed a decreasing trend with a significant APC from the first to fifth year. All sex- and age-stratified analyses revealed that male gender and old age contributed to greater use of healthcare services but did not change the overall trend. This study provides a better understanding of medical resource utilization across the full spectrum of dementia, which can allow policymakers, physicians, and caregivers to devise better care plans for PwD.

Correction: Impact of the COVID-19 Pandemic on Health Care Utilization in a Large Integrated Health Care System: Retrospective Cohort Study

BACKGROUND: The COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers. OBJECTIVE: The aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019. METHODS: We retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year. RESULTS: In the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020). CONCLUSIONS: In-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels.

Trends in Health Care Utilization and Expenditures in the United States Across 5 Decades: 1977-2017.

Health care expenditures in the United States are high and rising, with significant increases over the decades. The delivery, organization, and financing of the health care system has evolved over time due to technological innovation, policy changes, patient preferences, altering payment mechanisms, shifting demographics, and other factors. The objective of this study was to examine trends over time in health care utilization and expenditures in the United States. This analysis employs descriptive statistics to examine 5 decades of health care utilization and expenditure data from the Agency for Healthcare Research and Quality (AHRQ) for 1977-2017. Measures include utilization and expenditures (not charges) for inpatient, emergency department, outpatient physician, outpatient nonphysician, office-based physician, dental, and out-of-pocket retail prescription drugs. We demonstrate that while health care expenditures have increased significantly overall and by type of care, utilization trends are less pronounced. The population of the United States grew 53% between 1977 and 2017, while annual total expenditures on health care increased by 208%. Amidst attention to out-of-pocket exposure for unexpected medical care bills, out-of-pocket payments for care have declined from 32% in 1977 to 12% in 2017 but increased in amount. This article provides the first extended snapshot of the dynamics of health care utilization and expenditures in the United States. Aspects of health care are much different today than in previous decades, yet the inpatient setting still dominates the expenditures.

Pediatric Refugee Health and Patterns of Health Care Utilization in Durham, North Carolina.

This study explored the health needs, trends of health care utilization, and barriers to care of a diverse population of refugee children resettled in Durham County, North Carolina. Researchers conducted a retrospective chart review of 327 pediatric (aged 0-21 years) refugee patients who received care at Lincoln Community Health Center from 2016 to 2018. Results describe a low prevalence of infectious diseases, such as human immunodeficiency virus (0%), hepatitis B (2%), and tuberculosis (5%), but a high prevalence of nutritional problems, such as growth stunting (17%), overweight (21%), Vitamin D insufficiency (79% of the 39 tested), and anemia (13%). Subspecialty care was frequently utilized, despite prolonged appointment delays and frequent missed visits. Limitations of the study included a small sample size that only considered refugees in one geographic area and one primary care clinic, as well as variability in physician documentation. These findings highlight the need for tailored programs and processes, such as dedicated case management and improved screening practices, in order to facilitate integrated care and promote wellness among this vulnerable group of young refugees.

Impact of the COVID-19 Pandemic on Health Care Utilization in a Large Integrated Health Care System: Retrospective Cohort Study.

BackgroundThe COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers.ObjectiveThe aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019.MethodsWe retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year.ResultsIn the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020).ConclusionsIn-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels.

Evaluating the unevaluated: a secondary analysis of the National Survey for Family Growth (NSFG) examining infertile women who did not access care.

To characterize the demographic differences between infertile/sub-fertile women who utilized infertility services vs. those that do not. A retrospective analysis of cross-sectional data obtained during the 2011-2013, 2013-2015, and 2015-2017 cycles of National Survey for Family Growth from interviews administered in home for randomly selected participants by a National Center of Health Statistics (NCHS) surveyor was used to analyze married, divorced, or women with long-term partners who reported difficulty having biological children (sub-fertile/infertile women). Demographic differences such as formal marital status, education, race, and religion were compared between women who presented for infertility care vs. those that did not. The primary outcome measure was presenting for infertility evaluation and subsequently utilizing infertility services. Healthcare utilization trends such as having a usual place of care and insurance status were also included as exposures of interest in the analysis. Of the 12,456 women included in the analysis 1770 (15.3%) had used infertility services and 1011 (8.3%) said it would be difficult for them to have a child but had not accessed infertility services. On univariate analysis, compared to women who used infertility services, untreated women had lower average household incomes (295.3 vs. 229.8% of the federal poverty line respectively). Untreated women also had lower levels of education and were more likely to be divorced or never have married. In terms of health status, unevaluated women were less likely to have a usual place for healthcare (87.3%) as compared to women presenting for fertility care (91.9%) (p = 0.004). When examining insurance status, 23.3% of unevaluated women were uninsured as compared to 8.3% of evaluated women. On multivariate analysis, infertile women without insurance were at 0.37 odds of utilizing infertility care compared to women with insurance. Demographic factors are associated with the utilization of infertility care. Insurance status is a significant predictor of whether or not infertile women will access treatment. Data from the three most recent NSFG surveys along with prior analyses demonstrate the need for expanded insurance coverage in order to address the socioeconomic disparities between infertile women who are accessing services vs. those that are not.

Trends in the utilization of youth primary healthcare services and psychological distress

BackgroundPsychological distress among young people is increasing in Northern Europe. According to established healthcare utilization theory, this will create a greater need for youth primary healthcare and subsequently lead to more help-seeking behavior by distressed young people. The aim of this study was to investigate the association between the use of youth primary healthcare services and psychological distress in times of increasing mental health problems and increased service need.MethodsThis study consisted of five waves of repeated annual cross-sectional data collected from young people (aged 13–19) living in Norway between 2014 and 2018 (n = 368,579). Population-weighted and design-adjusted generalized linear regression with a log-link was used to examine the use of youth primary healthcare services over time.ResultsWe found that a large proportion of young people use primary healthcare services and that young people with high levels of psychological distress use primary healthcare services twice as much as their peers with low levels of psychological distress. In addition, between 2014 and 2018 both psychological distress and primary healthcare service utilization increased: psychological distress increased by 5% and total primary healthcare service use increased by 500 consultations per 1000 young people. Overall, psychological distress had a conditional association with youth primary healthcare service use and could account for between 16 and 66% of the change in the use of services between 2014 and 2018, depending on the service type. However, the absolute increase seen in the use of primary healthcare services was mainly driven by young people with low levels of psychological distress as opposed to young people with high psychological distress. This suggest a converging trend.ConclusionsOur findings suggest that there might be serious barriers between need and help-seeking behavior for young people with high levels of psychological distress and that the pattern of utilization among young people with lower distress may indicate overuse, possibly as an inadvertent consequence of a newly introduced school absence policy. While further research is needed to confirm these findings, our work may inform healthcare providers and policy makers about primary healthcare utilization trends among young people.

THE SYMPTOMS OF UPPER GASTROINTESTINAL, PSYCHOSOCIAL CO-MORBIDITY, EFFECTS ON PATIENTS &amp; HEALTH CARE SEEKING IN GENERAL PRACTICE

There is also a limited understanding of the pathophysiology of upper gastrointestinal (GI) effects. In patients with functional gastrointestinal problems, psychological symptoms have been shown to be more frequent, although it is disputed if they are directly related to GI symptoms or rather indicate reasons for seeking health treatment. The aim of our research was to compare co-morbidity between patients with and without upper GI symptoms, particularly psychological and social problems. Furthermore, we explored whether the occurrence of psychiatric and social disorders was part of a larger trend of health care utilization due to sickness. Case control research focused on the population based on the second Dutch National Survey of General Practice (conducted in 2001). Cases and controls (individuals not experiencing any of these complaints) matched by gender, age, PCP-practice and ethnicity were contrasted (adults attending their primary care provider (PCP) with upper GI symptoms). The key outcome indicators were communication duration, somatic and psychosocial diagnosis prevalence, (psycho) pharmacological agent dosage levels, and referral rates. Using odds ratios, the Chi square test and multivariable logistic regression analysis, the data was analyzed.&#x0D; As a result, data was analyzed for 13,389 patients with upper GI signs and 13,389 control patients. Twice as often as controls (8.6 vs 4.4 times/year), patients with upper GI symptoms attended their PCP. There were not only more psychiatric and emotional issues in people with upper GI signs, but also more clinical problems in their PCP (odds ratios (ORs) ranged from 1.37 to 3.45). Drugs of any ATC type (ORs range from 1.39 to 2.90), including psychotropic agents, have been used most commonly in patients with upper GI symptoms. When we corrected for non-attending control patients, the found variations were less pronounced. In the multivariate regression study, patients with upper GI effects were more closely correlated with communication frequency and not psychiatric or social co-morbidity.&#x0D; To conclude, people with upper GI symptoms most often attend their PCP for some organ system issues, even psychosocial problems. The correlation between upper GI symptoms and psychological issues is misleading and could represent higher health care standards in general.&#x0D; Keywords: gastrointestinal

S0036 Examining Healthcare Utilization Trends for Acute Pancreatitis in a Large Health System

INTRODUCTION: Acute pancreatitis (AP) is the third most common cause of gastrointestinal (GI)-related hospitalizations in the US and the fourth leading GI illness associated with all-cause 30-day readmissions. Readmissions are associated with increased healthcare utilization as well as mortality from AP at one year. To minimize risk for readmissions, guidelines recommend smoking/alcohol cessation counseling and same-admission cholecystectomy for alcoholic and gallstone AP, respectively. We examined healthcare utilization trends for AP using encounters as a proxy within a large health system. METHODS: ICD-10 codes for AP were used to identify patients who presented to emergency departments (ED) within the MedStar Health system between March 2015 and June 2019. 4,043 patient encounters were eligible for retrospective chart review; these included ED visits and inpatient admissions. Manual review yielded 2,542 charts with extractable clinical information, 1,903 of which had AP as defined by Revised Atlanta Classification (RAC). Variables such as demographics, ever-history of AP, and recent AP within the past 30 days requiring an ED visit were collected. Statistical analysis was performed using GraphPad PRISM. RESULTS: Of 1,903 patients who satisfied RAC for AP, 184 (9.67%) had represented within 30 days following discharge from index presentation. Of those who returned, 22.3% had gallstone pancreatitis and 27.7% had alcoholic pancreatitis as their diagnosis on index hospitalization. 39.7% of those with gallstone pancreatitis had a same-admission cholecystectomy. Those with ever-history of AP were more likely to return following discharge (OR 1.51, P = 0.0136); this effect was more pronounced in patients who had presented immediately prior to index encounter (OR 3.62, P < 0.001). Those who had a previous encounter within the past 30 days had a statistically significant longer length of stay. There was no statistically significant difference in need for ICU level of care between those who were admitted within past 30 days and those who were not. CONCLUSION: Patients with prior encounters for AP are at increased risk for returning to an acute care site and thus increased healthcare utilization. These re-encounters tend to be associated with longer length of stays. Following guidelines and identifying subpopulations most at risk for readmissions would allow for targeted interventions to decrease healthcare utilization.

S0740 Economic Impact and Health-Care Utilization Trends Related to Hospitalization and Hospital Readmissions in Patients With Inflammatory Bowel Disease (IBD): A U.S. Population Cohort Study

INTRODUCTION: Hospitalization and readmissions (RAs) are considered poor quality outcomes in IBD patients (pts). However, the financial impact of RAs and predictors of this outcome are less well characterized in IBD. We hypothesized that since newer biologics have improved care of pts with IBD over the past years then there should be a beneficial impact on the cost of care, length of stay (LOS) and mortality during the index and RA hospitalization and reduction in 30-day RAs in pts with IBD. METHODS: This is a retrospective cohort study using the National Readmission Database (data on 17 million discharges each year in 27 states, accounting for 56% of all U.S. hospitalization). We identified pts admitted with IBD from 2010 to 2014 using ICD-9-CM codes. We excluded patients with age <18 yrs or who died during their index hospitalization or had elective RA. Trends of the total cost, LOS and in-hospital mortality was assessed in both the index and the RA hospitalization. Trend analysis was performed using the Cochrane Armitage Trend test. The cost was inflation-adjusted in reference to 2020. We also evaluated risk factors associated with 30-day hospital RA using multivariable logistic regression. RESULTS: The total number of index IBD admissions were 1,350,428, of which 234,216 (17.3%) were readmitted to the hospital within 30 days. From 2010 to 2014, 30-day RA trends remained stable at ∼17% (Figure 1A) and the in-hospital mortality trend in readmitted pts remained stable at 0.5%. (Figure 1B). While the mean LOS of the index hospitalization was stable at 5.5 days from 2010 to 2014 (Figure 2A), the aggregate cost of hospitalization decreased from 59 million to 55 million USD. There was a simultaneous rise in RA cost from 9.4 million to 12.5 million USD (Figure 2B). Table 1 shows the independent predictors of 30-days hospital RA. Younger age, male sex, longer index hospital LOS, higher comorbidities, the presence of VTE and C. diff infection during the index hospitalization were associated with an increased risk of 30-days RA. CONCLUSION: Despite the advent of new biologics and their widespread use, we found that the 30-day hospital RA rate, index and RA LOS and in-hospital mortality were unchanged in a nationwide cohort of IBD pts from 2010 to 2014, and interestingly the economic burden related to RA is increasing. We identified risk factors associated with 30-days RA. Pts at risk for RA need to be targeted during their index hospitalization in order to attempt to lessen the economic burden.Figure 1.: A) Trend of 30-day all-cause readmission B) Trend of 30-day inpatient mortality.Figure 2.: A) The trend of the length of stay on index hospitalization and following readmission B) The trend of aggregate cost of hospitalization on index hospitalization and following readmission.Table 1.: Factors associated with 30-day readmission in IBD patients

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia.

Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD. Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis. The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant. Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Patterns and Trends of Healthcare Utilization among People with Multiple Sclerosis in the Age of Disease-Modifying Therapy: an Analysis of Administrative Claim Data from a Commercially Insured Population in the United States, 2004–2013 (4231)

Patterns and Trends of Healthcare Utilization among People with Multiple Sclerosis in the Age of Disease-Modifying Therapy: an Analysis of Administrative Claim Data from a Commercially Insured Population in the United States, 2004–2013 (4231)

Population-Based Estimates of Health Care Utilization and Expenditures by Adults During the Last 2 Years of Life in Canada’s Single-Payer Health System

Measuring health care utilization and costs before death has the potential to initiate health care improvement. To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada's single-payer health system. This population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015. Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents' postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure. Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups. Among 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates. In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.

Healthcare Costs and Utilization among Patients Hospitalized for Malignant Pleural Effusion

Background: Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. Objective: We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. Methods: We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. Results: We analyzed 92,034 hospital discharges spanning a decade (2004–2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). Conclusions: The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.

Longitudinal Trends in the Direct Costs and Health Care Utilization Ascribable to Inflammatory Bowel Disease in the Biologic Era: Results From a Canadian Population-Based Analysis.

The prevalence of inflammatory bowel disease (IBD) is increasing. The total direct costs of IBD have not been assessed on a population-wide level in the era of biologic therapy. We identified all persons with IBD in Manitoba between 2005 and 2015, with each matched to 10 controls on age, sex, and area of residence. We enumerated all hospitalizations, outpatient visits and prescription medications including biologics, and their associated direct costs. Total and per capita annual IBD-attributable costs and health care utilization (HCU) were determined by taking the difference between the costs/HCU accrued by an IBD case and their controls. Generalized linear modeling was used to evaluate trends in direct costs and Poisson regression for trends in HCU. The number of people with IBD in Manitoba increased from 6,323 to 7,603 between 2005 and 2015. The total per capita annual costs attributable to IBD rose from $3,354 in 2005 to $7,801 in 2015, primarily driven by an increase in per capita annual anti-tumor necrosis factor costs, which rose from $181 in 2005 to $5,270 in 2015. There was a significant decline in inpatient costs for CD ($99 ± 25/yr. P < 0.0001), but not for ulcerative colitis ($8 increase ±$18/yr, P = 0.63). The direct health care costs attributable to IBD have more than doubled over the 10 years between 2005 and 2015, driven mostly by increasing expenditures on biological medications. IBD-attributable hospitalization costs have declined modestly over time for persons with CD, although no change was seen for patients with ulcerative colitis.

Trends in access to health services, financial protection and satisfaction between 2010 and 2016: Has China achieved the goals of its health system reform?

Guided by the principle of universal health coverage, China began its complex health system reform in 2009. Using data from the China Family Panel Studies (CFPS), this study assesses trends in healthcare utilization, financial protection, and satisfaction between 2010 and 2016. We use difference-in-means tests and regression analysis to evaluate overall trends and compare subsample results by urban/rural residence and income quartiles to examine changes in inequity. Our results show that China has achieved substantial improvements in access to healthcare services and financial protection since the health system reform in 2009. First, China has experienced a substantial increase in both inpatient and outpatient care utilization between 2010 and 2016. Second, people receive better financial protection by measures of health insurance coverage, inpatient reimbursement rate, the likelihood of incurring catastrophic health expenditure, and the likelihood of medical impoverishment. Third, inequity in financial protection by income quartiles has significantly decreased, though poorer groups remain more vulnerable. However, we do not observe a concurrent increase in satisfaction towards the health system. We also find that people are more willing to seek medical services in hospitals rather than primary care institutions. All these results suggest that China's ongoing health system reform should pay more attention to establishing a tiered health delivery system, strengthening financial protection for the poor, and increasing responsiveness to rising expectations.

The increasing cost of pediatric otolaryngology care

IntroductionDefining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery.The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses. MethodsA retrospective cohort study using the Kids’ Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period. ResultsOf the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%. ConclusionsThe public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

Mental Health and Substance Use Disorders in Patients Diagnosed With Cancer: An Integrative Review of Healthcare Utilization.

The impact of mental health disorders (MHDs) and substance use disorders (SUDs) on healthcare utilization (HCU) in patients with cancer is an understudied phenomenon. A literature search of studies published prior to January 2018 that examined HCU in patients with preexisting MHDs or SUDs diagnosed with cancer was conducted. The research team evaluated 22 studies for scientific rigor and examined significant trends in HCU, as well as types of the MHD, SUD, and cancer studied. The heterogeneity of HCU outcome measures, MHD, SUD, sample sizes, and study settings contributed to inconsistent study findings. However, study trends indicated higher rates of HCU by patients with depression and lower rates of HCU by patients with schizophrenia. In addition, the concept of HCU measures is evolving, addressing not only volume of health services, but also quality and efficacy. Oncology nurses are essential to improving HCU in patients with MHDs and SUDs because of their close connections with patients throughout the stages of cancer care. Additional prospective studies are needed to examine specific MHDs and different types of SUDs beyond alcohol use, improving cancer care and the effectiveness of HCU in this vulnerable population.