Use Of Ambulatory Care Services Research Articles

Post-acute Ambulatory Care Service Use Among Patients Discharged Home After Stroke or TIA: The Cluster-randomized COMPASS Study.

We examined transitional care management within 90 days and 1 year following discharge home among acute stroke and transient ischemic attack patients from the Comprehensive Post-Acute Stroke Services (COMPASS) Study, a cluster-randomized pragmatic trial of early supported discharge conducted in 41 hospitals (40 hospital units) in North Carolina, United States. Data for 2262 of the total 6024 (37.6%; 1069 intervention and 1193 usual care) COMPASS patients were linked with the Centers for Medicare and Medicaid Services fee-for-service Medicare claims. Time to the first ambulatory care visit was examined using Cox proportional hazard models adjusted for patient characteristics not included in the randomization protocol. Only 6% of the patients [mean (SD) age 74.9 (10.2) years, 52.1% women, 80.3% White)] did not have an ambulatory care visit within 90 days postdischarge. Mean time (SD) to first ambulatory care visit was 12.0 (26.0) and 16.3 (35.1) days in intervention and usual care arms, respectively, with the majority of visits in both study arms to primary care providers. The COMPASS intervention resulted in a 27% greater use of ambulatory care services within 1 year postdischarge, relative to usual care [HR=1.27 (95% CI: 1.14-1.41)]. The use of transitional care billing codes was significantly greater in the intervention arm as compared with usual care [OR=1.87 (95% CI: 1.54-2.27)]. The COMPASS intervention, which was aimed at improving stroke post-acute care, was associated with an increase in the use of ambulatory care services by stroke and transient ischemic attack patients discharged home and an increased use of transitional care billing codes by ambulatory providers.

Does socio-economic status influence the effect of multimorbidity on the frequent use of ambulatory care services in a universal healthcare system? A population-based cohort study

BackgroundFrequent healthcare users place a significant burden on health systems. Factors such as multimorbidity and low socioeconomic status have been associated with high use of ambulatory care services (emergency rooms, general practitioners and specialist physicians). However, the combined effect of these two factors remains poorly understood. Our goal was to determine whether the risk of being a frequent user of ambulatory care is influenced by an interaction between multimorbidity and socioeconomic status, in an entire population covered by a universal health system.MethodsUsing a linkage of administrative databases, we conducted a population-based cohort study of all adults in Quebec, Canada. Multimorbidity (defined as the number of different diseases) was assessed over a two-year period from April 1st 2012 to March 31st 2014 and socioeconomic status was estimated using a validated material deprivation index. Frequents users for a particular category of ambulatory services had a number of visits among the highest 5% in the total population during the 2014–15 fiscal year. We used ajusted logistic regressions to model the association between frequent use of health services and multimorbidity, depending on socioeconomic status.ResultsFrequent users (5.1% of the population) were responsible for 25.2% of all ambulatory care visits. The lower the socioeconomic status, the higher the burden of chronic diseases, and the more frequent the visits to emergency departments and general practitioners. Socioeconomic status modified the association between multimorbidity and frequent visits to specialist physicians: those with low socioeconomic status visited specialist physicians less often. The difference in adjusted proportions of frequent use between the most deprived and the least deprived individuals varied from 0.1% for those without any chronic disease to 5.1% for those with four or more chronic diseases. No such differences in proportions were observed for frequent visits to an emergency room or frequent visits to a general practitioner.ConclusionEven in a universal healthcare system, the gap between socioeconomic groups widens as a function of multimorbidity with regard to visits to the specialist physicians. Further studies are needed to better understand the differential use of specialized care by the most deprived individuals.

Trends, Causes, and Outcomes of Hospitalizations for Homeless Individuals: A Retrospective Cohort Study.

In the United States, an estimated 553,000 people are homeless on any given night. Few data provide large-scale, contemporary insight with regard to recent patterns of acute illness in this vulnerable population. We evaluated patterns, causes, and outcomes of acute hospitalization among homeless persons compared with a demographics-standardized and risk-standardized nonhomeless cohort. Retrospective study comparing 185,292 hospitalizations for homeless individuals and 32,322,569 hospitalizations for demographics-standardized nonhomeless individuals between 2007 and 2013 in Massachusetts, Florida, and California. Annual hospitalization rates for homeless persons were calculated and causes of hospitalization were compared with a demographics-standardized nonhomeless cohort. Logistic and linear regression models were used to estimate risk-standardized outcomes. From 2007 to 2013, hospitalizations for the homeless increased in Massachusetts (294 to 420 hospitalizations per 1000 homeless residents), Florida (161 to 240/1000), and California (133 to 164/1000). Homeless patients were on average 46 years of age, often male (76.1%), white (62%), and either uninsured (41.9%) or insured by Medicaid (31.7%). Hospitalizations for homeless persons, compared with demographics-standardized nonhomeless, were more frequently for mental illness and substance use disorder (52% vs. 18%, P<0.001). Homeless compared with risk-standardized nonhomeless individuals had lower in-hospital mortality rates (0.9% vs. 1.2%, P<0.001), longer mean length of stay (6.5 vs. 5.9 d, P<0.001), and lower mean costs per day ($1 535 vs. $1 834, P<0.001). Hospitalizations among homeless persons are rising. Despite greater policy and public health focus over the last few decades, mental illness and substance use remain primary drivers of acute hospitalization among homeless adults. Policy efforts should address barriers to the use of ambulatory care services, and behavioral health services in particular, to help reduce acute care use and improve the long-term health of homeless individuals.

Health care service use among vulnerable adolescents

This article describes the patterns of health care service use among a cohort of vulnerable adolescents with a history of homelessness and uses the Expanded Behavioral Model for Vulnerable Populations to examine factors associated with use of ambulatory and emergent care. We incorporated a health care interview into an existing longitudinal study of newly homeless adolescents, at their 24-month assessment (n = 183) and assessed their sociodemographic characteristics, including living situation, health insurance rates, having a regular source of care, substance use and health care service use in the past 3 months. By the 24-month assessment, 63% of youth had returned home and 37% were currently homeless. In comparing youth who were currently homeless and those who had returned home, we found similar rates for ambulatory care use (48%) and for emergent care use (15%). The most common reason for seeking ambulatory care related to sexually transmitted disease (STD) testing/HIV testing/reproductive health for both groups. However, currently homeless youth were more likely to seek emergent care for trauma (15% vs. 4%, p < 0.01) and for common conditions such as skin problems/respiratory infections/gastrointestinal problems/other problems (16% vs. 7%, p < 0.05). Using multivariate logistic regression, we found older age [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.0–6.5] and health insurance (OR 2.3, 95% CI 1.1–4.5) to be associated with use of ambulatory care; however, only older age (OR 2.7, 95% CI 1.0–7.0) was found to be associated with use of emergent care. Housing status, emotional distress and substance use were not found to be associated with ambulatory or emergent care use. Our findings suggest that facilitating health insurance coverage for vulnerable adolescents with a history of homelessness may lead to increased use of ambulatory care services and may consequently prevent use of emergent care services for conditions that may be treated in the ambulatory care setting.

Changing Impact of Gastroesophageal Reflux in Medical and Otolaryngology Practice

A major trend in gastroesophageal reflux disease (GERD) is an observed increased prevalence of the problem, with an associated burden on health care resources. There are relatively few objective reports of increasing prevalence of this disease, and there are no epidemiologic reports that discuss changing practice strategies in managing the disease. The clinical problem is of critical importance to practicing otolaryngologists, who manage the impact of GERD on diseases affecting the ear, nose, and throat. The hypothesis of this thesis is that 1) GERD is an increasing problem affecting outpatient office visits over time, and 2) the disease is increasingly managed with prescription pharmacotherapy. Retrospective national medical database review using the National Ambulatory Medical Care Survey. Twelve years of data (1990-2001) were examined with visits weighted to provide U.S. estimates of care. Average annual frequencies and visit rates were calculated for total visits and by age, sex, race, and physician specialty. Selected issues in GERD treatment were also examined, including prescriptions and physician/patient counseling regarding stress management, tobacco abuse, and diet modification. Trends were reported based on changes in care across three time periods to satisfy statistical significance: 1990 to 1993, 1994 to 1997, and 1998 to 2001. Between 1990 and 1993 and 1998 and 2001, there was a significant increase in U.S. ambulatory care visits for GERD, from a rate of 1.7 per 100 to 4.7 per 100. There were no significant changes in race, although there was a small trend toward increased GERD visits in the age group over 44 years old and in the male sex. Office visits to otolaryngologists increased from 89,000 to 421,000 between the time periods of 1990 to 1993 and 1998 to 2001. This also represented a percent increase in office encounters by otolaryngologists compared with visits by all specialties from 2.9% to 4.4%. Over the three time periods, there was a fall in prescriptions for histamine (H2) blockers from 58.1% to 20.7% of total prescriptions. Over the same three time periods, prescriptions of proton pump inhibitors increased from 13.2% to 64.6%. Physician recommendations for over the counter medications fell from 18.8% to 6.6%. Average annual counseling during ambulatory care visits for GERD was assessed for the period from 1998 to 2001 as follows: diet counseling was provided at 27.2% of encounters, tobacco cessation counseling was provided at 3.9%, and stress management was discussed at 3.9%. During the 1990s, there was a substantial increase in the use of ambulatory care services for GERD. Although much of this increase was among the primary care community, otolaryngologists appeared to have an increasingly prominent role in the management of this disease. There have also been dramatic changes in physician prescribing patterns for GERD, with the emergence of the predominant role of proton pump inhibitors. However, the use of physician counseling for lifestyle modification of factors known to affect GERD remains very low. The increasing impact of GERD on physician practice emphasizes the importance of both physician and patient education in the delivery of health care related to this disease.

Factors associated with the health care utilization of homeless persons.

Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective. To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year. Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.

The Children's Health Council: a community foundation/state government partnership.

The Children's Health Council: a community foundation/state government partnership.

Position of the American Dietetic Association: Nutrition Services in Managed Care

Managed care organizations (MCOs) now provide health care to more than one third of the US population ( (1) Kretesz L. Outlook managed care. Mod Health Care. 1994; 25: 31-33 Google Scholar ). As traditional hospital and physician practice models evolve into integrated delivery systems (IDSs) (see the Figure), health care delivery systems will continue the transformation from an unstructured system to a market system characterized by intense entrepreneurial competition ( (2) Pearson DA. Assessment of the external environment. Presented at Assessment of the External Environment, 74th Meeting of the New England Healthcare Assembly; April 11, 1995; Boston, Mass. Google Scholar ). Numerous factors are driving this evolution of medical care delivery. Lack of access by underinsured and uninsured populations is placing pressure on the health care system to reform. New models of organizing health care delivery, including the increased number of IDSs, increased numbers of physicians in group practices, decreased use of acute-care facilities, and increased use of ambulatory care services, nursing home beds, and home health services, are leading to major changes. Communication technology has produced information systems that can link patient data from multiple providers and sites onto one medical record, leading the way to accountable reporting. Improved medical technology and bioengineering have led to greater application of less invasive clinical procedures, reducing the need for beds in acute-care facilities. Consumers are increasingly concerned about high costs and quality of services. Thus, emphasis on quality issues, specifically outcomes research, outcomes assessment, practice guidelines, and continuous quality improvement, is increasing.

The Changing American Family: Implications for Children's Health Insurance Coverage and the Use of Ambulatory Care Services

An increasing number of children are being raised by one parent, a divorced or never-married woman (see the Spring 1994 issue of The Future of Children). These families are a heterogeneous group in terms of income, education, employment, and ethnicity or race. Black and Hispanic children are disproportionately represented. This article focuses on one of many important consequences for children of this change in family structure in the United States: the utilization of ambulatory health services by children.

Effect of case management on rehospitalization and utilization of ambulatory care services.

To explore whether intensive case management would reduce discharged psychiatric inpatients' rates of rehospitalization and increase their use of outpatient ambulatory care services, the authors assigned 435 patients discharged from a public general hospital in New York City to three types of postdischarge services: multidisciplinary intensive outreach case management, less intensive Community Support System (CSS) case management services, or routine aftercare but no case management. Patients eligible for CSS were generally more impaired and had more extensive histories of psychiatric hospitalization. At follow-up 18 to 52 months after entering the study, patients who received intensive outreach case management had twice as many psychiatric hospitalizations as the routine aftercare group and had a pattern of utilization of hospital-based ambulatory care services similar to the more impaired CSS group. Intensive outreach case management did not appear to stimulate sufficient use of ambulatory care services to reduce patients' frequency of psychiatric hospitalization.

Preventive Care Use by School-Aged Children: Differences by Socioeconomic Status

Use of ambulatory care services by children from low-income families has increased substantially since the early 1960s. However, in few studies have attempts been made to disaggregate physician visits according to type (eg, preventive upsilon diagnosis and treatment). In this study, receipt of preventive care (including physical, vision, and dental examinations), based on a sample of 16,838 children aged 5 to 16 years from the 1982 National Health Interview Survey, was examined. The results indicate that children in families with incomes below the poverty level, especially those without Medicaid insurance, are much less likely to receive routine preventive care on a timely basis. Poor school-aged children with Medicaid are much more likely to receive timely preventive care than their counterparts without Medicaid coverage. The effectiveness of preventive care for children is discussed and suggestions for improving access to routine preventive care are presented.

Uniform basic data sets for health statistical systems.

The United States approach to coordinating health statistics involves introduction of multipurpose basic data sets describing health status and the health care system. Standard reporting procedures have been used for many years for vital statistics. Recently designated data sets cover health manpower, inpatient facilities, short-stay hospital discharges, and use of ambulatory care services. A data set for long-term health care is in the design stage. Advantages of this approach in the United States and internationally are: basic comparisons can be made between health care settings are geographic areas while maintaining the variety and flexibility of existing public and private information systems; shared local, regional, and national data systems can be set up; and better coordination can be achieved between government-sponsored general-purpose and administrative data systems. Problem areas are: avoiding undue proliferation, e.g. of disease-specific data sets; adhering to the principle of minimal requirements; linking data sets and coordinating them with census and other social indicators; promoting widespread use; assuring data quality; establishing mechanisms for review and revision; and extending the concept internationally.

Unscheduled use of ambulatory care services.

The objectives of this study were to describe changes over time in unscheduled use of ambulatory care services and to identify factors related to unscheduled use. The study setting was a prepaid group practice designed to provide services primarily by appointment. The data were obtained from Health Plan and Hospital Operating Statistics, an ongoing utilization study and a household interview survey. A major increase in unscheduled use of outpatient services occurred over the time period studied, particularly in the major departments of medicine, surgery and pediatrics. Unscheduled clinic visits rather than emergency department visits accounted for most of the increase in unscheduled use. The second phase of the study analyzed factors related to unscheduled use. Age, sex, and family size were associated with unscheduled use. Occupation and employment status were related to unscheduled use but only in certain age/sex groups. Satisfaction, health status, and morbidity were also important factors. Unscheduled use was highly related to scheduled use. Possible reasons are suggested for the rise in unscheduled use and its impact on the system is discussed. Recommendations are included for future research and for changes in the appointment system.

Utilization of health services in developing countries—Tunisia

This paper is based on a WHO study on determinants of utilization of government health services in a province of Tunisia (Governorate of Nabeul). Seven study areas were selected which were considered typical both of different types of health facilities and of towns and rural settings in the province. In these study areas, an interview survey of a sample of households was undertaken and the data gathered from the survey were linked to available medical records for the 3808 members of the 678 households studied. The most striking finding of the study was the much greater use of ambulatory care services by urban than by the rural populations studied. It is argued that this rural/urban differential is a result both of differences among the populations and of differences in technical sophistication of and accessibility to rural and urban health centres. In general, utilization of health services by the study group was low when compared with rates reported in most developed countries. Most persons used the health services only once or twice for a given episode of illness, and the great preponderance of diagnoses made were for acute illnesses, especially the common communicable diseases. It is also shown that when the population is grouped according to categories of respondents from high- and low-user families, a number of contrasting demographic, socio-cultural and economic characteristics, and attitudes tend to differentiate these groups (in both urban and rural areas). Among characteristics more likely to be exhibited by respondents from high-user households are: indicators of literacy and language ability, use of mass media, socio-economic participation, type of occupation and employment status, and positive attitudes towards the health services including health personnel and towards disease prevention. The applicability of analyses of determinants of utilization in developed countries to the situation of developing countries such as Tunisia is discussed. On this basis, a framework for further study is developed which focuses upon modernization as the key predictor of use of health services in developing countries. Some implications and related practical recommendations for better management of the health care delivery system in the studied area are also discussed.