Use Of Hospital Services Research Articles

A Model Applied to a Real Life Situation: Self-Management with a Written Action Plan for Early Treatment of COPD Exacerbations

Background: We hypothesized that self-management education with the use of a written action plan provided by a nurse case manager can help patients to gain the proper skills to start an early treatment for an acute exacerbation.
 
 Methods: COPD patients from an outpatient clinic with access to a written action plan and self-administered prescription were instructed to initiate their antibiotics and/or prednisone in case of exacerbation, and call their nurse case manager for supervision. The following data was collected: symptoms change, patients delay in taking action to treat their exacerbations (starting antibiotics and prednisone, calling the case manager) and use of hospital services.
 
 Results: We report on 187 exacerbations occurring in a cohort of 113 moderate / severe COPD patients with FEV1 of 37 ± 16% predicted (mean ± SD). 161 exacerbations were supervised by the case manager at the time of the event. The remaining 26 exacerbations were detected after the event. 87% of the supervised exacerbations presented with 2 major symptoms (increased dyspnea, increased sputum volume and/or purulent sputum). Patient’s delay to initiate treatment in supervised exacerbations was 2.04 ± 1.8 days; 85% took action to treat the exacerbation within 3 days. The treatment for supervised and unsupervised exacerbations was similar (slightly more antibiotics and prednisone were used for unsupervised ones) and they had similarly favourable outcomes in terms of health services use, with 68.5% of the exacerbations not requiring any hospital services.
 
 Conclusions: Patients can take an active role, acquire the skills to recognize exacerbation symptoms and start an early treatment of antibiotics and prednisone according to the directives of their written action plan.

Youth and Young Adults With Cerebral Palsy: Their Use of Physician and Hospital Services

Young NL, Gilbert TK, McCormick A, Ayling-Campos A, Boydell K, Law M, Fehlings DL, Mukherjee S, Wedge JH, Williams JI. Youth and young adults with cerebral palsy: their use of physician and hospital services. Objectives To examine patterns of health care utilization among youth and young adults who have cerebral palsy (CP) and to provide information to guide the development of health services for adults who have CP. Design This study analyzed health insurance data for outpatient physician visits and hospital admissions for a 4-year period. Setting Six children’s treatment centers in Ontario, Canada. Participants The sample included 587 youth and 477 adults with CP identified from health records. Youths were 13 to 17 years of age, and adults were 23 to 32 years of age at the end of the data range. Interventions Not applicable. Main Outcome Measures We computed the annual rates of outpatient physician visits and hospitalizations per 1000 persons and compared these with rates for the general population. Results Annual rates of outpatient physician visits were 6052 for youth and 6404 for adults with CP, 2.2 times and 1.9 times higher, respectively, than rates for age-matched peers ( P<.01). Specialists provided 28.4% of youth visits but only 18.8% of adult visits. Annual hospital admission rates were 180 for youth and 98 for adults with CP, 4.3 times and 10.6 times higher, respectively, than rates for age-matched peers ( P<.01). Conclusions It appears that youth and adults with CP continue to have complex care needs and rely heavily on the health care system. Comprehensive services are essential to support their health as they move into youth and adulthood. However, there appear to be gaps in the adult health care system, such as limited access to specialist physicians.

Medicare Financing and Redistribution in British Columbia, 1992 and 2002

Equity in healthcare in British Columbia is defined as the provision of services based on need rather than ability to pay and a separation of contributions to financing from the use of services. Physician and hospital services in Canada are financed mainly through general tax revenues, and there is a perception that this financing is progressive. This paper uses Gini coefficients, concentration indexes and Kakwani indexes of progressivity to assess the progressivity of medicare financing in British Columbia in 1992 and 2002. It also measures the overall redistributive effect of medicare services, considering both contributions to financing and use of hospital and physician services. The conclusion is that medicare does redistribute across income groups, but this redistribution is the result solely of the positive correlation between health status and income; financing is nearly proportionate across income groups, but use is higher among lower-income groups. Informed public debate requires a better understanding of these concepts of equity.

Differences in HIV Care Between Patients With and Without Severe Mental Illness

Differences in HIV Care Between Patients With and Without Severe Mental Illness

Don't let's forget, we're in it for the long-term

Turbulence in NHS reform has been marked by leading commentators writing about the risks. Chris Ham (2007) reminds us that it is “questionable is whether the reforms will support the development of integrated care to reduce the use of hospital services. The continued separation between GPs and hospitals, and increasing diversity of provision to support patient choice, has brought further fragmentation, not closer integration.”

Healthcare Use of Families of Injured Workers Before and After a Workplace Injury in British Columbia, Canada

To examine the overall healthcare and mental healthcare services use of families of injured workers before and after a workplace injury. We use an administrative database that links individual publicly funded healthcare data and Workers' Compensation Board (WCB) data for the entire population of British Columbia (BC), Canada. The spouses and children of all injured workers who filed a WCB claim in 1994 and missed one or more days of work due to the injury (lost time) were included. We compare their change in use of healthcare services relative to a year before the injury to families of workers who did not require time off for their injuries (no lost time) and families of individuals who were not injured (non-injured comparisons). Differences in healthcare services use among the three groups of spouses were marginal, and differences for increases in mental healthcare services use were non-significant. As well, all three groups of children decreased their use of physician and hospital services and increased their use of mental healthcare services, with very little difference among groups. This was a descriptive study looking at a broad group of injured workers and their families. Even modest increases in healthcare use following a workplace injury have some basis for further study.

Integrated care facilitation for older patients with complex health care needs reduces hospital demand

The evaluation of a new model of care for older people with complex health care needs that aimed to reduce their use of acute hospital services. Older people (over 55 years) with complex health care needs, who had made three or more presentations to a hospital emergency department (ED) in the previous 12 months, or who were identified by community health care agencies as being at risk of making frequent ED presentations, were recruited to the project. The participants were allocated a "care facilitator" who provided assistance in identifying and accessing required health care services, as well as education in aspects of self management. Data for the patients who had been participants on the project for a minimum of 90 days (n=231) were analysed for their use of acute hospital services (ED presentations, admissions and hospital bed-days) for the period 12-months pre-recruitment and post-recruitment. A similar analysis on the use of hospital services was conducted on the data of patients who were eligible and who had been offered participation, but who had declined (comparator group; n=85). Post recruitment, the recruited patients displayed a 20.8% reduction in ED presentations, a 27.9% reduction in hospital admissions, and a 19.2% reduction in bed-days. By comparison, the patients who declined recruitment displayed a 5.2% increase in ED presentations, a 4.4% reduction in hospital admissions, and a 15.3% increase in inpatient bed-days over a similar timeframe. A model of care that facilitates access to community health services and provides coordination between existing services reduces hospital demand.

How Close Have Universal Health Systems Come to Achieving Equity in Use of Curative Services? A Systematic Review

Most governments in established market economies have developed universal systems of health care, but these are being increasingly threatened by widespread health sector reforms. Hence, it is more important than ever to monitor the effects of policy changes on the ability of universal systems to achieve their equity goals. This article provides evidence for such monitoring. The authors present the results of a systematic review of equity in use of curative health services in universal systems, together with a critical appraisal of the essential components of studies to address this question. Of the 79 studies identified that addressed the review question, only 26 met the inclusion criteria and adjusted for differential health need across socioeconomic groups. The authors found a pro-rich bias in use of specialist hospital services and a reasonably equitable access to primary health care by different socioeconomic groups. There was a wide inter-study variation in the difference in utilization rates between people of high and low socioeconomic groups. Improvements are needed in the way that equity in universal systems is monitored, with particular attention to how "need" is defined and to the impact on patients of indirect costs.

Obesity and use of acute hospital services in participants of the Renfrew/Paisley study

Because overweight and obesity are associated with comorbidities, increasing levels of overweight and obesity may impact on hospital use. Body mass index (BMI) in middle age was related to acute hospital use in 7036 men and 8327 women from the Renfrew/Paisley prospective cohort study in Scotland. Participants in this general population study were examined between 1972 and 1976 when aged 45-64 years. Acute hospital admissions and bed days per 1000 person-years were calculated by the World Health Organization BMI categories in the follow-up period to 31 March 2004. Underweight and normal weight men had lower-than-expected admission rates, and overweight and obese men had higher-than-expected admission rates. Obese men had higher-than-expected bed day rates. For women, there was a U-shaped relationship with admission rate, with normal weight women having the lowest admission rate and underweight and obese women having similar high rates. Underweight and obese women had higher-than-expected bed day rates. Participants who were obese in midlife had more-than-expected acute hospital admissions and in particular more bed days. With levels of obesity increasing since this study was started in the 1970s, if these patterns persist, there may be increasing demand on health service resources.

How Many Assertive Community Treatment Teams Do We Need?

How Many Assertive Community Treatment Teams Do We Need?

Trends in use of referral hospital services for care of sick newborns in a community-based intervention in Tangail District, Bangladesh.

The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.

Gender Differences across Race/Ethnicity in Use of Health Care among Medicare-Aged Americans

Despite Medicare, medical services are not equally used by elderly women and men in the United States. Our purpose is to examine gender differences in healthcare utilization among older Americans, the persistence of gender differences across race/ethnicity, and the roles of sociodemographic, health, and economic factors to explain differences. Data from the 1998-2000 Health and Retirement Study are used to investigate gender differences in use of hospital, outpatient surgery, home health, and physician services. Analyses are controlled for sociodemographic, health (medical conditions, functional health), and economic (income, wealth, education, health insurance) factors. Women are significantly less likely to use hospital service (odds ratio [OR]=0.83) and outpatient surgery (OR=0.85) but are more likely to use home health care (OR=1.27) and physician services (OR=1.45), controlling for sociodemographics. Differences in health needs and economic resources partially mediate the gender differences in physician and home healthcare utilization but do not explain the gender differences in hospital service and outpatient surgery. Notably, African American, Hispanic, and white women compared with men show significantly less use of hospital services. Gender differences in medical use vary according to the type of services used and are largely consistent across racial/ethnic groups. As the size of the Medicare population increases, promoting equitable use of healthcare resources by both women and men is an important issue in developing healthcare policy and designing public health strategies.

Outcome of pregnancy in the Grandmultipara in Enugu, Nigeria

Context: Grandmultiparity is considered high-risk because of the associated maternal and fetal complications. Grandmultiparae constitute a significant proportion of the obstetric population in Nigeria hence the problems of grandmultiparity still abound. Objective: To describe the outcome of pregnancy in grandmultiparae. Design, Setting and Subjects: A retrospective study of the grandmultiparous patients delivered at the University of Nigeria Teaching Hospital, UNTH, Enugu, Nigeria, from 1 January 1998 to 31 December 2002. Main Outcome Measures: Data on the age, parity, booking status, literacy level, complications during pregnancy and labour, method of delivery, maternal and foetal outcome, were collected and analysed. Results: Of 3767 deliveries, 618 or 16.41% were grandmultiparous. Their mean age was 34.63 years and mean parity 5.77. 61.6% were illiterate and 83.82% were booked. Anaemia, hypertension and multiple pregnancies occurred in 18.29% in pregnancy. 17.95% had complications in labour. 74.3% achieved vaginal delivery. There was no maternal death. The perinatal mortality rate was 73.4/1000 deliveries. Conclusion: Grandmultiparae make up a significant proportion of our obstetric population. Illiteracy, desire for large families, high perinatal mortality and non-use of contraception are predisposing factors. Non-use of antenatal services and delay in referral worsen pregnancy outcome. Formal education, campaign against large families, reduction in childhood mortalities and improvement in use of family planning will reduce its incidence while use of hospital services will improve pregnancy outcome. Early referral, team work between health professionals and the roles of government, hospital management and non-governmental organizations are discussed. Keywords: grandmultiparity, pregnancy outcome, Enugu, Nigeria Tropical Journal of Obstetrics and Gynaecology Vol. 23(1) 2006: 8-11

Will to Live: AIDS Drugs and Local Economies of Salvation

Brazil’s groundbreaking response to AIDS combines prevention strategies with the distribution of free antiretroviral therapies (ARVs). This policy was initiated in 1996 through an inventive combination of activist forces, the interests of a reforming state, international institutions, and the pharmaceutical industry. Some 170,000 people are currently taking anti-HIV drugs that are paid for by the Brazilian government. Both AIDS mortality and the use of hospital services have subsequently fallen by more than 50 percent, and this policy is widely touted as a model for stemming the AIDS crisis in the developing world. But how do individual sufferers fare in the long term as they engage with this large-scale intervention, particularly in poor urban areas, where the epidemic is spreading most rapidly? In 1997 and in 2001, Torben Eskerod and I worked in Caasah, a communityrun AIDS hospice in the city of Salvador, in the Brazilian state of Bahia. Caasah was founded in 1992 when a group of homeless AIDS patients, former prostitutes, transvestites, and drug users squatted in an abandoned hospital formerly run by the Red Cross. Soon, if surprisingly, Caasah became a nongovernmental organization and began to receive funding from a World Bank loan disbursed through

Discharging older people from hospital to home: what do we know?

Aims and objectives. The aim of this literature review was to examine empirical research to date on hospital discharge and illuminate areas in need of further exploration. Background. Discharging older people from hospital has long been associated with difficulties and complications. With a steady increase in the ageing population in Ireland and their use of acute hospital services, the successful management of hospital discharge is now a central concern to health service management. Methods. Using a seven-step approach by Stolz et al. [Scandinavian Journal of Caring Sciences (2004) Vol. 18, 111-119] a keyword database search was conducted which revealed 44 studies that matched the author's inclusion criteria. Results. These studies uncover aspects of the discharge process that are in need of further research, and particularly suggest more rigour in the measurement of hospital discharge outcomes. Relevance to clinical practice. This review focuses on a very important clinical issue given the predicted increase in the use of acute services by older people and the known vulnerabilities of the interface between hospital and community settings.

How does lack of insurance affect use of intensive care? A population-based study*

One in six Americans aged <65 yrs are without health insurance. Although lack of insurance is associated with reduced access to many health services, the relationship between lack of insurance and use of intensive care services is unclear. We sought to compare the use of intensive care by insured and uninsured populations. Retrospective population-based cross-sectional study of five U.S. states (Florida, Massachusetts, New Jersey, New York, and Virginia), analyzing use of hospital and intensive care unit (ICU) services by all residents of these states <65 yrs of age. Data sources included the five 1999 state hospital discharge databases and the 2000 U.S. Census Bureau Current Population Survey. Nonfederal hospitals in the five states (all hospitalizations in these during 1999). None. There were 39.3 million and 7.8 million individuals aged 0-64 yrs with and without insurance, respectively, in the five-state sample. The uninsured population was far less likely to be hospitalized (odds ratio [OR], 0.458; 95% confidence interval [CI], 0.456-0.460; p < .001) and to be admitted to the ICU (OR, 0.581, 95% CI: 0.576-0.587, p < .001). Differences persisted irrespective of age, gender, ethnicity, or reason for admission. Among those hospitalized, the uninsured were more likely to receive intensive care (OR, 1.24; 95% CI, 1.22-1.25; p < .01). Hospital mortality rates for patients admitted to the ICU ranged by age from 4.0% to 6.9% for the uninsured and from 2.7% to 5.5% for the insured (OR, 1.12-1.54; p < .01). Americans without insurance use ICU services less often than those with insurance, primarily because of decreased likelihood of hospital admission in the first place. Outcome is worse for those who are admitted to the ICU, possibly because they are sicker when they seek care.

Fatal familial insomnia presenting as psychosis in an 18-year-old man

Asthma is the most common chronic disorder among Finnish children, however, the economic burden of paediatric asthma in Finland has not yet been comprehensively evaluated. The objective of this study was to compare inpatient resource utilisation between younger (2–5 yrs) and older children (6–14 yrs) with asthma in Finland. A national database of inpatient resource utilisation was applied to determine use of hospital services among children with asthma in 1999. Regional estimates of charges were combined with hospitalisation episodes to determine total inpatient cost. The results indicate that younger asthmatic children consume 3‐times more inpatient resources per capita. Incidence of first admissions because of asthma was 3‐times higher in younger children. Hospitalisation and rehospitalisation rates were also 3‐ and 4‐times higher, respectively. The total annual inpatient cost of asthma in children aged 2–5 and 6–14 yrs was E 1.98 million with each group accounting for E 1.12 million and E 0.86 million, respectively. Regional and age-related differences in hospitalisation rates and costs were likely related to variable clinical practice on the primary level, difficulties with diagnosis and compliance among younger children.

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Rural–Urban Differences in Medical Care for Nursing Home Residents with Severe Dementia at the End of Life

To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes. Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002. Minnesota and Texas nursing homes. Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01. Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission. The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization. Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.

The COPD-induced hospitalization burden from first admission to death

Hospitalization periods at the exacerbation stage of COPD place a major burden on the health services and entail substantial costs. Little is known, however, about the corresponding burden on hospitals as the disease advances. We therefore set out to determine from hospital discharge and cause of death registers the overall burden on hospital resources occasioned by a COPD patient on a relative time scale from first admission to death, differentiated by age group, prognosis and sex. Data on all subsequent hospital treatment periods after the first for patients with COPD who were over 44 years of age on admission were gathered from the Finnish National Research and Development Centre for Welfare and Health for the period 1991-2001. The actual material for this study consisted of the data on those patients who were alive after the first treatment period but had died by 2001. These were divided into three survival groups. The 8325 patients in this material had a total of 35,814 hospitalization periods in 1991-2001, of which men accounted for 73.6%. A total of 1895 of the patients (22.8%) had died within a year, 4257 (51.1%) within 1-5 years and 2173 (26.1%) after more than 5 years. Of those dying within a year, 20.9% had been in hospital care, while of those who lived on for over a year, 4.5% were in hospital when two-thirds of their remaining lifetime was still ahead of them and 7.3% when one-tenth of that time was still ahead. Almost one-fourth of the COPD patients had died within a year of first hospital admission for the disease. This group with a poor prognosis made abundant use of hospital services. The burden imposed on such services by severe COPD patients is U-shaped, with hospital use increasing towards the end of their lives.