Use Of Other Health Care Services Research Articles

The Care Needs of Patients With Cognitive Impairment in Late-Stage Parkinson's Disease.

Cognitive impairment is common in Parkinson's disease (PD), but care needs and resource use for those with significant cognitive impairment are not well established. 675 participants with PD from the international Care of Late-Stage Parkinsonism (CLaSP) study were grouped into those without (n = 333, 49%) and with cognitive impairment (MMSE < 24/30 or diagnosis of dementia or Mild Cognitive Impairment; n = 342, 51%) and their clinical features, care needs and healthcare utilisation compared. The relationship between cognition and healthcare consultations was investigated through logistic regression. Cognitive impairment was associated with more motor and non-motor symptoms, less antiparkinsonian but higher rates of dementia and antipsychotic medication, worse subjective health status and greater caregiver burden. A considerable proportion did not have a pre-established cognitive diagnosis. Care needs were high across the whole sample but higher in the cognitive impairment group. Home care and care home use was higher in the cognitive impairment group. However, use of healthcare consultations was similar between the groups and significantly fewer participants with cognitive impairment had had recent PD Nurse consultations. Worse cognitive impairment was associated with lower frequency of recent PD nurse and multidisciplinary therapy consultation (physiotherapy, massage, occupational therapy, speech training and general nursing). Those with cognitive impairment have more severe PD, higher care needs and greater social care utilisation than those with normal cognition, yet use of health care services is similar or less. Cognitive impairment appears to be a barrier to PD nurse and multidisciplinary therapy consultations. This challenges current models of care: alternative models of care may be required to serve this population. Parkinson's disease is a long-term progressive health condition. Over time, many people with Parkinson's develop problems with thinking and memory, called cognitive impairment. This can negatively impact the daily lives of the person with Parkinson's and their caregiver. It is also thought to be a barrier to accessing healthcare. How people with Parkinson's who have cognitive impairment use healthcare and detail of their care needs is not well known.We analysed data from a large sample of people with advanced Parkinson's from six European countries to investigate their symptoms, care needs and healthcare use. We compared those with cognitive impairment to (342 people) to those without cognitive impairment (333 people).We found that those with cognitive impairment had more severe Parkinson's across a range of symptoms compared to those without cognitive impairment. They also had more care needs, reported their health status to be worse, and their caregivers experienced greater strain from caring. Whilst use of other healthcare services was similar between the two groups, those with cognitive impairment were less likely to have recently seen a Parkinson's nurse than those without cognitive impairment. Further analysis showed an association between cognitive impairment and not having seen a Parkinson's nurse or therapist recently, taking psychiatric symptoms, functional disability and care home residence into account. Therapists included were physiotherapy, massage, occupational therapy, speech training and general nursing. These findings highlight unmet need. We suggest that healthcare should be more targeted to help this group of people, given their higher care needs.

Health care use and costs attributable to cardiovascular disease in Ireland: a cross-sectional study

Abstract Cardiovascular disease (CVD) is the leading cause of mortality and disability in Europe but the use of health services and costs associated with CVD are poorly quantified. We examined health service use attributable to CVD and corresponding costs in Ireland. Data on 8113 participants aged 50+ of the first wave of The Irish Longitudinal Study on Ageing was used. CVD was defined as having a self-reported doctor diagnosis of myocardial infarction, angina, heart failure, stroke, atrial fibrillation or transient ischaemic attack. Outcomes were the self-reported number of general practitioner (GP) and outpatient department (OPD) visits, accident and emergency department (A&amp;E) attendances and hospitalisations over the 12 months preceding the interview. Negative binomial regression adjusted for socio-demographic confounders and other chronic conditions was used to study the effects of CVD on the outcomes. Average marginal effects (AME) were estimated to examine the additional use of health services attributable to CVD. We estimated the total additional costs attributable to CVD at the population level using Census 2022 data. Participants with CVD reported higher utilization of all health services. In adjusted models, having CVD was associated with additional 1.19 (95% CI: 0.99, 1.39) GP and 0.79 (95% CI: 0.65, 0.93) OPD visits over the past year. There were twice as many additional hospitalisations attributable to CVD in males compared to females (AME: 0.20 (95% CI: 0.16, 0.23) in males vs AME: 0.10 (95% CI: 0.07, 0.14) in females), with no difference observed in the additional use of other healthcare services by gender or age groups. The population-level costs of the additional healthcare service use attributable to CVD were an estimated €352.2 million (95% CI: €272.8, €431.7), 93% of which was due to use of secondary care services. There is a substantial additional use of health services due to CVD in Ireland, with hospital admissions being the biggest contributor to costs. Key messages • The vast majority of additional costs attributable to CVD in Ireland are generated through use of secondary care services. • While a shift is being implemented in Ireland to manage uncomplicated CVD cases in primary care, sustained efforts aimed at CVD primary prevention are required to contain health service costs.

A tale of excess: the curious case of the woman with 1447 emergency visits

IntroductionFrequent attenders to emergency services are challenging and costly. We report the case of a woman in her mid-twenties who stands out for a total of 1447 emergency visits.ObjectivesOur primary objective was to describe the emergency visits of our patient. Secondary objectives were to assess her use of other healthcare services and to calculate her health expenditure.MethodsThis is a clinical case report. We reviewed the patient’s electronic medical records for sociodemographic and clinical data. We obtained detailed information of psychiatric ED visits (length, most frequent times and days) regarding the second most-visited hospital. We assessed the efficacy of hospitalizations in reducing ED visits with a paired samples t Test, comparing the number of visits 30 days pre- and post-hospitalization. We estimated the health expenditure using the regional public health system prices, including three direct costs: emergency visits, hospitalizations and ambulance transportation. We obtained written informed consent from the patient’s legal guardian.ResultsA 26-year-old woman from Barcelona (Catalonia, Spain), diagnosed with mild intellectual disability, made 1447 emergency visits between 2009 and 2021 (figure 1). 946 visits (65%) took place in psychiatric emergency departments (EDs), whilst 353 (24%) in non-psychiatric EDs and 148 (10%) in urgent primary care. She attended 24 hospitals (ranking number one the closest to the patient’s home, with 387 visits) and seven primary care centers, distributed across 17 cities in Catalonia. Most visits were self-referred, being the main presenting problems anxiety and instrumental suicidal behaviour. Saturday was her favorite day for hospital visits (24,1%), while she seeked care on Tuesdays much less often (4.5%). She made 73.5% of consultations between 1pm and 6pm, with a median length per visit of 2.8 hours (range 0.33-20.9 hours). Regarding other therapeutic approaches, she attended day hospitals, psychiatric rehabilitation programs and family therapy, among others (figure 2), for which she showed low adherence and scarce benefit. She had ten acute hospitalizations, interventions that did not reduce ED visits (t=-0.9835, p=0.36). Health expenditure reached 410.035€.Image:Image 2:ConclusionsThe most common definition of frequent attendance is a patient who has five or more visits per year. Many times, but not always, repeat visits are also inappropriate. The case we report is a grotesque example of both frequent and inappropriate attendance, which has been resistant to all kinds of interventions and has quality-of-care, financial and ethical implications. As of today, it is still a pending case. Maybe it is worth considering residential treatment?Disclosure of InterestNone Declared

Occupational health patients' parallel use of primary- and secondary-care services and linkage to work disability: A follow-up study in Finland.

This study aimed to investigate occupational health (OH) primary-care patients' use of other health-care services and whether parallel use affects their likelihood to have sickness absences (SA) or disability pensions (DP). Primary-care services in Finland are provided through three parallel health-care sectors, all available to the working population: public, private and OH sectors. Patients may also be referred to secondary care. This follow-up study combines real-world medical record data containing SA data from a nationwide OH provider with health-care attendance data from public and private primary-care sectors and public secondary care, sociodemographic data and DP decisions. Patients between 18 and 68 years of age who used OH primary care at least once during the study years 2014-2016 were included. The total study population comprised 59,650 patients. Odds ratios were used to analyse association between parallel service use and SA or DP. Females and patients with a lower educational level were more likely to use services in other health-care sectors in addition to OH than others. Those patients who used any other health-care sector in addition to OH primary care had an increased likelihood of having long SA or receiving DP. OH primary-care patients using the services of several health-care sectors in parallel have an increased likelihood of receiving disability benefits - either SA or DP. There is need for care coordination to ensure adequate measures for work-ability support.

Socioeconomic Disparity Trends in End-of-Life Care for Cancer and Non-Cancer Patients: Are We Closing the Gap?

PurposeSocioeconomic disparities in end-of-life care have been reported across underlying diseases, but there is a paucity of information on potential time trends. Thus, we aimed to examine time trends in use of health-care services at the end of life according to socioeconomic position in patients dying from cancer and non-cancer diseases.Materials and MethodsWe conducted a nationwide registry-based study among adults dying from cancer or non-cancer diseases (diabetes, dementia, heart failure, ischemic heart disease, stroke, chronic liver disease, and chronic obstructive pulmonary disease) in Denmark in 2006–2016. We obtained data on patients’ educational level and income level and use of health-care services within three months before death. Use of health-care services according to educational level and income level was plotted by calendar year of death and compared by regression analyses adjusting for age, sex, comorbidity, cohabitation, and municipality.ResultsIn both cancer (n = 169,694) and non-cancer patients (n = 180,350), we found limited socioeconomic disparities and no clear temporal trends in use of hospital, intensive care, emergency room, general practice, home care nurse, and hospice. In 2006/2007, one percentage point more cancer patients with high income level compared with low income level were affiliated with hospital-based specialist palliative care (adjusted mean difference: 0.01 (95% confidence interval (CI): 0.01; 0.02)), whereas this was 12 percentage points in 2016 (adjusted mean difference: 0.12 (95% CI: 0.09; 0.14)).ConclusionSocioeconomic disparities in specialist palliative care tended to increase over time among cancer patients but were limited and without clear time trends in use of other health-care services in both cancer and non-cancer patients.

Why telehealth does not always save money for the health system

PurposeThis study aims to determine elements of telehealth that have the potential to increase costs for the health system in the short to medium term.Design/methodology/approachA search of PubMed, EMBASE and Scopus databases was performed in May 2018 using broad terms for telehealth and economics. Articles were included if they identified and explained reasons for an increase in cost for telehealth services. Studies were categorised by economic analysis type for data extraction and descriptive synthesis.FindingsFourteen studies met inclusion criteria and were included in the review. These studies identified that increased health system costs were due to implementation costs (e.g. for equipment, software or staff training), increased use of other healthcare services (e.g. pharmaceutical services) and ongoing service costs (including staff salaries) resulting from telehealth being additive to traditional service (e.g. increased frequency of contact).Originality/valueTelehealth is often assumed to be a cost-effective method of delivering healthcare, even to the point where direct cost savings are expected by decision makers as a result of implementation. However, this investigation suggests it does not routinely reduce costs for the health system and can actually increase costs at both implementation and ongoing service delivery stages. Health services considering implementing telehealth should be motivated by benefits other than cost reduction such as improved accessibility, greater patient centricity and societal cost–benefit.

Health and care service utilisation and cost over the life-span: a descriptive analysis of population data

BackgroundCurrent demographic changes affect both the level and composition of health and care needs in the population. The aim of this study was to estimate utilisation and cost for a comprehensive range of health and care services by age and gender to provide an in-depth picture of the life-span pattern of service needs and related costs.MethodsData on service use in 2010 for the entire population in Norway were collected from four high-quality national registers. Cost for different services were calculated combining data on service utilisation from the registries and estimates of unit cost. Data on cost and users were aggregated within four healthcare services and seven long-term care services subtypes. Per capita cost by age and gender was decomposed into user rates and cost per user for each of the eleven services.ResultsHalf of the population is under 40 years of age, but only a quarter of the health and care cost is used on this age group. The age-group of 65 or older, on the other hand, represent only 15% of the population, but is responsible for almost half of the total cost. Healthcare cost dominates in ages under 80 and mental health services dominates in adolescents and young adults. Use of other healthcare services are high in middle aged and elderly but decreases for the oldest old. Use of care services and in particular institutional care increases in old age. Healthcare cost per user follows roughly the same age pattern as user rates, whereas user cost for care services typically are either relatively stable or decrease with age among adults. Gender differences in the age pattern of health and care costs are also revealed and discussed.ConclusionThe type of services used, and the related cost, show a clear life-span as well as gender pattern. Hence, population aging and narrowing gender-gap in longivety calls for high policy awarness on changing health and care needs. Our study also underscores the need for an attentive and pro-active stance towards the high service prevalence and high cost of mental health care in our upcoming generations.

Evaluability assessments as an approach to examining social prescribing.

We report on two evaluability assessments (EAs) of social prescribing (SP) services in South East England conducted in 2016/7. We aimed to demonstrate how EAs can be used to assess whether a programme is ready to be evaluated for outcomes, what changes would be needed to do so and whether the evaluation would contribute to improved programme performance. We also aimed to draw out the lessons learned through the EA process and consider how these can inform the design and evaluation of SP schemes. EAs followed the steps described by Wholey, New Dir Eval 33:77, (1987) and Leviton et al., Annu Rev Public Health 31:213, (2010), including collaboration with stakeholders, elaboration, testing and refinement of an agreed programme theory, understanding the programme reality, identification and review of existing data sources and assessment against key criteria. As a result, evaluation of the services was not recommended. Necessary changes to allow for future evaluation include gaining access to electronic patient records, establishing procedures for collection of baseline and outcome data and linking to data on use of other healthcare services. Lessons learned include ensuring that: (a) SP schemes are developed with involvement (and buy in) of relevant stakeholders; (b) information governance and data sharing agreements are in place from the start; (c) staffing levels are sufficient to cover the range of activities involved in service delivery, data monitoring, reporting, evaluation and communication with stakeholders; (d) SP schemes are co-located with primary care services; and (e) referral pathways and linkages to health service data systems are established as part of the programme design. We conclude that EA provides a valuable tool for informing the design and evaluation of SP schemes. EA can help commissioners to make best use of limited evaluation resources and prioritise which programmes need to be evaluated, as well as how, why and when.

Barriers to the Use of Psychosocial Support Services Among Adolescent and Young Adult Survivors of Pediatric Cancer.

Purpose: Adolescent and young adult (AYA) survivors of pediatric cancer commonly report both functional and emotional difficulties, yet many of their mental health needs are not met. Given the unique needs of these survivors, this study examined barriers to psychosocial support service utilization in this population, including accessibility, personal preferences, and practical barriers such as insurance and transportation. Methods: Thirty-six adolescent and young adult survivors of pediatric cancer (aged 15-29) with mental health difficulties (i.e., anxiety or depression) completed surveys assessing access and utilization of services and barriers to utilization. Services assessed included the use of mental health professionals, a pastor or someone in a place of worship, and support groups. Results: Half of the participants utilized a mental health professional, but other forms of support were used less frequently. Utilization of services was related to insurance status and use of prescription medication. Greater time since completion of treatment was a barrier to utilizing psychosocial support services. Conclusion: Use of psychosocial support services is linked closely with use of other healthcare services, including taking prescription medication for mood difficulties. Results have implications for how primary care and oncology providers address barriers to these services among AYA survivors of pediatric cancer.

Preparing to introduce personal health budgets

A large-scale study ( Forder et al 2012 ) piloting personal health budgets for people with long-term conditions found that they improved patients' quality of life and psychological wellbeing. They were cost-effective and reduced the use of other healthcare services. From April next year, people receiving NHS continuing healthcare funding will have the right to ask for personal health budgets. Some clinical commissioning groups are also introducing them for mental health service users and patients with other long-term conditions. This article outlines the benefits and challenges of introducing personal health budgets, and suggests how nursing managers can begin to consider their role in implementing them.

A randomized clinical trial of a nurse telephone follow‐up on paediatric tonsillectomy pain management and complications

To determine the effect of a nurse telephone follow-up on paediatric post-tonsillectomy pain intensity, complications, and use of other healthcare services. After tonsillectomy, children experience moderate-to-severe pain for days. Parents tend to give insufficient analgesia, with resulting increases in pain and postoperative complications. In adults, nurse telephone follow-up for ambulatory surgeries reduces postoperative pain. The study design was a randomized clinical trial. In this trial, children aged 4-12years undergoing elective tonsillectomy in June-October 2010 were assigned to a nurse telephone follow-up with parents on postoperative days 1, 3, 5 and 10, or standard care with no follow-up but data collection. Outcomes included pain intensity, analgesics administered, complications, and healthcare use. Of 45 participants, the intervention group (n=24) received more analgesics on postoperative days 1 and 3, increased their fluid intake at days 1 and 3, but had more constipation at day 3 than the control group (n=21). There was no significant difference regarding pain intensity or use of healthcare resources. Nurse telephone follow-up was beneficial for some pain management and prevention of complications, although better analgesic treatments are needed. The intervention was simple, safe, and appreciated by parents.

Caller self‐care decisions following teletriage advice

To examine caller self-care decisions following teletriage advice provided by nurses. The use of teletriage is gaining popularity as one way of enhancing capacity for self-care. Research from several countries suggests that teletriage reduces the use of other healthcare services without compromising safety. However, there is little or no research related to how often self-care advice is provided and whether or not callers follow the advice. A descriptive survey design was used with a random sample of 312 callers who were advised by a teletriage nurse to engage in self-care. Callers were randomly selected from all calls to a teletriage service each day of the month for nine months. Data were collected using a researcher-developed interview guide and analysed using a variety of inferential statistics for forced choice questions and content analysis for open-ended questions. The majority of callers who were advised to engage in self-care reported doing so. Callers with greater self-efficacy and satisfaction with the nurse interaction were more likely to follow advice to self-care. All callers would call the teletriage service again for the same or a different issue. Teletriage callers were confident in the advice provided and were willing to continue to use the service. This study indicates that teletriage programmes are a cost-effective way of addressing self-care needs of individuals who might otherwise visit an emergency department.

Determinants of participation in colorectal cancer screening with faecal occult blood testing

Colorectal cancer is one of the most common cancers in men and women. Participation rates in faecal occult blood testing (FOBT) screening activities are, however, relatively low. In terms of lowering the colorectal cancer mortality, high participation rates are essential, and therefore it is important to understand the barriers to FOBT screening. We undertook a systematic search through PUBMED, Medline, EMBASE and PsycINFO in order to identify studies that provide information on socio-demographic determinants of participation in FOBT screening. FOBT participation varied considerably across countries, but they have rarely been above 60%. The use of other health-care services was in most studies a strong determinant for participation in screening with FOBT. There was a tendency to higher participation among women than among men and among married as opposed to not married, but determinants varied across countries and test settings. There was no systematic variation in participation across age groups. The participation pattern depends in part on local circumstances, which makes it difficult to point to a general strategy for increasing the uptake in FOBT screening. This stresses the need for monitoring of individual screening programmes and developing information strategies targeted to the local participation pattern.

Homeopathic Treatment of Patients With Chronic Low Back Pain

To evaluate the details and effects of an individualized homeopathic treatment in patients with chronic low back pain in usual care. Prospective multicenter observational study. Consecutive patients beginning homeopathic treatment in primary care practices were evaluated over 2 years by using standardized questionnaires. Diagnoses (ICD-9) and symptoms with severity, health-related quality of life (QoL), medical history, consultations, homeopathic and conventional treatments, and other health service use were recorded. One hundred twenty-nine adults (64.3% women, mean age 43.6 +/- 12.7 y) were treated by 48 physicians. The patients mainly had chronic low back pain (average duration 9.6 +/- 9.0 y) and other chronic diseases. Nearly all the patients (91.3%) had been pretreated. The initial case-taking took 113 +/- 36, and the case analysis took 31 +/- 38 minutes. The 7.4 +/- 8.1 subsequent consultations (duration: 23.7 +/- 15.2 min) cumulated to 204.5 +/- 184.6 minutes. The patients received an average of 6.8 +/- 6.3 homeopathic prescriptions. The severity of the diagnoses and complaints showed marked and sustained improvements with large effect sizes (Cohen's d from 1.67 to 2.55) and QoL improved accordingly (SF-36 physical component scale d = 0.33; mental component scale d = 0.54). The use of conventional treatment and health services decreased markedly: the number of patients using low back pain-related drugs was half of the baseline. Classic homeopathic treatment represents an effective treatment for low back pain and other diagnoses. It improves health-related QoL and reduces the use of other healthcare services.

Preferred drug lists: Potential impact on healthcare economics

To analyze the implementation of Medicaid preferred drug lists (PDLs) in a number of states and determine its impact on quality of care and cost relative to other segments of healthcare. We reviewed research and case studies found by searching library databases, primarily MEDLINE and EBSCOHost, and searching pertinent journals. Keywords initially included "drug lists," "prior authorization," "prior approval," and "Medicaid." We added terms such as "influence use of other healthcare services," "quality of care," and "overall economic impact." We mainly used primary sources. Based on our literature review, we determined that there are a number of issues regarding Medicaid PDLs that need to be addressed. Some issues include: (a) the potential for PDLs to influence the utilization of other healthcare services, (b) criteria used by Medicaid for determining acceptance of drugs onto a PDL, (c) the effect of PDL implementation on compliance to new regimens, (d) the potential effects of restricting medication availability on quality of care, (e) administrative costs associated with PDLs, and (f) satisfaction rates among patients and medical providers. This review highlighted expected short-term cost savings with limited degree of compromised quality of PDL implementation, but raised the concern about the potential long-term decline in quality of care and overall economic impact. The number of concerns raised indicates that further studies are warranted regarding both short-term cost benefits as well as potential long-term effects of Medicaid PDL implementation. Objective analysis of these effects is necessary to ensure cost-effectiveness and quality of care.

Introduction: how will health systems adopt new genetics technology?

New discoveries in the field of genetics are announced daily, and the potential impact for particular patients and population groups is unmistakable and exciting. It is less well understood, however, how health systems will adopt these new technologies. Genetics is likely to alter the structure of health systems in fundamental ways. For example, the roles of professions such as health counsellors and educators are likely to expand substantially, while the case mix faced by physicians in both ambulatory and in-patient settings will shift. Health insurers will have to learn how to reimburse for new services, and there will be reductions in the use of other healthcare services. The pharmaceutical industry will have to develop drugs for smaller groups of patients, because the one-size-fits-all model of drug therapy will become obsolete in more and more areas. All this is both exciting and threatening at the same time. Exploring some of these broader pressures is important now, at the early stage of technological development.

Using the Addiction Severity Index to Predict Mental and Medical Health Service Utilization

This study assessed the utility of adding the Addiction Severity Index (ASI) to demographic and clinical diagnostic information for the purpose of predicting subsequent substance use disorder service use, and use of other healthcare services by 260 veterans admitted for outpatient substance use disorder treatment. Data collected included demographics, clinical diagnoses, assessment data from the ASI, as well as measures of six-month health service utilization (e.g., substance use disorder services, other mental health services, outpatient medical visits, urgent care visits, inpatient psychiatric and medical). Multivariate analysis using Tobit regression models showed six out of seven ASI scales were significant predictors, and that combining ASI data with demographics and clinical data significantly improved prediction of health care services. It also was found that certain psychiatric and medical diagnoses were related to service use measures, and that a diagnosis of depression was related to overall healthcare utilization.

Factors Related to Vision Care in an Older Adult Cohort

This study provides cross-sectional data on eye care utilization in a community-based adult population. Data are from a questionnaire administered during the 7-year follow-up of the Epidemiology of Hearing Loss Study in 2000 to 2002. Participants in the population-based Beaver Dam Eye Study were eligible for the Epidemiology of Hearing Loss Study, which began in 1997. The primary outcome was self-reported vision testing within the past year. Subject ages ranged from 55 to 99 years (n = 2433), and 60.4% were female. Fifty-three percent of subjects reported they had their vision tested in the past year. Diabetes was self-reported by 11.5% of subjects, and 70.9% of diabetic participants had their vision tested in the past year. A current hospitalization or health insurance plan was reported by 98.6% of subjects. In multivariate analyses, self-reported factors significantly associated with having a vision test in the past year were female gender (odds ratio [OR] = 1.27; 95% confidence interval [CI] 1.06-1.52), current use of refractive correction for distance (OR = 1.98; 95% CI 1.56-2.52), glaucoma (OR = 3.52; 95% CI 2.37-5.24), cataract surgery (OR = 1.57; 95% CI 1.21-2.03), age-related macular degeneration (ARMD) (OR = 1.74; 95% CI 1.22-2.47), diabetes (OR = 2.46; 95% CI 1.83-3.31), visiting a primary care practitioner for any reason in the past year (OR = 1.72; 95% CI 1.32-2.25), having a hearing test in the past year (OR = 1.79; 95% CI 1.40-2.28), and the cessation of driving because of poor vision (OR = 1.64; 95% CI 1.16-2.52). In participants 65 years of age or older, having private insurance was associated with increased odds (OR = 3.39, 95% CI 1.82-6.31) of vision testing in the past year. This study suggests that chronic ocular conditions, diabetes, health insurance beyond government entitlements, and the use of other healthcare services are associated with increased eye care utilization.