Use Of Specialized Care Research Articles

Change in care location of older adults who resided in group homes in Japan: An observational study using long‐term care insurance comprehensive database

AbstractBackgroundGroup homes have been introduced into Japanese public long‐term care insurance program to accommodate people with dementia in a homelike, small‐scale environments. The national dementia plan was launched in 2013 to promote provision of end‐of‐life care to people with dementia at group homes. However, discharge destinations from group homes have rarely been investigated. The present study examined the discharge destination of older adults between group homes and other types of homelike, small‐scale environments under the public long‐term care services.MethodWe used monthly data of January and July during 2013‐2016 from the long‐term care insurance comprehensive database. The 3,468 discharges from group home (n = 500), housing with care (n = 571), nursing home (n = 2097), or in‐home multiple service (n = 300) during 2013‐2016 were included in analysis.ResultOf the 500 discharges from group homes, 173 (34.6%) were admitted to hospitals, 110 (22.0%) were admissions to facilities, and 178 (35.6%) were deceased. Controlling for individual characteristics and the use of specialized care, residents of group homes were more likely to be admitted to hospital rather than discharged by death, in comparison to those of housings with care (adjusted odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.25‐0.48) or nursing homes (adjusted OR = 0.25, 95%CI = 0.19‐0.32).ConclusionGroup home residents were more likely to be hospitalised compared to residents of housings with care or nursing homes. Further dementia care strategies should be explored to reduce changes in location of care among people with dementia.

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.

Identification of Alcohol Risk Drinking Behaviour in Pregnancy Using a Web-Based Questionnaire: Large-Scale Implementation in Antenatal Care.

This study aimed to examine the feasibility of a web-based questionnaire when collecting information on alcohol consumption in pregnancy to identify women with risk drinking behaviour, and to describe factors associated with risk drinking behaviour, and the use of specialized care for prenatal risk drinking. In 2413 women referred to antenatal care at Odense University Hospital, Denmark, April-October 2018, self-reported alcohol intake was retrieved from a web-based questionnaire. Replies were screened for risk drinking behaviour: current intake of ≥7 drinks/week, ≥3 binge drinking episodes (intake of ≥5 drinks on a single occasion) in pregnancy, binge drinking after recognition of pregnancy and/or a TWEAK-score≥2 points. Women with risk drinking behaviour were called to clarify the need for specialized care. A summary of the interview was obtained from the medical records. Overall, 2168 (90%) completed the questionnaire. Of 2097 women providing information on alcohol intake, 77 (4%) had risk drinking behaviour. Risk drinking was associated with higher alcohol intake prior to pregnancy, spontaneous conception, younger age, nulliparity and higher level of physical activity in pregnancy. Amongst 47 women with risk drinking behaviour reached by phone, five (11%, 95% CI 4-23%) accepted examinations of the child by paediatrician and child psychologist, and<3 (not further specified due to small numbers) were referred to specialized antenatal care. A web-based questionnaire was feasible when collecting information on alcohol consumption in pregnancy to identify risk drinking behaviour. Women with risk drinking behaviour had a low acceptance of referral to specialized care.

Difference in access to health care for newly arrived refugees in Germany: a natural quasi-experiment

Abstract Background Providing quantitative evidence on structural access barriers to health care for newly arrived refugees constitutes a challenge due to a lack of suitable data. The coexistence of two different local access models in Germany allows for a comparative analysis of the association between access policies and realized access. Our study compares these two models to establish whether they lead to differences in access to care among refugees. Methods Municipalities in Germany’s largest federal state of North Rhine-Westphalia (NRW) have implemented different access models to which refugees are quasi-randomly assigned. We recruited 6 municipalities of which 3 decided to implement the health care voucher (HcV) model and 3 the electronic health card model (eHC) in a natural quasi-experimental study design. Analyses were based on claims data collected from the welfare offices or the statutory health insurance. We compared standardized incidence rates (SIR) based on 3 indicators: emergency service, ambulatory sensitive hospitalization and use of specialized care. Results We included data on health care use of all recently assigned refugees in the 6 municipalities over a period of 7 quarters (2016/17). The average quarterly sample size is n = 9,077 which corresponds to 6.5% of the population of recently assigned refugees in NRW at that time. We find differences in realized access between the models. For emergency care, the SIR differ significantly between municipalities using the HcV model (SIR:1.88; 95%-CI: 1.62-2.18) and eHC model (SIR:1.33; 95%-CI: 1.14-1.55). Conclusions Local decisions regarding the organization of access to health care are associated with differences in realized access to health care of refugees in NRW. The implementation of the eHC model may contribute to a decrease of emergency service. Further analyses should attempt to reduce a possible (self-)selection bias of municipalities which might have led to an underestimation of the difference between models. Key messages The organization of health care for newly arrived refugees on the local level is decisive for their access to care. Local policy makers may use their scope for action to remove access barriers for newly arrived refugees.

Effectiveness of integrated care model for type 2 diabetes: A population-based study in Reggio Emilia (Italy).

AimsTo compare the effectiveness of integrated care with that of the diabetes clinic care model in terms of mortality and hospitalisation of type 2 diabetes patients with low risk of complications.MethodsOut of 27234 people with type 2 diabetes residing in the province of Reggio Emilia on 31/12/2011, 3071 were included in this cohort study as eligible for integrated care (i.e., low risk of complications) and cared for with the same care model for at least two years. These patients were followed up from 2012 to 2016, for all-cause and diabetes-related mortality and hospital admissions. We performed a Poisson regression model, using the proportion of eligible patients included in the integrated care model for each general practitioner as an instrumental variable.Results1700 patients were cared for by integrated care and 1371 by diabetes clinics. Mortality rate ratios were 0.83 (95%CI 0.60–1.13) and 0.95 (95%CI 0.54–1.70) for all-cause and cardiovascular mortality, respectively, and incidence rate ratios were 0.90 (95%CI 0.76–1.06) and 0.91 (95%CI 0.69–1.20) for all-cause and cardiovascular disease hospitalisation, respectively.ConclusionFor low risk patients with type 2 diabetes, the integrated care model involving both general practitioner and diabetes clinic professionals showed similar mortality and hospitalisation as a model with higher use of specialized care in an exclusively diabetes clinic setting.

Immigrants' access to health care in Spain: a review

An important proportion of the population in Spain is immigrant and the international literature indicates their inadequate access to health services. The objective is to contribute to improving the knowledge on access to health care of the immigrant population in Spain. Review of original papers published (1998-2012) on access to health services of the immigrant population in Spain published in Medline and MEDES. Out of 319 studies, 20 were selected, applying predefined criteria. The results were analyzed using the Aday and Andersen framework. Among the publications, 13 quantitative studies analysed differences in health care use between the immigrant and the native population, and 7 studied determinants of access of immigrants. Studies showed less use of specialized care by immigrants, higher use of emergency care and no differences in the use of primary care between groups. Five quantitative articles on determinants of access focused on factors related to the immigrant population (sex, age, educational level and holding private health insurance), but without observing clear patterns. The two qualitative studies analyzed factors related to health services, describing access to healthcare barriers such as the limited provision of information or the requirements for personal health card. Access to health care in immigrants has been scarcely studied, using different approaches and the barely analysed factors related to the services. No clear patterns were observed, as differences depend on the classification of migrants according to country of origin and the level of care. However, studies showed less use of specialized care by immigrants, higher use of emergency care and the existence of determinants of access different to their needs.

Adolescents' use of care for behavioral and emotional problems: types, trends, and determinants.

ObjectiveWhile adolescents use various types of care for behavioral and emotional problems, evidence on age trends and determinants per type is scarce. We aimed to assess use of care by adolescents because of behavioral and emotional problems, overall and by type, and its determinants, for ages 10–19 years.MethodsWe obtained longitudinal data on 2,230 adolescents during ages 10–19 from four measurements regarding use of general care and specialized care (youth social care and mental healthcare) in the preceding 6 months, the Child Behavior Checklist (CBCL) and Youth Self-Report, and child and family characteristics. We analyzed data by multilevel logistic regression.ResultsOverall rates of use increased from 20.1% at age 10/11 to 32.2% at age 19: general care was used most. At age 10/11 use was higher among boys, at age 19 among girls. Use of general care increased for both genders, whereas use of specialized care increased among girls but decreased among boys. This differential change was associated with CBCL externalizing and internalizing problems, school problems, family socioeconomic status, and parental divorce. Preceding CBCL problems predicted more use: most for mental health care and least for general care. Moreover, general care was used more frequently by low and medium socioeconomic status families, with odds ratios (95%-confidence intervals): 1.52 (1.23;1.88) and 1.40 (1.17;1.67); youth social care in case of parental divorce, 2.07 (1.36;3.17); and of special education, 2.66 (1.78;3.95); and mental healthcare in case of special education, 2.66 (1.60;4.51).DiscussionAdolescents with behavioral and emotional problems use general care most frequently. Overall use increases with age. Determinants of use vary per type.

Adolescent use of care for behavioural and emotional problems: types, determinants and trends

SA Reijneveld, PA Wiegersma, DEMC Jansen Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands Contact: s.a.reijneveld@umcg.nl Background Adolescents frequently have behavioural and emotional problems, that limit their daily functioning. A minority of them receives care. Evidence on determinants and types of care used, including the role of specialized vs. general care is lacking. Objective: To assess the use of various types of care by adolescents because of behavioural and emotional problems, the determinants of this use, and to what extent these determinants explain trends in use by age, for ages 10-19 years. Design/Methods We obtained longitudinal data on 2,230 adolescents during ages 10-19 years in four measurement waves. Data concerned use of various types of care (general including paediatric care, and specialized car i.e. youth social care, and youth mental healthcare) in the preceding 6 months, behavioural and emotional problems (CBCL), and child and family characteristics. We used multilevel logistic regression to analyse the effects of determinants on use per type of care. Results At all ages, use of general care was higher than of specialized care. Overall rates of use increased from 20.1% at age 10/11 to 32.2%. at 19. At age 10/11 use was higher among boys than among girls, but towards age 19, it more than doubled among girls while being rather stable among boys. Use of general care increased among both genders, whereas use of specialized care increased among girls but decreased among boys. This differential change could partially be accounted for by a few factors, being CBCL externalizing and internalizing problems, school problems, family socioeconomic status (SES) and parental divorce. Moreover, use of general care was more likely among low and medium SES families (odds ratios, OR: 1.52 (1.23; 1.88) and 1.40 (1.17;1.67). Use of social care was more likely in case of parental divorce (OR 2.07 (1.36; 3.17) and special education, OR 2.66 (1.78; 3.95), and use of mental healthcare in special education, OR 2.66 (1.60; 4.51). Conclusions Adolescents with behavioural and emotional problems most frequently use general care provided by e.g. general practitioners and child health physicians. Overall use increases with age in girls. Social care or mental health care is used relatively more frequently if adolescents have more behavioral and emotional problems, and receive special education. Key messages Adolescents with behavioural and emotional problems most frequently use general care provided by e.g. general practitioners and child health physicians. Overall use increases in particular in girls from age 11 to age 19, and increases in behavioral and emotional problems explain this partially.

Prematurity, asphyxia and congenital malformations underrepresented among neonates in a tertiary pediatric hospital in Vietnam

BackgroundEstimated 17,000 neonates (≤ 28 days of age) die in Vietnam annually, corresponding to more than half of the child mortality burden. However, current knowledge about these neonates is limited. Prematurity, asphyxia and congenital malformations are major causes of death in neonates worldwide. To improve survival and long term development, these vulnerable neonates need access to the specialized neonatal care existing, although limited, in lower middle-income countries like Vietnam. The aim of this study was to describe these conditions in a specialized Vietnamese hospital, compared to a Danish hospital.MethodsWe performed a comparative observational study of all neonates admitted to a tertiary pediatric hospital in South Vietnam in 2009–2010. The data were prospectively extracted from the central hospital registry and included basic patient characteristics and diagnoses (International Classification of Diseases, 10th revision). Prematurity, asphyxia and designated congenital malformations (oesophageal atresia, gastroschisis, omphalocoele, diaphragmatic hernia and heart disease) were investigated. In a subgroup, the prematurity diagnosis was validated using a questionnaire. The hospitalization ratio of each diagnosis was compared to those obtained from a Danish tertiary hospital. The Danish data were retrieved from the neonatal department database for a ten-year period.ResultsThe study included 5763 neonates (missing<1%). The catchment population was 726,578 live births. The diagnosis was prematurity in 7%, asphyxia in 2% and one of the designated congenital malformations in 6%. The diagnosis of prematurity was correctly assigned to 85% of the neonates, who were very premature or had very low birth weight according to the questionnaire, completed by 2196 neonates. Compared to the Danish Hospital, the hospitalization ratios of neonates diagnosed with prematurity (p<0.01), asphyxia (p<0.01) and designated congenital malformations (p<0.01- 0.04) were significantly lower.ConclusionOur findings suggest the investigated diagnoses were underrepresented in the Vietnamese study hospital. In contrast, relatively mild diagnoses were frequent. These results indicate the use of specialized care may not be optimal. Pre-hospital selection mechanisms were not investigated and additional studies are needed to optimise utilisation of specialized care and improve neonatal survival.

Specialized cardiological care may be overutilized in urban areas of Québec

Urban/rural differences in secondary cardiovascular disease (CVD) events have previously been observed for Québec. These differences could be attributable to differential utilization of specialized cardiological care, such as revascularization procedures and visits to cardiologists; if this were the case, policies to increase utilization in rural areas would be indicated. This is a population-based cohort study. We analysed mortality and hospital re-admission in Québec within 1 year after an initial cardiovascular event in relation to urban/rural location and specialized care utilization, controlling for demography, comorbidities, and cumulative hospitalization. Analysis showed higher hospital re-admissions and slightly lower CVD mortality in rural areas, as well as less use of specialized care in rural areas. However, urban/rural differentials were not attributable to differences in utilization of care. Paradoxically, comorbidities were lower among patients who saw specialists. Ultimately, urban/rural differences in secondary CVD outcomes were not attributable to differences in care utilization or our measures of underlying health status, and were likely due to cultural or lifestyle factors that are both hard to model and hard to change through policy. There appears to be overutilization of specialized care in urban areas, an issue which requires further study. Our results suggest that substantial caution is required when interpreting health service usage data and that critical factors in the relationship between specialized cardiological care and outcomes are still poorly understood at a population level.

The impact of second‐level specialized care on hospitalization in persons with diabetes: a multilevel population‐based study

We evaluated whether differences in the use of specialized care have an impact on rates of hospitalization for diabetes. In 2001 we determined the number of hours of second-level diabetes care provided by local health units (LHU) of the Piemonte Region (Italy) and created an indicator of the mean weekly number of hours of care per 1000 residents for each LHU. From the database of the Piemonte Hospital Information System, we extracted all hospitalizations for 20-75-year-old residents with a main discharge diagnosis of diabetes mellitus (n = 3457). For each LHU, we calculated the hospitalization rate, the percentage of unplanned hospital admissions, the mean length of hospital stay, the percentage of day-hospital admissions and the percentage of re-admissions for diabetes-related complications within 6 months. The association between the indicators of specialized care and of hospital care was studied using two-level generalized hierarchical linear regression models (level 1: patient; level 2: LHU), taking into account the clustered nature of the data. Age, educational level and an indicator of disease severity were used as adjustment parameters. In the tertile of LHUs that provided the greatest number of hours of diabetes care, we observed, compared with the lowest tertile fewer unplanned hospital admissions [odds ratio (OR) 0.37; 95% confidence interval (CI) 0.20-0.67], greater day-hospital use (OR 1.99; 0.72-5.49) and a lower mean duration of hospital stay (coefficient -0.26; 95% CI -0.45 to -0.06), independently of the socio-economic level, which was a separate risk factor. The intensity of specialized diabetes care greatly influences the characteristics of hospitalization.

Medical care. Local population responsibility in Finnish health centres in 1989-1993

Background: Since 1991, the working patterns in Finnish primary care health centres have been changing from traditional group practices towards local population responsibility (LPR) with personal patient lists. As a result, it was expected the services would change notably. Methods: A controlled intervention study included 30 health centres changing their working pattern to LPR and 30 control health centres. We studied the use of health services in both primary and secondary care in the areas served by these health centres during the transition phase from 1989 to 1993. Data were collected from national statistics. Results: The application of LPR was associated with an initial increase in physician consultations. Consultations for preventive care decreased in both LPR and control health centres. The use of specialized care and consultations with private physicians particularly decreased in large LPR municipalities. Conclusions: The most significant changes occurred in the working patterns of large health centres that had introduced LPR. A wide range of variations between the health centres was observed for all activities in both groups.

Cross-border use of health care: A survey of frontier workers' knowledge, attitudes and use

This study examined the impact of enlarging access to health care to residents of frontier zones in northern France and Belgium. A postal survey was carried out on representative samples of French frontier workers (n=176) and Belgian frontier workers (n=366). The survey explored the level of awareness of the arrangements for double access to health care, the patterns of cross-border use of health care and the obstacles and incentives to use cross-border health care. The results showed that approximately one-fifth of the respondents were unaware of their eligibility and this was particularly pronounced about their dependants' entitlement. Frontier workers tended to use cross-border care for the purchase of medications, the use of hospital care and the use of specialized care. There was an increased flow of consumption from Belgium to France which might be explained by the higher proportion of Belgian workers being of French nationality or having dual nationality.

An evaluation of potential prognostic indicators in cardiac patients

Cardiovascular disease results in more deaths and higher medical costs than any other medical problem. Cardiac patients may be transported to centers for specialized care. We evaluated historical, current event, and physiologic items (n = 32) for ability to predict use of specialized care and hospital costs. For 199 patients studied, seven items were prognostic. A model classifying patients by presence of predictors was developed. For the group without predictors and the group with multiple predictors, sensitivity and specificity were respectively very good. For 125 (63%) of the patients in middle categories, the model was not sufficiently sensitive to be prognostic. A scoring system for all cardiac patients could not be developed. Patients requiring only diagnostics were responsible for financial deficits, as were all Medicare patient groups. Patients staying longer than seven days, or having surgery, or both, were responsible for the largest deficits (if on Medicare) and the highest profits (if not on Medicare). Advance validation of the need to transport is difficult, with far-reaching medical and financial implications.