Primary Health Care Utilization Research Articles

PS2-28: Primary Non-adherence and Health Care Utilization

Background New prescriptions unfilled by patients (primary non-adherence) contribute to the overwhelming problem associated with medication non-adherence. Little research has been conducted in this area relative to refill non-adherence. The overall impact of unclaimed prescriptions is potentially significant depending on the medication and its indication. Because primary non-adherence has been recognized as an issue within our organization, we are conducting a retrospective study to evaluate fills up to twelve months following a new prescription in order to assess patient and clinical variables associated with primary non-adherence.

Abolishing user fees for children and pregnant women trebled uptake of malaria-related interventions in Kangaba, Mali

Malaria is the most common cause of morbidity and mortality in children under 5 in Mali. Health centres provide primary care, including malaria treatment, under a system of cost recovery. In 2005, Médecins sans Frontieres (MSF) started supporting health centres in Kangaba with the provision of rapid malaria diagnostic tests and artemisinin-based combination therapy. Initially MSF subsidized malaria tests and drugs to reduce the overall cost for patients. In a second phase, MSF abolished fees for all children under 5 irrespective of their illness and for pregnant women with fever. This second phase was associated with a trebling of both primary health care utilization and malaria treatment coverage for these groups. MSF's experience in Mali suggests that removing user fees for vulnerable groups significantly improves utilization and coverage of essential health services, including for malaria interventions. This effect is far more marked than simply subsidizing or providing malaria drugs and diagnostic tests free of charge. Following the free care strategy, utilization of services increased significantly and under-5 mortality was reduced. Fee removal also allowed for more efficient use of existing resources, reducing average cost per patient treated. These results are particularly relevant for the context of Mali and other countries with ambitious malaria treatment coverage objectives, in accordance with the United Nations Millennium Development Goals. This article questions the effectiveness of the current national policy, and the effectiveness of reducing the cost of drugs only (i.e. partial subsidies) or providing malaria tests and drugs free for under-5s, without abolishing other related fees. National and international budgets, in particular those that target health systems strengthening, could be used to complement existing subsidies and be directed towards effective abolition of user fees. This would contribute to increasing the impact of interventions on population health and, in turn, the effectiveness of aid.

Do place of residence and ethnicity affect health services utilization? evidence from greece

BackgroundEqual utilization of health services for equal need, is one of the main targets for public health systems. Given the public-private structure of the Greek NHS, the main aim of the study was to investigate the impact of underlying factors, such as health care needs, socio-demographic characteristics and ethnicity, on the utilization of primary and hospital health care in an urban and rural population of the Greek region, Thessaly.MethodsA cross-sectional study was carried out in 2006 in Thessaly, a Greek region of Central Greece, in a representative sample of 1372 individuals (18+ years old, response rate 91.4%) via face-to-face interview. Health care needs were determined by self-perceived health status estimated by the SF-36 Health Survey, using the summary scores of physical and mental health. The utilization of primary care was measured by last month visits to 1) primary public services and 2) private practitioners visits and utilization of secondary care was measured by past year visits to 3) public hospital emergency departments and 4) admissions to public hospitals. Multivariable stepwise logistic regression analysis was applied in the whole sample and separately for the urban and rural population, in order to determine the predictors of health services utilization. Statistical significance was determined with a p value < 0.05.ResultsHealth care needs were the most significant determinants of primary and secondary health services utilization in both the urban and rural areas. Poor physical and mental health was associated with higher likelihood of use. In the urban areas middle-aged, elderly and Greeks were more likely to use primary health services, whereas primary education was associated with more visits to the emergency departments. Wealthier individuals were two times more likely to be admitted to hospitals. Individuals from the rural areas with university education visited more the public primary services, while wealthier individuals visited more the private practitioners. Immigrants had a higher likelihood of visiting emergency departments.ConclusionsAlthough health care needs were the main determinant of health services utilization in both the urban and rural population, socio-economic and ethnic differences also seem to contribute to the inequities observed in some types of health services use, favouring the better-off. Such findings provide important information to policy makers, which attempt to reduce inequalities in health care according to place of residence and ethnicity.

Cost-effectiveness of exercise on prescription with telephone support among women in general practice over 2 years

AimTo assess the cost-effectiveness of exercise on prescription with ongoing support in general practice.MethodsProspective cost-effectiveness study undertaken as part of the 2-year Women's lifestyle study randomised controlled trial involving 1089...

Rotavirus Infections and Vaccines

Rotaviruses are the most common cause of severe gastroenteritis in children. By 5 years of age virtually every child worldwide will have experienced at least one rotavirus infection. This leads to an enormous disease burden, where every minute a child dies because of rotavirus infection and another four are hospitalized, at an annual societal cost in 2007 of $US2 billion. Most of the annual 527 000 deaths are in malnourished infants living in rural regions of low and middle income countries. In contrast, most measurable costs arise from medical expenses and lost parental wages in high income countries. Vaccines are the only public health prevention strategy likely to control rotavirus disease. They were developed to mimic the immunity following natural rotavirus infection that confers protection against severe gastroenteritis and consequently reduces the risk of primary healthcare utilization, hospitalization and death. The two currently licensed vaccines--one a single human strain rotavirus vaccine, the other a multiple strain human-bovine pentavalent reassortant rotavirus vaccine--are administered to infants in a two- or three-dose course, respectively, with the first dose given at 6-14 weeks of age. In various settings they are safe, immunogenic and efficacious against many different rotavirus genotypes. In high and middle income countries, rotavirus vaccines confer 85-100% protection against severe disease, while in low income regions of Africa and Asia, protection is less, at 46-77%. Despite this reduced efficacy in low income countries, the high burden of diarrheal disease in these regions means that proportionately more severe cases are prevented by vaccination than elsewhere. Post-licensure effectiveness studies show that rotavirus vaccines not only reduce rotavirus activity in infancy but they also decrease rates of rotavirus diarrhea in older and unimmunized children. A successful rotavirus vaccination program will rely upon sustained vaccine efficacy against diverse and evolving rotavirus strains and efficient vaccine delivery systems. The potential introduction of rotavirus vaccines into the world's poorest countries with the greatest rates of rotavirus-related mortality is expected to be very cost effective, while rotavirus vaccines should also be cost effective by international standards when incorporated into developed countries immunization schedules. Nonetheless, cost effectiveness in each country still depends largely on the local rotavirus mortality rate and the price of the vaccine in relation to the per capita gross domestic product.

Health care utilisation and problems in accessing health care of female undocumented immigrants in the Netherlands

ObjectiveTo obtain information about the actual use of health care facilities by undocumented women and to identify obstacles they experience in accessing health care facilities.MethodsA mixed methods study, with structured questionnaires and semi-structured interviews, was chosen to obtain a complete understanding. One-hundred undocumented women were recruited. Diversity was sought according to age, origin and reason for being undocumented.ResultsUndocumented female immigrants have unmet health care needs (56%) and low health care utilisation. Sixty-nine per cent of the women reported obstacles in accessing health care facilities. These included many personal obstacles such as shame, fear and/or lack of information. Poor language proficiency (OR 0.28;. CI 0.09–0.90) reduces utilisation of primary health care services.ConclusionHealth care utilisation of undocumented women is low. Undocumented women refrain from seeking health care because of personal obstacles. These women need to be identified and informed about their rights, the health care system and the duty of professional confidentiality of doctors. Finally, institutional obstacles to access care should be removed since they strengthen reluctance to seek help.

The road to efficiency? Re-examining the impact of the primary care physician workforce on health care utilization rates

Research suggests that primary care physicians may help to control health care costs by encouraging more efficient service use. However, most studies do not account for data aggregation effects that can significantly affect the direction and magnitude of findings. To re-examine the association between the proportion of primary care physicians and health care utilization rates in an area, and investigate the potential impact of aggregating data to different geographic levels on these observed associations, we estimate four distinct cross-sectional multivariate regression models to predict health care utilization at the county level and the metropolitan statistical area (MSA) level using data from 2007. Our study focuses on health care utilization in the United States using inpatient admissions, outpatient visits, emergency room visits, and total (both inpatient and outpatient) surgeries as dependent variables in separate regressions. The key independent variable is the proportion of primary care physicians in the area. Several community-level control variables are also included. We find that a higher proportion of primary care physicians in the area's physician supply is associated with a decreased number of inpatient admissions at the MSA level, but not the county level, and a decreased number of emergency room visits at the county level, but not the MSA level. Outpatient visits and total surgeries are not associated with the proportion of primary care physicians. From our findings we are able to conclude that there is some evidence that a higher concentration of primary care physicians is associated with a decrease in health care utilization, but these findings depend on the level of aggregation. Investigators should be aware of the implications of aggregating data and acknowledge any resultant limitations.

The effect of a poverty reduction policy and service quality standards on commune-level primary health care utilization in Thai Nguyen Province, Vietnam

Although universal access to quality health services is a primary policy goal of the Government of Vietnam (GOVN), economic restructuring and privatization of health services have been associated with emerging inequities in access to care. A GOVN programme for socio-economic development known as Program 135 (P135) designates communes known to be relatively poor as priority localities for development resources. Under this programme, basic curative and preventive health services, including some prescription drugs, are provided free of charge at commune health centres (CHCs). In an effort to improve the quality of care provided at CHCs, the national Ministry of Health (MOH) has implemented a set of national benchmarks for commune health care, which defines a minimum configuration of equipment, staff, training and other elements of service provision. This research examines the impact of P135 poverty reduction policy, achievement of MOH benchmark indicators and commune socio-economic characteristics on CHC utilization rates in Thai Nguyen Province, Vietnam. The analysis uses administrative data reported from 178 CHCs in Thai Nguyen Province for nine quarters, including 2004, 2005 and the first quarter of 2006. Mixed linear regression models are used to estimate the main and interaction effects on utilization rates of exposure to the P135 policies, achievement of MOH benchmarks, poverty, distance to the district hospital and ethnic composition. Communes that are poor and remote have comparatively high CHC utilization rates. Multivariate regression results suggest that communes exposed to the P135 policy have higher utilization rates, but these effects are conditional upon achievement of benchmark standards, thus perceived quality care enhances CHC utilization. Combining Program P135 with benchmark investment reduced the gap between primary health care utilization in poor communes versus those that are less poor. These commune-level findings suggest that CHC policies differentially benefit poor communities and reduce inequality in use of health care services.

Controlled 3-year follow-up of a multidisciplinary pain rehabilitation program in primary health care

Purpose. The high prevalence of musculoskeletal pain generates significant costs for primary health care and the whole of society. The development of appropriate interventions is therefore necessary. The aim of this effectiveness study was to assess the long-term effects of a primary health care multidisciplinary rehabilitation program in Sweden.Methods. An experimental group comprising 89 patients from two primary health care units received individualised treatment interventions after a multidisciplinary investigation. A control group of 69 patients with the same inclusion criteria from four other primary health care units were treated according to routine. All participants completed questionnaires measuring pain, sick leave, quality of life, health care utilisation, drug consumption and psychosocial factors at baseline and at 3-year follow-up.Results. After 3 years, utilisation of primary health care was significantly lower in the experimental group and work capacity was slightly but not significantly higher. The control group showed a trend of having a higher risk of high consumption after 3 years compared to the intervention group. There was no significant difference between the two groups concerning remaining variables such as function, catastrophising and pain.Conclusion. Both groups demonstrated considerable improvement over the course of 3 years. The experimental group had lower health care utilisation and a reduced risk of using large amounts of medication at the 3-year follow-up, indicating that compared with participants in the control group they were coping in a better way with pain.

Personality problems are considerably associated with somatic morbidity and health care utilisation

Purpose To explore the associations between the presence of personality problems and somatic morbidity and health care utilisation. Methods The Iowa Personality Disorder Screen was administered in order to identify persons with personality problems in a Norwegian population survey (the Oslo Health Study – HUBRO). Cases consisted of 369 individuals, 30, 40 and 45 years of age with personality problems matched on age and gender with five controls each. Data on somatic morbidity and health care utilisation were collected by questionnaires. Results The cases more frequently reported persistent muscular pain, asthma, fibromyalgia and alcohol problems than the controls. They also more often used nonprescribed analgesics and antidepressants. The cases more frequently had consulted a general practitioner (GP) in the last 12 months, less frequently got referral to somatic specialist care and were less satisfied with their last visit to a GP. Conclusion In this population based study, personality problems in young adults based on DSM-IV personality disorder criteria were associated with increased occurrence of somatic morbidity and primary health care utilisation. The relevance for GP to take personality problems into account during consultations is underlined and a method for doing so is suggested.

The Magnitude, Variation, and Determinants of Rural Hospital Resource Utilization Associated With Hospitalizations Due to Ambulatory Care Sensitive Conditions

Using data from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, we examined the magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs). An estimated $9.5 billion in charges incurred in rural hospitals nationwide in 2002 was found to be associated with hospitalizations due to ACSCs. Our findings suggest that the smaller a rural hospital, the greater the portion of its financial resources used to treat patients with ACSC. Regional variation in ACSC-related hospital charges is generally consistent with the geographic variation in the population's economic status and primary care physician supply-residents of the South region have the poorest access to primary healthcare. In summary, smaller rural communities spend more of their healthcare resources on avoidable hospital inpatient care than do larger rural communities, leaving smaller rural communities potentially fewer resources to spend on preventive and primary healthcare. Health intervention programs and health policies should be designed to increase access to and utilization of appropriate preventive and primary healthcare in rural areas, especially in small and remote communities.

Do invitations to attend Well Man Checks result in increased male health screening in primary health care?

Male health outcomes lag behind those of women in many areas. Male utilisation of primary health care and uptake of preventative health care is relatively lower. Our question was: will inviting males who have not received recent health screening nor attended the practice frequently result in a higher rate of male health checks? An auditable uniform classification 'Well Man Check' was established and education sessions on the importance of increasing male health care were held for all clinical staff. Recording of Well Man Check was audited for time periods prior to and after mailing out invitations to attend a Well Man Check. Thirty cases were reviewed to see if previously unrecognised health risks or symptomatic problems were detected. inviting males to attend for a Well Man Check almost triples the number of recorded Well Man Checks, and does not reduce the number of opportunistic Well Man Checks carried out. A range of problems and health risks requiring intervention or follow-up were detected. Further mail-outs to wider age ranges and ongoing discussion of results to stimulate ongoing interest amongst clinical staff is planned. Mail-out invitations do increase recorded Well Man Checks both within the age group mailed to, and also for males outside that age group.

Individual determinants of primary healthcare utilisation in Gaza Strip, Palestine

Objectives:To examine the extent to which primary care patients are using the primary healthcare (PHC) services in Gaza Strip, Palestine, and to determine the factors that are associated with the...

Utilization of primary health care facilities: Lessons from a rural community in southwest Nigeria

This study assessed service/organisational factors and clients' perceptions that influenced utilisation of Primary Health Care (PHC) facilities in a rural community in Nigeria. A cross-sectional household survey in the community as well as key-informant interviews of opinion leaders and health care providers and participant observations of health facilities and utilisation pattern was used to collect data. Forty-four percent of respondents to the survey who were ill in the preceding six months visited a PHC facility for treatment, while others relied on self-medication/self-treatment. Education was positively associated with utilisation of PHC services (P<0.05). Maternal and child health (45.4%), prompt attention (23.0%), and appropriate outpatient (20.5%) services attracted respondents to use PHC services. Poor education about when to seek care, poverty, perceived high cost of PHC services, lack of drugs and basic laboratory services, and a regular physician on site at the facility were identified as barriers to utilisation. We conclude that community perceptions of poor quality and inadequacy of available services was responsible for low use of PHC services.

PTSD symptom clusters associated with physical health and health care utilization in rural primary care patients exposed to natural disaster

This study investigated the influence of exposure to a tornado disaster and disaster-related posttraumatic stress disorder (PTSD) symptomatology on physical health complaints and primary health care utilization among rural medical patients. One-hundred five patients completed self-report measures assessing disaster exposure, PTSD symptoms, and self-reported physical health complaints. Objective rates of health care utilization were gathered by a review of medical records. Tornado disaster exposure and generalized psychological distress were associated with physical health complaints one year following the disaster. After controlling for age, gender, and levels of predisaster health care utilization, PTSD Cluster C (avoidance) symptoms were associated with increased rates of postdisaster health care utilization. Implications of these findings for interventions within the medical system are discussed.

Comparative analyses of childhood deaths in Sagamu, Nigeria : implications for the fourth MDG

Background: The fourth Millennium Development Goal (MDG) aims at reducing childhood deaths in the developing world by 2015. Objective: To examine the pattern of childhood deaths in a Nigerian tertiary hospital which serves at least three states of the federation between 1996 and 2005? Method: A retrospective study of paediatric deaths between January 1996 and December 2005. Subjects admitted in the pre-MDG period were compared with those admitted in the MDG period. Results: Out of 10,451 paediatric admissions, 1320 (12.6%) died but only 1225 were studied. The male-to-female ratio was 1.4:1. Although the yearly mortality rate ranged from 10.7% to 14.9%, however the overall mortality rate for the pre-MDG period was similar to that obtained during the MDG-period (p = 0.135) Most deaths (69.1%) occurred within 48 hours of hospitalization. Of the 1225 mortalities, 57.3% were neonates. These neonatal deaths were commonly due to prematurity (34.6%), perinatal asphyxia (30.8%) and septicaemia (24.8%) while severe anaemia was the most common cause of death among infants (20.1%) and toddlers (25.1%). Severe malaria, severe anaemia and tetanus formed 33.3% of all the deaths among children older than 5 years. There was no significant difference in the role of prematurity (p = 0.298) and measles (p = 0.927) as causes of death before and during the MDG. HIV/AIDS (p = 0.046) became commoner as a result of the HIV pandemic while severe malaria (p = 0.041) became less common as causes of death during the same period. Conclusion: Childhood mortality rate remained high over the ten-year period studied. The causes of the deaths were mostly infectious and other preventable conditions. The utilization of specific target-oriented interventions IMCI and primary health care may reduce the childhood deaths before 2015.

Patterns in Primary Health Care Utilization Among Individuals With Intellectual and Developmental Disabilities in Florida

Individuals living with intellectual and developmental disabilities face complex medical problems. Primary care physicians tend to provide basic medical care, serving as a base through which other forms of care can be accessed. In this study we describe patterns of primary care utilization among adults enrolled on the Florida Medicaid's Home and Community-Based Services Waiver. About 40% of the adults on the Waiver did not see a primary care provider between 1999 and 2003. Primary health care utilization was higher in the northern parts of Florida and conversely lower in the southeast. The establishment of a medical home can ensure the timely receipt of preventive care as well as help coordinate the complex care that many individuals with disabilities need.

Who’s In and Who’s Out: Use of Primary Medical Care Among People Living With HIV

We sought to achieve a more comprehensive picture of access to medical care for the treatment of HIV (HIV primary care) by combining evidence of medical services used (health utilization) and epidemiological client-level data. This study integrated health information from several data sources to measure utilization of HIV primary care in the St Louis, Mo, area between 1998 and 2002. Data from disparate HIV health utilization databases were combined with data from the Missouri HIV and AIDS Reporting System database and then deidentified to measure client-level utilization of HIV primary care over time. About half of those with HIV showed evidence of having utilized HIV primary care in a given year. Although most of this group utilized HIV primary care in the first year after they received their HIV diagnosis, evidence of subsequent utilization was inconsistent. Utilization of primary care was most strongly associated with an AIDS diagnosis. About one quarter of people diagnosed with HIV after 1997 had an AIDS diagnosis when they first tested positive for HIV. This study was the first of its kind to integrate several databases to understand HIV primary health care utilization over a period of years. Our findings reinforce the importance of CD4 and viral load values as indicators of utilization of HIV primary health care, particularly in the absence of other health data sets. The lack of available data and the way in which source data were available limited the study.

Determinants of healthcare utilization in Greece: Implications for decision-making

Objective: To explore factors influencing the utilization of primary and secondary healthcare in Greece. Methods: A national, geographically stratified sample was randomly selected. From November 2001 to March 2002, 5000 questionnaires were mailed, 4427 were actually received, and 1819 were completed and returned (response rate 41%). The questionnaire investigated respondents’ characteristics and their health services utilization. A number of potential utilization determinants were explored, such as region, gender, age, education, income, insurance coverage, number of family members, self-rated health status, country of birth, and parents’ country of birth. Results: The utilization of primary healthcare services depended on self-rated health status, age, income, gender, and region. Individuals with moderate and poor self-rated health, older people, women, and residents of the region of Epirus showed increased utilization of primary healthcare services. Income was a factor affecting the utilization of primary healthcare only at lower income levels. The frequency of visits for primary healthcare was negatively correlated with self-rated health status and increased as self-evaluation of health status worsened. Hospitalization was associated with self-rated health and insurance coverage for primary healthcare. Individuals with better self-rated health status, as well as those who were covered by health insurance for primary care, showed decreased hospital care utilization. The frequency of hospitalization depended on region and lower evaluations of health status.Conclusion: The findings of our research are encouraging, since they suggest that the utilization of health services in Greece is mostly determined by health status rather than other socioeconomic factors. It is believed that similar studies should be conducted in the country, since they can improve health service planning and reinforce decision-making towards healthcare resource allocation according to healthcare needs.

The Cost-Effectiveness of Cognitive Behavior Therapy for Borderline Personality Disorder: Results from the BOSCOT Trial

Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (-689 pounds sterling), although this group also reported a lower quality of life (-0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study.