Variation In Health Care Use Research Articles

Regional variation in length of stay for stroke inpatient rehabilitation in traditional Medicare and Medicare Advantage.

Regional variation in health care use threatens efficient and equitable resource allocation. Within the Medicare program, variation in care delivery may differ between centrally administered traditional Medicare (TM) and privately managed Medicare Advantage (MA) plans, which rely on different strategies to control care utilization. As MA enrollment grows, it is particularly important for program design and long-term health care equity to understand regional variation between TM and MA plans. This study examined regional variation in length of stay (LOS) for stroke inpatient rehabilitation between TM and MA plans in 2019 and how that changed in 2020, the first year of the COVID-19 pandemic. Results showed that MA plans had larger across-region variations than TM (SD = 0.26 vs 0.24 days; 11% relative difference). In 2020, across-region variation for MA further increased, but the trend for TM stayed relatively stable. Market competition among all inpatient rehabilitation facilities (IRFs) within a region was associated with a moderate increase in within-region variation of LOS (elasticity = 0.46). Policies reducing administrative variation across MA plans or increasing regional market competition among IRFs can mitigate regional variation in health care use.

Variations in healthcare utilization for mental health problems prior to suicide by socioeconomic status: a Norwegian register-based population study

BackgroundSuicide poses a major public health challenge, claiming around 650 lives annually in Norway. There is limited understanding of mental healthcare utilization patterns preceding suicide, particularly relating to socioeconomic status (SES). This study analyzes mental health service use among Norwegian citizens aged 20–64 from 2009 to 2021, emphasizing disparities related to SES.MethodsThis is a population-wide registry-based study. We include mental health consultations with both primary and specialist healthcare services, and investigate patterns of service use regarding educational attainment, employment status and income and compare this to the population in general. All suicides in the period (N = 4731) are included in the study. The aim is to investigate potential discrepancies in service use the year and month preceding suicide, seeking to enhance targeted preventive interventions.ResultsOur results show significant variations in healthcare use for mental health problems the last year preceding suicide, according to the components of SES, for both men and women. Those with higher education utilize the mental healthcare services prior to suicide to a higher degree than men and women with high school education or less, whereas employed men and men with high income level have significantly lower mental healthcare usage prior to suicide both the last year and month compared to the non-employed men and men with low-income level. Employed women also had a lower mental healthcare usage, whereas the results regarding income are not significant for women.ConclusionMental healthcare use prior to suicide varies across the SES components. Notably, the SES groups exhibit heterogeneity, with gendered patterns. Targeted interventions for low consultation rates among employed men, and men with high income and lower education are needed, while women, and men in at-risk groups, such as the non-employed and those with low income, demonstrate higher mental healthcare utilization, warranting comprehensive suicide prevention measures.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use – results of a scoping review

BackgroundBesides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.MethodsWe used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the ‘Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)’ recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.ResultsOf the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.ConclusionsSocioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Social and spatial inequalities in healthcare use among people living with dementia in England (2002–2016)

Objectives Healthcare services for people living with dementia (PLWD) are stretched, and government promises of increased funding remain undelivered. With the UK dementia population to surpass 1 million by 2024, and dementia care costs predicted to almost treble by 2040, it is essential we understand differences in healthcare use among PLWD. This study aimed to explore social and spatial variations in healthcare use among people diagnosed with dementia (2002–2016). Methods Data were derived from Electronic Health Records of Clinical Practice Research Datalink GP patients in England (n = 142,302). To standardise healthcare contacts, rates of healthcare contacts per year were calculated for three primary (GP observations and medications) and three secondary healthcare types [Accident & Emergency (A&E) attendances and, emergency and elective hospital admissions]. Fully-adjusted generalised linear regression models were used to identify healthcare use variation by social and spatial groups. Twelve models were generated, one for each healthcare type in early- and late-onset populations separately. Results This study highlights numerous social and spatial variations in healthcare use among PLWD. Among PLWD, several groups tended to have healthcare service use more closely associated with negative outcomes, including a greater likelihood of A&E attendances and emergency and elective hospital admissions. These groups include: men, people from White ethnicity groups and people from more deprived and rural areas. Conclusions Systemic and social measures are needed to reduce variations in healthcare use inequalities in PWLD. These include greater healthcare continuity, health checks and medicines reviews, culturally appropriate services, better and more accessible treatment and improved infrastructure.

Creation of the first national linked colorectal cancer dataset in Scotland: prospects for future research and a reflection on lessons learned.

IntroductionCurrent understanding of cancer patients, their treatment pathways and outcomes relies mainly on information from clinical trials and prospective research studies representing a selected sub-set of the patient population. Whole-population analysis is necessary if we are to assess the true impact of new interventions or policy in a real-world setting. Accurate measurement of geographic variation in healthcare use and outcomes also relies on population-level data. Routine access to such data offers efficiency in research resource allocation and a basis for policy that addresses inequalities in care provision.ObjectiveAcknowledging these benefits, the objective of this project was to create a population level dataset in Scotland of patients with a diagnosis of colorectal cancer (CRC).MethodsThis paper describes the process of creating a novel, national dataset in Scotland.ResultsIn total, thirty two separate healthcare administrative datasets have been linked to provide a comprehensive resource to investigate the management pathways and outcomes for patients with CRC in Scotland, as well as the costs of providing CRC treatment. This is the first time that chemotherapy prescribing and national audit datasets have been linked with the Scottish Cancer Registry on a national scale.ConclusionsWe describe how the acquired dataset can be used as a research resource and reflect on the data access challenges relating to its creation. Lessons learned from this process and the policy implications for future studies using administrative cancer data are highlighted.

Regional Variation in Healthcare Use Among Medicare Beneficiaries With Alzheimer’s Disease and Related Dementias

In this national prospective study we describe regional variation in healthcare utilization among Medicare beneficiaries with Alzheimer’s disease and related dementias (ADRD) in the six years after diagnosis. We use 2008-2015 Medicare claims and other administrative data to map nursing home, home health, hospital, and hospice use across hospital referral regions; and examine the relationship of state and county supply-side factors to time beneficiaries spend in different settings. The sample includes 1,158,655 Medicare fee-for-service beneficiaries diagnosed with ADRD in 2008 and 2009. Nationally, beneficiaries spent a mean of 70.6% of survived days in the community, 23.9% of days in nursing home, and 5.4% of days in hospital. 37.2% of beneficiaries who died within six years had received hospice. Distinct regional patterns emerged. Adjusting for beneficiary and local characteristics, beneficiaries in Midwestern states spent the most time in nursing homes, while beneficiaries in Western states spent the most time in community. The probability of receiving hospice was generally highest in Western and Southern states, and lowest in the Midwest and Northeast. Controlling for beneficiary, local, and state characteristics, we found the following factors to be associated with beneficiaries spending less time in nursing homes: fewer nursing home beds in the county, higher state Medicaid long-term care spending for home and community-based services (HCBS), and state use of Certificate of Need laws. These findings illustrate that state investment in HCBS, and state and local regulation of provider supply are important factors influencing where individuals with ADRD receive care.

Queensland Cardiovascular Data Linkage (QCard): A population-based cohort study

Queensland is Australia's hotspot for cardiovascular disease (CVD). Critically, beyond modifiable lifestyle risk factors; socio-demographic differences and environmental factors account for significant variations in healthcare use and outcomes among cardiac patients across the country. To better understand the impacts of these factors on the health of cardiac patients, there is a need for a comprehensive and robust longitudinal cohort study that can unpack the underlying dynamics. This paper describes the protocol for the Queensland Cardiovascular Linkage (QCard) Study. The QCard is a longitudinal linkage cohort study of cardiac patients who were first hospitalised with any cardiac condition in 2010, with follow up hospitalisations until December 2015. The primary aim of the QCard is to identify and characterise the nature and impact of socio-demographic inequality among those presenting for the first time with the most common form of CVD in Australia (heart disease) in Queensland from 2010 with minimum 5-years follow-up of subsequent healthcare utilisation and outcomes. A secondary aim is to undertake an exploration of the impact of environmental and specific health service factors on healthcare use and survival time in the same QCard cohort. Administrative public and private hospital inpatient, outpatient and emergency department data for all of Queensland will be linked with individual primary care data and pharmaceutical data. These data will also be linked to regional socio-demographic data and environmental data, as well as data that describes the features of each hospital in the region. The findings from the study will provide critical information for cardiac patients, clinicians and health policymakers. Such information ranges from identifying most vulnerable cardiac patients who may require targeted needs to providing estimates for cost-effective ways of evaluating healthcare interventions that seek to improve the health of cardiac patients.

Heartbeat: is cardiovascular health affected by marital status, living alone or loneliness?

Many studies suggest there is a higher risk of cardiovascular disease (CVD) in individuals who are lonely, not married or living alone.1–4 But which is it: a feeling of loneliness,...

Utilization Variation In Military Versus Civilian Care: Evidence From TRICARE

The Defense Health Agency was established five years ago to integrate and centralize the provision of health care that had been managed separately by the Army, Navy, and Air Force. One favored proposal is to increase the use of private-sector or civilian health care providers. This study compared geographic variation in health care use (a common proxy for efficiency) between patients with a military (direct care) system and those with a civilian (purchased care) system primary care provider-both of which are offered in TRICARE Prime, a health plan that resembles a health maintenance organization. We found similar levels of variation across care utilization metrics with the exception of specialty care, in which the military sample had less variation than its civilian counterpart did. In the military system, risk-adjusted utilization levels were substantially lower for primary care visits and higher for specialty care visits, compared to these visits under the civilian system. Our findings suggest that expanding the use of the civilian system might not achieve the desired efficiencies. Rather, focusing on specialty care in the military system and expanding primary care in the civilian system could help achieve operational readiness and enhanced efficiency.

Heterogeneity/granularity in ethnicity classifications project: the need for refining assessment of health status.

Identifying ethnic inequalities in health requires data with sufficiently 'granular' (fine detailed) classifications of ethnicity to capture sub-group variation in healthcare use, risk factors and health behaviors. The Robert Wood Johnson Foundation (RWJF), in the USA, commissioned us to explore granular approaches to ethnicity data collection outside of the USA, commencing with the European Union. We examined official data sources (population censuses/registers) within the EU-28 to determine the granularity of their approach to ethnicity. When ethnic information was not available, related variables were sought (e.g. country of birth). Within the EU-28, we found 55% of countries collected data on ethnicity. However, only 26% of these countries (England, Wales, Northern Ireland, Scotland, Republic of Ireland, Hungary, Poland and Slovakia) had a granular approach, with half of these being within the UK. Estonia, Lithuania, Croatia, Bulgaria, Republic of Cyprus and Slovenia collected one to six categories. A 'write-in' option only was found in Latvia, Romania and the Czech Republic. Forty-five percent of countries did not collect ethnicity data but collected other related variables. (i) Although there is reasonable attention to the diversity of ethnic groups in data collection, a granular approach does not predominate within EU-28 classifications. (ii) Where ethnicity is collected, it is conceptualized in different ways and diverse terminology is used. (iii) A write-in option provides the most granular approach. (iv) Almost half of the countries did not collect data on ethnicity, but did collect related variables that could be used as a proxy.

Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany

ObjectivesA considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general...

Health Care Use And Spending Patterns Vary By Wage Level In Employer-Sponsored Plans.

Employees face an increasing financial burden for health services as health care costs increase relative to earnings. Yet little is known about health care utilization patterns relative to employee wages. To better understand this association and the resulting implications, we examined patterns of health care use and spending by wage category during 2014 among 42,936 employees of four self-insured employers enrolled in a private health insurance exchange. When demographics and other characteristics were controlled for, employees in the lowest-wage group had half the usage of preventive care (19percent versus 38percent), nearly twice the hospital admission rate (31 individuals per 1,000 versus 17 per 1,000), more than four times the rate of avoidable admissions (4.3 individuals per 1,000 versus 0.9 per 1,000), and more than three times the rate of emergency department visits (370 individuals per 1,000 versus 120 per 1,000) relative to top-wage-group earners. Annual total health care spending per patient was highest in both the lowest-wage ($4,835) and highest-wage ($5,074) categories relative to the middle two wage groups ($3,952 and $3,987, respectively). These findings provide new insights about wage-associated variations in health care use and spending in employer-sponsored plans. For policy makers, these findings can inform employer benefit design strategies and research priorities, to encourage effective use of health care services.

Health care variation: time to act.

Geographic variation in health care use has been demonstrated in many countries over many years. Such variation can be warranted - in response to patient need or preference for care - or unwarranted. Unwarranted variation raises concerns about equity and appropriateness of care. Recent analyses of health care provision in the Australian atlas of healthcare variation show that when routinely available Australian data are mapped by residence of patient, there are wide variations in rates of use of diagnostic tests, dispensing of prescriptions for a range of indications, surgical procedures and hospital admission rates. Despite the wealth of studies demonstrating variation in care internationally, there is relatively little research that explores the best ways of responding to unwarranted variation. Recommendations for action in the Australian Atlas focus on some approaches that could be used in Australia.

Improving the implementation of evidence-based knowledge in healthcare

Information overload & know-do gap The pace of development of new healthcare technologies and related knowledge is very fast. Implementation of high quality evidence-based knowledge is thus mandatory to warrant an effective healthcare system and patient safety. However, even though only a small fraction of the approximate 2500 scientific publications indexed daily in Medline is actually useful to clinical practice, the amount of new information is much too large to allow busy healthcare professionals to stay aware of possibly important evidence-based information [1]. Indeed, there are well-recognized barriers to the translation of this knowledge to clinical practice and organization of care [2,3]. We focus here on ‘type 2’ translational research that concerns the implementation of clinical research results (e.g., clinical trials) into actual practice, in an attempt to fill the ‘know-do-gap’ [4]. The aforementioned barriers to knowledge translation generate delays to adopting new effective and efficient interventions, the persistence of obsolete treatments (i.e., comparatively low effectiveness and high elevated occurrence of secondary effects and inconvenience), not to mention large unexplained variations in healthcare use, the overuse of ineffective or inappropriate interventions and the underuse of effective preventive, diagnostic and therapeutic care [3,5].

Differences in health care utilisation between elderly from ethnic minorities and ethnic Dutch elderly.

IntroductionIn the Netherlands, as in other Western countries, ethnic minority elderly are more often in poorer health than the indigenous population. The expectation is that this health disadvantage results in more frequent use of health care services.MethodsWe studied registered data on the proportion of health care receivers, frequency of use, and health care costs collected by a major Dutch health insurance company in 2010. Data from 10,316 Turkish, 14,490 Moroccan, 8,619 Surinamese, and 1,064 Moluccan adults aged 55 years and older were compared with data from a sample of 33,725 ethnic Dutch older adults.ResultsUnadjusted and adjusted (for age and gender) analyses showed the following. Moluccans had lower usage levels for all types of health care services. Use of primary health care facilities was higher for Turks, Moroccans, and Surinamese compared with the ethnic Dutch, with the exception that physical therapy was less frequently used among the Turks and Moroccans. Use of hospital care was lower, except for the Surinamese, who had a similar level of usage to that of the ethnic Dutch.ConclusionsThe health disadvantage previously observed within most ethnic minority elderly populations does not result in an overall more frequent use of health care services. Further research is needed for the interpretation of the ethnic variations in health care use as potentially inequitable, by taking medical need, patient treatment preferences, and treatment adherence into account.

Patterns of healthcare use and employment among people with disabilities

BackgroundEmployment rates among people with disabilities are low. Poor health is often cited as a barrier to work. Disability or a lack of disability-related resources may interfere with the ability to secure and maintain work. ObjectiveThis paper presents an exploratory examination of the association between variation in service use and employment. MethodsThe paper uses data from North Carolina Medicaid recipients age 18–64 who were eligible in fiscal year 2007 due to receipt of Supplemental Security Income (n = 60,190). Logistic regression was used to model employment as a function of variation in healthcare use, with conditional models stratifying by days of service use and unconditional models run by quantile of service use. ResultsPeople with the least service use (<12 days) had the highest employment rate (over 20%); those with the most service use (≥54 days) had the lowest employment rate (7.8%). Those in between displayed remarkably little variation in employment rate by level of service use. The amount of week-to-week variation in service use was positively associated with the probability of employment. ConclusionsAmong Medicaid enrollees with disabilities who use outpatient services, amount of service use is negatively associated with employment and variation in use is positively associated with employment. Future research involving more extensive administrative data, primary data collection, and the use of mixed methods would improve understanding of these findings.

Shared Decision Making

A primary challenge to the American healthcare system is to improve quality by being more evidence based, cost-effective, and patient centered.1,2 The first 2 markers of quality are familiar to physicians and policy makers, wherein disease-specific performance measures and cost data are commonly used to gauge outcomes. The third quality parameter, patient-centered care, has gained increased awareness among the healthcare community but remains elusive to many. Patient-centered outcomes focus on patients’ experiences (eg, symptoms, quality of life) and preferences for these and other outcomes. Thus, the best outcome may be different for different individuals, depending on their priorities, values, and goals. For example, in assessing the outcome of implanting a defibrillator in an 80-year-old patient, we may need to look beyond 1-year mortality and ask whether the decision is consistent with the patient’s values concerning dying and acceptance of potential inappropriate shocks.3 In a patient-centered model, the focus is on high-quality decision making, stemming from the exchange of (1) balanced, evidence-based, disease-specific information; (2) presentation of treatment options and their inherent benefits and tradeoffs; (3) assessment of patient values, priorities, and goals; and (4) alignment of patient values with treatment decisions.4 This process of shared decision making (SDM) has the potential to advance patients’ desired wishes and to achieve better patient-centered outcomes while lowering the costs of care should patients choose less expensive treatment options.5,6 Decision aids are commonly used to facilitate SDM, conveying information about a particular disease and the risks and benefits associated with different treatment strategies, including no treatment at all.7 Decision aids may take the form of a Web-based tool, video, or pamphlet and may be administered in the hospital or office or even independently by patients before their visit. To date, >86 randomized trials have been …

Direct Health Care Costs of Children and Adolescents with Down Syndrome

To assess the direct annual health care costs for children and adolescents with Down syndrome in Western Australia and to explore the variation in health care use including respite, according to age and disease profile. Population-based data were derived from a cross-sectional questionnaire that was distributed to all families who had a child with Down syndrome as old as 25 years of age in Western Australia. Seventy-three percent of families (363/500) responded to the survey. Mean annual cost was $4209 Australian dollars ($4287 US dollars) for direct health care including hospital, medical, pharmaceutical, respite and therapy, with a median cost of $1701. Overall, costs decreased with age. The decline in costs was a result of decreasing use of hospital, medical, and therapy costs with age. Conversely, respite increased with age and also with dependency. Health care costs were greater in all age groups with increasing dependency and for an earlier or current diagnosis of congenital heart disease. Annual health care costs did not vary with parental income, including cost of respite. Direct health care costs for children with Down syndrome decrease with age to approximate population costs, although costs of respite show an increasing trend.

Regional Variations in Palliative Care: Do Cardiologists Follow Guidelines?

Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life. We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios. We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008). Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.

How Much Do Patients’ Preferences Contribute To Resource Use?

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients' care-seeking preferences and use of services, using a national survey of Medicare patients. Patients' preferences, in addition to health and sociodemographic characteristics, are associated with differences in individuals' use of office visits. However, we find that patients' preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.