Asthma morbidity measures across Black ethnic subgroups.

BACKGROUND: Black adults are disproportionately affected by asthma and are often considered a homogeneous group in research studies despite cultural and ancestral differences. OBJECTIVE: We sought to determine if asthma morbidity differs across adults in Black ethnic subgroups. METHODS: Adults with moderate-severe asthma were recruited across the continental United States and Puerto Rico for the PREPARE (PeRson EmPowered Asthma RElief) trial. Using self-identifications, we categorized multiethnic Black (ME/B) participants (n = 226) as Black Latinx participants (n = 146) or Caribbean, continental African, or other Black participants (n = 80). African American (AA/B) participants (n = 518) were categorized as Black participants who identified their ethnicity as being American. Baseline characteristics and retrospective asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids [SCs], emergency department/urgent care [ED/UC] visits, hospitalizations) were compared across subgroups using multivariable regression. RESULTS: Compared with AA/B participants, ME/B participants were more likely to be younger, residing in the US Northeast, and Spanish speaking and to have lower body mass index, health literacy, and <1 comorbidity, but higher blood eosinophil counts. In a multivariable analysis, ME/B participants were significantly more likely to have ED/UC visits (incidence rate ratio [IRR] = 1.34, 95% CI = 1.04-1.72) and SC use (IRR = 1.27, 95% CI = 1.00-1.62) for asthma than AA/B participants. Of the ME/B subgroups, Puerto Rican Black Latinx participants (n = 120) were significantly more likely to have ED/UC visits (IRR = 1.64, 95% CI = 1.22-2.21) and SC use for asthma (IRR = 1.43, 95% CI = 1.06-1.92) than AA/B participants. There were no significant differences in hospitalizations for asthma among subgroups. CONCLUSIONS: ME/B adults, specifically Puerto Rican Black Latinx adults, have higher risk of ED/UC visits and SC use for asthma than other Black subgroups.

The impact of outpatient supportive oncology on cancer care cost and utilization.

BACKGROUND: Supportive oncology (SO) care reduces symptom severity, admissions, and costs in patients with advanced cancer. This study examines the impact of SO care on utilization and costs. METHODS: Retrospective analysis of utilization and costs comparing patients enrolled in SO versus three comparison cohorts who did not receive SO. Using claims, the authors estimated differences in health care utilization and cost between the treatment group and comparison cohorts. The treatment group consisting of patients treated for cancer at an National Cancer Institute-designated cancer center who received SO between January 2018 and December 2019 were compared to an asynchronous cohort that received cancer care before January 2018 (n = 60), a contemporaneous cohort with palliative care receiving SO care from other providers in the Southeastern Pennsylvania region during the program period (n = 86), and a contemporaneous cohort without palliative care consisting of patients at other cancer centers who were eligible for but did not receive SO care (n = 393). RESULTS: At 30, 60, and 90 days post-enrollment into SO, the treatment group had between 27% and 70% fewer inpatient admissions and between 16% and 54% fewer emergency department visits (p < .05) compared to non-SO cohorts. At 90 days following enrollment in SO care, total medical costs were between 4.4% and 24.5% lower for the treatment group across all comparisons (p < .05). CONCLUSIONS: SO is associated with reduced admissions, emergency department visits, and total costs in advanced cancer patients. Developing innovative reimbursement models could be a cost-effective approach to improve care of patients with advanced cancer.

Three-Year Post-Neonatal Intensive Care Unit Health Care Utilization Among Infants with Congenital Anomalies.

OBJECTIVE: To describe 3-year post-neonatal intensive care unit (NICU) health care use among children with congenital anomalies discharged home from a level IV NICU. STUDY DESIGN: Retrospective chart review of children with congenital anomalies enrolled in a previous prospective cohort study from 201 to 2020. We assessed hospital readmission rate, number of surgeries, and durable medical equipment (DME) use by type of anomaly. RESULTS: Among 166 infants enrolled in the original study, 158 survived to NICU discharge. One-third of the cohort had a genetic anomaly. Six of 158 patients (4%) died before 3 years of age. More than one-half the children were readmitted within the first 2 years of life, and one-third were readmitted in the third year of life. Readmissions were greatest for those with multiple, musculoskeletal, and central nervous system anomalies and lowest for abdominal-wall defects. Approximately one-half the children underwent surgeries, and this proportion remained constant over the 3-year time. Sixty-two percent of patients received DME at discharge, with gastrostomy tubes being the most common. Gastrostomy tubes were still present in 75% of the patients at 3 years of age. CONCLUSION: Children with congenital anomalies are at risk for increased health care use during early childhood. Those with multiple anomalies, a genetic syndrome, musculoskeletal, and central nervous system anomalies and those discharged with DME are at greatest risk whereas those with abdominal-wall defects are at lowest risk. Provider awareness, high-quality discharge training, parent psychological support, greater assimilation of families in the NICU, and telehealth may be some strategies to better support these families.

Factors associated with 90-day reintervention following lower extremity revascularization.

OBJECTIVE: Peripheral artery disease (PAD) represents a high-volume, high-cost burden on the health care system. The Centers for Medicare and Medicaid Services has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders. METHODS: We conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and Centers for Medicare and Medicaid Services-linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010, and December 31, 2018. Procedures for acute limb ischemia and aneurysms were excluded. The primary outcome was 90-day reintervention. Reintervention at 30 days was a secondary outcome. Covariates of interest included demographics, comorbidities, and patient- and facility-level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions. RESULTS: Among 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median age was 74 years (interquartile range, 69-80 years), 57.9% were male, and 84.3% were White. Chronic limb-threatening ischemia was the operative indication in 40.4% of the procedures. Overall, 42.8% were completed in the outpatient setting (40.3% outpatient, 2.5% office-based lab). Over 70% of procedures for chronic limb-threatening ischemia were completed as inpatient, whereas 60% of the claudication interventions were done as outpatient. The 90-day reintervention rate was 14.5%, and the 30-day reintervention rate was 5.5%. Compared with inpatient procedures, PAD interventions completed in the outpatient or office-based lab setting had significantly higher 90- and 30-day reintervention rates (reference, inpatient; outpatient 90-day reintervention: hazard ratio [HR], 1.41; 95% confidence interval [CI] 1.25-1.60; outpatient 30-day reintervention: HR, 1.90; 95% CI, 1.62-2.24; office-based lab 90-day reintervention: HR, 2.09; 95% CI, 1.82-2.41; office-based lab 30-day reintervention: HR, 3.54; 95% CI, 3.17-3.94). Open and hybrid approaches demonstrated lower risk of reintervention compared with endovascular procedures at 30 and 90 days and, compared with aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention, but no difference was noted at 30 days. CONCLUSIONS: Although outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.

Health Care Use Among Patients Retroactively Insured via a Hospital-Based Insurance Linkage Program.

OBJECTIVE: Over 25% of the 27 million uninsured individuals in the United States are eligible for Medicaid. Many hospitals have insurance linkage programs that assist eligible patients with enrollment, but little is known about the impact of these programs on care utilization. This research assessed health care utilization and health outcomes among patients enrolled in Medicaid via a hospital-based insurance linkage program. METHODS: This retrospective cohort study included adults aged 18-64 admitted to the hospital from 2016 to 2021. Those who obtained insurance retroactively via insurance linkage (RI) were compared with those who presented with Medicaid (MI) or remained uninsured (UI). The primary outcome was the presence of at least one visit with a primary care provider (PCP) in the 12 months following index admission. Secondary outcomes included having an assigned PCP, ED revisits, and hospital readmissions. For patients with diabetes and hypertension, 12-month hemoglobin A1c (HbA1c) and blood pressure (BP) readings were tracked. RESULTS: Of 3882 patients admitted with no insurance, 2905 (74.8%) were enrolled in insurance (RI). In multivariable analysis, RI patients were 14% more likely (OR 1.14, p = 0.020) to have completed at least one PCP visit by 12 months after index admission compared to those with preexisting Medicaid (MI), and uninsured patients were 29% less likely (OR 0.71, p = 0.003). MI and RI patients also had more ED revisits (p < 0.001) and greater 12-month reductions in blood pressure (p < 0.001) compared with uninsured patients. CONCLUSION: Hospital-based insurance linkage reached three-quarters of uninsured patients and was associated with increased utilization of acute and outpatient health care services. An acute care encounter represents an opportunity to connect patients to insurance, a key step toward improving their health outcomes.

The Associations Between Medical and Mental Health Conditions and Health Care Utilization in US Adults with Past-Year Criminal Legal Involvement.

BACKGROUND: Every year, millions of US adults return home from prison or jail, and they visit the emergency department and experience hospitalizations at higher rates than the general population. Little is known about the primary conditions that drive this acute care use. OBJECTIVE: To determine the individual and combined associations between medical and mental health conditions and acute health care utilization among individuals with recent criminal legal involvement in a nationally representative sample of US adults. DESIGN: We examined the association between having medical or mental, or both, conditions (compared to none), and acute care utilization using negative binomial regression models adjusted for relevant socio-demographic covariates. PARTICIPANTS: Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported past year criminal legal involvement. MAIN MEASURES: Self-reported visits to the emergency department and nights spent hospitalized. RESULTS: Among 9039 respondents, 12.4% had a medical condition only, 34.6% had a mental health condition only, and 19.2% had both mental and medical conditions. In adjusted models, incident rate ratio (IRR) for ED use for medical conditions only was 1.32 (95% CI 1.05, 1.66); for mental conditions only, the IRR was 1.36 (95% CI 1.18, 1.57); for both conditions, the IRR was 2.13 (95% CI 1.81, 2.51). For inpatient use, IRR for medical only: 1.73 (95% CI 1.08, 2.76); for mental only, IRR: 2.47 (95% CI 1.68, 3.65); for both, IRR: 4.26 (95% CI 2.91, 6.25). CONCLUSION: Medical and mental health needs appear to contribute equally to increased acute care utilization among those with recent criminal legal involvement. This underscores the need to identify and test interventions which comprehensively address both medical and mental health conditions for individuals returning to the community to improve both health care access and quality.

Association of Patient-Reported Social Needs with Emergency Department Visits and Hospitalizations Among Federally Qualified Health Center Patients.

BACKGROUND: Health care systems are increasingly screening for unmet social needs. The association between patient-reported social needs and health care utilization is not well understood. OBJECTIVE: To investigate the association between patient-reported social needs, measured by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), and inpatient and emergency department (ED) utilization. DESIGN: This cohort study analyzed merged 2017-2019 electronic health record (EHR) data across multiple health systems. PARTICIPANTS: Adult patients from a federally qualified health center (FQHC) in central North Carolina who completed PRAPARE as part of a primary care visit with behavioral health services. MAIN MEASURES: The count of up to 12 unmet social needs, aggregated as 0, 1, 2, or 3 + . Outcomes include the probability of an ED visit and hospitalization 12 months after PRAPARE assessment, modeled by logistic regressions controlling for age, sex, race, ethnicity, comorbidity burden, being uninsured, and prior utilization in the past 12 months. KEY RESULTS: The study population consisted of 1924 adults (38.7% male, 50.1% Black, 36.3% Hispanic, 55.9% unemployed, 68.2% of patients reported 1 + needs). Those with more needs were younger, more likely to be unemployed, and experienced greater comorbidity burden. 35.3% of patients had ED visit(s) and 36.3% had hospitalization(s) 1 year after PRAPARE assessment. In adjusted analysis, having 3 + needs was associated with a percentage point increase in the predicted probability of hospitalization (average marginal effect 0.06, SE 0.03, p < 0.05) compared with having 0 needs. Similarly, having 2 needs (0.07, SE 0.03, p < 0.05) or 3 + needs (0.06, SE 0.03, p < 0.05) was associated with increased probability of ED visits compared to 0 needs. CONCLUSIONS: Patient-reported social needs were common and associated with health care utilization patterns. Future research should identify interventions to address unmet social needs to improve health and avoid potentially preventable escalating medical intervention.

Long-term physical and psychiatric morbidities and mortality of untreated, deferred, and immediately treated epilepsy.

OBJECTIVE: In Australia, 30% of newly diagnosed epilepsy patients were not immediately treated at diagnosis. We explored health outcomes between patients receiving immediate, deferred, or no treatment, and compared them to the general population. METHODS: Adults with newly diagnosed epilepsy in Western Australia between 1999 and 2016 were linked with statewide health care data collections. Health care utilization, comorbidity, and mortality at up to 10 years postdiagnosis were compared between patients receiving immediate, deferred, and no treatment, as well as with age- and sex-matched population controls. RESULTS: Of 603 epilepsy patients (61% male, median age = 40 years) were included, 422 (70%) were treated immediately at diagnosis, 110 (18%) received deferred treatment, and 71 (12%) were untreated at the end of follow-up (median = 6.8 years). Immediately treated patients had a higher 10-year rate of all-cause admissions or emergency department presentations than the untreated (incidence rate ratio [IRR] = 2.0, 95% confidence interval [CI] = 1.4-2.9) and deferred treatment groups (IRR = 1.7, 95% CI = 1.0-2.8). They had similar 10-year risks of mortality and developing new physical and psychiatric comorbidities compared with the deferred and untreated groups. Compared to population controls, epilepsy patients had higher 10-year mortality (hazard ratio = 2.6, 95% CI = 2.1-3.3), hospital admissions (IRR = 2.3, 95% CI = 1.6-3.3), and psychiatric outpatient visits (IRR = 3.2, 95% CI = 1.6-6.3). Patients with epilepsy were also 2.5 (95% CI = 2.1-3.1) and 3.9 (95% CI = 2.6-5.8) times more likely to develop a new physical and psychiatric comorbidity, respectively. SIGNIFICANCE: Newly diagnosed epilepsy patients with deferred or no treatment did not have worse outcomes than those immediately treated. Instead, immediately treated patients had greater health care utilization, likely reflecting more severe underlying epilepsy etiology. Our findings emphasize the importance of individualizing epilepsy treatment and recognition and management of the significant comorbidities, particularly psychiatric, that ensue following a diagnosis of epilepsy.

Characterizing emergency department and inpatient health care utilization after seizure-related hospitalization: A retrospective cohort study.

OBJECTIVE: Seizure care is a significant driver of health care costs in both emergency department (ED) and inpatient settings, but the majority of studies have focused on inpatient admissions as the only metric of health care utilization. This study aims to better characterize ED and inpatient encounters among patients with seizure to inform care and policy. METHODS: Using statewide administrative data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from Florida and New York, we identified patients with a seizure-related index hospitalization between January 1, 2016, and December 31, 2018. Among this cohort, we examined the incidence and characteristics of subsequent acute care visits in the ED and inpatient settings for 365 days after initial hospital discharge. RESULTS: A total of 54 456 patients had an eligible seizure-related hospitalization. Patients were 49% female, predominantly White (64%) and non-Hispanic (84%), and used a public primary payer (68%). There were 36 838 (68%) patients with at least one acute care visit in the year following discharge. Overall, patients had a median of 2 (interquartile [IQR] = 1-5) subsequent acute care visits and the median time to first acute care visit was 53 days (IQR = 15-138). Of the 154 369 subsequent acute care visits, 97 399 (63%) were ED-only visits, 56 970 (37%) were readmissions, and 37 176 (24%) were seizure-related. There were 18 786 patients (35%) with four or more acute care visits over 365 days of follow-up. Patients with four or more visits contributed 84% of acute care visits and 78% of costs after initial hospitalization. SIGNIFICANCE: The majority of patients hospitalized for seizure return to the ED or hospital at least once in the year after discharge. A small portion of patients account for the majority of ED and inpatient visits as well as health care costs associated with this population, identifying a subgroup of patients who may benefit from improved inpatient and outpatient management.

Health care utilization and mortality for people with epilepsy during COVID-19: A population study.

OBJECTIVE: This study was undertaken to characterize changes in health care utilization and mortality for people with epilepsy (PWE) during the COVID-19 pandemic. METHODS: We performed a retrospective study using linked, individual-level, population-scale anonymized health data from the Secure Anonymised Information Linkage databank. We identified PWE living in Wales during the study "pandemic period" (January 1, 2020-June 30, 2021) and during a "prepandemic" period (January 1, 2016-December 31, 2019). We compared prepandemic health care utilization, status epilepticus, and mortality rates with corresponding pandemic rates for PWE and people without epilepsy (PWOE). We performed subgroup analyses on children (<18 years old), older people (>65 years old), those with intellectual disability, and those living in the most deprived areas. We used Poisson models to calculate adjusted rate ratios (RRs). RESULTS: We identified 27 279 PWE who had significantly higher rates of hospital (50.3 visits/1000 patient months), emergency department (55.7), and outpatient attendance (172.4) when compared to PWOE (corresponding figures: 25.7, 25.2, and 87.0) in the prepandemic period. Hospital and epilepsy-related hospital admissions, and emergency department and outpatient attendances all reduced significantly for PWE (and all subgroups) during the pandemic period. RRs [95% confidence intervals (CIs)] for pandemic versus prepandemic periods were .70 [.69-.72], .77 [.73-.81], .78 [.77-.79], and .80 [.79-.81]. The corresponding rates also reduced for PWOE. New epilepsy diagnosis rates decreased during the pandemic compared with the prepandemic period (2.3/100 000/month cf. 3.1/100 000/month, RR = .73, 95% CI = .68-.78). Both all-cause deaths and deaths with epilepsy recorded on the death certificate increased for PWE during the pandemic (RR = 1.07, 95% CI = .997-1.145 and RR = 2.44, 95% CI = 2.12-2.81). When removing COVID deaths, RRs were .88 (95% CI = .81-.95) and 1.29 (95% CI = 1.08-1.53). Status epilepticus rates did not change significantly during the pandemic (RR = .95, 95% CI = .78-1.15). SIGNIFICANCE: All-cause non-COVID deaths did not increase but non-COVID deaths associated with epilepsy did increase for PWE during the COVID-19 pandemic. The longer term effects of the decrease in new epilepsy diagnoses and health care utilization and increase in deaths associated with epilepsy need further research.

Epilepsy and the risk of COVID-19-related hospitalization and death: A population study.

OBJECTIVE: People with epilepsy (PWE) may be at an increased risk of severe COVID-19. It is important to characterize this risk to inform PWE and for future health and care planning. We assessed whether PWE were at higher risk of being hospitalized with, or dying from, COVID-19. METHODS: We performed a retrospective cohort study using linked, population-scale, anonymized electronic health records from the SAIL (Secure Anonymised Information Linkage) databank. This includes hospital admission and demographic data for the complete Welsh population (3.1 million) and primary care records for 86% of the population. We identified 27 279 PWE living in Wales during the study period (March 1, 2020 to June 30, 2021). Controls were identified using exact 5:1 matching (sex, age, and socioeconomic status). We defined COVID-19 deaths as having International Classification of Diseases, 10th Revision (ICD-10) codes for COVID-19 on death certificates or occurring within 28 days of a positive SARS-CoV-2 polymerase chain reaction (PCR) test. COVID-19 hospitalizations were defined as having a COVID-19 ICD-10 code for the reason for admission or occurring within 28 days of a positive SARS-CoV-2 PCR test. We recorded COVID-19 vaccinations and comorbidities known to increase the risk of COVID-19 hospitalization and death. We used Cox proportional hazard models to calculate hazard ratios. RESULTS: There were 158 (.58%) COVID-19 deaths and 933 (3.4%) COVID-19 hospitalizations in PWE, and 370 (.27%) deaths and 1871 (1.4%) hospitalizations in controls. Hazard ratios for COVID-19 death and hospitalization in PWE compared to controls were 2.15 (95% confidence interval [CI] = 1.78-2.59) and 2.15 (95% CI = 1.94-2.37), respectively. Adjusted hazard ratios (adjusted for comorbidities) for death and hospitalization were 1.32 (95% CI = 1.08-1.62) and 1.60 (95% CI = 1.44-1.78). SIGNIFICANCE: PWE are at increased risk of being hospitalized with, and dying from, COVID-19 when compared to age-, sex-, and deprivation-matched controls, even when adjusting for comorbidities. This may have implications for prioritizing future COVID-19 treatments and vaccinations for PWE.

The impact of COVID-19 on psychiatric clinical encounters among low-income racially-diverse children.

BACKGROUND: There is a lack of longitudinal data to examine the impact of COVID-19 on all types of clinical encounters among United States, underrepresented BIPOC (Black, Indigenous, and people of color), children. This study aims to examine the changes in all the outpatient clinical encounters during the pandemic compared to the baseline, with particular attention to psychiatric encounters and diagnoses. METHOD: This study analyzed 3-year (January 2019 to December 2021) longitudinal clinical encounter data from 3,394 children in the Boston Birth Cohort, a US urban, predominantly low-income, Black and Hispanic children. Outcomes of interest were completed outpatient clinical encounters and their modalities (telemedicine vs. in person), including psychiatric care and diagnoses, primary care, emergency department (ED), and developmental and behavioral pediatrics (DBP). RESULTS: The study children's mean (SD) age is 13.9 (4.0) years. Compared to 2019, psychiatric encounters increased by 38% in 2020, most notably for diagnoses of adjustment disorders, depression, and post-traumatic stress disorders (PTSD). In contrast, primary care encounters decreased by 33%, ED encounters decreased by 55%, and DBP care decreased by 16% in 2020. Telemedicine was utilized the most for psychiatric and DBP encounters and the least for primary care encounters in 2020. A remarkable change in 2021 was the return of primary care encounters to the 2019 level, but psychiatric encounters fluctuated with spikes in COVID-19 case numbers. CONCLUSIONS: Among this sample of US BIPOC children, compared to the 2019 baseline, psychiatric encounters increased by 38% during 2020, most notably for the new diagnoses of adjustment disorder, depression, and PTSD. The 2021 data showed a full recovery of primary care encounters to the baseline level but psychiatric encounters remained sensitive to the pandemic spikes. The long-term impact of the pandemic on children's mental health warrants further investigation.

Emergency Department Utilization for Pediatric Gastrostomy Tubes Across the United States.

INTRODUCTION: Emergency Department (ED) visits for gastrostomy tube complications in children represent a substantial health-care burden, and many ED visits are potentially preventable. The number and nature of ED visits to community hospitals for pediatric gastrostomy tube complications is unknown. METHODS: Using the 2019 Nationwide Emergency Department Sample, we performed a retrospective cross-sectional analysis of pediatric patients (<18 y) with a primary diagnosis of gastrostomy tube complication. Our primary outcome was a potentially preventable ED visit, defined as an encounter that did not result in any imaging, procedures, or an inpatient admission. Univariate and multivariable logistic regression analyses were used to determine the associations between patient factors and our primary outcome. RESULTS: We observed 32,036 ED visits at 535 hospitals and 15,165 (47.3%) were potentially preventable. The median (interquartile range) age was 2 (1, 6) years and 17,707 (55%) were male. Compared to White patients, patients with higher odds of potentially preventable visits were Black (adjusted odds ratio (aOR) [95% confidence interval {CI}]: 1.07 [1.05-1.11], P < 0.001) and Hispanic (aOR [95% CI]: 1.05 [1.02-1.08], P = 0.004). Patients with residential zip codes in the first (aOR [95% CI]: 1.08 [1.04, 1.12], P < 0.001), second (aOR [95% CI]: 1.07 [1.03, 1.11], P < 0.001), and third (aOR [95% CI]: 1.09 [1.05, 1.13], P < 0.001) median household income quartiles had higher odds of potentially preventable visits compared to the highest. CONCLUSIONS: In a nationally representative sample of EDs, 47.3% of visits for pediatric gastrostomy tubes were potentially preventable. Efforts to improve outpatient management are warranted to reduce health-care utilization for these patients.

Utility of Postoperative Phone Calls in Reducing Unplanned Health Care Utilization.

INTRODUCTION: Postoperative phone calls ideally proactively identify concerns. This study aimed to determine whether postoperative phone calls after elective outpatient pediatric urology surgery were associated with differences in postoperative healthcare utilization. METHODS: This retrospective cross-sectional study included patients undergoing elective outpatient pediatric urologic surgery in selected months of 2019-2021. Data were abstracted on patient demographics, postoperative call completion, number and timing of parent-initiated calls within 30 d, concerns for parent-initiated calls, and timing and indication for emergency department visits within 30 d. Patients with and without completed postoperative calls were compared. RESULTS: Of 1494 patients, 416 (38.6%) had completed postoperative phone calls; 1078 (61.4%) did not. Calls were more likely to be completed in more disadvantaged areas (Area Deprivation Index deciles 9-10; odds ratio [OR] = 3.87, 95% confidence interval [CI]: 2.70-5.54, P < 0.0001). Overall, the proportions of patients seeking emergency care within 30 d (3.6% versus 4.0%, OR = 0.90, 95% CI: 0.49-1.64, P = 0.73) and with parent-initiated phone calls (31.7% versus 31.3%, OR = 1.02, 95% CI: 0.80-1.20, P = 0.86) were similar in patients with and without postop calls completed. For children in less disadvantaged areas (Area Deprivation Index decile 1-2), the likelihood of a parent-initiated call was higher when postop calls were completed (47.8% versus 33.6%, OR = 1.79, 95% CI: 1.15-2.79, P = 0.01). CONCLUSIONS: Routine postoperative phone calls within 72 h of outpatient pediatric urologic surgery are not associated with decreased overall postoperative health care utilization, and in some cases are associated with an increase in calls to clinic. Defining patient and provider expectations for postoperative contact may make postoperative calls more useful.

Health Care Discrimination and Care Avoidance Due to Patient-Clinician Identity Discordance Among Sexual and Gender Minority Adults.

Sexual and gender minority (SGM) adults experience poor health outcomes, in part due to frequent avoidance of necessary health care. Little is known, however, about factors contributing to patterns of health care utilization in this population. Using national data from the All of Us Research Program, this study evaluated the prevalence of care avoidance due to patient-clinician identity discordance (PCID) and its association with health care discrimination among SGM adults. Sexual minority (20.0% vs 9.4%; adjusted rate ratio [aRR] = 1.58; 95% CI, 1.49-1.67, P <0.001) and gender minority adults (34.4% vs 10.3%; aRR = 2.00; 95% CI, 1.79-2.21, P <0.001) were significantly more likely than their non-SGM counterparts to report care avoidance due to PCID. Exposure to health care discrimination was also more prevalent in this population and was dose-dependently associated with significantly higher rates of PCID-based care avoidance. Study findings highlight the importance of diversifying the health care workforce, expanding SGM-related clinical training, and preventing health care discrimination against SGM patients.

Rural-urban inequalities in health care utilization in Bhutan: a decomposition analysis.

BACKGROUND AND OBJECTIVE: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. METHODS: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca-Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. RESULTS: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural-urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. CONCLUSIONS: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Does supplemental private health insurance impact health care utilization and seeking behavior of residents covered by social health insurance? Evidence from China National Health Services Survey.

BACKGROUND: Supplemental private health insurance (PHI) plays a crucial role in complementing China's social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system. METHODS: Data from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences. RESULTS: Among UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities. CONCLUSION: The findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes.

Potential risk factors for reduced quality of life and increased health care utilization in ARDS survivors: results from the multicenter cohort study DACAPO.

AIM: To analyze the association of individual pre-ICU risk factors (obesity, physical and mental comorbidity, smoking status) on the long-term recovery process in survivors of the acute respiratory distress syndrome (ARDS; outcomes: health related quality of life, health care utilization; measured at 12, 24, and 36 months after ICU discharge). FINDINGS: Results show a possible causal link between pre-ICU risk factors and subsequent recovery of survivors of ARDS, especially with regard to mental health related quality of life. PURPOSE: Identifying relevant pre-existing risk factors, such as mental health problems, will enable the identification of at-risk patients, thus aiding in the improvement of long-term healthcare for survivors of critical illness.

The impact of integrated care on health care utilization and costs in a socially deprived urban area in Germany: A difference-in-differences approach within an event-study framework.

We investigated the impact of an integrated care initiative in a socially deprived urban area in Germany. Using administrative data, we empirically assessed the causal effect of its two sub-interventions, which differed by the extent to which their instruments targeted the supply and demand side of healthcare provision. We addressed confounding using propensity score matching via the Super Learner machine learning algorithm. For our baseline model, we used a two-way fixed-effects difference-in-differences approach to identify causal effects. We then employed difference-in-differences analyses within an event-study framework to explore the heterogeneity of treatment effects over time, allowing us to disentangle the effects of the sub-interventions and improve causal interpretation and generalizability. The initiative led to a significant increase in hospital and emergency admissions and non-hospital outpatient visits, as well as inpatient, non-hospital outpatient, and total costs. Increased utilization may indicate that the intervention improved access to care or identified unmet need.

Pregnant women's satisfaction with the quality of antenatal care and the continued willingness to use health facility care in Lusaka district, Zambia.

BACKGROUND: Antenatal healthcare (ANC) reduces maternal and neonatal deaths in low-middle-income countries. Satisfaction with ANC services and perception of quality of care are critical determinants of service utilization. The study aimed to assess pregnant women's satisfaction with ANC and identify sociodemographic factors associated with satisfaction and their continued willingness to use or recommend the facility to relatives or friends, in Lusaka district, Zambia. METHODS: This was a cross-sectional study involving 499 pregnant women in Lusaka district. A combination of stratified, multistage, and systematic sampling procedures was used in selecting health facilities and pregnant women. This allowed the researcher to assess exposure and status simultaneously among individuals of interest in a population. Structured survey instruments and face-face-interview techniques were used in collecting data among pregnant women who were receiving ANC in selected health facilities. RESULTS: Overall, the proportion of pregnant women who were fully satisfied with ANC was 58.9% (n = 292). Pregnant women's satisfaction score ranged from physical aspects (40.9 - 58.3%), interpersonal aspects (54.3 - 57.9%) to technical aspects of care (46.9 - 58.7%). Husbands' employment status (OR = 0.611, 95%CI = 0.413 - 0.903, p = 0.013), monthly household income level of > 3000 - ≤6000 Kwacha (OR = 0.480, 95%CI = 0.243 - 0.948, p = 0.035 were significantly associated with the interpersonal aspects and the physical aspects of care, respectively. Besides, pregnant women who were in their third trimester (above 33 weeks), significantly predicted satisfaction with the physical environment of antenatal care (OR = 3.932, 95%CI = 1.349 - 11.466, p = 0.012). In terms of the type of health facility, women who utilized ANC from Mtendere (OR = 0.236, 95% CI = 0.093 - 0.595, p = 0.002) and N'gombe (OR = 0.179, 95% CI = 0.064 - 0.504, p = 0.001) clinics were less satisfied with the physical environment of care. Place of residence and educational attainment showed significant association with 'willingness to return'. N'gombe clinic (n = 48, 77.4%) received the lowest consideration for 'future care'. CONCLUSION: Drawing on Donabedian framework on assessing quality of healthcare, we posit that pregnant women's satisfaction with the quality of antenatal care was low due to concerns about the physical environment of health facilities, the interpersonal relationships between providers and pregnant women as well as the technical aspects of care. All these accounted for pregnant women's dissatisfaction with the quality of care, and the indication of unwillingness to return or recommend the health facilities to colleagues. Consistent with Donabedian framework, we suggest that the codes and ethics of healthcare must be upheld. We also call for policy initiatives to reshape the physical condition of ANC clinics and to reinforce healthcare providers' focus on the 'structures' and the 'processes' relevant to care in addition to the 'outcomes'.