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Background: Many cancer survivors experience late effects after cancer. Comorbidity, health literacy, late effects, and help-seeking behavior may affect healthcare use and may differ among socioeconomic groups. We examined healthcare use among cancer survivors, compared with cancer-free individuals, and investigated educational differences in healthcare use among cancer survivors. Methods: A Danish cohort of 127,472 breast, prostate, lung, and colon cancer survivors from the national cancer databases, and 637,258 age- and sex-matched cancer-free individuals was established. Date of entry was 12 months after diagnosis/index date (for cancer-free individuals). Follow-up ended at death, emigration, new primary cancer, December 31st, 2018, or up to 10 years. Information about education and healthcare use, defined as the number of consultations with general practitioner (GP), private practicing specialists (PPS), hospital, and acute healthcare contacts 1–9 years after diagnosis/index date, was extracted from national registers. We used Poisson regression models to compare healthcare use between cancer survivors and cancer-free individuals, and to investigate the association between education and healthcare use among cancer survivors. Results: Cancer survivors had more GP, hospital, and acute healthcare contacts than cancer-free individuals, while the use of PPS were alike. One-to-four-year survivors with short compared to long education had more GP consultations (breast, rate ratios (RR) = 1.28, 95% CI = 1.25–1.30; prostate, RR = 1.14, 95% CI = 1.10–1.18; lung, RR = 1.18, 95% CI = 1.13–1.23; and colon cancer, RR = 1.17, 95% CI = 1.13–1.22) and acute contacts (breast, RR = 1.35, 95% CI = 1.26–1.45; prostate, RR = 1.26, 95% CI = 1.15–1.38; lung, RR = 1.24, 95% CI = 1.16–1.33; and colon cancer, RR = 1.35, 95% CI = 1.14–1.60), even after adjusting for comorbidity. One-to-four-year survivors with short compared to long education had less consultations with PPS, while no as

Background: Many cancer survivors experience late effects after cancer. Comorbidity, health literacy, late effects, and help-seeking behavior may affect healthcare use and may differ among socioeconomic groups. We examined healthcare use among cancer survivors, compared with cancer-free individuals, and investigated educational differences in healthcare use among cancer survivors. Methods: A Danish cohort of 127,472 breast, prostate, lung, and colon cancer survivors from the national cancer databases, and 637,258 age- and sex-matched cancer-free individuals was established. Date of entry was 12 months after diagnosis/index date (for cancer-free individuals). Follow-up ended at death, emigration, new primary cancer, December 31st, 2018, or up to 10 years. Information about education and healthcare use, defined as the number of consultations with general practitioner (GP), private practicing specialists (PPS), hospital, and acute healthcare contacts 1–9 years after diagnosis/index date, was extracted from national registers. We used Poisson regression models to compare healthcare use between cancer survivors and cancer-free individuals, and to investigate the association between education and healthcare use among cancer survivors. Results: Cancer survivors had more GP, hospital, and acute healthcare contacts than cancer-free individuals, while the use of PPS were alike. One-to-four-year survivors with short compared to long education had more GP consultations (breast, rate ratios (RR) = 1.28, 95% CI = 1.25–1.30; prostate, RR = 1.14, 95% CI = 1.10–1.18; lung, RR = 1.18, 95% CI = 1.13–1.23; and colon cancer, RR = 1.17, 95% CI = 1.13–1.22) and acute contacts (breast, RR = 1.35, 95% CI = 1.26–1.45; prostate, RR = 1.26, 95% CI = 1.15–1.38; lung, RR = 1.24, 95% CI = 1.16–1.33; and colon cancer, RR = 1.35, 95% CI = 1.14–1.60), even after adjusting for comorbidity. One-to-four-year survivors with short compared to long education had less consultations with PPS, while no as

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose-response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas. Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and, Zoom Meeting ID: 681 2716 1861, Passcode: 650584

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose-response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas. Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and, Zoom Meeting ID: 681 2716 1861, Passcode: 650584

Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas. Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and, Zoom Meeting ID: 681 2716 1861, Passcode: 650584

Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas. Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and, Zoom Meeting ID: 681 2716 1861, Passcode: 650584

Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas. Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and, Zoom Meeting ID: 681 2716 1861, Passcode: 650584

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania. METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data. RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare. CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania. METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data. RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare. CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania. METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data. RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare. CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

Background: There is little verified information on global healthcare utilization by irregular migrants. Understanding how immigrants use healthcare services based on their needs is crucial to establish effective health policy. We compared healthcare utilization between irregular migrants, documented migrants, and Spanish nationals in a Spanish autonomous community. Methods: This retrospective, observational study included the total adult population of Aragon, Spain: 930,131 Spanish nationals; 123,432 documented migrants; and 17,152 irregular migrants. Healthcare utilization data were compared between irregular migrants, documented migrants and Spanish nationals for the year 2011. Multivariable standard or zero-inflated negative binomial regression models were generated, adjusting for age, sex, length of stay, and morbidity burden. Results: The average annual use of healthcare services was lower for irregular migrants than for documented migrants and Spanish nationals at all levels of care analyzed: primary care (0.5 vs 4 vs 6.7 visits); specialized care (0.2 vs 1.8 vs 2.9 visits); planned hospital admissions (0.3 vs 2 vs 4.23 per 100 individuals), unplanned hospital admissions (0.5 vs 3.5 vs 5.2 per 100 individuals), and emergency room visits (0.4 vs 2.8 vs 2.8 per 10 individuals). The average annual prescription drug expenditure was also lower for irregular migrants (euro9) than for documented migrants (euro77) and Spanish nationals (euro367). These differences were only partially attenuated after adjusting for age, sex, and morbidity burden. Conclusions: Under conditions of equal access, healthcare utilization is much lower among irregular migrants than Spanish nationals (and lower than that of documented migrants), regardless of country of origin or length of stay in Spain.

Rationale: Some reports indicate longitudinal variability in sputum differential cell counts, whereas others describe stability. Highly variable sputum eosinophil percentages are associated with greater lung function loss than persistently elevated eosinophil percentages, but elevated neutrophils are linked to more severe asthma.Objectives: To examine sputum granulocyte stability or variability longitudinally and associations with important clinical characteristics.Methods: The SARP III (Severe Asthma Research Program III) cohort underwent comprehensive phenotype characterization at baseline and annually over 3 years. Adult subjects with acceptable sputum levels were assigned to one of three longitudinal sputum groups: eosinophils predominantly <2%, eosinophils predominantly ≥2%, or highly variable eosinophil percentages (>2 SDs determined from independent, repeated baseline eosinophil percentages). Subjects were similarly assigned to one of three longitudinal neutrophil groups with a 50% cut point.Measurements and Main Results: The group with predominantly <2% sputum eosinophils had the highest lung function (prebronchodilator FEV1% predicted, P < 0.01; FEV1/FVC ratio, P < 0.001) at baseline and throughout 3 years compared with other eosinophil groups. Healthcare use did not differ, although the highly variable eosinophil group reported more asthma exacerbations at Year 3. Longitudinal neutrophil groups showed few differences. However, a combination of predominantly ≥2% eosinophil and ≥50% neutrophil groups resulted in the lowest prebronchodilator FEV1% predicted (P = 0.049) compared with the combination with predominantly <2% eosinophils and<50% neutrophils.Conclusions: Subjects with predominantly ≥2% sputum eosinophils in combination with predominantly ≥50% neutrophils showed greater loss of lung function, whereas those with highly variable sputum eosinophils had greater healthcare use.

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania. METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data. RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare. CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania. METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data. RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare. CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

Objective To examine healthcare utilisation and adherence to colorectal cancer (CRC) follow-up guidelines. Methods A total of 2450 out of 3025 stage I-III CRC survivors diagnosed between 2000 and 2009 completed the Hospital Anxiety and Depression Scale, SF-12, EORTC QLQ-CR38 and Fatigue Assessment Score questionnaires, in December 2010. Multivariable regression analyses were performed to identify predictors for increased follow-up care (>1 visit than recommended by guidelines). Results In the first follow-up year, the average number of cancer-related visits to the general practitioner and medical specialist was 1.7 and 4.2, respectively. More than 80% of the CRC survivors was comfortable with their follow-up schedule, and 49-72% of them received follow-up according to the guidelines. Around 29-47% was followed more than recommended. Simultaneously, around 4-14% of the CRC survivors received less follow-up care than recommended. Survivors of stage III disease treated with chemotherapy received the most follow-up care. In addition, lower socio-economic status stoma and fatigue were associated with increased follow-up care. Conclusion CRC survivors were predominantly followed according to national guidelines. Increased follow-up care is driven by advanced disease stage, chemotherapy, SES, stoma and fatigue. Future studies should investigate how increased follow-up care use can be reduced, while still addressing patients' needs.

OBJECTIVES: Healthcare use in fibromyalgia (FM) is relatively high. Besides disease-related variables, cognitive-behavioural factors have been concurrently associated with healthcare use. It is unknown whether cognitive-behavioural and social factors also predict future healthcare use. The aim of this study was to identify cognitive-behavioural and social factors predicting recurrent secondary healthcare use in FM. METHODS: Using self-reported questionnaires, healthcare use, cognitive-behavioural, social, sociodemographic and disease-related variables including comorbidities were collected in 199 patients with FM, in a prospective longitudinal cohort spanning 18 months. Patients were recruited after receiving their diagnosis and protocolled treatment advice by a rheumatologist. Univariate and multivariate logistic regression models examined whether and which variables were predictors for recurrent secondary healthcare use. Internal validation was performed to correct for over-fit of the final multivariate model. RESULTS: Recurrent secondary healthcare use was lower than initial secondary healthcare use. Univariate analysis showed that having at least one comorbidity, depressive feelings, severe consequences of FM, low personal control and a high severity of fibromyalgia predicted recurrent secondary healthcare use. In the multivariate model, having at least one comorbidity was the only remaining predictor for recurrent secondary healthcare use. CONCLUSIONS: Our results suggest that the existence of comorbidities as communicated by the patient is the strongest warning signal for recurrent secondary healthcare use in FM. There seems no value in using cognitive-behavioural and social factors for early identification of patients with FM at risk for recurrent secondary healthcare use.

Research on child‐related risk factors for filicide is scant. We investigated whether prior healthcare use for injury (including poisoning) influences filicide risk. Victims (0–14 years; n = 71) were identified in a national autopsy database for the years 1994–2012 and compared to matched, general population controls (n = 355). Healthcare use data were retrieved from a national patient registry. Risks were estimated using odds ratios (ORs) and 95% confidence intervals (CIs). For females, prior inpatient care for injury conferred a statistically significant sevenfold risk (OR = 6.67 [95% CI: 1.49–29.79]), and any prior injury‐related healthcare use conferred a statistically significant fourfold risk (OR = 3.57 [95% CI: 1.13–11.25]), of filicide victimization. No statistically significant risks were found for males. Healthcare personnel should be aware that children treated for injuries, especially females, may be at an elevated risk of filicide victimization. Nevertheless, the filicide base rate remains low, and parents may be stigmatized by unfounded alerts; thus, prudent reflection should precede reports to the authorities.

Objectives To develop and validate a tool to predict the risk of an older adult experiencing medication-related harm (MRH) requiring healthcare use following hospital discharge. Design, setting, participants Multicentre, prospective cohort study recruiting older adults (≥65 years) discharged from five UK teaching hospitals between 2013 and 2015. Primary outcome measure Participants were followed up for 8 weeks in the community by senior pharmacists to identify MRH (adverse drug reactions, harm from non-adherence, harm from medication error). Three data sources provided MRH and healthcare use information: Hospital readmissions, primary care use, participant telephone interview. Candidate variables for prognostic modelling were selected using two systematic reviews, the views of patients with MRH and an expert panel of clinicians. Multivariable logistic regression with backward elimination, based on the Akaike Information Criterion, was used to develop the PRIME tool. The tool was internally validated. Results 1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases (â 'possible' and 'aprobable') were excluded, leaving a tool derivation cohort of 818. 119 (15%) participants experienced 'definite' MRH requiring healthcare use and 699 participants did not. Modelling resulted in a prediction tool with eight variables measured at hospital discharge: Age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The tool's discrimination C-statistic was 0.69 (0.66 after validation) and showed good calibration. Decision curve analysis demonstrated the potential value of the tool to guide clinical decision making compared with alternative approaches. Conclusions The PRIME tool could be used to identify older patients at high risk of MRH requiring healthcare use following hospital discharge. Prior to clinical use we recommend the tool's evaluation in other settings., Applied Ergonomics and Design

Objectives To develop and validate a tool to predict the risk of an older adult experiencing medication-related harm (MRH) requiring healthcare use following hospital discharge. Design, setting, participants Multicentre, prospective cohort study recruiting older adults (≥65 years) discharged from five UK teaching hospitals between 2013 and 2015. Primary outcome measure Participants were followed up for 8 weeks in the community by senior pharmacists to identify MRH (adverse drug reactions, harm from non-adherence, harm from medication error). Three data sources provided MRH and healthcare use information: Hospital readmissions, primary care use, participant telephone interview. Candidate variables for prognostic modelling were selected using two systematic reviews, the views of patients with MRH and an expert panel of clinicians. Multivariable logistic regression with backward elimination, based on the Akaike Information Criterion, was used to develop the PRIME tool. The tool was internally validated. Results 1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases (â 'possible' and 'aprobable') were excluded, leaving a tool derivation cohort of 818. 119 (15%) participants experienced 'definite' MRH requiring healthcare use and 699 participants did not. Modelling resulted in a prediction tool with eight variables measured at hospital discharge: Age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The tool's discrimination C-statistic was 0.69 (0.66 after validation) and showed good calibration. Decision curve analysis demonstrated the potential value of the tool to guide clinical decision making compared with alternative approaches. Conclusions The PRIME tool could be used to identify older patients at high risk of MRH requiring healthcare use following hospital discharge. Prior to clinical use we recommend the tool's evaluation in other settings., Applied Ergonomics and Design

The aim of this study was to assess whether negative psychological consequences of conization reported in questionnaire studies translated into increased use of the healthcare services that could relieve such symptoms. This was a population-based register study comparing women undergoing conization with a control group of women with normal cytology results. Data were derived from Danish registers. Using the difference-in-differences method, we measured contacts with general practitioners (GPs), hospitals, psychiatrist/psychologists, and use of anxiolytic and antidepressant prescription drugs over 5 years 'before' and 'after' the conization in the study group, and in comparable periods in the control group. During the 'before' period, women who later had a conization had greater contact with GPs and hospitals, and slightly more contact with psychiatrist/psychologists, than control women. In both groups, healthcare use increased significantly from the 'before' to the 'after' period. For contacts with GPs and hospitals, the increase was significantly larger for the conization group than for the control group, but this could be attributed to the standard postconization follow-up process. In the 'before' period, women who later had a conization used fewer drugs than women of the control-group, but their drug use increased similarly over time. The conization event did not result in an increased use of the healthcare services that could relieve potential negative side effects. However, women who underwent a conization seemed to constitute a select group as they already used GPs and hospitals more frequently, and anxiolytic and antidepressant drugs less frequently, than other women in the years 'before' the conization event.

The aim of this study was to assess whether negative psychological consequences of conization reported in questionnaire studies translated into increased use of the healthcare services that could relieve such symptoms. This was a population-based register study comparing women undergoing conization with a control group of women with normal cytology results. Data were derived from Danish registers. Using the difference-in-differences method, we measured contacts with general practitioners (GPs), hospitals, psychiatrist/psychologists, and use of anxiolytic and antidepressant prescription drugs over 5 years 'before' and 'after' the conization in the study group, and in comparable periods in the control group. During the 'before' period, women who later had a conization had greater contact with GPs and hospitals, and slightly more contact with psychiatrist/psychologists, than control women. In both groups, healthcare use increased significantly from the 'before' to the 'after' period. For contacts with GPs and hospitals, the increase was significantly larger for the conization group than for the control group, but this could be attributed to the standard postconization follow-up process. In the 'before' period, women who later had a conization used fewer drugs than women of the control-group, but their drug use increased similarly over time. The conization event did not result in an increased use of the healthcare services that could relieve potential negative side effects. However, women who underwent a conization seemed to constitute a select group as they already used GPs and hospitals more frequently, and anxiolytic and antidepressant drugs less frequently, than other women in the years 'before' the conization event.

Background: Adverse childhood experiences (ACEs) include child maltreatment and household dysfunction experiences. ACEs are risk factors for poor health outcomes. Inflammatory bowel disease (IBD) is a chronic inflammatory condition that also is associated with adverse health outcomes. We hypothesized that persons diagnosed with IBD and exposed to an ACE would exhibit greater healthcare use than persons with IBD never exposed to an ACE. Research Objectives: The objectives were to estimate the prevalence of ACEs in individuals diagnosed with IBD, test the association between the number and type of ACEs and healthcare use, and test the association between perceived level of trauma from ACEs and healthcare use. Methods: The cohort included 345 participants from the population-based Manitoba IBD Cohort Study. Self-reports of ACEs were linked to provincial administrative health data. IBD and non-IBD-related healthcare use measures included general and specialist physician visits, hospitalizations, length of hospital stay, and prescription drug use. Mean annual estimates of healthcare use measures were produced for the 60-month period following ACE report. Generalized linear models (GLMs) were used to test the association between healthcare use and ACEs. All models were adjusted for confounding covariates of demographics, IBD disease characteristics, behavioral risk factors, comorbid conditions, and perceived psychological stress. Results: The prevalence of at least one ACE in the study cohort was 74.2%. Mean annual estimates for non-IBD-related GP visits were significantly increased for cohort members exposed to physical and sexual abuse relative to those not exposed. The GLMs revealed significant decreases in IBD-related healthcare use for cohort members exposed to an upheaval between parents and who report high perceived trauma from ACEs. Conclusions: The estimated prevalence of at least one self-reported ACE in persons with diagnosed IBD was higher than estimates from

Background: Adverse childhood experiences (ACEs) include child maltreatment and household dysfunction experiences. ACEs are risk factors for poor health outcomes. Inflammatory bowel disease (IBD) is a chronic inflammatory condition that also is associated with adverse health outcomes. We hypothesized that persons diagnosed with IBD and exposed to an ACE would exhibit greater healthcare use than persons with IBD never exposed to an ACE. Research Objectives: The objectives were to estimate the prevalence of ACEs in individuals diagnosed with IBD, test the association between the number and type of ACEs and healthcare use, and test the association between perceived level of trauma from ACEs and healthcare use. Methods: The cohort included 345 participants from the population-based Manitoba IBD Cohort Study. Self-reports of ACEs were linked to provincial administrative health data. IBD and non-IBD-related healthcare use measures included general and specialist physician visits, hospitalizations, length of hospital stay, and prescription drug use. Mean annual estimates of healthcare use measures were produced for the 60-month period following ACE report. Generalized linear models (GLMs) were used to test the association between healthcare use and ACEs. All models were adjusted for confounding covariates of demographics, IBD disease characteristics, behavioral risk factors, comorbid conditions, and perceived psychological stress. Results: The prevalence of at least one ACE in the study cohort was 74.2%. Mean annual estimates for non-IBD-related GP visits were significantly increased for cohort members exposed to physical and sexual abuse relative to those not exposed. The GLMs revealed significant decreases in IBD-related healthcare use for cohort members exposed to an upheaval between parents and who report high perceived trauma from ACEs. Conclusions: The estimated prevalence of at least one self-reported ACE in persons with diagnosed IBD was higher than estimates from

Background: Adverse childhood experiences (ACEs) include child maltreatment and household dysfunction experiences. ACEs are risk factors for poor health outcomes. Inflammatory bowel disease (IBD) is a chronic inflammatory condition that also is associated with adverse health outcomes. We hypothesized that persons diagnosed with IBD and exposed to an ACE would exhibit greater healthcare use than persons with IBD never exposed to an ACE. Research Objectives: The objectives were to estimate the prevalence of ACEs in individuals diagnosed with IBD, test the association between the number and type of ACEs and healthcare use, and test the association between perceived level of trauma from ACEs and healthcare use. Methods: The cohort included 345 participants from the population-based Manitoba IBD Cohort Study. Self-reports of ACEs were linked to provincial administrative health data. IBD and non-IBD-related healthcare use measures included general and specialist physician visits, hospitalizations, length of hospital stay, and prescription drug use. Mean annual estimates of healthcare use measures were produced for the 60-month period following ACE report. Generalized linear models (GLMs) were used to test the association between healthcare use and ACEs. All models were adjusted for confounding covariates of demographics, IBD disease characteristics, behavioral risk factors, comorbid conditions, and perceived psychological stress. Results: The prevalence of at least one ACE in the study cohort was 74.2%. Mean annual estimates for non-IBD-related GP visits were significantly increased for cohort members exposed to physical and sexual abuse relative to those not exposed. The GLMs revealed significant decreases in IBD-related healthcare use for cohort members exposed to an upheaval between parents and who report high perceived trauma from ACEs. Conclusions: The estimated prevalence of at least one self-reported ACE in persons with diagnosed IBD was higher than estimates from

Background: Adverse childhood experiences (ACEs) include child maltreatment and household dysfunction experiences. ACEs are risk factors for poor health outcomes. Inflammatory bowel disease (IBD) is a chronic inflammatory condition that also is associated with adverse health outcomes. We hypothesized that persons diagnosed with IBD and exposed to an ACE would exhibit greater healthcare use than persons with IBD never exposed to an ACE. Research Objectives: The objectives were to estimate the prevalence of ACEs in individuals diagnosed with IBD, test the association between the number and type of ACEs and healthcare use, and test the association between perceived level of trauma from ACEs and healthcare use. Methods: The cohort included 345 participants from the population-based Manitoba IBD Cohort Study. Self-reports of ACEs were linked to provincial administrative health data. IBD and non-IBD-related healthcare use measures included general and specialist physician visits, hospitalizations, length of hospital stay, and prescription drug use. Mean annual estimates of healthcare use measures were produced for the 60-month period following ACE report. Generalized linear models (GLMs) were used to test the association between healthcare use and ACEs. All models were adjusted for confounding covariates of demographics, IBD disease characteristics, behavioral risk factors, comorbid conditions, and perceived psychological stress. Results: The prevalence of at least one ACE in the study cohort was 74.2%. Mean annual estimates for non-IBD-related GP visits were significantly increased for cohort members exposed to physical and sexual abuse relative to those not exposed. The GLMs revealed significant decreases in IBD-related healthcare use for cohort members exposed to an upheaval between parents and who report high perceived trauma from ACEs. Conclusions: The estimated prevalence of at least one self-reported ACE in persons with diagnosed IBD was higher than estimates from

Background - Malnutrition is common in patients with chronic obstructive pulmonary disease (COPD). This study aimed to explore its association with all-cause mortality, emergency hospitalisation and subsequently healthcare costs. Methods - A prospective cohort observational pilot study was carried out in outpatients with COPD that attended routine respiratory clinics at a large tertiary Australian hospital during 2011. Electronic hospital records and hospital coding was used to determine nutritional status and whether a patient was coded as nourished or malnourished and information on healthcare use and 1-year mortality was recorded. Results - Eight hundred and thirty four patients with COPD attended clinics during 2011, of those 286 went on to be hospitalised during the 12 month follow-up period. Malnourished patients had a significantly higher 1-year mortality (27.7% vs. 12.1%; p = 0.001) and were hospitalised more frequently (1.11 SD 1.24 vs. 1.51 SD 1.43; p = 0.051). Only malnutrition (OR 0.36 95% CI 0.14–0.91; p = 0.032) and emergency hospitalisation rate (OR 1.58 95% CI 1.2–2.1; p = 0.001) were independently associated with 1-year mortality. Length of hospital stay was almost twice the duration in those coded for malnutrition (11.57 SD 10.93 days vs. 6.67 SD 10.2 days; p = 0.003) and at almost double the cost (AUD $23,652 SD $26,472 vs. $12,362 SD $21,865; p = 0.002) than those who were well-nourished. Conclusion - Malnutrition is an independent predictor of 1-year mortality and healthcare use in patients with COPD. Malnourished patients with COPD present both an economic and operational burden.

Purpose – The objective of this study was to examine any unanticipated effects of an educational intervention among newly arrived adult immigrants attending a language school in Denmark. Methodology – A qualitative case study was conducted including interviews with nine informants, observations of two complete intervention courses and an analysis of the official intervention documents. Findings – This case study exemplifies how the basic normative assumptions behind an immigrant-oriented intervention and the intrinsic power relations therein may be challenged and negotiated by the participants. In particular, the assumed (power) relations inherent in immigrant-oriented educational health interventions, in which immigrants are in a novice position, are challenged, as the immigrants are experienced adults (and parents) in regard to healthcare. The paper proposes that such unexpected conditions for the implementation—different from the assumed conditions—not only challenge the implementation of the intervention but also potentially produce unanticipated yet valuable effects. Research implications – Newly arrived immigrants represent a hugely diverse and heterogeneous group of people with differing values and belief systems regarding health and healthcare. A more detailed study is necessary to fully understand their health seeking behaviours in the Danish context. Originality/value – Offering newly arrived immigrants a course on health and the healthcare system as part of the mandatory language courses is a new and underexplored means of providing and improving newly arrived immigrants knowledge and use of the Danish healthcare system.

The purpose of the study was to develop, from the perspective of the user, a better understanding of the factors that influence use of healthcare services by homeless veterans in the U.S. The study employed the Grounded Theory (GT) methodology and was guided by Critical Social Theory (CST) and Symbolic Interactionism (SI) as the philosophical underpinnings. There is a scant but growing number of studies on the social experience of homeless veterans in accessing care at the Department of Veteran Affairs (VA). Understanding these issues is important because of the myriad health, psychiatric, and substance abuse problems they encounter. As many VA programs have implemented programs for homeless veterans, an investigation of the current social experience is imperative for homeless veterans. CST, or critical theory, was useful in understanding the sociopolitical and historical contexts of health and healthcare and important in understanding the power relations between the U.S. government and the homeless veterans within the healthcare setting. This approach enabled the development of knowledge from the subjective perspective. CST was useful in exploring injustices related to homeless veterans’ access to VA healthcare because this approach exposes the hidden relations of domination and powers inherent in society’s fundamental structures and ideologies. SI provided a tool to understand the social interaction of veterans acquiring healthcare. Eighteen homeless veterans were recruited and interviewed at one homeless shelter and two transitional housing programs in the Skid Row area of Los Angeles and the Westside. The qualitative methodology of GT was employed to understand the perspective of the participant or agent, which is in line with the emancipatory aims of CST. The GT developed from these data led to the focus of the theory, which is on the tensions involved in push and pull forces and the outcomes that arise as a result. Hence the theory has two major concepts: Push

The purpose of the study was to develop, from the perspective of the user, a better understanding of the factors that influence use of healthcare services by homeless veterans in the U.S. The study employed the Grounded Theory (GT) methodology and was guided by Critical Social Theory (CST) and Symbolic Interactionism (SI) as the philosophical underpinnings. There is a scant but growing number of studies on the social experience of homeless veterans in accessing care at the Department of Veteran Affairs (VA). Understanding these issues is important because of the myriad health, psychiatric, and substance abuse problems they encounter. As many VA programs have implemented programs for homeless veterans, an investigation of the current social experience is imperative for homeless veterans. CST, or critical theory, was useful in understanding the sociopolitical and historical contexts of health and healthcare and important in understanding the power relations between the U.S. government and the homeless veterans within the healthcare setting. This approach enabled the development of knowledge from the subjective perspective. CST was useful in exploring injustices related to homeless veterans’ access to VA healthcare because this approach exposes the hidden relations of domination and powers inherent in society’s fundamental structures and ideologies. SI provided a tool to understand the social interaction of veterans acquiring healthcare. Eighteen homeless veterans were recruited and interviewed at one homeless shelter and two transitional housing programs in the Skid Row area of Los Angeles and the Westside. The qualitative methodology of GT was employed to understand the perspective of the participant or agent, which is in line with the emancipatory aims of CST. The GT developed from these data led to the focus of the theory, which is on the tensions involved in push and pull forces and the outcomes that arise as a result. Hence the theory has two major concepts: Push

The primary goal of the present study was to examine patterns of health care use in a sample of young adults entering the U.S. Navy and to examine changes in patterns of use over time following entry into the Military Health System (MHS). Analysis of covariance was used to compare health care use at baseline and across time as a function of sex, race/ethnicity, and socioeconomic status, while controlling for differences in physical health status. Few systematic differences in reported use were noted with respect to socioeconomic status or race/ethnicity. Entrance into the MHS was marked by greater use of preventive care than used while still a civilian during the year before entering military service. Women consistently used more health care than did men, and women's use increased more over time. However, this disproportionate increase was largely driven by pregnancy during military service. Whereas both men and women reported significant increases in outpatient visits over time, only pregnant service women reported a significant increase over time in hospitalizations (and a marginally significant increase in emergency department visits). Patterns of increased use among female service members parallel those of their civilian peers. In contrast, unlike their civilian counterparts, male service members demonstrated increased use of preventive care but no increase in use of emergency department care over time. These results suggest that individuals with access to universal health care are likely to increase their overall use of services. However, these effects were quite small in absolute terms, and they were strongest for preventive care rather than more intensive and expensive kinds of services., Published in the International Journal of Health Planning and Management v29 pe186-e204, 2014.

Variations in the rate of use of health care services (a.k.a. medical practice variations) have been described in the literature for over eighty years. The literature suggests three general sources of variation: patients, physicians, and environment. The relative influence of these sources and the specific mechanisms that produce observed variations are not well understood. This thesis presents four studies that identify and examine methodological issues that preclude our ability to understand the variation phenomenon. It is commonly believed that the physician is in part responsible for observed variation in health care services use. However, determining the influence of the physician in this regard is problematic, as it is difficult to isolate the effect of the physician from that of the patient and environment (including available resources). The first study presented in this thesis suggests there is meaningful variation in treatment recommendations between physicians working in a common environment, even after controlling for important patient clinical characteristics. Next, I present an experiment that suggests that factors related to the patient’s unique social context might influence how the physician intends to manage a patient’s care. As variations studies do not measure or adjust for social context, this might indicate an important methodological limitation of those studies if indeed context is an important (and justifiable) determinant of what care the patient will receive. Not all variation is necessarily bad. The third study I present explores how previous researchers discriminate between warranted and unwarranted variation. This study indicates that few researchers explicitly do so, and that a clear, consistent, and functional definition of unwarranted variation is lacking – a feature that potentially limits the interpretation of study results. The final study argues that traditional methods for examining regional variations are inadeq, Doctor of Philosophy (PhD)

For healthcare agencies and other professionals to most efficiently provide aid following large scale community tragedies, agencies and professionals must understand the determinants that lead individuals to require and seek various forms of help. This study examined Andersen's Behavioral Model of Healthcare Use and its utility in predicting service use in a population of students at Virginia Tech following the shootings on April 16, 2007. Data were gathered from surveys given to students at Virginia Tech three months following the shootings and at a one year follow-up. Logistic regression was used to determine variables that predicted service use. Female gender, prior exposure to traumatic events, higher pre-event functioning, higher social support, higher levels of posttraumatic stress and higher psychological distress were found to be predictive of higher probability of service use. Exploratory hypotheses related to the prediction of outcomes as well as service use as a mediator between predictors and outcomes were also examined. Implications for the use of Andersen's model in predicting service use and equitable and efficient distribution of services are discussed.

Background: Falls are a common mechanism of injury in the older population, putting an increasing demand on scarce healthcare resources. The objective of this study was to determine healthcare costs due to falls in the older population. Methods: An incidence-based cost model was used to estimate the annual healthcare costs and costs per case spent on fall-related injuries in patients ≥65 years, The Netherlands (2007-2009). Costs were subdivided by age, gender, nature of injury, and type of resource use. Results: In the period 2007-2009, each year 3% of all persons aged ≥65 years visited the Emergency Department due to a fall incident. Related medical costs were estimated at €675.4 million annually. Fractures led to 80% (€540 million) of the fall-related healthcare costs. The mean costs per fall were €9370, and were higher for women (€9990) than men (€7510) and increased with age (from €3900 at ages 65-69 years to €14,600 at ages ≥85 year). Persons ≥80 years accounted for 47% of all fall-related Emergency Department visits, and 66% of total costs. The costs of long-term care at home and in nursing homes showed the largest age-related increases and accounted together for 54% of the fall-related costs in older people. Discussion: Fall-related injuries are leading to a high healthcare consumption and related healthcare costs, which increases with age. Programmes to prevent falls and fractures should be further implemented in order to reduce costs due to falls in the older population and to avoid that healthcare systems become overburdened.

The effects of supplemental health insurance on health-care consumption crucially depend on specific institutional features of the health-care system. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. Within this institutional background, we find only weak evidence of adverse selection in the coverage of supplemental health insurance. We find much stronger effects of socio-economic background. We estimate a bivariate probit model and cannot reject the assumption of exogeneity of insurance availability for the explanation of health-care use. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights per spell. We comment on the implications of our findings for equality of access to health care in Belgium. Copyright

Deprivation assessed using the index of multiple deprivation (IMD) has been shown to be an independent risk factor for 1-year mortality in outpatients with chronic obstructive pulmonary disease; COPD (Collins et al, 2010). IMD combines a number of economic and social issues (eg, health, education, employment) into one overall deprivation score, the higher the score the higher an individual's deprivation. Whilst malnutrition in COPD has been linked to increased healthcare use it is not clear if deprivation is also independently associated. This study aimed to investigate the influence of deprivation on 1-year healthcare utilisation in outpatients with COPD. IMD was established in 424 outpatients with COPD according to the geographical location for each patient's address (postcode) and related to their healthcare use in the year post-date screened (Nobel et al, 2008). Patients were routinely screened in outpatient clinics for malnutrition using the ‘Malnutrition Universal Screening Tool’, ‘MUST’ (Elia 2003); mean age 73 (SD 9.9) years; body mass index 25.8 (SD 6.3) kg/m2 with healthcare use collected 1 year from screening (Abstract P147 Table 1). Deprivation assessed using IMD (mean 15.9; SD 11.1) was found to be a significant predictor for the frequency and duration of emergency hospital admissions as well as the duration of elective hospital admission. Deprivation was also linked to reduced secondary care outpatient appointment attendance but not an increase in failure to attend and deprivation was not associated with increased disease severity, as classified by the GOLD criteria (p=0.580). COPD outpatients residing in more deprived areas experience increased hospitalisation rates but decreased outpatient appointment attendance. The underlying reason behind this disparity in healthcare use requires further investigation.