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Objective To examine the associations between post-traumatic stress of parents of infants with complex congenital heart defects and their healthcare use for their infants during the early months of life. Study design The current study is a secondary data analysis from a randomized controlled trial in which 216 parent–infant dyads were recruited from 3 cardiac intensive care units of large pediatric centers in Northeastern America. The current sample included 153 dyads with post-traumatic stress data at hospital discharge and at 4-months’ follow-up. Poisson regressions were used to estimate the effect of post-traumatic stress change scores on number of emergency department (ED) visits, unscheduled cardiologist visits, and unscheduled pediatrician visits outcomes. Results Infants whose parents gained post-traumatic stress disorder over the study period were at increased risk for ED visits and unscheduled cardiologist visits. Increased symptom severity predicted more unscheduled cardiologist visits and more unscheduled pediatrician visits. Increased symptom clusters (avoidance, arousal, re-experiencing) predicted more ED visits, more unscheduled cardiologist visits, and more unscheduled pediatrician visits. Conclusions Parents of infants with cardiac conditions may experience post-traumatic stress following cardiac surgery, which can be linked to greater healthcare use. Findings highlight the importance of screening and treating post-traumatic stress to preserve parental mental health and prevent adverse outcomes.

Question Does feeling reassured after a consultation reduce future disability or healthcare use in people with acute low back pain (LBP)? Design Mediation analysis of a randomised, sham-controlled trial. Participants Two hundred and two people with acute LBP at above average risk (high risk) of developing chronic LBP. Intervention All participants received guideline-based care from their usual clinician. Participants received two additional 1-hour sessions of patient education focused on emphasising the benign nature of LBP or sham patient education that included active listening only. Outcome measures The two primary outcomes for this study were self-reported disability and healthcare use. The mediator was feeling reassured that LBP was not caused by serious illness. Results Data from 194 (96%) participants and 178 (88%) participants were included in the analysis for disability and healthcare use outcome models, respectively. Feeling reassured did not mediate the effect of the intervention on disability (indirect effect −0.23, 95% CI −0.71 to 0.18) or healthcare use (indirect effect 0.00, 95% CI −0.04 to 0.04). Patient education intervention increased feeling reassured (1.14 points, 95% CI 0.43 to 1.85) compared with sham patient education. However, the mediator (ie, feeling reassured) did not reduce disability (−0.20 points, 95% CI −0.58 to 0.19) or healthcare use (OR 1.09, 95% CI 0.98 to 1.21). Conclusion Feeling reassured after a consultation did not lead to improvements in disability and healthcare use for people with acute LBP. Clinicians should reflect on the time that they allocate to reassuring their patients and consider reallocating time to other aspects of the consultation that could reduce disability and future healthcare use. Trial registration ACTRN12612001180808, study protocol https://osf.io/4tfaz/ .

Frailty and multimorbidity are interrelated complex syndromes. Individuals living with frailty are likely to be multimorbid, but not all multimorbid individuals are frail. Frailty and multimorbidity are principal causes of polypharmacy. In combination, they are associated with significant healthcare use, unscheduled hospital admissions and mortality. However, multiple medication use is not always inappropriate. Early detection of frailty, patient-centred decision-making and review of multimorbid conditions underpinned by principles of comprehensive geriatric assessment are the cornerstones of patient management.

Objective: To determine the government and out‐of‐pocket community costs (out‐of‐hospital medical services and prescription medicines) associated with screen‐detected and community‐detected cancers (i.e. cancers detected outside of Australia's organised screening program [BreastScreen]). Methods: We analyse administrative data on government‐subsidised medical services and prescription medicines for 568 Victorian women diagnosed with breast cancer or ductal carcinoma in situ (DCIS). Using multivariable regression analysis, we estimate the government and out‐of‐pocket community costs incurred in the three years after diagnosis for screen‐detected cancers and community‐detected cancers. Additionally, we estimate the government costs associated with diagnosis within and outside of BreastScreen. Results: Average government costs for breast cancer diagnosis were similar within and outside of BreastScreen [$808 (lower limit 676; upper limit 940) vs $837 (95%CI 671; 1,003) respectively]; however, women with community‐detected cancers incurred an additional $254 (95%CI 175; 332) out‐of‐pocket. Controlling for differences in known cancer characteristics, compared to screen‐detected cancers, community‐detected breast cancers were associated with an additional $2,622 (95%CI 644; 4,776) in government expenditure in the three years following diagnosis. Adverse cancer characteristics that were more prevalent in community‐detected cancers (high grade, lymph node involvement, HER2 positive receptor status) were associated with increased government and out‐of‐pocket costs. Conclusions: Community‐detected breast cancers were associated with increased government and out‐of‐pocket costs. Implications for public health: These costs should be considered when evaluating current and alternative breast cancer screening strategies.

In this paper we analyze the importance of individuals' locus of control for their health and healthcare use. We estimate the direct effects of locus of control. We also examine whether the effects of locus of control on health and healthcare use are explained by lifestyle choices and social capital. Our analysis reveals that individuals with an internal locus of control have better self-assessed health as well as physical and mental health. They rely less on medical care, both preventive and curative. Locus of control predicts health through different pathways, including social capital and health behaviors related to smoking, drinking and physical activity. Similar pathways can explain the link between locus of control and curative care but not necessarily preventive care. Interventions considering not only the direct but also the indirect effects of locus of control are promising avenues for promoting better health.

Background Studies on healthcare service use among persons with visual impairments in countries with different healthcare systems are needed for drawing global inferences. Objective The goal was to assess the impact of visual impairment on healthcare service use. Methods A retrospective cohort study on health insurance claims data from the National Health Insurance System (NHIS) was conducted. All data from 2002 to 2013 for 2206 and 8824 persons with and without visual impairments, respectively, were extracted and aggregated monthly, generating a total of 162,876 and 568,459 person-month observations, respectively. The dependent variable was total expenditures. Difference-in-difference estimations based on a multivariate log-normal random-effect regression were employed. Results Persons with visual impairments spent 5.7% and 6.8% more on total healthcare expenditures per month and outpatient healthcare expenditures, respectively, than those without visual impairments, after adjusting for pre-impairment differences. Further results revealed an upward trend in expenditures, particularly among those with visual impairments; this increase was the highest during the year prior impairment (approximately 32% and 21% more for total and outpatient services, respectively, compared with baseline). Inpatient healthcare expenditures showed a similar increase (by approximately 26%) during the year prior impairment compared with baseline; however, the magnitude dropped to approximately 14% and 6% during the 1st and 2nd years of impairment, respectively. Conversely, the annual pattern of expenditure increase was parallel over time for persons without visual impairments, regardless of service. Conclusion Our findings suggest a need for health management and effective care use, particularly the year prior to visual impairment onset.

© 2018 The Royal Society for Public Health Objectives: Relationships between the health insurance status and healthcare use among justice-involved youths transitioning into adulthood is an underexplored topic, even if transition to adulthood is a crucial time period for healthcare outcomes. To fill in these knowledge gaps, this study had two aims: (1) to examine trajectories of health insurance coverage and healthcare use among serious juvenile offenders transitioning into adulthood; and (2) to explore associations between the lack of health insurance, healthcare use and reincarceration. Study design: We conducted a secondary analysis on the data of the US longitudinal Pathways to Desistance study between ages 20 and 23 years (2000–2010). Methods: Participant data on health insurance coverage, healthcare use, reincarceration and sociodemographic variables (n = 1215) were extracted and analysed using descriptive statistics, generalized linear regressions and cross-lagged panel models. Results: About half of the young offenders had no health insurance coverage or intermittent coverage between the age of 20 and 23 years. Emergency services were used (≥17.4%), notably more by insured participants and were increasingly used over time. Being uninsured at the age of 20 years was associated with reincarceration at the age of 23 years (b = −0.052, p = 0.014, odd-ratio = 0.95), but incarceration at the age of 20 years did not predict the insurance status at the age of 23 years (b = 0.009, p = 0.792). Conclusions: Serious juvenile offenders, especially if uninsured, faced major barriers to accessing health care and often reported an inappropriate healthcare use. This likely led to reincarceration. The lack of continuity of care and of access to health care may, therefore, increase health disparities, and efforts are needed to mitigate detrimental outcomes, by effective in and out of detention coordination of health insurance coverage and among health services.

Veterans Health Administration (VHA) has implemented screening for past-year intimate partner violence (IPV) in some healthcare facilities along with secondary screening of risk for severe violence among those screening positive in order to facilitate follow-up care for high-risk patients. We evaluated the adoption, penetration, and effectiveness of secondary screening as a tool to facilitate timely follow-up services.Retrospective review of medical records (screening and healthcare use) of 774 women screening positive for past-year IPV (IPV+) at 11 facilities nationwide from April 2014-April 2016. Chi-square and t-tests examined factors related to secondary screening.Three of eleven (27.3%) facilities that implemented primary IPV screening adopted secondary screening. At adopting sites, 56.4% eligible (i.e., IPV+) women received secondary screening. Among 185 IPV+ women who completed secondary screening, 33.0% screened positive for severe IPV. Screening positive during secondary screening was associated with higher rate of psychosocial care within 60 days (73.8% vs. 54.0% of IPV+ patients screening negative; p .05), posttraumatic stress disorder diagnosis (31.1% vs. 15.3%; p .05), and being physically threatened or harmed (50% vs.15%; p .001).Secondary risk assessment following IPV screening may expedite access to psychosocial follow-up care in integrated healthcare settings. However, program uptake needs to be enhanced.

Smartphones have become an integral part in life of users, mainly because over the course of recent years, they have become extremely mainstream, cheap, flexible, and they pack high-end hardware that offers high computational capabilities. Many, if not all of today’s smartphones are equipped with sophisticated sensors which enable smart mobile sensing. The programmable nature of these sensors in the smartphones enable a wide array of possibilities to achieve user-centric or environmental sensing. Even though there have been different approaches proposed to develop a smartphone app, platform, design frameworks, APIs, and even application-specific architectures, there is a lack of generalised referenceable architecture in the literature. In this paper, we propose a generic reference architecture, which can be derived to create more concrete mobile sensing or mobile app architectures. Furthermore, we realise the proposed reference architecture in a healthcare use case, specifically in the context of applying smart mobile sensing to support tinnitus research.

Background Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system. Prodromal symptoms and higher healthcare use have been suggested in patients who later develop MS. Objectives Assess the healthcare utilization pattern of relapsing-remitting MS (RRMS) patients in the five years prior to MS diagnosis. Methods Retrospective, multicentric study. Demographic and clinical data, drug prescriptions and diagnostic tests were collected from electronic health records five-years previous to MS diagnosis and compared with national data. Results Included 168 patients, 112 (66.7%) female, median age 34±11 years. The mean number of healthcare use per patient per year was 3.14±2,69, most of them in primary healthcare (47%). Most frequent symptoms were musculoskeletal (22%), gastrointestinal (17%), sensitive (14%) and sensory organs (14%). Median number of diagnostic tests per patient was 6 (IQR 7), and drug prescriptions per patient was 6 (IQR 9). Most frequently prescribed drugs were analgesic/anti-inflammatories, antibiotics and anxiolytics and there was a high request rate of MRIs. Conclusion RRMS patients had a high frequency of healthcare utilization when compared to national data. This supports the current evidence showing a prodromal phase in MS.

Objective To compare healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings. Study design This was a prospective, single-center cohort of infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on predetermined criteria. Actual discharge feeding decisions were at clinical discretion. At 3 months’ postdischarge, we compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. We calculated NICU days saved by home NG discharges. Results Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastrointestinal or tube-related readmissions and emergency encounters (unadjusted OR 3.97, 95% CI 1.3-12.7, P = .02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95% CI 0.1-1.7, P = .225). Multivariable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1574 NICU days. Conclusions NICU discharge with NG feeds is associated with reduced NICU stay without increased postdischarge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased postdischarge healthcare use.

This paper uses a difference-in-difference framework to estimate the effects of mobile money transfer technology (MMT) on healthcare use in the face of negative health shocks. We use survey data from 2013 to 16 with quarterly observations on about 1800 households of 10 villages in the Kisumu region of Western Kenya. We find evidence that MMT, likely through greater ease of informal borrowing, helps households increase utilization of formal healthcare services in terms of visits to a clinic, consultation and medication expenditures in comparison with non-users of this technology. MMT appears to be complementary with other risk-sharing mechanisms such as farm sales and in-kind transfers.

Diabetes mellitus (DM) and major depressive disorder (MDD) are diseases that are expanding globally. Separately, each presents with several comorbidities for patients. When the two diseases present simultaneously in the same subject, there is a drastic worsening in the quality of life of the patient. This study reviewed the literature relating to the relationship between MDD and DM, bringing forward studies showing that DM develops due to MDD, and others that report the opposite. According to the studies reviewed, DM and MDD are both debilitating conditions that are associated with significant morbidity, mortality, and healthcare costs. When these two diseases coexist, the association results in a decreased adherence to treatment, poor metabolic control, higher rates of complications, a decrease in the quality of life for the patient, increased healthcare use and cost, increased disability and lost productivity, and an increased risk of death. Therefore, it becomes essential that there are larger studies targeting the association of these two diseases, as for the patient, preventing even one of them will ensure improvements in their quality of life.

Background To describe the state of health, through healthcare consumption and mortality, of people admitted to nursing homes (Ehpad) in France. Methods People over the age of 65 years admitted to an Ehpad institution during the first quarter of 2013, beneficiaries of the national health insurance general scheme (69% of the population of this age), were identified from the Resid-Ehpad database and their reimbursed health care was extracted from the SNIIRAM database, identifying 56 disease groups by means of algorithms (long-term disease diagnoses and hospitalisations, medicinal products, specific procedures). Disease prevalences were compared to those of other beneficiaries by age- and sex-standardized morbidity/mortality ratios (SMR). Results A total of 25,534 people were admitted (mean age: 86 years, 71% women). Before admission, these people presented a marker for cardiovascular or neurovascular disease (48% of cases), dementia (34%), cancer (18%), and psychiatric disorders (14%). Compared to non-residents, new residents more frequently presented dementia (SMR = 3–40 according to age and sex), psychiatric disorders (SMR = 2.5–12, including psychotic disorders SMR = 18–21 in the 65–74 year age-group), neurological disorders (SMR = 2–12, including epilepsy SMR = 14 in the 65–74 year age-group), and cardiovascular and neurovascular disease (SMR = 1.2–3). Overall mortality in 2013 was 22%, with a maximum excess between the ages of 65–74 years (males, SMR = 8.8, females, SMR = 15.9). Conclusion Medical and administrative data derived from linking the Resid-Ehpad/Sniiram databases reveal a severely impaired state of health, considering healthcare use of institutionalized dependent elderly people, and a high prevalence of diseases responsible for severe dependence and excess mortality, especially among the younger residents.

This study looked at the management of diabetes patients during the year prior to the initiation of dialysis.For this observational study, data were extracted from the National Health Insurance database for general-scheme beneficiaries (77% of the French population). Diabetes patients were identified by at least three reimbursements for antidiabetic drugs in 2012, while the initiation of dialysis was identified by specific refunds in 2013.Of the 6412 patients initiating dialysis, 37% (n=2378) had diabetes (men: 61%, median age: 71 years, haemodialysis: 92%). Six months prior to dialysis, 68% had filled at least one prescription for insulin, 38% for other antidiabetics (25% glinides, 8% sulphonylureas, 8% metformin, 6% DPP-4 inhibitors), 69% for three or more classes of antihypertensive drugs and 55% for erythropoiesis-stimulating agents. Within 12 months to 1 month of dialysis, 81% were hospitalized, 28% with a main diagnosis of kidney disease. No nephrologist referral or hospitalization was identified at 6-0 months before dialysis in 6% of patients or in 24% at 12-7 months. One in five patients with diabetes consulted a private endocrinologist within 6 months of dialysis. An arteriovenous fistula was created 1 month before haemodialysis in 43% of patients.The quality of preparation for dialysis was variable despite frequent hospitalizations. These data illustrate the need to mobilize patients with diabetes, and for healthcare professionals to more effectively anticipate and coordinate dialysis.

Introduction Public transport (PT) availability may be more important for people with disabilities (PWD), as typically they have greater healthcare needs and mobility barriers compared with people without disabilities. This paper investigates how PT availability is associated with healthcare use for people aged 18–60 years, with and without disabilities in Australia. Method We used unique Australian healthcare use administrative data linked to the 2016 Census, where individuals report whether they have a disability (severe or profound core activity limitation). These data were merged with detailed information on local area PT availability for Australia's 21 largest cities. We estimated regression models to examine the association between PT availability and different types of healthcare use, while controlling for individual characteristics and larger area attributes. Results PT availability was positively associated with visits to general practitioners (GP), with a higher magnitude observed for people with disabilities (PWD). While people without disabilities had on average 0.1 more GP visits per year when PT availability was high compared with low, PWD on average visited their GP 0.5 more times per year if they lived in areas with high as opposed to low PT availability. Nervous system prescriptions (which includes antidepressants) were 0.27 per year fewer for PWD living in areas with high compared with low PT availability. Conversely, nervous system scripts were 0.06 higher for people without disability with high compared with low PT availability. Conclusion We conclude that PT availability is likely to be a key factor of healthcare use. Increasing PT availability may help overcome some barriers to healthcare use for PWD. Our findings are also consistent with PT increasing access to preventive care, which may reduce the severity or better management of illnesses. PT can play an important role in improving health and decreasing health inequalities between those with and without disabilities.

International audience; Background: DSM-V has been criticized for excessively expanding criteria for bereavement-related depression. The aim of this study was to quantify a potential increase in depression prevalence due to changes in diagnostic criteria and to assess the severity, clinical profile and healthcare use of new cases.Methods: A cross-sectional telephone survey was performed in 2005-2006 in four French regions. Twelve-month prevalence of psychiatric disorders was measured by CIDI-SF. Bereavement was assessed in those who endorsed the gate question to the depression module. Persons with bereavement-related depression according to DSM-IV and DSM-V diagnosis criteria were compared.Results: Of the 22,138 respondents, 692 were bereaved. The prevalence of depression among those bereaved was 49.9% (95% CI ¼=43.7−56.0) according to DSM-IV and 59.6% (53.1−66.1) according to DSM-V [corrected]. The overall prevalence of major depression increased from 8.6% (8.1–9.1) with DSM-IV to 8.8% (8.3−9.3) with DSM-V . Cases diagnosed using DSM-IV presented more symptoms than cases diagnosed using DSM-V but clinical features were similar except regarding criterion E׳s symptoms. Healthcare use was similar between the two groups regarding consultations and psychotropic drug prescription.Limitations: Some DSM-IV and DSM-V criteria were difficult to operationalize in the survey. The observed difference in prevalence according to DSM-IV and DSM-V may be reduced when clinical judgment is taken into account.Conclusions: The overall prevalence of major depression is only marginally increased by the new criteria. However, diagnostic changes increase the prevalence by 10 points among those bereaved. Diagnostic changes do not appear to modify service use.

The Great Recession started in Portugal in 2009, coupled with severe austerity. This study examines its impact on hospital care utilization, interpreted as caused by demand-side effects (related to variations in population income and health) and supply-side effects (related to hospitals' tighter budgets and reduced capacity). The database included all in-patient stays at all Portuguese NHS hospitals over the 2001–2012 period ( n =17.7 millions). We analyzed changes in discharge rates, casemix index, and length of stay (LOS), using a before–after methodology. We additionally measured the association of health care indicators to unemployment. A 3.2% higher rate of discharges was observed after 2009. Urgent stays increased by 2.5%, while elective in-patient stays decreased by 1.4% after 2011. The LOS was 2.8% shorter after the crisis onset, essentially driven by the 4.5% decrease among non-elective stays. A one percentage point increase in unemployment rate was associated to a 0.4% increase in total volume, a 2.3% decrease in day cases, and a 0.1% decrease in LOS. The increase in total and urgent cases may reflect delayed out-patient care and health deterioration; the reduced volume of elective stays possibly signal a reduced capacity; finally, the shorter stays may indicate either efficiency-enhancing measures or reduced quality.

Objective To determine the rate of healthcare utilization for older primary care patients by depression status. Design Cross-sectional data analysis. Setting Primary care practices, western New York state. Participants 753 patients aged 65 years and older. Measures Diagnostic depression categories were determined using the Structured Clinical Interview for DSM-IV (SCID). The Cornell Services Index (CSI) measured outpatient medical visits. Demographic, clinical, and functional variables were obtained from medical records and interview data. Results 41.23% had subsyndromal or minor depression (M/SSD) and 53.15% had no depression. The unadjusted mean number of outpatient medical visits was greater in those with M/SSD (3.96 visits within 3 months) compared to those without depression (2.84), with a significant difference after adjusting for demographic, functional, and clinical factors. Conclusion Those with M/SSD had higher rates of healthcare utilization compared with those without depressive symptoms. Future research should examine whether interventions for older adults with M/SSD reduce healthcare utilization.

The aim of this study is to assess the association between different patterns of Body Mass Index (BMI) development from birth on and later healthcare utilisation and costs in children aged about 10 years based on two birth cohort studies: the GINIplus study (3287 respondents) and the LISAplus study (1762 respondents). Direct costs were estimated using information on healthcare utilisation given by parents in the 10-year follow-up. To meet this aim, we (i) estimate BMI-standard deviation score (BMIZ) trajectories using latent growth mixture models and (ii) examine the correlation between these trajectories and utilisation of healthcare services and resulting costs at the 10-year follow-up. We identified three BMI-trajectories: a normative BMIZ growth class (BMI development almost as in the WHO growth standards), a rapid BMIZ growth up to age 2 years class (with a higher BMI in the first two years of life as proposed by the WHO growth standards) and a persistent rapid BMIZ growth up to age 5 years class (with a higher BMI in the first five years of life as proposed by the WHO growth standards). Annual total direct medical costs of healthcare use are estimated to be on average €368 per child. These costs are doubled, i.e. on average €722 per child, in the group with the most pronounced growth (persistent rapid BMIZ growth up to age 5 years class).

Osteoarthritis (OA) is the leading cause of disability in older adults. Total healthcare costs tend to rise as pain severity associated with OA increases. To understand treatment and healthcare resource utilization (HCRU) by OA pain severity, data were collected from Feb-May 2017 using US Adelphi Disease Specific Programme, a cross-sectional survey of primary care physicians, rheumatologists, orthopedists and their patients. Descriptive statistics were used and all data were analysed using SPSS v6 and Stata v14.1. A total of 841 patients seeking care for OA were included. Patient-reported pain severity (Numeric Rating Scale; 0-10) over the last week was categorized as none/mild (45.4%; 0-3), moderate (35.9%, 4-6) and severe (18.7%; 7-10) pain. The majority of patients were female (61%) and white (78%) and the average age was 64.6 years. Increased pain severity was associated with a higher Body Mass Index and increased reliance on walking aids (21%, 38%, 47%), modifications to home (9%, 19%, 31%), and need for caregivers (5%, 14%, 31%) (all p

Introduction Cystic fibrosis (CF) can adversely affect quality of life. This study on tai chi (TC) for cystic fibrosis (CF) was an uncontrolled pilot trial assessing the feasibility of a future controlled trial. Methods Adults with CF, recruited from the Royal Brompton Hospital, UK, were taught weekly TC (based on the “eternal spring” set) for 5 weeks in participants’ homes. They continued with DVD and home practice for 5 further weeks. Cystic fibrosis questionnaire revised (CFQ-R), hospital anxiety and depression scale and brief pain inventory were completed at baseline, 5 and 10 weeks. Healthcare use, TC practice, symptoms, and wellbeing were recorded weekly, medical data at baseline and 10 weeks. Data compared before and after TC. Two online focus groups explored experiences and feedback on research methods. Results Eleven patients were recruited, mean age 38, five working/studying, baseline predicted FEV 1 between 26% and 74%. Treatment constraints and respiratory symptoms (CFQ-R) significantly improved (mean decrease 27.78 ( p = 0.023) and 11.90 ( p = 0.05) respectively). Numerous health fluctuations were recorded. TC was perceived as a “powerful tool”, relaxing and calming. Challenges to TC practice included hospitalisation, poor health, other treatments and forgetting movements. The DVD was helpful. No problems participating were reported. Conclusion TC may reduce CF treatment impact, improve respiratory symptoms, self-efficacy and sleep. Participants’ poor and fluctuating health and the small sample potentially affected results. Such research appears appropriate and feasible. Suggestions for a future trial include measurements of quality of life, dypsnoea, self-efficacy, coping, sleep, exercise levels, longer follow up and frequent assessment.

Orofacial clefts are a common problem that can lead to significant healthcare use and costs, as well as suffering on the part of the affected individuals and families. There are several theories explaining their origin, but some of the findings are inconsistent. The most accepted theories involve a major genetic basis that could be modified by the presence of external agents. Understanding the underlying causes could help to prevent its occurrence, an area in which the family physician can play an important role.

ResumenObjetivosAnalizar los cambios producidos en la prestación real sanitaria media por edad y sexo durante la década 1998-2008 en España, así como evaluar sus implicaciones en las proyecciones de gasto sanitario público.MétodosSe estiman perfiles de gasto por persona en términos constantes para la población española, desagregada por sexo y grupos de edad quinquenales para los años 1998, 2003 y 2008, a partir de los datos del Conjunto Mínimo Básico de Datos al alta hospitalaria y de las Encuestas Nacionales de Salud. Una vez elaborados los perfiles y tomando como año base 1998, se comparan las cifras de gasto efectivamente observadas en 2003 y 2008 con las previsiones derivadas de aplicar la metodología de proyección utilizada por el Grupo de Trabajo sobre Envejecimiento de la Unión Europea.ResultadosEl crecimiento anual medio de la prestación real por persona en 1998-2008 fue del 2,79%, superior al crecimiento del producto interior bruto per cápita (1,90%), como consecuencia de su elevado ritmo de aumento en la segunda mitad de la década. En 1998-2008, el gasto por persona aumenta en la mayor parte de los grupos de edad, y en particular en los tramos de 45-49, 60-64 y 75 años y más. Las proyecciones de gasto por persona en términos constantes para el año 2003 cubren el valor realmente observado, mientras que para 2008 son inferiores al valor real.ConclusionesLa evolución de la cantidad y de la calidad de los servicios sanitarios que consume cada persona es un factor importante en la evolución del gasto sanitario, que es necesario introducir en el cálculo de proyecciones.AbstractObjectivesTo analyze changes in real per capita spending by age and sex from 1998 to 2008 in Spain, and to assess their effects on public healthcare expenditure projections.MethodsAge- and sex-related expenditure profiles in constant terms were estimated for the Spanish population for 3 distinct years (1998, 2003 and 2008) by using data from hospital records and several National Health Surveys. These profiles were used to compare actual healthcare expenditure for 2003 and 2008 with the projections obtained by considering 1998 as the base year and by applying the methodology used by the Working Group on Aging of the European Union.ResultsThe average annual growth rate of real per capita spending per person from 1998 to 2008 was 2.79%, which was higher than the GDP per capita growth rate (1.90%), basically due to its high rate of increase in the second half of the decade. From 1998 to 2008, per capita healthcare expenditure increased in most age groups, particularly in the groups aged 45-49 years, 60-64 years and 75 years and older. Projections of per capita expenditure in constant terms covered the real value observed for 2003, but were below the real value for 2008.ConclusionsChanges in the quantity and quality of healthcare services consumed by each person are an important factor in changes in healthcare expenditure and must be included in spending projections.

MRI is a powerful diagnostic imaging tool and its use has increased significantly in hospitals all over the world. Due to the technical particularities of MRI, all staff members dealing with the scanner need to have adequate knowledge of how it works and of aspects related to safety. The European parliament and council's directive on minimum health and safety requirements for workers dealing with electromagnetic fields (EMF) 2004/40/CE represents a threat to the clinical development and healthcare use of MRI. The efforts of the Alliance for MRI led to a postponement of the European parliament's decision, first until April 2012 and finally until October 2013. The purpose of this article is to define and propose a set of practical rules to ensure the protection of workers involved with MRI scanners. It also aims to define our position with respect to UE directive (2004/40/CE).

A number of studies report that U.S. state mortality rates, particularly for the elderly, decline during economic downturns. Further, several prior studies use microdata to show that as state unemployment rates rise, physical health improves, unhealthy behaviors decrease, and medical care use declines. We use data on elderly mortality rates and data from the Medicare Current Beneficiary Survey from a time period that encompasses the start of the Great Recession. We find that elderly mortality is countercyclical during most of the 1994-2008 period. Further, as unemployment rates rise, seniors report worse mental health and are no more likely to engage in healthier behaviors. We find suggestive evidence that inpatient utilization increases perhaps because of an increased physician willingness to accept Medicare patients. Our findings suggest that either elderly individuals respond differently to recessions than do working age adults, or that the relationship between unemployment and health has changed.

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.

Summary Objective The objective of this analysis was to investigate whether patients with severe or difficult-to-treat asthma who experienced recent severe asthma exacerbations are at increased risk of future asthma exacerbations. Methods We conducted a 1.5-year prospective analysis of 2780 patients ⩾12 years of age from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study. Severe exacerbations were defined as either an asthma-related emergency department visit or night of hospitalization in the 3 months prior to study visit; a secondary analysis assessed prior steroid bursts as an independent predictor and outcome. Potential confounding was assessed by statistical adjustment for demographic and clinical factors, as well as asthma severity and asthma control. Results Compared with patients without a recent severe exacerbation, patients with a recent exacerbation were at increased risk of future exacerbation (odds ratio=6.33; 95% CI 4.57, 8.76), even after adjustment for demographics and clinical factors (odds ratio=3.77; 95% CI 2.62, 5.43), asthma severity (physician-assessed: odds ratio=5.62; 95% CI 4.03, 7.83), National Asthma Education and Prevention Program (odds ratio=5.07; 95% CI 3.62, 7.11), Global Initiative for Asthma (odds ratio=5.32; 95% CI 3.80, 7.47), and asthma control (odds ratio=3.90; 95% CI 2.77, 5.50). Conclusion This analysis suggests that recent severe asthma exacerbations are a strong independent factor predicting future exacerbations and, as such, should be considered as part of the clinical assessment of patients with severe or difficult-to-treat asthma.

To examine and identify predictors of healthcare use and prostatitis-related and total healthcare costs for primary and secondary care patients with new episodes of care for prostatitis.We compared the use and costs for 270 men with a new episode of care for prostatitis to those of randomly selected male health maintenance organization enrollees matched by age and primary care provider. We examined the episode of care (index visit and next 2 months) and the previous and subsequent years. Patients with prostatitis were interviewed 1 month after the index visit.Compared with controls, patients with prostatitis had significantly greater total healthcare use (P0.001) and costs (P0.05) in each period. The prostatitis costs were only a small proportion of the total costs of the patients with prostatitis and of the difference in costs between patients with prostatitis and controls. The 10% of patients with prostatitis with the greatest total costs accounted for about one half of all costs. White race (P = 0.04), less education (P = 0.02), greater disability (P = 0.003), and greater number of non-pelvic pain sites (P = 0.004) at baseline predicted greater total healthcare costs after the index visit.Health maintenance organization enrollees who seek care for prostatitis have greater total healthcare use and costs than do other enrollees of the same age and primary care provider. Most of the difference in costs reflects care for problems other than prostatitis. A small proportion of patients account for most of the costs.

Recognize differences in medication utilization by number and class by hospice diagnosis. Original Research Background. Although hospice focuses on the palliation of conditions associated with the terminal prognosis, the potential continuation of preventative and disease-modifying therapies may put hospice patients at risk of polypharmacy. Research Objectives. To describe medication use during the last week of life in hospice patients with cancer, dementia, debility, heart disease, and lung disease. Methods. Retrospective cross-sectional study design of a U.S. nationally representative sample of 695 hospices in the 2007 National Home and Hospice Care Survey. Participants included 2,623 sampled patients ages 65 and older with an primary diagnosis of cancer (49%), dementia (12%), debility (14%), heart disease (16%) or lung disease (10%); receiving end-of-life care during their last week of life. Medication data were obtained from hospice staff familiar with the patients’ care and who were asked, ‘‘What are the names of all the medications and drugs the patient was taking seven days prior to and on the day of his/her death while in hospice? Please include any standing, routine, or PRN medications.’’ Results. Overall, the average number of medications taken was 10.2 (from 9.5 among dementia patients to 11.4 among lung disease patients). Commonly taken drug therapeutic classes includedanalgesics (98%), antiemetics/antivertigos (78%), anxiolytics/sedatives/hypnotics (76%), anticonvulsants (71%), and laxatives (53%). About one-quarter of patients took proton pump inhibitors, anticoagulants, and antidepressants. Less than 20% took antacids and antibiotics. More cancer patients took opioid analgesics than dementia and debility patients.Heartdiseasepatients tended to takediuretics, while lung disease patients tended to take bronchodilators. More dementia and debility patients took antidepressants than cancer and lung disease patients. Conclusions. Older hospice patients took a high number of medications in the last week of life and differences in medication use support individualized care plans. It is unclear how this medication burden affects quality of end-of-life care. Implications for Research, Policy, or Practice. Provides a benchmark for medication utilization for dying patients.

BackgroundChronic Fatigue Syndrome sCFS) is characterised by persistent fatigue, disability and a range of other symptoms. The PACE trial was randomised to compare four non-pharmacological treatments for patients with CFS in secondary care clinics. The aims of this sub study were to describe the use of complementary and alternative medicine (CAM) in the trial sample and to test whether CAM use correlated with an improved outcome.MethodCAM use was recorded at baseline and 52 weeks. Logistic and multiple regression models explored relationships between CAM use and both patient characteristics and trial outcomes.ResultsAt baseline, 450/640 (70%) of participants used any sort of CAM; 199/640 (31%) participants were seeing a CAM practitioner and 410/640 (64%) were taking a CAM medication. At 52 weeks, those using any CAM fell to 379/589 (64%). Independent predictors of CAM use at baseline were female gender, local ME group membership, prior duration of CFS and treatment preference. At 52 weeks, the associated variables were being female, local ME group membership, and not being randomised to the preferred trial arm. There were no significant associations between any CAM use and fatigue at either baseline or 52 weeks. CAM use at baseline was associated with a mean (CI) difference of 4.10 (1.28, 6.91; p = 0.024) increased SF36 physical function score at 52 weeks, which did not reach the threshold for a clinically important difference.ConclusionCAM use is common in patients with CFS. It was not associated with any clinically important trial outcomes.

Depression is a common and often unrecognized clinical condition among those with chronic medical illnesses, including rheumatoid arthritis. Because depression is associated with higher rates of morbidity, mortality, and healthcare use, its prompt diagnosis and treatment are essential. This article focuses on the different clinical concepts of depression, depression in medical conditions in general, and depression in rheumatoid arthritis in particular. Epidemiologic, etiopathogenic, assessment, and management issues are covered. Emphasis is placed on multimodal, multidisciplinary treatment, which includes pharmacotherapy, psychotherapy, and cognitive-behavioral and educational approaches.