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Aim: To examine the impact of the COVID-19 pandemic on the mental health of parents of infants with colic and on healthcare use. Methods: Retrospective cohort study. Data of 64 parents of infants with colic prepandemic and 43 parents of infants with colic during the pandemic were analysed using validated questionnaires on parental stress, depression and anxiety. Additionally, we evaluated the number of outpatient clinic visits and admission rates pre- and during the pandemic by collecting data on the diagnosis treatment combination ‘excessive crying’ from electronic patient files in three secondary hospitals in the Netherlands. Results: Mothers in the pandemic group reported significantly higher levels of depression than mothers in the prepandemic group (12.3 ± 7.0 and 8.8 ± 5.2; p = 0.04). Moreover, mothers showed a trend towards higher stress levels during the pandemic (29.6 ± 9.6 and 25.2 ± 8.1; p = 0.06). During the pandemic, admission numbers of infants with colic compared to prepandemic data increased with 34% (146 vs. 196). Conclusion: Mothers of infants with colic reported significantly more feelings of depression during the COVID-19 pandemic. Furthermore, the pandemic was associated with increased healthcare use amongst infants with colic. With the continuing pandemic, we recommend active perinatal support for this vulnerable population.

Rationale: Acute hypercapnic respiratory failure has been shown to be associated with worse outcomes for various disease states, but less is known about patients with compensated hypercapnic respir...

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.

Background The Gallstone Pancreatitis: Admission vs Normal Cholecystectomy (Gallstone PANC) Trial demonstrated that cholecystectomy within 24 hours of admission (early) compared with after clinical resolution (control) for mild gallstone pancreatitis, significantly reduced 30-day length-of-stay (LOS) without increasing major postoperative complications. We assessed whether early cholecystectomy decreased 90-day healthcare use and costs. Study Design A secondary economic evaluation of the Gallstone PANC Trial was performed from the healthcare system perspective. Costs for index admissions and all gallstone pancreatitis-related care 90 days post-discharge were obtained from the hospital accounting system and inflated to 2020 USD. Negative binomial regression models and generalized linear models with log-link and gamma distribution, adjusting for randomization strata, were used. Bayesian analysis with neutral prior was used to estimate the probability of cost reduction with early cholecystectomy. Results Of 98 randomized patients, 97 were included in the analyses. Baseline characteristics were similar in early (n = 49) and control (n = 48) groups. Early cholecystectomy resulted in a mean absolute difference in LOS of -0.96 days (95% CI, -1.91 to 0.00, p = 0.05). Ninety-day mean total costs were $14,974 (early) vs $16,190 (control) (cost ratio [CR], 0.92; 95% CI, 0.73-1.15, p = 0.47), with a mean absolute difference of $1,216 less (95% CI, -$4,782 to $2,349, p = 0.50) per patient in the early group. On Bayesian analysis, there was an 81% posterior probability that early cholecystectomy reduced 90-day total costs. Conclusion In this single-center trial, early cholecystectomy for mild gallstone pancreatitis reduced 90-day LOS and had an 81% probability of reducing 90-day healthcare system costs.

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.

Objectives This study aimed to investigate associations between eating disorder mental health literacy (EDMHL), defense style, eating disorder (ED) symptom severity, psychological distress and mental-health-related quality of life (MHRQoL) and the likelihood of formal and informal healthcare use (HCU) across multiple time points. Methods A community sample of 445 young women with ED symptoms were followed over 7 years. Questionnaires were distributed via email and postal mail across multiple time points; this study includes data from years 2 (baseline in this study), 4 and 9. The inclusion criteria was provision of HCU data at year 2. Results ED symptom severity at baseline was significantly associated with greater HCU two and seven years later. Accurate identification of an ED by participants (i.e. EDMHL) at baseline was associated with greater HCU seven years later. Defense style, psychological distress, MHRQoL and other aspects of EDMHL were not significantly associated with HCU over time. Conclusions Individuals with more severe ED symptoms, and with greater EDMHL, may be more likely to seek help over time. However, individuals with EDs may not seek help directly for poorer MHRQoL and higher levels of psychological distress. This reinforces the importance of ED screening, particularly in primary care settings.

BackgroundDespite the severe symptoms experienced by dying COPD patients, specialized palliative care (SPC) services focus mainly on cancer patients. We aimed to study the access to SPC that COPD and lung cancer (LC) patients receive and how that access affects the need for acute hospital care.MethodsA descriptive regional registry study using data acquired through VAL, the Stockholm Regional Council’s central data warehouse, which covers nearly all healthcare use in the county of Stockholm. All the patients who died of COPD or LC from 2015 to 2019 were included. T-tests, chi-2 tests, and univariable and multivariable logistic regression analyses were performed on the accumulated data.ResultsIn total, 6479 patients, (2917 with COPD and 3562 with LC) were studied. The patients with LC had more access to SPC during the last three months of life than did those with COPD (77% vs. 18%, respectively; p 2 = 287, p ConclusionsCompared to dying COPD patients, LC patients have more access to SPC. Access to SPC reduces the need for emergency room visits and admissions to acute hospitals.

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 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

Using mortality registers and administrative data on income and population, we develop new evidence on the magnitude of life expectancy inequality in Hungary and the scope for health policy in mitigating this. We document considerable inequalities in life expectancy at age 45 across settlement-level income groups, and show that these inequalities have increased between 1991-96 and 2011-16 for both men and women. We show that avoidable deaths play a large role in life expectancy inequality. Income-related inequalities in health behaviours, access to care, and healthcare use are all closely linked to the inequality in life expectancy.Supplementary material for this article is available at: https://doi.org/10.1080/00324728.2021.1877332.

Background There is a lack of knowledge about patients’ journeys across the stroke care continuum, especially regarding the transition from inpatient to outpatient care and rehabilitation. Therefore, the aim of the present study was to explore and describe patterns of healthcare use over a one-year period, health outcomes at 3 and 12 months for patients following a referral-based transition to subsequent rehabilitation in the home, and the caregiver burden on their significant others. A further aim was to explore factors associated with the use of rehabilitation and healthcare after the referral-based transition to continued rehabilitation in the home for people recovering from a stroke. Methods Data regarding healthcare use during the first 12 months post-stroke was collected from the Region Stockholm computerized register. Data on patient characteristics, disease-related data, and functioning were retrieved drawn from medical records and questionnaires. Descriptive statistics were used to present healthcare use, participants’ characteristics, disease-related data, and patient functioning. Multivariable regression models were created to explore associations between the total number of outpatient contacts, total visits with the neurorehabilitation team, and the independent variables. Results The mean age for the 190 participants was 73 years for men and 78 years for women. Twenty-one participants (11%) had an acute rehospitalization within 30 days after discharge, and 41 participants (21%) were re-hospitalized within 90 days. Twenty-two (12%) of the participants had no visits with the neurorehabilitation team, 73 (39%) participants had 1–3 visits, 57 (30%) had 4–16 visits, and 38 (20%) had ≥17 visits. Female sex and length of hospital stay were associated with a higher number of visits with the neurorehabilitation team. Living alone, higher self-rated recovery, and being able to walk independently were associated with a lower number of visits with the neurorehabilitation team. Female sex, having home help services before the stroke, longer length of hospital stay, and more comorbidities were associated with a higher number of outpatient contacts. Conclusions The findings indicate that there is no generic pattern of healthcare use during the first-year post-stroke in patients receiving referral-based transition to continued rehabilitation in the home. The different patterns of healthcare use seemed to mirror the participants’ level of functioning. However, there is a need to further investigate how follow-up and rehabilitation correspond to the needs of patients and their significant others in the short- and long-term perspective. Trial registration ClinicalTrials.gov, registration number: NCT02925871. Date of registration: October 6, 2016.

INTRODUCTION: COVID-19 has had a profound effect on the NHS. Little information has been published as to how the unselected medical take has been affected. METHODS: We retrospectively reviewed patients who were referred to general medicine during March 2020. We compared clinical outcomes of patients with and without COVID-19. RESULTS: 814 patients were included, comprising 777 unique patients. On average, 26 patients were admitted per day. 38% of admitted patients were suspected of COVID-19, with greater numbers of COVID-19 patients in the second half compared to the first half of the month (p

OBJECTIVES Compare patient characteristics by hospital discharge disposition (home without services, home with home healthcare (HHC) services, or post-acute care (PAC) facilities). Examine timing and rates of 30-day healthcare utilization (rehospitalization, emergency department (ED) visit, or observation (OBS) visit) and patient characteristics associated with rehospitalization by discharge location. DESIGN Retrospective analysis of hospital administrative and clinical data. SETTING AND PARTICIPANTS A total of 3,294 older adult inpatients discharged home with or without HHC services or to a PAC facility. MEASUREMENTS Patient-level sociodemographic and clinical characteristics. Number of and time to occurrences of rehospitalization or ED/OBS visit within 30 days of hospital discharge. RESULTS Most rehospitalizations and ED/OBS visits occurred within 14 days from hospital discharge. Patients who returned within 24 hours came mostly from inpatient rehabilitation facilities (IRFs). More intense levels of PAC services were linked with higher rehospitalization risk. However, specific predictors differed by discharge location. Being unemployed, being single, and having more comorbidities were most associated with rehospitalization in those who went home with or without services, whereas patients rehospitalized from IRFs were younger, with less chronic illness burden, but greater and recent functional decline. Those discharged with HHC services had more return ED/OBS visits. CONCLUSIONS Although sicker patients were referred for more intense levels of PAC services, patients with greater chronic illness burden were still most often rehospitalized. In addition to unique patient differences, rehospitalizations from IRF within 24 hours suggest systems factors are contributory. Most return acute healthcare utilization occurred within 14 days; therefore, interventions should focus on smoothing transitions to all discharge locations. Because predictors of rehospitalization risk differed by discharge disposition, future research is necessary to study approaches aimed at matching patients' care needs with the most suitable PAC services at the right time. J Am Geriatr Soc 68:2279-2287, 2020.

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.

Background/Aim: To quantify the association between a previous cancer diagnosis and healthcare use among breast cancer (BC) patients, and estimate five-year recurrence-free survival (RFS). Patients and Methods: Women with BC were classified according to a previous cancer diagnosis (BC or other). Healthcare use during the first year and five-year RFS were obtained through clinical and administrative records. Adjusted odds ratios and hazard ratios (HR) were estimated. Results: Among 681 BC patients, 21 had a previous BC and 32 a previous non-BC. The latter were less likely to receive anthracycline-based combination chemotherapy. The former had higher odds of mastectomy and genetic testing. Five-year RFS HRs (95% confidence interval) were 2.75 (0.79-9.52) and 0.52 (0.07-3.89) for previous BC and non-BC, respectively. Conclusion: Previous cancer was associated with less anthracycline-based combination chemotherapy, and patients were more likely to undergo mastectomy and genetic testing. These findings highlight the need for assessment of previous treatments, personal genetic risk and current BC characteristics. This study was funded by FEDER through the Operational Programme Competitiveness and Internationalization and national funding from the Foundation for Science and Technology – FCT (Portuguese Ministry of Science, Technology and Higher Education), under the project “A five-year prospective cohort study on the neurological complications of breast cancer: frequency and impact in patient reported outcomes” (POCI-01-0145-FEDER-016867; ref. PTDC/DTP-EPI/7183/2014), and the Unidade de Investigação em Epidemiologia – Instituto de Saúde Pública da Universidade do Porto (EPIUnit) (POCI-01-0145-FEDER-006862; ref. UID/DTP/04750/2019). SM and LC were also funded under the scope of the project "NEON-PC -Neuro-oncological complications of prostate cancer: longitudinal study of cognitive decline" (POCI-01-0145-FEDER-032358; ref.PTDC/SAU-EPI/32358/2017). Individual grants attributed to ARC (SFRH/BD/102181/2014) and NA (SFRH/BD/119390/2016) were co-funded by FCT and the Programa Operacional Capital Humano (POCH/FSE). Data management activities up to the first year of follow-up were supported by the Chair on Pain Medicine of the Faculty of Medicine, University of Porto and by the Grünenthal Foundation – Portugal.

Context: Patients treated with maintenance hemodialysis experience significant symptom burden resulting in impaired quality of life. However, the association of patient reported symptom burden and the risk of healthcare use for patients with end stage kidney disease on hemodialysis has not been fully explored. Objectives: To investigate if higher symptom burden, assessed by the Edmonton Symptom Assessment System-revised (ESASr), is associated with increased healthcare use in patients with end stage kidney disease on hemodialysis. Methods: Prospective, single-center, study of adult patients on HD. Participants completed the ESASr questionnaire at enrollment. Baseline demographic, clinical information as well as healthcare use events during the 12-month following enrollment were extracted from medical records. The association between symptom burden and healthcare use was examined with a multivariable adjusted negative binomial model. Results: Mean (SD) age of the 80 participants was 71 (13) years, 56% diabetic, and 70% male. The median (IQR) dialysis vintage was 2 (1–4) years. In multivariable adjusted models, higher global [incident rate ratio (IRR) 1.02, 95% confidence interval (CI) 1.00–1.04, p = .025] and physical symptom burden score [IRR 1.03, CI 1.00–1.05, p = .034], but not emotional symptom burden score [IRR 1.05, CI 1.00–1.10, p = .052] predicted higher subsequent healthcare use. Conclusions: Our preliminary evidence suggests that higher symptom burden, assessed by ESASr may predict higher risk of healthcare use amongst patients with end stage kidney disease on hemodialysis. Future studies need to confirm the findings of this preliminary study and to assess the utility of ESASr for systematic symptom screening.

Aim: To evaluate the rates of infection and nonunion and determine the impact of infections on healthcare resource use and costs following open and closed fractures of the tibial shaft requiring open reduction internal fixation. Methods: Healthcare use and costs were compared between patients with and without infections following pen reduction internal fixation using MarketScan ® databases. Results: For commercial patients, the rates of infection and nonunion ranged from 1.82 to 7.44% and 0.48 to 8.75%, respectively, over the 2-year period. Patients with infection had significantly higher rates of hospital readmissions, emergency room visits and healthcare costs compared with patients without infection. Conclusion: This real-world study showed an increasing rate of infection up to 2 years and infection significantly increased healthcare resource use and costs.

This research aimed to determine the health care cost and utilisation of older Australian women with osteoporosis. A wide range of healthcare services were used and approximately AU$593.9 was spent over a 12-month period for these services. This highlights the significant cost burden of osteoporosis on the healthcare system. PURPOSE: Osteoporosis is a common skeletal condition among women that has a considerable impact on quality of life. The purpose of this study is to determine the prevalence of healthcare use and to estimate associated out-of-pocket expenditure for the management of osteoporosis in older Australian women. METHODS: Data was obtained from 393 Australian women from the 45 and Up Study who had osteoporosis. The women were asked about healthcare use for their osteoporosis, including conventional medicine, complementary medicine, and self-care practices or self-care products, and associated out-of-pocket expenditure for that use over 12 months. RESULTS: The average age of participants was 72.0 years. Over a 12-month period, the majority of participants (72%) consulted a doctor for their osteoporosis, 24% consulted an allied health practitioner, and 20% consulted a complementary medicine practitioner. Participants had a mean of 6.8 consultations with healthcare practitioners in the previous 12 months for the osteoporosis. In addition, 46% participants used three or more types of complementary medicine products/practices in the previous 12 months. Overall, the participants incurred a (arithmetic) mean ofAU$594 (median = $350; inter-quartile range = $450) in out-of-pocket expenditure for healthcare use over the 12-month period. CONCLUSIONS: Women with osteoporosis use a wide range of healthcare services that are associated with significant annual out-of-pocket expenditure. Preventive strategies can help decrease the cost burden of osteoporosis on the healthcare system.

Key summary points Aim To investigate the extent to which Dutch older adults reported cancellation or avoidance of medical care during the first months of the COVID-19 pandemic. Findings One third of the study sample reported cancellation or avoidance of medical care during the first months of the pandemic, and this was more common among those with multiple chronic conditions. Message Delay of routine care during the pandemic may impact morbidity and related adverse outcomes in the long term, which should be monitored in future research., Purpose Delay of routine medical care during the COVID-19 pandemic may have serious consequences for the health and functioning of older adults. The aim of this study was to investigate whether older adults reported cancellation or avoidance of medical care during the first months of the COVID-19 pandemic, and to explore associations with health and socio-demographic characteristics. Methods Cross-sectional data of 880 older adults aged ≥ 62 years (mean age 73.4 years, 50.3% female) were used from the COVID-19 questionnaire of the Longitudinal Aging Study Amsterdam, a cohort study among community-dwelling older adults in the Netherlands. Cancellation and avoidance of care were assessed by self-report, and covered questions on cancellation of primary care (general practitioner), cancellation of hospital outpatient care, and postponed help-seeking. Respondent characteristics included age, sex, educational level, loneliness, depression, anxiety, frailty, multimorbidity and information on quarantine. Results 35% of the sample reported cancellations due to the COVID-19 situation, either initiated by the respondent (12%) or by healthcare professionals (29%). Postponed help-seeking was reported by 8% of the sample. Multimorbidity was associated with healthcare-initiated cancellations (primary care OR = 1.92, 95% CI = 1.09–3.50; hospital OR = 1.86, 95% CI = 1.28–2.74) and respondent-initiated hospital outpatient cancellations (OR = 2.02, 95% CI = 1.04–4.12). Depressive symptoms were associated with postponed help-seeking (OR = 1.15, 95% CI = 1.06–1.24). Conclusion About one third of the study sample reported cancellation or avoidance of medical care during the first months of the pandemic, and this was more common among those with multiple chronic conditions. How this impacts outcomes in the long term should be investigated in future research.

Colorectal cancer (CRC) has negative long-term impacts on survivors' health and work capacity. We aimed to investigate specialized healthcare use and sickness absence and disability pension among CRC survivors and matched references.In this longitudinal register-based cohort study, 6679 patients with a first primary CRC in 2008-2011 (when aged 18-62) and 26,716 CRC-free matched references were followed from 2 years before up to 5 years after diagnosis date. Mean numbers of hospital days and outpatient visits were illustrated for survivors and references for the 7-year period. Crude and adjusted mean numbers of sickness absence/disability pension net days were calculated for post-diagnosis Years 3 and 5.Survivors' healthcare use was higher compared to their references throughout the 7 years around CRC diagnosis and was mostly due to CRC, secondary neoplasms, and digestive disorders. In Year 5, survivors had 1.94 mean outpatient visits and 2.13 mean inpatient days (compared to 1.00 and 0.82 for references, respectively). Survivors' adjusted mean sickness absence/disability pension days amounted to 85 d in Year 3 and 77 in Year 5 (compared to 57 and 54 d in the references). Higher mean number of future days was found among women, lower-educated, foreign-born, with previous comorbidities or previous mental disorders. Those with many sickness absence days in 2 years pre-diagnosis had the highest number of future sickness absence/disability pension days.Post-diagnostic healthcare use remained high among CRC survivors, mostly due to cancer (CRC and other neoplasms) and digestive diagnoses. Their sickness absence and disability pension decreased gradually over the period but remained higher than among references. Pre-morbid characteristics may be used in early work-related clinical planning for the survivors.

Background The Nice terror attack of July 14, 2016 resulted in 84 deaths and 434 injured, with many hospital staff exposed to the attack, either as bystanders on site at the time of the attack (‘bystander exposure’) who may or may not have provided care to attack victims subsequently, or as care providers to victims only (‘professional exposure only’). The objective of this study is to describe the impact on mental health among hospital staff by category of exposure with a particular focus on those with ‘professional exposure only’, and to assess their use of psychological support resources. Method An observational, cross-sectional, multicenter study conducted from 06/20/2017 to 10/31/2017 among all staff of two healthcare institutions in Nice, using a web questionnaire. Collected data included social, demographic and professional characteristics; trauma exposure category (‘bystanders to the attack’; ‘professional exposure only’; ‘unexposed’); indicators of psychological impact (Hospital Anxiety and Depression Scale); PTSD (PCL-5) level; support sought. Responders could enter open comments in each section of the questionnaire, which were processed by inductive analysis. Results 804 staff members’ questionnaires were analysed. Among responding staff, 488 were exposed (61%): 203 were ‘bystanders to the attack’, 285 had ‘professional exposure only’. The staff with ‘professional exposure only’ reported anxiety (13.2%), depression (4.6%), suicidal thoughts (5.5%); rates of full PTSD was 9.4% and of partial PTSD, 17.7%. Multivariate analysis in the ‘professional exposure only’ category showed that the following characteristics were associated with full or partial PTSD: female gender (OR = 2.79; 95% CI = 1.19–6.56, p = 0.019); social isolation (OR = 3.80; 95% CI = 1.30–11.16, p = 0.015); having been confronted with an unfamiliar task (OR = 3.04; 95% CI = 1.18–7.85; p = 0.022). Lastly, 70.6% of the staff with ‘professional exposure only’ with full PTSD did not seek psychological support. Conclusion Despite a significant impact on mental health, few staff with ‘professional exposure only’ sought psychological support. Robust prevention and follow-up programs must be developed for hospital staff, in order to manage the health hazards they face when exposed to exceptional health-related events such as mass terror attacks. Study registration Ethical approval for the trial was obtained from the National Ethics Committee for Human Research (RCBID N° 2017-A00812–51).

Background Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients’ subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6–12 months from the index admission). Methods Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients’ age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo’s boroughs to control for supply-side and unobserved effects. Results The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23–0.76) of living in a nursing home at 6–12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF. Conclusions The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

Objective: To estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after start of medical specialist rehabilitation.& nbsp; Design: Observational.& nbsp; Patients: Consecutive patients who received med ical specialist rehabilitation in the Stroke Cohort Out-comes of REhabilitation (SCORE) study.& nbsp; Methods: Participants completed questionnaires on health-related quality of life (EuroQol EQ-5D-3L), absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after start. Clinical characteristics and reha-bilitation costs were extracted from the medical and financial records, respectively.& nbsp; Results: From 2014 to 2016 a total of 313 stroke patients completed the study. Mean age was 59 (standard deviation (SD) 12) years, 185 (59%) were male, and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were US$70,601 and US$27,473, respectively. For in-patients, utility (an expression of quality of life) in-creased significantly between baseline and 6 months (EQ-5D-3L 0.66 & ndash;0.73, p = 0.01; visual analogue scale 0.77 & ndash;0.82, p < 0.001) and between baseline and 12 months (visual analogue scale 0.77 & ndash;0.81, p < 0.001).& nbsp; Conclusion: One-year societal costs from after the start of rehabilitation in stroke patients were con-siderable. Future research should also include costs prior to rehabilitation. For inpatients, health-related quality of life, expressed in terms of utility, improved significantly over time.

Background Many adults with congenital heart disease (ACHD) are cared for by non‐ACHD specialists, if they receive care at all. Little is known about the differences between those who access care at an ACHD center and those who do not access ACHD‐specific care. Methods and Results The Oregon All Payer All Claims database was queried to identify subjects aged 18 to 65 years with an International Classification of Diseases, Ninth Revision ( ICD‐9 ) code consistent with ACHD from 2010 to 2015. ACHD center providers were identified using National Provider Identification numbers. Usage rates and percentages were calculated with person‐years in the denominator, and rate ratios and odds ratios (ORs) were estimated using negative binomial and logistic regression. Only 11.7% of identified individuals (N=10 199) were seen at the ACHD center. These individuals were younger (median 36 versus 47 years; P P P P Conclusions Patients at an ACHD center comprise a distinct and complex group with a high rate of healthcare use and a relatively higher compliance with guideline‐indicated annual follow‐up. These findings underscore the importance of building and supporting robust systems for ACHD care in the United States.

Purpose To analyze the impact of a 12-week extended International Normalized Ratio (INR) follow-up interval on healthcare use. Methods A prospective cohort study of the use of an extended INR follow-up interval of up to 12 weeks was conducted over 2 years in a pharmacist-managed anticoagulation clinic. A detailed protocol was used to extend the INR follow-up interval to 5–6 weeks and then 7–8 weeks and 11–12 weeks. The number of planned and unplanned anticoagulation encounters, procedures requiring warfarin interruption, telephone triage phone calls, emergency department visits, and hospitalizations were collected. A post hoc subanalysis was also completed on participants who were scheduled for 4 consecutive 12-week intervals. Results Compared to baseline, at 12 months there was a mean decrease in planned anticoagulation encounters of 2.24 visits (p < 0.001) among 44 participants. From 12 to 24 months compared to baseline, there was a mean decrease in planned anticoagulation encounters of 3.13 visits (p < 0.001) and an increase of 0.54 unplanned anticoagulation encounters (p = 0.04) among 39 participants. The remainder of healthcare use variables were not statistically significantly different from baseline at any time point. Of the 15 participants scheduled for 4 consecutive 12-week intervals, there was a decrease from baseline of approximately 5 visits over the course of a year (p < 0.001). Conclusion An extended INR follow-up interval appears to decrease anticoagulation healthcare use without an increase in acute healthcare use. While this intervention could be cost-effective, institutions need to consider safety, efficacy, and feasibility prior to implementation.

ObjectivesTo 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, participantsMulticentre, prospective cohort study recruiting older adults (≥65 years) discharged from five UK teaching hospitals between 2013 and 2015.Primary outcome measureParticipants 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.Results1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases (‘possible’ and ‘probable’) 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.ConclusionsThe 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.

OBJECTIVE: Asthma carries a high burden of disease for residents of Puerto Rico. We conducted this study to better understand asthma-related healthcare use and to examine potential asthma triggers. METHODS: We characterized asthma-related healthcare use in 2013 by demographics, region, and date using outpatient, hospital, and emergency department (ED) insurance claims with a primary diagnostic ICD-9-CM code of 493.XX. We examined environmental asthma triggers, including outdoor allergens (i.e., mold and pollen), particulate pollution, and influenza-like illness. Analyses included descriptive statistics and Poisson time-series regression. RESULTS: During 2013, there were 550,655 medical asthma claims reported to the Puerto Rico Healthcare Utilization database, representing 148 asthma claims/1,000 persons; 71% of asthma claims were outpatient visits, 19% were hospitalizations, and 10% were ED visits. Females (63%), children aged ≤9 years (77% among children), and adults aged ≥45 years (80% among adults) had the majority of asthma claims. Among health regions, Caguas had the highest asthma claim-rate at 142/1,000 persons (overall health region claim-rate = 108). Environmental exposures varied across the year and demonstrated seasonal patterns. Metro health region regression models showed positive associations between increases in mold and particulate matter

The intervention of behaviors, including physical activity (PA), has become a strategy for many hospitals dealing with patients with chronic diseases. Given the limited evidence available about PA and healthcare use with chronic diseases, this study explored the association between different levels of PA and annual hospital service use and expenditure for inpatients with coronary heart disease (CHD) in China. We analyzed PA information from the first follow-up survey (2013) of the Dongfeng-Tongji cohort study of 1460 CHD inpatients. We examined factors such as PA exercise volume and years of PA and their associations with the number of inpatient visits, number of hospital days, and inpatient costs and total medical costs. We found that the number of hospital days and the number of inpatient visits were negatively associated with intensity of PA level. Similarly, total inpatient and outpatient costs declined when the PA exercise volume levels increased. Furthermore, there were also significant associations between the number of hospital days, inpatient costs or total medical costs and levels of PA years. This study provides the first empirical evidence about the effects of the intensity and years of PA on hospital service use and expenditure of CHD in China. It suggests that the patients' PA, especially the vigorous PA, should be promoted widely to the public and patients in order to relieve the financial burden of CHD.

Background transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable. Objective to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia. Design retrospective cohort study. Setting electronic records from a mental health provider in London, linked to national mortality and hospital data. Subjects people with dementia who died in 2007–2016. Methods end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression. Results of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11–1.59), age (>90 vs Conclusions in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.

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.

OBJECTIVE: Severe sepsis is a significant cause of healthcare use and morbidity among pediatric patients, but little is known about readmission diagnoses. We sought to determine the most common readmission diagnoses after pediatric severe sepsis, the extent to which post-sepsis readmissions may be potentially preventable, and whether patterns of readmission diagnoses differ compared to readmissions after other common acute medical hospitalizations. DESIGN: Observational Cohort Study SETTING: National Readmission Database (2013-2014), including all-payer hospitalizations from 22 states. PATIENTS: 4528 pediatric severe hospitalizations, matched by age, gender, comorbidities, and length of stay to 4528 pediatric hospitalizations for other common acute medical conditions. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: We compared rates of 30-day all-cause, diagnosis-specific, and potentially preventable hospital readmissions using McNemar’s chi-square tests for paired data. Among 5841 eligible pediatric severe sepsis hospitalizations with live discharge, 4528 (77.5%) were matched 1:1 to 4528 pediatric hospitalizations for other acute medical conditions. Of 4528 matched sepsis hospitalizations, 851 (18.8% (95% CI 16.0, 18.2)) were re-hospitalized within 30 days, compared to 775 (17.1% (95% CI 17.1, 20.0)) of matched hospitalizations for other causes (p=0.02). The most common readmission diagnoses were chemotherapy, device complication, and sepsis, all of which were several-fold higher after sepsis versus after matched non-sepsis hospitalization. Only 11.5% of readmissions were for ambulatory care sensitive conditions compared to 23% of rehospitalizations after common acute medical conditions. CONCLUSION: More than 1 in 6 children surviving severe sepsis were re-hospitalized within 30 days, most commonly for maintenance chemotherapy, medical device complications, or recurrent sepsis. Only a small proportion of readmissions were for ambulatory care sensitive conditions.

Objective.Observational axial spondyloarthritis (axSpA) research in large datasets has been limited by a lack of adequate methods for identifying patients with axSpA, because there are no billing codes in the United States for most subtypes of axSpA. The objective of this study was to develop methods to accurately identify patients with axSpA in a large dataset.Methods.The study population included 600 chart-reviewed veterans, with and without axSpA, in the Veterans Health Administration between January 1, 2005, and June 30, 2015. AxSpA identification algorithms were developed with variables anticipated by clinical experts to be predictive of an axSpA diagnosis [demographics, billing codes, healthcare use, medications, laboratory results, and natural language processing (NLP) for key SpA features]. Random Forest and 5-fold cross validation were used for algorithm development and testing in the training subset (n = 451). The algorithms were additionally tested in an independent testing subset (n = 149).Results.Three algorithms were developed: Full algorithm, High Feasibility algorithm, and Spond NLP algorithm. In the testing subset, the areas under the curve with the receiver-operating characteristic analysis were 0.96, 0.94, and 0.86, for the Full algorithm, High Feasibility algorithm, and Spond NLP algorithm, respectively. Algorithm sensitivities ranged from 85.0% to 95.0%, specificities from 78.0% to 93.6%, and accuracies from 82.6% to 91.3%.Conclusion.Novel axSpA identification algorithms performed well in classifying patients with axSpA. These algorithms offer a range of performance and feasibility attributes that may be appropriate for a broad array of axSpA studies. Additional research is required to validate the algorithms in other cohorts.

Our primary goal was to study the use of outpatient attendances by lung cancer patients in Hospital Universitario Puerta de Hierro Majadahonda (HUPHM), Spain, by leveraging our Electronic Patient Record (EPR) and structured clinical registry of lung cancer cases as well as assessing current Data Science methods and tools. We applied the Cross-Industry Standard Process for Data Mining (CRISP-DM) to integrate and analyze activity data extracted from the EPR (9.3 million records) and clinical data of lung cancer patients from a previous registry that was curated into a new, structured database based on REDCap. We have described and quantified factors with an influence in outpatient care use from univariate and multivariate points of view (through Poisson and negative binomial regression). Three cycles of CRISP-DM were performed resulting in a curated database of 522 lung cancer patients with 133 variables which generated 43,197 outpatient visits and tests, 1538 ER visits and 753 inpatient admissions. Stage and ECOG-PS at diagnosis and Charlson Comorbidity Index were major contributors to healthcare use. We also found that the patients’ pattern of healthcare use (even before diagnosis), the existence of a history of cancer in first-grade relatives, smoking habits, or even age at diagnosis, could play a relevant role. Integrating activity data from EPR and clinical structured data from lung cancer patients and applying CRISP-DM has allowed us to describe healthcare use in connection with clinical variables that could be used to plan resources and improve quality of care.

Sepsis is a leading cause of death and disability whose heterogeneity is often cited as a key impediment to translational progress.To test the hypothesis that there are consequential and significant differences in sepsis outcomes that result from differences in a patient's clinical course leading up to sepsis hospitalization.We conducted an observational cohort study of U.S. Health and Retirement Study (HRS) participants in Medicare (1998-2012) and U.S. Department of Veterans Affairs beneficiaries (2009). Using latent profile analysis, we identified patient subtypes based on trajectory of presepsis healthcare facility use. Subtypes were identified in the derivation cohort (1,512 sepsis hospitalizations among earlier HRS participants), then validated them in two additional cohorts (1,992 sepsis hospitalizations among later HRS participants; 32,525 sepsis hospitalizations among U.S. Department of Veterans Affairs beneficiaries). We measured the association between presepsis path and 90-day mortality using chi-square tests and multivariable logistic regression.We identified three subtypes: low use of inpatient healthcare facilities, comprising 84% of the derivation cohort; rising use, 12%; and high use, 4%. The shape and distribution of presepsis trajectories were similar in all three cohorts. In the derivation cohort, 90-day mortality differed by presepsis trajectory as follows: 38% (low use), 63% (rising use), and 48% (high use) (P 0.001). This association persisted in the validation cohorts (P 0.001 for each). The rising use class remained an independent predictor of mortality after adjustment for potential confounders, including detailed physiologic data.In national cohorts of patients with sepsis, we have shown that several distinct paths into sepsis exist. These paths, identified by trajectories of presepsis healthcare use, are predictive of 90-day mortality.

© 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.

Background: US epidemiologic data show that nearly one in 10 individuals aged 50+ report past-year cannabis use, and nearly one in five users report medical use. However, research on older cannabis...

Aim: Assess treatment patterns and healthcare resource utilization (HRU) in patients with treatment-naive (TN) or relapsed/refractory (R/R) acute myeloid leukemia (AML) in Europe. Patients & methods: Cross-sectional, retrospective, web-based survey of AML-treating healthcare professionals (HCPs) in 12 European countries. Results: 320 HCPs provided information on 1280 TN or R/R patients. Patients ineligible versus eligible for intensive induction therapy required more general practitioner visits (4.1 vs 2.4), more uses of healthcare-related transport (6.9 vs 4.5), but less hospitalization (11.4 vs 27.5 days). Differences were observed in HRU and treatment patterns across countries. Conclusions: This analysis of ‘real-world’ patients with TN or R/R AML in Europe demonstrates substantial healthcare use, including higher use of resources in patients ineligible for intensive induction therapy.

Resume Position du probleme L’epidemie de COVID-19 du printemps 2020 a fortement affecte le systeme de soins. Le confinement et les risques d’exposition au coronavirus ont incite les patients a modifier leur recours aux soins. L’objectif etait de partager un retour d’experience sur la mise en place d’un dispositif de surveillance en temps reel de l’activite des medecins liberaux de la region Provence-Alpes-Cote d’Azur, et de l’evolution des remboursements de medicaments prescrits aux assures du regime general pour le diabete, pour des troubles de la sante mentale et pour certains vaccins. Methodes Les donnees ont ete extraites a partir des bases regionales de l’Assurance maladie pour les annees 2019 et 2020. Elles ont permis de construire des indicateurs en date de soins pour le regime general stricto sensu, calcules de facon hebdomadaire, a partir de la semaine 2. Resultats On constate une chute d’activite des medecins liberaux lors du confinement (−23 % pour les medecins generalistes ; −46 % pour les specialistes), suivie d’un quasi retour a la normale par la suite. Dans le meme temps, les teleconsultations ont connu un veritable essor : elles ont constitue 30 % des actes des medecins liberaux au plus fort de la crise. Le debut du confinement a ete marque par un pic d’approvisionnement en medicaments, tandis que la vaccination a fortement diminue (−39 % concernant le vaccin contre la rougeole, les oreillons et la rubeole chez les enfants âges de moins de 5 ans ; −54 % pour le vaccin contre les papillomavirus humains chez les filles âgees de 10–14 ans). Conclusion L’epidemie de COVID-19 risque d’entrainer d’autres consequences sanitaires que celles directement imputables a la COVID-19 elle-meme. Le renoncement aux soins pourrait causer des retards de soins fortement prejudiciables aux individus et a la collectivite. Ces questions inquietent les autorites publiques, qui mettent en place des actions visant a inciter les patients a se soigner sans tarder. Mais la crise liee a la COVID-19 a aussi cree des opportunites, telles que le deploiement de la teleconsultation et de la tele-expertise. Bien que partiels, les indicateurs mis en œuvre peuvent permettre aux decideurs publics d’etre reactifs et de mettre en place certaines actions afin de repondre aux besoins de sante des populations.

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

Background Patients with persistent atrial fibrillation (AF) undergoing catheter‐based AF ablation have lower success rates than those with paroxysmal AF. We compared healthcare use and clinical outcomes between patients according to their AF subtypes. Methods and Results Consecutive patients undergoing AF ablation were prospectively identified from a population‐based registry in Ontario, Canada. Via linkage with administrative databases, we performed a retrospective analysis comparing the following outcomes between patients with persistent and paroxysmal AF: healthcare use (defined as AF‐related hospitalizations/emergency room visits), periprocedural complications, and mortality. Multivariable Poisson modeling was performed to compare the rates of AF‐related and all‐cause hospitalizations/emergency room visits in the year before versus after ablation. Between April 2012 and March 2016, there were 3768 consecutive patients who underwent first‐time AF ablation, of whom 1040 (27.6%) had persistent AF. The mean follow‐up was 1329 days. Patients with persistent AF had higher risk of AF‐related hospitalization/emergency room visits (hazard ratio [HR], 1.21; 95% CI, 1.09–1.34), mortality (HR, 1.74; 95% CI, 1.15–2.63), and periprocedural complications (odds ratio, 1.36; 95% CI, 1.02–1.75) than those with paroxysmal AF. In the overall cohort, there was a 48% reduction in the rate of AF‐related hospitalization/emergency room visits in the year after versus before ablation (rate ratio [RR], 0.52; 95% CI, 0.48–0.56). This reduction was observed for patients with paroxysmal (RR, 0.45; 95% CI, 0.41–0.50) and persistent (RR, 0.74; 95% CI, 0.63–0.87) AF. Conclusions Although patients with persistent AF had higher risk of adverse outcomes than those with paroxysmal AF, ablation was associated with a favorable reduction in downstream AF‐related healthcare use, irrespective of AF type.

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 (€9) than for documented migrants (€77) and Spanish nationals (€367). 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.

Aims Gulf War Illness (GWI) is a prevalent and disabling condition characterized by persistent physical symptoms. Clinical practice guidelines recommend self-management to reduce the disability from GWI. This study evaluated which GWI self-management strategies patients currently utilize and view as most effective and ineffective. Materials and methods Data were collected from 267 Veterans during the baseline assessment of a randomized clinical trial for GWI. Respondents answered 3 open-ended questions regarding which self-management strategies they use, view as effective, and view as ineffective. Response themes were coded, and code frequencies were analyzed. Key findings Response frequencies varied across questions (in-use: n = 578; effective: n = 470; ineffective: n = 297). Healthcare use was the most commonly used management strategy (38.6% of 578), followed by lifestyle changes (28.5% of 578), positive coping (13% of 578), and avoidance (13.7% of 578). When asked about effective strategies, healthcare use (25.9% of 470), lifestyle change (35.7% of 470), and positive coping (17.4% of 470) were identified. Avoidance was frequently identified as ineffective (20.2% of 297 codes), as was invalidating experiences (14.1% of 297) and negative coping (10.4% of 297). Significance Patients with GWI use a variety of self-management strategies, many of which are consistent with clinical practice guidelines for treating GWI, including lifestyle change and non-pharmacological strategies. This suggests opportunities for providers to encourage effective self-management approaches that patients want to use.

Background. The cost of breast cancer care rises with higher stage at diagnosis; however, there are no real-world data regarding the cost of care according to breast cancer subtypes. This study aimed to estimate direct medical costs for early breast cancer care in the first 3 years after diagnosis according to subtype and stage, using patient-level data. Methods. Women with newly diagnosed stage I–III breast cancer, admitted in 2012 to a Portuguese cancer centre were prospectively followed within the NEON-BC cohort. The use of health resources was obtained from each patient’s clinical and administrative records and costs were computed. Tumours were classified into the classic subtypes (hormone receptor-positive (HR+)/HER2−; HER2-positive (HER2+); triple-negative breast cancer (TNBC)) and surrogate intrinsic subtypes (luminal A-like; luminal B-like; HER2 enriched; basal like). Results. A total of 703 patients were included: 48.9% had stage I, 35.8% stage II and 15.2% stage III breast cancer; 76.4% had HR+/HER2−, 15.9% HER2+ and 7.7% TNBC. Median cost of care was €9215/patient in stage I, €13 019/patient in stage II and €15 011/patient in stage III and €10 540/patient in HR+/HER2−, €11 224/patient in TNBC and €41 513/patient in HER2+ breast cancer. Systemic therapy accounted for 69.2% of the cost of care among patients with HER2+, 12.0% among HR+/HER2− and 7.5% among TNBC patients. Similar differences were observed across surrogate intrinsic subtypes. Conclusions. The cost of early breast cancer care was mainly driven by the tumour subtype and, to a lesser extent, by stage. The median cost of care was fourfold higher among patients with HER2+ tumours compared with those with HR+/HER2− and TNBC. These data provide information for the economic evaluation of innovative treatments for early breast cancer and highlight the weight that targeted systemic therapy might have in the overall cost of care among patients with early breast cancer. This study was funded by the European Regional Development Fund (FEDER) through the Operational Programme Competitiveness and Internationalisation and national funding from the Foundation for Science and Technology – FCT (Portuguese Ministry of Science, Technology and Higher Education), under the project 'A 5-year prospective cohort study on the neurological complications of breast cancer: frequency and impact in patient-reported outcomes' (POCI-01-0145-FEDER-016867, Ref. PTDC/DTP-EPI/7183/2014), and national funding from FCT, under the Unidade de Investigação em Epidemiologia – Instituto de Saúde Pública da Universidade do Porto (EPIUnit) (UIDB/04750/2020). SM and LL-C were also funded under the scope of the project 'NEON-PC Neuro- oncological complications of prostate cancer: longitudinal study of cognitive decline' (POCI-01-0145-FEDER-032358; ref. PTDC/SAU-EPI/32358/2017). An individual grant attributed to NA (SFRH/BD/119390/2016) was cofunded by FCT and the 'Programa Operacional Capital Humano' (POCH/FSE). Data management activities up to the first year of follow-up were supported by the Chair on Pain Medicine of the Faculty of Medicine, University of Porto and by the Grünenthal Foundation—Portugal.

BACKGROUND The objectives of this retrospective cohort study are to describe rates of adherence to laboratory testing 6 months to 3 years post-liver transplantation and to examine demographic and clinical factors related to lab non-adherence and the association with medication adherence and clinical outcomes. METHODS Medical chart review was conducted for 54 youth (mean age = 5.0 years) transplanted between 2003 and 2014. Lab adherence (≥80%) was measured as the proportion of completed labs out of the number expected. Immunosuppressant drug-level variability was used as a proxy for medication adherence. Clinical outcomes included LAR, viral infection, hospitalization, and non-routine clinic visit ≥12 months after transplant. RESULTS Lab adherence decreased substantially over time. Single-parent household (aOR 5.86; 95% CI: 1.38-24.93) and no history of early rejection (aOR 3.96; 95% CI: 1.04-15.24) were independently associated with non-adherence. Lab non-adherence was significantly associated with medication non-adherence (P

Aim: Compare healthcare utilization and costs between Medicare beneficiaries with idiopathic pulmonary fibrosis (IPF) receiving pirfenidone or nintedanib. Methods: Retrospective cohort study of Medicare beneficiaries (100% Research Identifiable Files) with IPF who initiated pirfenidone or nintedanib between 15 October 2014 and 31 December 2015. Inverse probability of treatment weighting using propensity scores adjusted for baseline covariates. Outcomes: hospitalization and monthly costs. Results: Hazard and incidence rate ratios (95% CI) for all-cause (0.79 [0.68–0.91]; 0.69 [0.59–0.82]) and respiratory-related (0.80 [0.65–0.97]; 0.71 [0.57–0.90]) hospitalizations favored pirfenidone versus nintedanib. Monthly inpatient costs were lower for pirfenidone versus nintedanib patients; outpatient and pharmacy costs were similar. Conclusion: In patients with IPF, pirfenidone compared with nintedanib has a moderate but significant protective effect on hospitalization, corresponding to lower inpatient costs.

Real-world evidence specific to HR+/HER2– metastatic breast cancer (MBC) prior to introduction of CDK4/6 inhibitors is limited. In an effort to provide context for the introduction of new treatments, we assessed treatment patterns, adverse events, productivity loss, and direct/indirect economic burden in a privately insured population of patients with HR+/HER2– MBC. Using a retrospective cohort design, patients aged 18–64 years, selected from MarketScan databases (2007–2014), were analyzed using descriptive and multivariable methods. Among 5,563 eligible patients, endocrine therapy was the most common first-line (1L) therapy; its utilization trended downward from 63% (1L) to 23% (4L), with a simultaneous increase in chemotherapy use, 25% (1L) to 50% (4L). Two hundred and seventy-eight unique treatment regimens were used in the 1L setting. The average per patient monthly all-cause costs were $14,424. The 12-month indirect costs for short-term disability were substantially higher in MBC patients ($10,397) than in matched noncancer patients ($394). The increasing use of chemotherapy as patients progressed to second and later lines and the substantial direct/indirect economic burden underscore an unmet need. The high number of 1L regimens highlights significant heterogeneity and a lack of consensus related to the management of HR+/HER2– MBC in routine practice.

Background Multimorbidity is frequently encountered in primary care and is associated with increasing use of healthcare services. The Andersen Behavioral Model of Health Services Use is a multilevel framework classifying societal, contextual, and individual characteristics about the use of healthcare services into three categories: 1. predisposing factors, 2. enabling factors, and 3. need factors. The present study aimed to explore multimorbid patients’ use of ambulatory healthcare in terms of homecare and other allied health services, visits to GPs, and number of specialists involved. A secondary aim was to apply Andersen’s model to explore factors associated with this use. Method In a cross-sectional study, 100 Swiss GPs enrolled up to 10 multimorbid patients each. After descriptive analyses, we tested the associations of each determinant and outcome variable of healthcare use, according to the Andersen model: predisposing factors (patient’s demographics), enabling factors (health literacy (HLS-EU-Q6), deprivation (DipCare)), and need factors (patient’s quality of life (EQ-5D-3L), treatment burden (TBQ), severity index (CIRS), number of chronic conditions, and of medications). Logistic regressions (dichotomous variables) and negative binomial regressions (count variables) were calculated to identify predictors of multimorbid patients’ healthcare use. Results Analyses included 843 multimorbid patients; mean age 73.0 (SD 12.0), 28–98 years old; 48.3% men; 15.1% (127/843) used homecare. Social deprivation (OR 0.75, 95%CI 0.62–0.89) and absence of an informal caregiver (OR 0.50, 95%CI 0.28–0.88) were related to less homecare services use. The use of other allied health services (34.9% (294/843)) was associated with experiencing pain (OR 2.49, 95%CI 1.59–3.90). The number of contacts with a GP (median 11 (IQR 7–16)) was, among other factors, related to the absence of an informal caregiver (IRR 0.90, 95%CI 0.83–0.98). The number of specialists involved (mean 1.9 (SD 1.4)) was linked to the treatment burden (IRR 1.06, 95%CI 1.02–1.10). Conclusion Multimorbid patients in primary care reported high use of ambulatory healthcare services variably associated with the Andersen model’s factors: healthcare use was associated with objective medical needs but also with contextual or individual predisposing or enabling factors. These findings emphasize the importance of adapting care coordination to individual patient profiles.

Background: There are limited data on population-wide assessment of cost in Crohn's disease (CD) and ulcerative colitis (UC). Aim: To estimate the societal cost of actively treated CD and UC in Sweden. Methods: We identified 10 117 prevalent CD and 19 762 prevalent UC patients, aged ≥18 years on 1 January 2014 and 4028 adult incident CD cases and 8659 adult incident UC cases (2010-2013) from Swedish Patient Register. Each case was matched to five population comparators. Healthcare costs were calculated from medications, outpatient visits, hospitalisations and surgery. Cost of productivity losses was derived from disability pension and sick leave. Results: The mean annual societal costs per working-age patient (18-64 years) with CD and UC were $22 813 (vs $7533 per comparator) and $14 136 (vs $7351 per comparator) respectively. In patients aged ≥65 years, the mean annual costs of CD and UC were $9726 and $8072 vs $3875 and $4016 per comparator respectively. The majority of cost for both CD (56%) and UC (59%) patients originated from productivity losses. Higher societal cost of working-age CD patients as compared to UC patients was related to greater utilisation of anti-TNF (22.2% vs 7.4%) and increased annual disability pension (44 days vs 25 days). Among incident CD and UC patients, the mean total cost over the first year per patient was over three times higher than comparators. Conclusion: In Sweden, the societal cost of incident and prevalent CD and UC patients was consistently two to three times higher than the general population. (Less)