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Objective: To investigate whether the first wave of the COVID-19 pandemic impacted healthcare consultations (HCC) and hospitalization among people with and without osteoarthritis (OA). Methods: Using register data, we included individuals aged ≥35 years residing in Skåne region, Sweden, during 2009–2019 with (n ​= ​123,523) and without (n ​= ​552,412) a diagnosis of OA during January 1, 2009–December 31, 2019. We collected bi-weekly individual data on HCC/hospitalization between January and May for years 2017–2020. Treating the year 2020 as intervention and 2017–2019 as control as well as dividing data to pre– (January–February) and post–pandemic (March–May), we applied event study design to measure the dynamic effects of the COVID-19 pandemic on HCC/hospitalization. We used fixed-effect Poisson regressions for estimation and subgroup analyses by sex, age, and comorbidity were conducted among OA patients. Results: The impact of the pandemic on healthcare use was evident from mid-March 2020 (34–45%/12–25% reductions in in-person HCC/hospitalization) among people with OA relative to 2017–2019. Smaller reductions were seen in those without OA with 25–34%/8–16% reductions in in-person HCC/hospitalization. On contrary, there were increases in remote HCC following the pandemic (5–25% and 11–31% in people with and without OA, respectively). Among persons with OA, there were variations in the pandemic's effects by sex, age and comorbidity. Conclusion: Despite no lockdown in Sweden there were substantial reductions in in-person healthcare use during the first wave of COVID-19 pandemic with greater reductions among people with than without OA.

Background: The number of children with life-limiting conditions in England is known to be increasing, which has been attributed in part to increased survival times. Consequently, more of these young people will reach ages at which they start transitioning to adult healthcare (14-19 years). However, no research exists that quantifies the number of young people with life-limiting conditions in England reaching transition ages or their medical complexity, both essential data for good service planning. Methods: National hospital data in England (Hospital Episode Statistics) from NHS Digital were used to identify the number of young people aged 14-19 years from 2012/13 to 2018/19 with life-limiting conditions diagnosed in childhood. The data were assessed for indicators of medical complexity: number of conditions, number of main specialties of consultants involved, number of hospital admissions and Accident & Emergency Department visits, length of stay, bed days and technology dependence (gastrostomies, tracheostomies). Overlap between measures of complexity was assessed. Results: The number of young people with life-limiting conditions has increased rapidly over the study period, from 20363 in 2012/13 to 34307 in 2018/19. There was evidence for increased complexity regarding the number of conditions and number of distinct main specialties of consultants involved in care, but limited evidence of increases in average healthcare use per person or increased technology dependence. The increasing size of the group meant that healthcare use increased overall. There was limited overlap between measures of medical complexity. Conclusions: The number of young people with life-limiting conditions reaching ages at which transition to adult healthcare should take place is increasing rapidly. Healthcare providers will need to allocate resources to deal with increasing healthcare demands and greater complexity. The transition to adult healthcare must be managed well to limit impacts on healthcare resource use and improve experiences for young people and their families.

This study estimates and decomposes components of different measures of inequality in health and healthcare use among millennial adolescents, a sizeable cohort of individuals at a critical stage of life. Administrative data from the UK Hospital Episode Statistics are linked to Next Steps, a survey collecting information about millennials born between 1989 and 1990, providing a uniquely comprehensive source of health and socioeconomic variables. Socioeconomic inequalities in psychological distress, long-term illness and the use of emergency and outpatient hospital care are measured using a corrected concentration index. Shapley-Shorrocks decomposition techniques are employed to measure the relative contributions of childhood socioeconomic circumstances to adolescents' health and healthcare inequality of opportunity. Results show that income-related deprivation contributes to significant inequalities in mental and physical health among adolescents aged between 15 and 17 years old. There are also pro-rich inequalities in the use of specific outpatient hospital services (e.g., orthodontic and mental healthcare), while pro-poor disparities are found in the use of emergency care services. Regional and parental circumstances are leading factors in influencing inequality of opportunity in the use of hospital care among adolescents. These findings shed light on the main drivers of health inequalities during an important stage of human development and have potentially important implications on human capital formation across the life-cycle. • Socioeconomic deprivation contributes to significant health inequalities for millennial adolescents. • There are pro-rich inequalities in the use of mental health and orthodontic outpatient hospital services. • Pro-poor disparities are found in the use of, and waiting times for, emergency hospital services. • Findings have important implications on human capital formation across life-cycles. [ABSTRACT FROM AUTHOR]

This cross-sectional study explored associations between demographics, pain intensity and cognitions on the one hand and healthcare use (HCU) on the other hand in people undergoing surgery for lumbar radiculopathy. HCU during the 2 months preceding surgery was evaluated using a retrospective questionnaire. Demographics included sex, age and level of education and equivalent income. Back and leg pain intensity were evaluated using a visual analogue scale. Pain cognitions were assessed with the Tampa scale of kinesiophobia, the pain catastrophizing scale and the pain vigilance and awareness questionnaire. The sample comprised 120 participants (52% males; 49 years (Quartile (Q)1–Q3: 37.3–57.43)). The number of visits to the general practitioner was associated with sex (incidence rate ratio (IRR) for males = 0.811; p = 0.050), pain catastrophizing (IRR = 1.010; p = 0.041), pain magnification (IRR = 1.058; p = 0.004) and leg pain intensity (IRR = 1.004; p = 0.038). The number of neurosurgeon visits was associated with level of education (IRR moderate education = 1.518; p = 0.016 (reference: low education)). Receiving zero physiotherapy visits was associated with higher back pain intensity (Beta = 0.018; p = 0.028). Highest level of analgesics used was associated with sex (IRR for males = 0.502; p = 0.047) and leg pain (IRR = 1.014; p = 0.034). Only the association between general practitioner visits and pain magnification remained significant in multivariable analyses (IRR = 1.061; p = 0.033). The results suggest a rather indirect relationship between HCU and demographics, pain intensity and cognitions, involving a potential interplay between several patient- and healthcare system-related factors.

Aim: Concerns around loneliness leading to increased healthcare use persist in spite of a mixed evidence base and lack of adjustment for key potential confounders. We investigated the associations among loneliness, health and healthcare use in older adults including stratification to investigate whether these associations differ by gender. Subject and methods: Secondary analysis of a nationally representative sample of 8175 community-dwelling adults aged 50 years and over from The Irish Longitudinal Study on Ageing (TILDA). Primary outcomes were self-reported general practitioner (GP) and emergency department (ED) visits in the past 12 months. Negative binomial and logistic regression analysis was used to investigate associations between loneliness and healthcare use, later adjusting for potential mediators (health and health behaviours). Results: Loneliness was consistently positively associated with number of GP visits according to both cross-sectional and longitudinal analyses, with incidence rate ratios (IRRs) ranging from 1.08 to 1.33 in the sample overall. Associations with ED visits were less consistent. After adjusting for health and health behaviours, male loneliness does not appear to influence ED or GP visits. However, women who reported loneliness had an elevated risk of an ED visit at wave 1 (W1; odds ratio (OR) 1.08 [1.01–1.16]), as well as increased GP visits at both waves (IRRs ranging from 1.05 [1.02–1.07] to 1.16 [1.07–1.26]). Conclusion: Older women experiencing loneliness visit their GP more often irrespective of health, health behaviours or social isolation. While effect sizes were small, there are implications for health service resources at a population level. Importantly, however, this may also be a useful opportunity to redirect towards appropriate services and tailored resources. [ABSTRACT FROM AUTHOR]

We explored the association between caregiving for preschool children with developmental disabilities and maternal health and healthcare use using linked primary care and Born in Bradford birth cohort data. Adjusting for prenatal health, healthcare use and socioeconomic status, mothers who were caregivers were more likely than other mothers to have symptoms of psychological distress (odds ratio 1.24; 95% CI 1.01, 1.53), exhaustion (1.42; 1.12, 1.80) and possibly head and musculoskeletal pain (1.18; 0.97, 1.43). Despite the higher prevalence of symptoms, they did not access healthcare services more and may seek healthcare for psychological distress less often (0.64; 0.40, 1.02). In general, socioeconomic disadvantage was associated with worse health. Pakistani ethnicity (versus white British) and prenatal consultation were strongly associated with higher postnatal consultation rates. Prenatal ill health, healthcare use and socioeconomic status are important factors in the detection of postnatal ill health via primary care services. If caregiver burden and the risk of under-detecting (and thus under treating) caregiver ill health is not addressed during the preschool period health inequalities between caregivers and other mothers and their families may persist and grow. The health of mothers of young disabled children, in particular their unmet health needs, warrants attention in research and clinical practice. [ABSTRACT FROM AUTHOR]

Background: Healthcare use is increasing, and health anxiety (HA) is recognized as an important associated factor. Previous research on the association between HA and healthcare use has mostly explored HA as a dichotomous construct, which contrasts the understanding of HA as a continuous construct, and compared healthcare use to non-use. There is a need for studies that examine the association between healthcare use and the continuum of HA in a general population.Aim: To explore the association between HA and primary, somatic specialist and mental specialist healthcare use and any differences in the association by level of healthcare use.Methods: This study used cross-sectional data from the seventh Tromsø study. Eighteen thousand nine hundred sixty-seven participants aged 40 years or older self-reported their primary, somatic specialist and mental specialist healthcare use over the past 12 months. Each health service was categorized into 5 groups according to the level of use. The Whiteley Index-6 (WI-6) was used to measure HA on a 5-point Likert scale, with a total score range of 0-24. Analyses were conducted using unconstrained continuation-ratio logistic regression, in which each level of healthcare use was compared with all lower levels. Morbidity, demographics and social variables were included as confounders.Results: HA was positively associated with increased utilization of primary, somatic specialist and mental specialist healthcare. Adjusting for confounders, including physical and mental morbidity, did not alter the significant association. For primary and somatic specialist healthcare, each one-point increase in WI-6 score yielded a progressively increased odds ratio (OR) of a higher level of use compared to all lower levels. The ORs ranged from 1.06 to 1.15 and 1.05 to 1.14 for primary and somatic specialist healthcare, respectively. For mental specialist healthcare use, the OR was more constant across levels of use, ranging between 1.06 and 1.08.Conclusions: In an adult general population, HA, as a continuous construct, was significantly and positively associated with primary, somatic specialist and mental healthcare use. A small increase in HA was associated with progressively increased healthcare use across the three health services, indicating that the impact of HA is more prominent with higher healthcare use. [ABSTRACT FROM AUTHOR]

Background: Mismatch between need and mental healthcare (MHC) use (under-and overuse) has mainly been studied with cross-sectional designs, not accurately capturing patterns of persistence or change in clinical burden and MHC-use among persons with depressive and/or anxiety disorders.Aims: Determining and describing [mis]match of longitudinal trajectories of clinical burden and MHC-use.Methods: Six-year longitudinal burden and MHC-use data came from the Netherlands Study of Depression and Anxiety (n=2981). The sample was split into four subgroups: I) no clinical burden but constant MHC use, II) constant clinical burden but no MHC-use, III) changing clinical burden and MHC-use, and IV) healthy non-users. Within subgroups I)-III), specific clinical burden and MHC trajectories were identified (growth mixture modeling). The resulting classes' associations with predisposing, enabling, and need factors were investigated (regression analysis).Results: Subgroups I-III revealed different trajectories. I) increasing MHC without burden (4.1%). II) slightly increasing (1.9%), strongly increasing (2.4%), and decreasing (9.5%) burden without MHC. III) increasing (41.4%) or decreasing (19.4%) burden and concurrently increasing MHC use (first underuse, then matched care), thus revealing delayed MHC-use. Only having suicidal ideation (p<.001, Cohen's d= .6-1.5) was a significant determinant of being in latter classes compared to underusers (strongly increasing burden without MHC-use).Limitations: More explanatory factors are needed to explain [mis]match.Conclusion: Mismatch occurred as constant underuse or as delayed MHC-use in a high-income country (Netherlands). Additionally, no meaningful class revealed constantly matched care on average. Presence of suicidal ideation could influence the probability of symptomatic individuals receiving matched MHC or not. [ABSTRACT FROM AUTHOR]

Rationale: Palliative care focuses on improving quality of life for patients with life-limiting conditions. Although previous studies have shown palliative care to be associated with reduced acute healthcare use in people with cancer and other illnesses, these findings may not generalize to patients with chronic obstructive pulmonary disease (COPD). Objectives: We examined the association between palliative care and rates of days at home, locations of death, and acute healthcare use in patients with COPD. Methods: We used health administrative databases in Ontario, Canada, to identify patients with advanced COPD hospitalized between April 2010 and March 2017 and followed up until March 2018. Patients who received palliative care were matched 1:1 with those who did not receive palliative care in terms of age, sex, long-term oxygen, previous COPD hospitalizations and propensity scores. Rate ratios (RR) were estimated by using Poisson models with generalized estimating equations to account for matching. Results: Among 35,492 patients, 1,788 (5%) received palliative care. In the matched cohort (1,721 pairs), people with COPD receiving palliative care had similar rates of days at home (RR, 1.01; 95% confidence interval [CI], 0.97-1.05) but were more likely to die at home (16.4% vs. 10.0%; P < 0.001) compared with those who did not receive palliative care. Rates of healthcare use were similar except for increased hospitalizations in the palliative care group (RR, 1.09; 95% CI, 1.01-1.18). Conclusions: Receipt of palliative care did not reduce days at home or healthcare use but was associated with a modest increase in the proportion who died at home. Future work should evaluate palliative care strategies designed specifically for patients with COPD. [ABSTRACT FROM AUTHOR]

Background: Rapid testing, tracing, and isolation among symptomatic patients are the standard for controlling the COVID‐19. However, during spring 2020, Japan employed a RT‐PCR test policy by using a guideline, which was used for the public to visit hospitals or clinics when they had mild symptoms for 4 days or longer ("4‐day rule") among low‐risk patients. It is unknown of patients' experience of healthcare use and testing during the period under the guideline. Thus, we investigated the healthcare visiting and testing among patients who developed cold‐like symptoms during the period. Methods: Our survey was conducted online in September 2020 to a nationally representative sample of adults throughout Japan. We investigated the public's understanding of the guideline. In addition, we asked their experience with healthcare use and testing if they had noticed new‐onset cold‐like symptoms. Results: Of 2,137 people surveyed, 1,698 (79.5%) recognized the guidelines, but 422 people (19.7%) misunderstood. There were 144 (6.7% of 2,137 people) who developed cold‐like symptoms, and many of them experienced difficulties in getting through telephone calls to a public health center, and 25 (17% of 144 people) visited healthcare institutions. Of these 25 symptomatic patients, 15 (60%) could not receive testing because of decisions by physicians (14 patients) or a local public health center (1 patient). Conclusion: There was a low use of healthcare and testing among symptomatic patients during the first wave of the pandemic in Japan. Testing capacity should be increased to provide effective care for patients with suspected COVID‐19 in Japan. [ABSTRACT FROM AUTHOR]

Background: Respiratory tract infections (RTIs) are important health problems with high incidence and consequent economic costs. The study aimed to analyze trajectories of experienced RTI symptoms and use of healthcare and antibiotics. Method: The study adopted a cross-sectional design and face-face interview using a structured questionnaire. The questionnaire comprised: a) social demographics; b) last episode of symptomatic RTIs; c) responses to the RTIs; d) antibiotics obtained from clinics and medicine shops for the RTIs. The study subjects were residents in randomly selected villages in Anhui, China. The study settings were the residents households. Descriptive analyses were conducted to draw symptoms trajectory and identify relationship between healthcare seeking and symptoms and common sociodemographic variables. Result: A total 91.1% (1968) of 2160 eligible residents completed the interview who reported 1.83 episodes of RTIs in the pass year on average. Over half (54.8%) of these RTI episodes had led to visit to clinics for professional care and 51.9%, to use of antibiotics. The trajectories of common RTI symptoms featured a sharp increase and peak followed by a long tail along the days after onset of the infection. Over 60.5% of healthcare-seeking happened between two days before and one day after the symptoms peak. The study also revealed interesting pattern in the timing of different type of treatment following, e.g., taking leftover medicine and antibiotics happened the earliest and seeking professional help and getting antibiotics from clinics, the latest. Conclusion: RTIs incur a large volume of healthcare-seeking and antibiotics use and there is an urgent need for effective education measures on proper service especially antibiotics use. Patients’ reported RTI symptoms manifest peculiar trajectories and their retrospective recall of the course of prior RTI episodes and associated actions may guide their future responses to similar infections. Knowledge of these may help inform doctors about patient expectations, enabling them better manage shared decision- making around antibiotic treatment.

Abstract Background The Emergency Department (ED) can be considered an indicator of accessibility and quality and can be influenced in period of economic downturns. In the last fifteen years, the number of migrants in Italy has doubled (from 2.4 million in 2005 to 5.2 in 2019, 4.1 and 8.7% of the total population, respectively). However, evidence about migrants’ healthcare use is poor, and no studies focused on the ED utilisation rate during the Great Recession are available. This study aims to analyse trends in all-cause and cause-specific ED utilisation among migrants and Italians residing in Rome, Italy, before and after 2008. Methods Longitudinal study based on data from the Municipal Register of Rome linked to the Emergency Department Register from 2005 to 2015. We analysed 2,184,467 individuals, aged 25–64 in each year. We applied a Hurdle model to estimate the propensity to use the ED and to model how often individuals accessed the ED. Results Migrants were less likely to be ED users than Italians, except for Africans (RR = 1.46, 95%CI 1.40–1.52) and Latin Americans (RR = 1.04, 95%CI 1.00–1.08) who had higher all-cause utilisation rates than non-migrants. Compared to the pre-2008 period, in the post-2008 we found an increase in the likelihood of being an ED user (OR = 1.34, 95%CI 1.34–1.35), and a decrease in ED utilisation rates (RR = 0.96, 95%CI 0.96–0.97) for the whole population, with differences among migrant subgroups, regardless of cause. Conclusions This study shows differences in the ED utilisation between migrants and Italians, and within the migrant population, during the Great Recession. The findings may reflect differentials in the health status, and barriers to access primary and secondary care among migrants. In this regard, health policies and cuts in health spending measures may have played a key role, and interventions to tackle health and access disparities should include policy measures addressing the underlying factors, adopting a Health in All Policies perspective. Further researches focusing on specific groups of migrants, and on the causes and diagnoses related to the ED utilisation, may help to explain the differences observed.

Women have consistently lower mortality rates than men at all ages and with respect to most causes. However, gender differences regarding hospital admission rates are more mixed, varying across ages and causes. A number of intuitive metrics have previously been used to explore changes in hospital admissions over time, but have not explicitly quantified the gender gap or estimated the cumulative contribution from cause-specific admission rates. Using register data for the total Danish population between 1995 and 2014, we estimated the time to first hospital admission for Danish men and women aged 60. This is an intuitive population-level metric with the same interpretive and mathematical properties as period life expectancy. Using a decomposition approach, we were able to quantify the cumulative contributions from eight causes of hospital admission to the gender gap in time to first hospital admission. Between 1995 and 2014, time to first admission increased for both, men (7.6 to 9.4 years) and women (8.3 to 10.3 years). However, the magnitude of gender differences in time to first admission remained relatively stable within this time period (0.7 years in 1995, 0.9 years in 2014). After age 60, Danish men had consistently higher rates of admission for cardiovascular conditions and neoplasms, but lower rates of admission for injuries, musculoskeletal disorders, and sex-specific causes. Although admission rates for both genders have generally declined over the last decades, the same major causes of admission accounted for the gender gap. Persistent gender differences in causes of admission are, therefore, important to consider when planning the delivery of health care in times of population ageing. [ABSTRACT FROM AUTHOR]

Objective: This study systematically reviewed the association of psychological problems among cancer patients with healthcare and societal resource use and costs. Methods: PubMed, PsycINFO, and Embase were searched (until 31 January 2021) for studies on psychological symptoms (anxiety, depression, distress, fear of recurrence) or psychiatric disorders (anxiety, depression, adjustment) and healthcare use (e.g., mental, inpatient healthcare), economic losses by patients and family, economic losses in other sectors (e.g., absence from work), and costs. The search, data extraction, and quality assessment were performed by two authors. Results: Of the 4157 identified records, 49 articles were included (psychological symptoms (n = 34), psychiatric disorders (n = 14), both (n = 1)) which focused on healthcare use (n = 36), economic losses by patients and family (n = 5), economic losses in other sectors (n = 8) and/or costs (n = 13). In total, for 12 of the 94 associations strong evidence was found. Psychological symptoms and psychiatric disorders were positively associated with increased healthcare use (mental, primary, inpatient, outpatient healthcare), losses in other sectors (absence from work), and costs (inpatient, outpatient, total healthcare costs). Moderate evidence was found for a positive association between (any) psychiatric disorder and depression disorder with inpatient healthcare and medication use, respectively. Conclusions: Psychological problems in cancer patients are associated with increased healthcare use, healthcare costs and economic losses. Further research is needed on psychological problems in relation to understudied healthcare use or costs categories, productivity losses, and informal care costs. [ABSTRACT FROM AUTHOR]

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: [ABSTRACT FROM AUTHOR]

Aim: This study assessed the self-reported health perception and use of health care by adults born very preterm before 30 weeks of gestation.Methods: The participants were part of a cross-sectional observational study that assessed the global health of young adults aged 18-29 years born very preterm in Quebec, Canada. Health perception was explored from 2011 to 2016 using the second Short-Form 36 Health Survey (SF-36v2), and objective health measures were obtained. Further in-depth open-ended questions were asked in 2018.Results: The 101 preterm subjects had similar perceptions of their health to 105 term-born controls, according to the SF-36v2, despite significantly more adverse health conditions. Their healthcare use was similar. However, the later in-depth questionnaire showed that 23% of 45 preterm subjects and 3% of 34 term-born subjects perceived their health as poorer than the general population. Major factors that could improve their respective health were lifestyle habits (74% vs. 81%) and eliminating specific adverse symptoms (52% vs. 27%). Only 10% of preterm individuals had been asked about their perinatal history by physicians.Conclusion: Adults born very preterm said their health was poorer than the general population and identified specific factors that should be addressed during routine health monitoring. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Rationale: Pulmonary rehabilitation (PR) is the most effective strategy to improve health outcomes in people with chronic obstructive pulmonary disease (COPD), although it has had limited success in promoting sustained physical activity. PR with a strong focus on disease self-management may better facilitate long-term behavior change. Objectives: To compare a newly developed enhanced PR (EPR) program with a traditional PR program on outcome achievement. Methods: In this randomized parallel-group controlled trial, PR classes were block-randomized to EPR or traditional PR and were delivered over 16 sessions each. The EPR program incorporated new and updated "Living Well with COPD" education modules, which had a stronger focus on chronic disease self-management. Fidelity of the intervention for content and delivery was assessed. Physical activity, self-efficacy, exercise tolerance, and health-related quality of life (HRQoL) were collected before, after, and 6 months after PR. Healthcare visits were collected 2 years before PR and 1 year after. Mortality was recorded 1 year after PR. Results: Of the 207 patients with COPD enrolled, 108 received EPR and 99 received traditional PR. Physical activity (steps) and self-efficacy improved from before to after PR in both programs, with no differences between groups. These effects were not sustained at 6 months. Exercise tolerance and HRQoL improved from before to after PR with no between-group differences and were maintained at 6 months. Visits to primary care providers and respiratory specialists decreased in the EPR program relative to the traditional PR program. EPR was delivered as intended, and there was no meaningful cross-contamination between the two programs. Conclusions: Enhancing PR to have a greater emphasis on chronic disease self-management did not result in a superior improvement of physical activity and health outcomes compared with traditional PR except for reduced resource usage from primary and specialist physician visits in the EPR program.Clinical trial registered with ClinicalTrials.gov (NCT02917915). [ABSTRACT FROM AUTHOR]

Abstract Background Advances in healthcare delivery have allowed for the increase in the number of ambulatory surgery procedures performed in Canada. Despite these advances, patients return to hospital following discharge. However, the reason for unplanned healthcare use after ambulatory surgery in Canada is not well understood. Aims To examine unplanned healthcare use, specifically emergency department visit and hospital admissions, in the 3 days after ambulatory surgery in Ontario, Canada. Methods This population-based retrospective cohort study was conducted using de-identified administrative databases. Participants were residents in the province of Ontario, Canada; 18 years and older; and underwent common ambulatory surgical procedures between 2014 and 2018. The outcomes included emergency department (ED) visit and hospital admission. Incidence rates were calculated for the total cohort, for each patient characteristic and for surgical category. The odds ratios and 95% confidence intervals were calculated for each outcome using bivariate and multivariate logistic regression. Results 484,670 adults underwent select common surgical procedures during the study period. Patients had healthcare use in the first 3 days after surgery, with 14,950 (3.1%) ED visits and 14,236 (2.9%) admissions. The incidence of ED use was highest after tonsillectomy (8.1%), cholecystectomy (4.2%) and appendectomy (4.0%). Incidence of admissions was highest after appendectomy (21%). Acute pain (19.7%) and haemorrhage (14.2%) were the most frequent reasons for an ED visit and “convalescence following surgery” (49.2%) followed by acute pain (6.2%) and haemorrhage (4.5%) were the main reasons for admission. Conclusions These findings can assist clinicians in identifying and intervening with patients at risk of healthcare use after ambulatory surgery. Pain management strategies that can be tailored to the patient, and earlier follow-up for some patients may be required. In addition, administrative decision-makers could use the results to estimate the impact of specific ambulatory procedures on hospital resources for planning and allocation of resources.

Abstract 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.

Abstract 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.

Abstract Background This study aimed to examine the healthcare-seeking (hospital, primary and preventive care) and healthcare utilisation behaviour of patients with private health insurance (PHI) in Australia. It also aimed to examine the socioeconomic, demographic and lifestyle factors that influence the choice of hospital care in Australia. Method A logistic regression model with repeated measure t-test and Pearson’s Chi-square test were used to identify the factors that affect the choice of care. Data from waves 9 (2009) and 13 (2013) of the nationally-representative Household, Income and Labour Dynamics in Australia (HILDA) survey were used in the analysis. Results Patients with PHI had a higher number of hospital nights’ stay despite having a lower number of hospital admissions than those without private cover. Significant disparities were identified in preventive and specialist care use between patients with cover and without cover. No significant variations were observed in healthcare utilisation for PHI patients before and after dropping PHI. One in four patients chose to use public hospitals despite holding PHI cover. Moreover, those insured and from lower socioeconomic backgrounds and those who were younger and without long-term health conditions showed a higher probability of selecting public rather than private care. Conclusions It is evident that PHI cover encourages people to use private care. However, a considerable number of PHI patients are using public care, even though eligible for private care may indicate consumer information asymmetry.

Abstract Background Like many other low- and middle-income countries (LMICs), the Ghanaian healthcare system remains poor which is likely to affect the utilisation of healthcare services, especially among poor older people who are faced with multiple health problems. Yet, factors that explain healthcare use among poor older people in LMICs, particularly Ghana remain largely unexplored. Understanding the predictors of healthcare use among poor older people could have a huge impact on health policies in LMICs including Ghana. This study, therefore, examined factors associated with healthcare use among poor older people under the Livelihood Empowerment Against Poverty (LEAP) programme in the Atwima Nwabiagya District of Ghana. Methods Cross-sectional data were obtained from an Ageing, Health, Lifestyle and Health Services (AHLHS) study conducted between 1 and 20 June 2018 (N = 200) in Atwima Nwabiagya District, Ghana. Sequential logistic regression models were performed to estimate the variables that predict healthcare use among poor older people. All test results were considered significant at 0.05 or less. Results The fully adjusted model showed that respondents aged 85–89 years (AOR = 0.094, CI: 0.007–1.170), acquired basic education (AOR =0.251, CI: 0.085–0.987), received no family support (AOR = 0.771, CI: 0.120–0.620), with no past illness records (AOR = 0.236, CI: 0.057–0.197) and who were not diagnosed of chronic non-communicable diseases (AOR = 0.418, CI: 0.101–0.723) were significantly less likely to utilise health facility compared with their respective counterparts. Moreover, those with no disability (AOR = 19.245, CI: 2.415–29.921) and who consumed low fruits (AOR = 1.435 = CI: 0.552–8.740) and vegetables (AOR = 1.202 = CI: 0.362–10.20) had a higher likelihood to use healthcare. Conclusion The study has outlined multiple factors influencing utilisation of healthcare among poor older people under the LEAP programme in Ghana. The results, therefore, validate the importance of social and behavioural determinants of healthcare use in the Ghanaian poor older population. We highlight the need for health planners and stakeholders to consider demographic, socio-economic, health-related and lifestyle factors when formulating health policy for poor older people in Ghana.

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.

Abstract The care pathway of patients with colorectal cancer (CRC) 1 year prior to death, their causes of death and the healthcare use, and associated expenditure remain poorly described together. People managed for CRC (2014‐2015), covered by the national health insurance general scheme and who died in 2015 were selected from the national health data system. A total of 15 361 individuals (mean age: 75 years, SD: 12.5 years) were included, almost 66% of whom died in short‐stay hospital (SSH), 9% in hospital at home (HaH), 4% in rehabilitation units (Rehab), 6% in skilled nursing homes (SNH), and 15% at home. At least one other cancer was identified for one‐third of these people. Almost one‐half of people presented cardiovascular comorbidity, 21% had chronic respiratory disease, and 13% had a neurological or degenerative disease. During the last month of life, 83% were admitted at least once to SSH, 39% had at least one emergency department admission, 17% were admitted to an intensive care unit, 15% received at least one chemotherapy session (

Chronic insomnia is highly prevalent and associates with poor physical and mental health, leading to high societal cost. Data on insomnia from Austria, including help-seeking behaviour, are currently lacking. In 2017 we conducted an online survey in Austrian adults aged between 18 and 67 years. Chronic insomnia was defined based on the 3rd edition of the diagnostic criteria of the International Classification of Sleep Disorders (ICSD-III) using an exact and a broad definition. Daytime functioning had to be affected “much” to “very much” for the exact (chronic insomnia) and “somewhat” for the broad (chronic insomnia symptoms) definition, respectively. We evaluated the distribution of sociodemographic characteristics, sleep problems overall and stratified by help-seeking behaviour. A total of 1004 participants (50.4% female, age 42 ± 13 years) completed the survey. In 8.9 % sleep problems were classified as chronic insomnia symptoms (broad definition) and in 7.8% as chronic insomnia (exact definition). Among participants with chronic insomnia symptoms and chronic insomnia, 26% and 53% respectively, reported active help-seeking behavior for their sleep problems. In conclusion, the prevalence of chronic insomnia appears comparable to that of other European countries with a higher proportion of people with chronic insomnia symptoms not fulfilling current diagnostic criteria. The low rates of active help-seeking behavior in both groups warrant more attention to public health initiatives regarding patient education and early treatment of insomnia.

Background: The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED's FUs within the Paris region.Methods: We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance's claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon.Results: FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5-12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities.Conclusion: FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories. [ABSTRACT FROM AUTHOR]

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

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 users, especially medical cannabis users, is scant. Objectives: We examined medical and nonmedical cannabis users aged 50+ on health-related characteristics, cannabis use patterns, and cannabis sources. Hypotheses were that compared to nonmedical users, medical users are more likely to have physical and mental health problems, use healthcare services, discuss their drug use with a healthcare professional, use cannabis more frequently, and purchase cannabis from a medical dispensary and other sources rather than obtain it as a gift, share someone else's, or use other means. Methods: We used 2018 and 2019 National Survey on Drug Use and Health data (N = 17,685 aged 50+; male = 8,030; female = 9,655). Hypotheses were tested using logistic regression analysis. Results: The past-year cannabis use rate was 8.9%. Of past-year users, 18.5% reported medical use. Compared to nonmedical use, medical use was associated with lower odds of alcohol use disorder but higher odds of discussing drug use with a healthcare professional (AOR = 4.18, 95% CI = 2.53–6.89), high-frequency use (e.g., AOR = 2.56, 95% CI = 1.35–4.86 for 200–365 days), and purchase at a medical cannabis dispensary (AOR = 4.38, 95% CI = 2.47–7.76). Conclusion: Medical and nonmedical users did not differ on physical and most behavioral health indicators. Most obtained cannabis from private/informal sources. Some medical users are likely to self-treat without healthcare professional consultation. Healthcare professionals should engage older adults in discussions of cannabis use and behavioral health needs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

War-related migration may deprive people of access to a regular healthcare system and cause new diseases to be battled. Since refugee women are more vulnerable to diseases during this period, protective healthcare services awareness is critical for early disease diagnosis. Following the civil war that triggered the migration of millions of Syrians, an extensive survey was undertaken in coordination with the World Health Organization Country Office in Turkey to explore the health status of Syrian refugees in Turkey. Employing the survey data, we aimed to investigate the determinants of the awareness of protective health services (Pap smear test, mammogram, HIV test) among female Syrian refugees. Logit regression analysis was applied in order to investigate the determinants of the awareness of protective health services among the female refugee population. The results revealed a notably low rate of awareness of protective health services among female Syrian refugees. Furthermore, the association of explanatory variables, including socioeconomic factors, healthcare use, and health literacy with the protective health services awareness, was found to be significant.

Background: Few have explored associations between loneliness and healthcare use independent of health and health behaviors. Recent indication of gender effects also requires validation across health service and cultural settings. We investigated the associations among loneliness, health and healthcare use (HCU) in older adults including stratification to investigate whether associations differed by gender.Methods: Secondary analysis of a nationally representative sample of 8,309 community-dwelling adults aged 50 and over from the Northern Ireland Cohort for the Longitudinal Study of Aging. Primary outcomes were: self-reported General Practice (GP) and emergency department (ED) visits in past year. Negative binomial and logistic regression analysis were used to investigate associations between loneliness and HCU, later adjusting for potential confounders (health and health behaviors).Results: Loneliness was consistently positively associated with both GP and ED visits (with IRRs ranging from 1.10 to 1.49 for GP visits, 1.16 to 1.98 for ED visits and ORs ranging from 1.13 to 1.51 for reporting at least one ED visit). With addition of health and health behaviors, all associations between loneliness and HCU became non-significant, excepting a small independent association between UCLA score and GP visits [IRR 1.03 (95% CI 1.01–1.05)]. Stratification of models revealed no gender effects.Conclusion: All but one association between loneliness and HCU became non-significant when health and health behaviors were included. The remaining association was small but implications remain for health service resources at population level. No gender effects were present in contrast to recent findings in the Republic of Ireland. Further studies on gender, loneliness and healthcare use needed.

Background: Exacerbation of asthma symptoms increases the likelihood of emergency department (ED) visits and hospitalizations. Because the ED is an important healthcare resource for immediate asthma care with acute exacerbations, we identify those populations most likely to seek ED treatment for asthma and describe the asthma burden for post-ED visit hospitalizations and critical care units. Methods: We examined the characteristics of asthma-related ED visits and hospital admissions and assessed the association between them using multivariable logistic regression models by analyzing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) during 2010–2015. Results: Of all ED visits, 1.32% were asthma-related; of all ED visits that resulted in hospitalization, 1.12% were asthma-related and, of all ED visits that resulted in admission to a critical care unit, 1.20% were asthma related. The percentages of asthma-related ED visits and post-ED hospitalizations (H) were greater among children (adjusted prevalence ratio: ED: 2.28 [1.96.29–2.65]; H: 8.75 [5.93–12.92]) than among adults and greater for blacks (ED: (2.26 [1.97–2.60]; H: 3.25 [2.07–5.12]) and Hispanics (ED: (1.74 [1.47–2.08]; H: 2.424 [1.46–4.00]) than for whites. The percentage of ED visits was also greater for those covered by Medicaid or the Children's Health Insurance Program (CHIP) than by private insurance. Conclusions: Both asthma-related ED visits and post-ED hospitalizations were greater for children, blacks, and Hispanics. ED visits were also greater for Medicaid/CHIP. These findings might help prompt future studies on identifying additional potential risk factors for frequent ED visits among disproportionally affected subpopulations. [ABSTRACT FROM AUTHOR]

Study Objective: To determine the impact of surgical wait time on healthcare use and surgical outcomes for patients undergoing hysterectomy for benign gynecologic indications.Design: Retrospective cohort study.Setting: Urban, academic tertiary care center.Patients: Patients who underwent hysterectomy for benign disease between 2012 and 2018.Interventions: None.Measurements and Main Results: Patients were categorized into 2 groups, dichotomized by surgical wait times >30 days or ≤30 days. Healthcare use was measured by the number of discrete patient interactions with the healthcare system through phone calls, secure electronic messaging, and office and emergency room visits. Univariate and multivariable logistic regression models were performed to assess the association between surgical wait time and healthcare use and perioperative outcomes while controlling for confounders. A total of 277 patients were included in our analysis: 106 (38.3%) had surgical wait times >30 days (median 47 days, range 24-68 days), and 171 (67.1%) had surgical wait times ≤30 days (median 19 days; range 12-26 days). The groups did not differ by age, insurance status, substance use, or comorbid conditions. Patients in the group with surgical wait times >30 days were more likely to have increased healthcare use (69 of 106, 65% vs 43 of 171, 25%; odds ratio 5.55; 95% confidence interval, 3.27-9.41). There were no differences in intraoperative complications (9 of 106, 8% vs 19 of 171, 11%; p = .482) or postoperative complications (28 of 106, 26% vs 32 of 171, 19%; p = .13) between the groups; however, after controlling for potential confounders, patients with surgical wait times >30 days were 3.22 times more likely to be readmitted than patients with surgical wait times ≤30 days (95% confidence interval, 1.27-8.19).Conclusion: A surgical wait time >30 days in patients undergoing a hysterectomy for benign disease is associated with increased healthcare use in the interim. Although patients who experience longer surgical wait times do not experience worse surgical outcomes, they may be at higher risk for readmission after surgery. Targeted interventions to optimize perioperative coordination of care for patients undergoing a hysterectomy for benign disease, especially those within vulnerable populations, are needed to improve quality of care, decrease any redundant or inefficient healthcare use, and reduce any unnecessary delays. [ABSTRACT FROM AUTHOR]

Abstract Background With the number of centenarians increasing exponentially in Spain, a deeper knowledge of their socio-demographic, clinical, and healthcare use characteristics is important to better understand the health profile of the very elderly. Methods We conducted a retrospective, cross-sectional observational study in the EpiChron Cohort (Aragón, Spain) aimed at analyzing the socio-demographic, clinical, drug use and healthcare use characteristics of 1680 centenarians during 2011–2015, using data from electronic health records and clinical-administrative databases. Results Spanish centenarians (79.1% women) had 101.6 years on average. Approximately 80% of centenarians suffered from multimorbidity, with an average of 4.0 chronic conditions; 50% were exposed to polypharmacy, with an average of 4.8 medications; only 6% of centenarians were free of chronic diseases and only 7% were not on medication. Centenarians presented a cardio-cerebrovascular pattern in which hypertension, heart failure, cerebrovascular disease and dementia were the most frequent conditions. Primary care was the most frequently visited healthcare level (79% of them), followed by medical specialist consultations (23%), hospitalizations (13%), and emergency service use (9%). Conclusions Multimorbidity is the rule rather than the exception in Spanish centenarians. Addressing medical care in the very elderly from a holistic geriatric view is critical in order to preserve their health, and avoid the negative effects of polypharmacy.

Abstract Background There is an increase in studies investigating the use of healthcare services prior to suicide. Although studies generally report high usage, there are no previous studies comparing immigrants’ use of primary healthcare (PHC) prior to suicide with that of majority populations. There is a strong influx of immigrants in Europe, and thus a growing demand for filling this knowledge gap and exploiting unused potential for suicide prevention. Method By linking three national registers, we examine contact with PHC prior to suicide in all suicide cases in Norway from 2007 to 2014 among individuals aged 15 years and over (N = 4341). We report the percentage of individuals in personal contact within the last 6 months, 1 month and 1 week prior to suicide, and use the chi square-test for association. Results Overall, immigrants have less contact with PHC prior to suicide. We find significantly lower rates of contact among immigrants, both 6 months and 1 month prior to suicide, for both sexes. The trend is similar in the last week prior to suicide, but less pronounced. The largest variance in contact with PHC prior to suicide is amongst 30–44 year olds. Young, male immigrant suicide victims have the lowest rates of contact with PHC prior to suicide. Contact rates increase with age for all men and women in the majority population, but not for female immigrant suicide victims. Conclusions There is a clear difference in rates of contact with PHC prior to suicide between the majority and immigrant populations. The rates are especially low among young males, and measures should be made to lower their threshold for consulting PHC for young males in general and young male immigrants in particular. The difference in contact due to immigrant status appears to be of equal importance as the difference due to sex, although, with few significant results, a conclusion is hard to draw.

Abstract Background For many survivors of acute respiratory distress syndrome (ARDS), the process from discharge from intensive care unit (ICU) to recovery is long and difficult. However, healthcare use after discharge from ICU has received only little attention by research. This study sets out to investigate the extent of ambulatory and stationary healthcare use among survivors of ARDS in Germany (multicenter DACAPO cohort) and to analyze predictors of stationary healthcare use. Results A total of 396 survivors of ARDS provided data at 1 year after discharge from ICU. Fifty percent of 1-year survivors were hospitalized for 48 days or longer after discharge from ICU, with 10% spending more than six out of 12 months in stationary care. The duration of hospitalization increased significantly by the length of the initial ICU stay. All participants reported at least one outpatient visit (including visits to general practitioners), and 50% contacted four or more different medical specialties within the first year after discharge from ICU. Conclusions For most of the patients, the first year after ARDS is characterized by an extensive amount of healthcare utilization, especially with regard to stationary health care. These findings shed light on the substantial morbidity of patients after ARDS and contribute to a better understanding of the situation of patients following discharge from ICU.

Chia-Lin Li,1,2 Fiona F Stanaway,3 Jen-Der Lin,2 Hsing-Yi Chang4 1Department of Health Care Management, College of Management, Chang Gung University, Kwei-Shan, Tao-Yuan 333, Taiwan; 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Tao-Yuan 333, Taiwan; 3Sydney School of Public Health, University of Sydney, Sydney 2006, NSW, Australia; 4Division of Preventive Medicine and Health Service Research, Institute of Population Health Sciences, National Health Research Institutes, Maoli 350, Taiwan Purpose: The aims of this study were to investigate the prevalence of frailty and its relationship with health care use among community-dwelling older adults with diabetes.Methods: We analyzed data from a nationally representative sample of people aged 65 years and above (n=3,203) participating in the 2013 National Health Interview Survey in Taiwan. A total of 719 participants had a history of self-reported physician-diagnosed diabetes. The presence of frailty was determined based on the Fatigue, Resistance, Ambulation, Illness, and Loss of weight (FRAIL) scale proposed by the International Association of Nutrition and Aging. FRAIL scores range from 0 to 5 and are categorized as frail (3–5), pre-frail (1–2), and robust (0). Participants were asked whether they had been hospitalized or had visited an emergency department in the past year.Results: Among community-dwelling older adults with diabetes, 9.4% of participants were frail and 35.3 % were pre-frail. After adjustment for other factors, being frail was significantly associated with hospitalization during the past year (OR =5.31, 95% CI =1.87–15.10), whereas being pre-frail was not associated with hospitalization. Both being pre-frail and frail were significantly associated with emergency department visits during the past year (OR =2.64, 95% CI =1.35–5.17 and OR =4.05, 95% CI =1.31–12.49, respectively) after adjustment for other factors.Conclusion: Our results highlight the high prevalence of frailty in community-dwelling older adults with diabetes. Furthermore, being frail is associated with a greater burden of hospitalizations and emergency department visits. Keywords: diabetes mellitus, elderly, frailty, health care use, Taiwan

Objective: To examine the possible association between diaper need, difficulty affording an adequate amount of diapers, and pediatric care visits for urinary tract infections and diaper dermatitis.Study Design: This cross-sectional analysis using nationally representative survey data collected July-August 2017 using a web-based panel examined 981 parents of children between 0 and 3 years of age in the US (response rate, 94%). Survey weighting for differential probabilities of selection and nonresponse was used to estimate the prevalence of diaper need and to perform multivariable logistic regression of the association between parent reported diaper need and visits to the pediatrician for diaper rash or urinary tract infections within the past 12 months.Results: An estimated 36% of parents endorsed diaper need. Both diaper need (aOR 2.37; 95% CI 1.69-3.31) and visiting organizations to receive diapers (aOR 2.14; 95% CI 1.43-3.21) were associated with diaper dermatitis visits. Similar associations were found for diaper need (aOR 2.63; 95% CI 1.54-4.49) and visiting organizations to receive diapers (aOR 4.50; 95% CI 2.63-7.70) for urinary tract infection visits.Conclusions: Diaper need is common and associated with increased pediatric care visits. These findings suggest pediatric provider and policy interventions decreasing diaper need could improve child health and reduce associated healthcare use. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

College is a critical time in a person's life. Young adults experience transitional changes in their independence, physical and mental health, and utilization of health care. The purpose of this research study is to examine the use of the Andersen Behavioral Model of Health Services Use in predicting how health impacts the academic performance of college students through predisposing, enabling, and need factors. Data was collected from 438 college students attending a large university in the Southeast. Students answered questions about their demographic characteristics, health, healthcare use, and academics using a survey adapted from the 2018 National College Health Assessment (NCHA) II conducted by the American College Health Association (ACHA). Bivariate and multivariate statistical analyses were run on the data and summarized. Results indicate that the Andersen Model is a useful model for framing the relationship between health and academic performance among college students. Enabling factors were more likely to predict health impact on academic performance while predisposing factors were least likely to predict these impacts. University administrators and government personnel can use these findings to explore the healthrelated needs of college students and implement services to accommodate these needs. [ABSTRACT FROM AUTHOR]

Background: Managing multimorbidity is complex for both patients and healthcare systems. Patients with multimorbidity often use a variety of primary and secondary care services. Country-specific research exploring the healthcare utilisation and cost consequences of multimorbidity may inform future interventions and payment schemes in the UK.Aim: To assess the relationship between multimorbidity, healthcare costs, and healthcare utilisation; and to determine how this relationship varies by disease combinations and healthcare components.Design and Setting: A systematic review.Method: This systematic review followed the bidirectional citation searching to completion method. MEDLINE and grey literature were searched for UK studies since 2004. An iterative review of references and citations was completed. Authors from all articles selected were contacted and asked to check for completeness of UK evidence. The National Institutes of Health National Heart, Lung, and Blood Institute quality assessment tool was used to assess risk of bias. Data were extracted, findings synthesised, and study heterogeneity assessed; meta-analysis was conducted when possible.Results: Seventeen studies were identified: seven predicting healthcare costs and 10 healthcare utilisation. Multimorbidity was found to be associated with increased total costs, hospital costs, care transition costs, primary care use, dental care use, emergency department use, and hospitalisations. Several studies demonstrated the high cost of depression and of hospitalisation associated with multimorbidity.Conclusion: In the UK, multimorbidity increases healthcare utilisation and costs of primary, secondary, and dental care. Future research is needed to examine whether integrated care schemes offer efficiencies in healthcare provision for multimorbidity. [ABSTRACT FROM AUTHOR]

The main purpose of this study is to examine the relationship between the healthcare professionals' level of showing healthy lifestyle behavior and their attitudes towards the use of healthcare services. The universe of the research is the middle and/or upper level managers of the general private hospitals operating in Istanbul under the umbrella of the Republic of Turkey Ministry of Health Private Health Institutions. In the study in which the quantitative research method (quantitative research design) was used, the data were collected by face-to-face questionnaire technique (the total number of questionnaires that were used and evaluated in the analysis is 390). In the study; descriptive statistics, explanatory factor analysis, multiple linear regression analysis and confirmatory factor analysis techniques were used. SPSS and AMOS package programs were used together in the analysis of the data. According to the results of multiple linear regression analysis of the research; it has been determined that the healthcare professionals' attitudes towards healthy lifestyle affect their attitudes towards vaccine practices positively and statistically significant. According to the results of the confirmatory factor analysis; it is seen that the majority of the fit indices of the proposed research model are at the acceptable fit level. [ABSTRACT FROM AUTHOR]

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

Background: Systematic reviews of preventive, non-disease-specific primary care trials for older people often report effects according to what is thought to be the intervention's active ingredient., Aim: To examine the effectiveness of preventive primary care interventions for older people and to identify common components that contribute to intervention success., Design and Setting: A systematic review and meta-analysis of 18 randomised controlled trials (RCTs) published in 22 publications from 2009 to 2019., Method: A search was conducted in PubMed, MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, and the Cochrane Library. Inclusion criteria were: sample mainly aged ≥65 years; delivered in primary care; and non-disease-specific interventions. Exclusion criteria were: non-RCTs; primarily pharmacological or psychological interventions; and where outcomes of interest were not reported. Risk of bias was assessed using the original Cochrane tool. Outcomes examined were healthcare use including admissions to hospital and aged residential care (ARC), and patient-reported outcomes including activities of daily living (ADLs) and self-rated health (SRH)., Results: Many studies had a mix of patient-, provider-, and practice-focused intervention components (13 of 18 studies). Studies included in the review had low-to-moderate risk of bias. Interventions had no overall benefit to healthcare use (including admissions to hospital and ARC) but higher basic ADL scores were observed (standardised mean difference [SMD] 0.21, 95% confidence interval [CI] = 0.01 to 0.40) and higher odds of reporting positive SRH (odds ratio [OR] 1.17, 95% CI = 1.01 to 1.37). When intervention effects were examined by components, better patient-reported outcomes were observed in studies that changed the care setting (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.17, 95% CI = 1.01 to 1.37), included educational components for health professionals (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.27, 95% CI = 1.05 to 1.55), and provided patient education (SMD for basic ADLs 0.28, 95% CI = 0.09 to 0.48). Additionally, admissions to hospital in intervention participants were fewer by 23% in studies that changed the care setting (incidence rate ratio [IRR] 0.77, 95% CI = 0.63 to 0.95) and by 26% in studies that provided patient education (IRR 0.74, 95% CI = 0.56 to 0.97)., Conclusion: Preventive primary care interventions are beneficial to older people's functional ability and SRH but not other outcomes. To improve primary care for older people, future programmes should consider delivering care in alternative settings, for example, home visits and phone contacts, and providing education to patients and health professionals as these may contribute to positive outcomes., (© The Authors.)