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A prospective study of 87 independently living adults with spinal cord injury (SCI) as a major disabling condition showed the following average annual health care utilization rates: 1.3 hospital admissions, 16.8 days hospitalized, 1.7 emergency room (ER) visits, and 22.4 outpatient contacts (in person or by telephone). Those hospitalized (n = 66) experienced a mean of 22.2 days hospitalized per person per year. Mean length of stay (LOS) was 11.1 days per admission. Stepwise regression analysis indicated no statistically significant (p less than or equal to .05) predictors of hospital admissions. There were three independent predictors of days hospitalized (greater age, fewer years of education, and more days hospitalized during the previous year), three predictors of days hospitalized for those hospitalized only (greater age, fewer years of education, and longer hospital LOS during the previous year), one predictor of LOS (self-assessment of health), three of emergency room (ER) visits (more unmet instrumental activities of daily living needs, lack of organizational memberships, and more ER visits during the previous year), and five predictors of outpatient contacts (greater age, less satisfaction with health care providers' expressions of concern for their health, lower frequency of leaving apartments, lower levels of life satisfaction, and nonparticipation in a managed medical care demonstration project). Many predictors of health services utilization are immutable. However, changes which facilitate social interaction and changes in the organization of health services may reduce certain types of medical care utilization by people with SCI.

A prospective study of the medical care utilization experience of 205 severely-disabled independently-living adults in Eastern Massachusetts shows that there was a mean of 0.83 ± 1.26 hospital admissions, 9.9 ± 22.7 hospital days, 1.5 ± 2.31 emergency room (ER) visits, and 26.88 ± 44.4 outpatient contacts per person per year. Among those hospitalized, the mean experience was 16.2 ± 27.1 days per person per year; mean length-of-stay was 9.3 ± 14.7 days per admission. Regression analysis indicates that those with spinal cord injuries as major disabling conditions were significantly more likely to be hospitalized. So were those with lower self-assessments of health, higher levels of depressions, and more baseline ER visits. Self-assessment of health is a significant predictor of hospital days for the total cohort (including those with no admissions); so are age at onset of disability (greater age; higher risk), and bed disability days in the month before the baseline survey (more disability days; higher risk). Among those hospitalized, the total number of days hospitalized is significantly related to both age at onset of disability (later onset; more days) and baseline days hospitalized (greater number; more days). Lengths-of-stay are significantly related to two factors; age and age at onset of disability (in both cases, greater age associated with longer stays). Prior ER visits are a significant predictor of subsequent ER visits (more baseline; more subsequent); so are respondents' reported satisfaction with their participation in their medical care (lower reported satisfaction; more ER visits), organizational affiliations, and frequencies of contacts with friends or relatives. Higher levels of social interaction (.e. organizational affiliation and more frequent social contacts) were associated with more ER visits. Prior contacts with physicians, nurse-practitioners, or physician-assistants was the most powerful predictor of subsequent outpatient contacts (more baseline;,more subsequent). There were also significant relationships between subsequent contacts and respondents' assessments of their health relative to others with similar disabilities (relatively worse health; more contacts), age (greater age; more contacts), and baseline ER visits (more visits; more contacts).

Fifty-seven elderly homebound patients with arthritis and orthopedic disabilities were randomized to a goal-oriented outreach rehabilitation program or to usual treatment. Although 64% of patient goals were met, there were no overall significant differences in functional scores, institutionalization, or contentment between treatment and control periods. Twenty-three patients had maintained clinical improvement at the end of the study and some patients were dramatically improved with simple measures. The program's marginal costs were modest and consisted primarily of expenses associated with therapist's visits. The total costs of assistive devices and home modifications amounted to $1,902. Twenty-five percent of the homebound population could benefit from such services but the actual number who would partake is small.

We describe an approach to health care in the inner city: a multidisciplinary system of physicians and mid-level practitioners that provides individualized care to chronically ill, elderly, homebound, and nursing-home residents of urban Boston who would otherwise be forced into an inappropriate reliance on teaching hospitals. Linked to four neighborhood health centers, three home-care programs, and a teaching hospital, and financially self-supporting except for the home-care component, the system cared for 3000 ambulatory, 280 homebound, and 358 nursing-home patients in the representative year described. In-hospital use, particularly hospital days, was reduced when judged by existing data for comparable (though not identical) populations. Based on stable physician practices, the system offers a workable approach to the related problems of care, manpower, and cost in the urban core.

We conducted an 18-month longitudinal evaluation of a model-managed medical care program for severely disabled, independently living adults. Regression analyses using an additive model (no interaction effects) suggest that persons in the study group did not have statistically significantly different utilization experiences than members of the comparison group. Regression analyses that include interaction effects suggest that, for certain segments of the cohort, the study group's utilization experience was significantly lower than that of members of the comparison group. Persons in the study group with higher baseline emergency room (ER) utilization had significantly fewer hospital admissions (P = 0.0055). The participants with better self-assessments of health experienced significantly fewer hospital days per person (P = 0.0075) and days per person hospitalized (P = 0.0056), and persons with organizational affiliations reported significantly fewer ER visits (P = 0.0264).