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Bo-Chieh Chang,1 Meng-Hsuan Kuo,1 Chi-Hui Lee,1 Ya-Lan Chu,1 Kuang-Peng Chen,2 Chun-Liong Tung,2 Ya-Hui Yang,3 Chuan-Sheng Hung,4 Jui-Hsiu Tsai,2,5 Hung-Yi Chuang6 1Department of Pharmacy, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; 2Department of Psychiatry, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; 3Department of Long-Term Care and Health Management, Cheng Shiu University, Kaohsiung, Taiwan; 4Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan; 5School of Medicine, Tzu Chi University, Hualien, Taiwan; 6Department of Environmental and Occupational Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanCorrespondence: Jui-Hsiu Tsai, Department of Psychiatry, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Min-Sheng Road, Dalin Town, Chiayi, 622, Taiwan, Email faanvangogh@gmail.comIntroduction: Poor adherence to antipsychotics in patients with schizophrenia is a leading cause of relapse and functional deterioration. Long-acting injectable paliperidone may reduce relapse risks, health-care utilisation, and health-care costs in these patients.Methods: In this 24-month mirror-image study, we compared health-care utilization and costs before and after the initiation of paliperidone palmitate 3-monthly (PP3M) treatment in patients with schizophrenia spectrum disorders. Before the initiation of PP3M, the patients received paliperidone 1-monthly (PP1M) treatment. The primary study outcomes were changes in health-care utilisation and costs over the study period.Results: This study included 34 patients with schizophrenia spectrum disorders. During the 12-months period after the initiation of PP3M treatment, the mean duration of hospitalisation decreased from 57.7 to 28.5 days (p = 0.03). Moreover, significant reductions were noted in emergency room visits (PP1M vs PP3M: 0.3 vs 0.0, respectively; p = 0.05) and health-care costs (PP1M vs PP3M: 107,328.8 vs 57,848.6, respectively; p = 0.03).Conclusion: PP3M may significantly reduce hospitalisation duration, emergency room visits, and health-care costs in patients with schizophrenia.Keywords: schizophrenia, long-acting injectable antipsychotics, paliperidone palmitate, health-care cost, health-care utilisation

Purpose: Population ageing is a demographic transition and burdens every country's health sector. A lack of social security combined with low government health-sector spending has made health-care utilisation difficult among elderly in many developing countries like India. This makes population ageing a global phenomenon for policymakers, researchers and stakeholders to discuss and debate in 21st century. The purpose of this paper is to examine the behavioural determinants of health-care utilisation among elderly population in Punjab. Design/methodology/approach: This study examines health-care utilisation among the elderly population in Punjab. A structured questionnaire was used to collect the data in the state of Punjab, with a multi-stage stratified random sample of 385 respondents. Logit regression was used to analyse the association between several behavioural factors like age, gender, place of residence, source of livelihood, education and frequency of visits with health-care utilisation among elderly aged 60 and above. Findings: This study revealed that gender, age, place of residence, source of livelihood, education and frequency of visits were significant determinants of health-care utilisation among elderly population. Originality/value: This study directs the need to improve health-care utilisation in a country, reducing inequalities that exist among the elderly population with respect to socio-economic and demographic differences. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to investigate occupational health (OH) primary-care patients' use of other health-care services and whether parallel use affects their likelihood to have sickness absences (SA) or disability pensions (DP). Methods: Primary-care services in Finland are provided through three parallel health-care sectors, all available to the working population: public, private and OH sectors. Patients may also be referred to secondary care. This follow-up study combines real-world medical record data containing SA data from a nationwide OH provider with health-care attendance data from public and private primary-care sectors and public secondary care, sociodemographic data and DP decisions. Patients between 18 and 68 years of age who used OH primary care at least once during the study years 2014–2016 were included. The total study population comprised 59,650 patients. Odds ratios were used to analyse association between parallel service use and SA or DP. Results: Females and patients with a lower educational level were more likely to use services in other health-care sectors in addition to OH than others. Those patients who used any other health-care sector in addition to OH primary care had an increased likelihood of having long SA or receiving DP. Conclusions: OH primary-care patients using the services of several health-care sectors in parallel have an increased likelihood of receiving disability benefits – either SA or DP. There is need for care coordination to ensure adequate measures for work-ability support. [ABSTRACT FROM AUTHOR]

Objectives: To investigate characteristics of frequent users of general practice (GP; ≥21 visits in a year), medical specialist (≥10 visits), emergency department (ED; ≥2 presentations) and hospital services (≥2 overnight hospitalisations) and the association with mortality for people aged over 75 years. Methods: The study included residents from Central and Eastern Sydney, Australia, aged over 75 years who participated in a large community‐dwelling cohort study. Demographic, social and health characteristics data were extracted from the 45 and Up Study survey. Health service (GP, medical specialist, ED and hospitalisations) use and mortality data were extracted from linked administrative data. We calculated adjusted prevalence ratios to identify independent characteristics associated with frequent users of services at baseline (approx. 2008) and adjusted hazard ratios to assess the association between frequent users of services and mortality. Results: Frequent users of services (GPs, medical specialists, EDs and hospitals) were more likely to be associated with ever having had heart disease and less likely to be associated with reporting good quality of life. Characteristics varied by service type. Frequent users of services were 1.5–2.0 times more likely to die within 7 years compared to those who were less frequent service users after controlling for all significant factors. Conclusions: Our analysis found that frequent service users aged over 75 years had poorer quality of life, more complex health conditions and higher mortality and so their health service use was not inappropriate. However, better management of these frequent service users may lead to better health outcomes. [ABSTRACT FROM AUTHOR]

Background: The elderly population is continuously growing and respiratory diseases account for 20% of chronic diseases among ageing people; these diseases are often treated imprecisely. Thus, the health-care system should adapt to the growing health needs of the elderly population. Aims: To study health care utilisation by geriatric patients with respiratory diseases. Material and Methods: A cross-sectional study of the elderly aged 60 years and over was conducted in the urban and rural areas of the National Capital Region and the Ghaziabad district of Uttar Pradesh. The first part of the study included socio-demographic characteristics and self-reported co-morbidities. In this first part, suspected respiratory cases were screened out, and a questionnaire regarding health-care utilisation was administered. The effect of socio-demographic factors on health-care utilisation was analysed. Results: In urban areas, 282/1522 (18.5%) and in rural areas, 298/1503 (19.8%) were found to suffer from respiratory illnesses. Health-care utilisation among elderly patients was significantly higher in urban areas compared to rural areas. In both areas, a large number of elderly people (70.5% rural and 61.7% urban) were insufficiently utilising health-care services. The socio-economic status (P = 0.034) and the source of income (P = 0.002) of urban residents were found to be significant factors. Among rural residents, health security (P = 0.05) and source of income (P = 0.002) were found to be statistically significant. Among the combined population (580), socio-economic status (P = 0.020) and source of income (P = 0.002) were found to be statistically significant. Conclusion: Health-care utilisation was better in urban residents than in rural elderly. However, majority of the elderly were utilising health-care services insufficiently in both areas. Socio-economic status and source of income had a significant effect on health-care utilisation.

A growing number of older men are living alone. They are often referred to as an at-risk group in health-care systems. The purpose of this article is to establish an overview of these men's health and health-care utilisation. We do so by drawing on three sources: an online survey with health-care professionals, data from a national self-report health study and register-based data on health-care utilisation. The results show that older men living alone generally have lower health scores than older men co-habiting and that, among older men living alone, lower educational level is associated with lower health scores but also a greater use of free-of-charge health-care services. Health-care professionals conducting preventive home visits consider older men's social needs the most pronounced problem for the men's wellbeing and call for new services to be custom made for them. In this article, we discuss differences between older men living in rural and urban areas and between those who are single, divorced or widowed. We conclude that health and social care systems must differentiate between sub-groups of older men living alone when developing new services and that free-of-charge services, such as general practitioners and home care, should be considered as vehicles for addressing health inequities. [ABSTRACT FROM AUTHOR]

Despite many patients waiting more than 2 years for treatment at publicly funded multidisciplinary chronic pain services, waitlist studies rarely examine beyond 6 months. We investigated psychological adjustment and health-care utilisation of individuals (N = 339) waiting ≤30 months for appointments at an Australian tertiary pain unit. Outcomes were relatively stable during the first 6 months, but long-term deteriorations in pain-related interference, distress and pain acceptance were evident, albeit with sex differences. Sexes also differed in uptake of new treatments. Medication use increased over time, but pain severity and medication relief did not. Results suggest that early intervention is important, especially for women. [ABSTRACT FROM AUTHOR]

Aim: Asthma is a major contributor to direct and indirect health-care costs and resource use. In May 2015, the Royal Children's Hospital (RCH) amended its clinical practice guideline for acute asthma management from discharging patients if the anticipated salbutamol requirement was every 3-4 h to discharging patients who were clinically well at 1 h after initial treatment. Our objective was to examine the impact of the new discharge recommendation on emergency department (ED) length of stay (LOS), rates of admission and representation.Methods: We retrospectively audited the case notes of children presenting with mild or moderate asthma to the RCH ED over the equivalent 2-week periods in winter 2014 (pre-implementation of the new guideline) and 2015 (post-implementation).Results: A total of 105 patients in 2014 and 92 patients in 2015 were included. In both years, all patients who initially presented with mild or moderate asthma either improved or stayed within the same severity classification at the 1-h assessment. For patients who were clinically well by the 1-h assessment, there was a significant reduction in admissions between 2014 and 2015 (40 vs. 10%, P = 0.001). There was also a reduction for these patients in median LOS from 3 h 13 min in 2014 to 2 h 31 min in 2015 (P = 0.03). In both years, all patients who were moderate at 1 h were admitted. There was no difference in the rate of representation or subsequent deterioration in those patients who were discharged at 1 h between the 2 years.Conclusion: Early discharge of patients who are clinically well 1 h after initial therapy may be associated with a reduction in LOS and admission rate without an apparent compromise in patient safety. Further evaluation of this intervention is required to determine whether this is a true causal relationship. [ABSTRACT FROM AUTHOR]

Low back pain (LBP) is a major public health problem globally, resulting in a significant personal and societal burden. However, little is known about health-care utilisation for optimal management of LBP. The aim of this systematic review and meta-analysis was to determine the prevalence rate of health-care utilisation for LBP. The electronic databases MEDLINE, EMBASE via Ovid, CINAHL, and Scopus were searched for peer-reviewed articles published in English before March 2018. Meta-analysis was performed using Stata version 14 software. The reported summary statistics including the pooled prevalence rate of health-care utilisation were calculated using a random-effects model. Of 5801 identified records, 20 met the inclusion criteria and were reviewed. The prevalence rate of health-care utilisation for LBP varied regionally, the pooled prevalence rate was 67%, 95% confidence interval (CI) 50–84 in the USA, 47%, 95% CI 39–56 in the UK and 48%, 95% CI 33–63 in Europe. General practitioners, chiropractors and physical therapists were health-care providers commonly engaged in the management of LBP patients, while medication treatment, exercise, massage therapy and spinal manipulation were common prescriptions. A range of factors influencing the decision to seek and use health-care for LBP were also identified. Despite LBP being a common public health problem, a significant proportion of people with the pain fail to use health-care. It is apparent from this review that there is possibly skewed data, as the evidence to date is largely from developed countries. Therefore, it is warranted that future studies investigate the epidemiology of health-care utilisation for LBP in developing countries. [ABSTRACT FROM AUTHOR]

Background: The Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness. Objectives: To explore the process of implementation of the SICP and the impact on patient outcomes and costs. Design: Qualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies. Setting: Salford in the north-west of England. Participants: Older people aged ≥ 65 years, carers, and health and social care professionals. Interventions: A large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’). Main outcome measures: Patient self-management, care experience and quality of life, and health-care utilisation and costs. Data sources: Professional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation. Results: The SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776). Limitations: The Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were

Abstract: Background and aims: Little is known about the long‐term economic consequences of smoking during pregnancy. We estimated the association between smoking in pregnancy and the costs of delivering health‐care to infants and children in England, and investigated which aspects of care are the key drivers of these costs. Methods: We used Hospital Episode Statistics (HES) linked with Clinical Practice Research Datalink (CPRD) data in England from January 2003 to January 2015 in children with longitudinal data for at least 1, 5 and 10 years after birth. Poisson regression provided rate ratios (RR) and 95% confidence intervals (CIs) comparing health‐care episode rates between those exposed and not exposed to smoking during pregnancy. Linear regression was used to compare estimated costs between groups (£ sterling, 2015 prices) and generalized linear multivariable (GLM) models adjusted for potentially moderating factors. Results: A total of 93 152 singleton pregnancies with the required data were identified. Maternal smoking in pregnancy was associated with higher primary care, prescription and hospital in‐patient episode rates, but lower out‐patient visit and diagnostic test rates. Adjusting for year of birth, socio‐economic deprivation, parity, sex of child and delivery method showed that maternal smoking in pregnancy was associated with increased child health‐care costs at 1 year [average cost difference for children of smokers, β = £91.18, 95% confidence interval (CI) = £47.52–134.83 and 5 years of age (β = £221.80, 95% CI = £17.78–425.83], but not at 10 years of age (β = £365.94, 95% CI = –£192.72 to £924.60). Conclusion: In England, maternal smoking in pregnancy is associated with increased child health‐care costs over the first 5 years of life; these costs are driven primarily by greater hospital in‐patient care. [ABSTRACT FROM AUTHOR]

Background: This study focuses on health care received by people with serious mental illness (SMI). The aim is to examine the economic implications of different locations of management of care and the views of service users and staff regarding services set up as alternatives to secondary care. Objectives: Specific objectives are to (1) identify people with SMI managed in primary or secondary care; (2) identify those who could be potentially transferred to primary care; (3) compare the characteristics of these groups; (4) compare service use and costs; (5) generate models to estimate cost changes following transfer between settings; (6) identify characteristics associated with time to transition to secondary care; (7) investigate experiences of patients receiving support from community-based interventions; and (8) assess the economic impact of interventions to facilitate transfer of care management. Methods: (1) Quantitative component – using linked primary and secondary care data we examined differences between those discharged to primary care (n = 1410) and those still in secondary care (n = 1629). Service use and costs were compared and predictors of costs were identified using regression models. (2) Qualitative component – interviews following a topic guide were conducted at two time points with 31 people using and 10 people working in services set up as alternatives to secondary care. (3) Economic modelling – an analysis of the health-care costs of the above services compared with usual care was conducted using decision modelling. Data were obtained from local services where possible, and the time horizon was 12 months. Results: (1) Quantitative component – characteristics of those discharged to primary care (n = 1410) were similar to those still in secondary care (n = 1629). Costs for those discharged to primary care were 48% lower than for those remaining in secondary care. Other variables strongly associated with costs were a history of violence and a diagnosis of schizophrenia or bipolar disorder. Few patients in secondary care had a high probability of primary care management and, therefore, excess costs were only around £150,000 across the sample. (2) Qualitative component – service users’ views about a community options team and a primary care support service were positive and compared favourably to services used previously. Views about peer support were slightly less consistent. Staff had concerns with regard to caseload sizes and staff turnover. (3) Economic modelling – services to help transition had costs that were 40% of those for standard care. The results of this showed that triaging patients into these services would save £1578 over a 1-year period and that the results were robust to changes in most parameters. Limitations: Analysis was hindered by the extent to which data were available. Qualitative analyses were limited by the fact that most of the participants did not have a SMI as usually defined and that many had been out of contact with secondary services for a long period of time. Conclusions: Costs are substantially lower in primary care than secondary care, even after controlling for service-user patient differences. Generally, there is satisfaction with services to help facilitate primary care provision and these appear to be cost saving. Future work should continue the analysis of linked data and involve a more comprehensive evaluation of the specific services investigated here. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Background User fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from healthcare. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation. Methods Sixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible. Results Fourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range -10 to 33). The modelled mean healthcare utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69). Conclusions Our research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess whether prematurely born infants have a genetic predisposition to respiratory syncytial virus (RSV) infection-related respiratory morbidity. One hundred and forty-six infants born at less than 36 weeks of gestation were prospectively followed. Nasopharygeal aspirates were obtained on every occasion the infants had a lower respiratory tract infection (LRTI) regardless of need for admission. DNA was tested for 11 single-nucleotide polymorphisms (SNPs). Chronic respiratory morbidity was assessed using respiratory health-related questionnaires, parent-completed diary cards at a corrected age of 1 year and review of hospital notes. Lung function was measured at a post menstrual age (PMA) of 36 weeks and corrected age of 1 year. A SNP in ADAM33 was associated with an increased risk of developing RSV LRTIs, but not with significant differences in 36-week PMA lung function results. SNPs in several genes were associated with increased chronic respiratory morbidity (interleukin 10 (IL10), nitric oxide synthase 2A (NOS2A), surfactant protein C (SFTPC), matrix metalloproteinase 16 (MMP16) and vitamin D receptor (VDR)) and reduced lung function at 1 year (MMP16, NOS2A, SFTPC and VDR) in infants who had had RSV LRTIs. Conclusions: Our results suggest that prematurely born infants may have a genetic predisposition to RSV LRTIs and subsequent respiratory morbidity which is independent of premorbid lung function. [ABSTRACT FROM AUTHOR]

Aim: Despite well-known emotional and behavioural sequela, few studies investigate health-care utilisation and injury impacts of children exposed to intimate partner violence (IPV). This study examines the association between mothers' IPV experience and general practitioner (GP) and hospital presentations by their children within the first 6 years of life. Methods: In 2000, a cohort of Pacific infants born in Auckland was established. At 6 weeks, 2 years and 6 years post-partum, maternal home interviews were conducted and IPV experience elicited using the Conflict Tactic Scale, together with reports of children's GP and hospital visitations. Results: At 6 weeks, 2 years and 6 years, 1098, 921 and 799 participating mothers were in intimate relationships. Severe physical IPV was reported by 22.1, 23.0 and 7.1% of mothers, respectively, and minor IPV was reported by another 18.7, 16.9 and 6.1%, respectively. Compared with children without maternal physical IPV exposure, children of mothers disclosing severe physical IPV were 1.19 (95% confidence interval (CI): 1.08–1.31) times as likely to visit GPs, and children of mothers disclosing minor physical IPV were 1.13 (95% CI: 1.02–1.25) times as likely to visit GPs, after adjusting for socio-demographic, maternal mental health and other confounding factors. No significant association was found between maternal IPV and children's hospital visits, or GP or hospital visits for injury. Conclusions: IPV is common for many mothers of Pacific children, and is associated with significantly more GP visits for exposed children. Identification of maternal IPV during mothers' and children's GP and hospital visits may help guide services to prevent future presentations to children. [ABSTRACT FROM AUTHOR]