Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers

While the frequency of children’s behavioral health (BH)-related visits to the emergency department (ED) is rising nationwide, few studies have examined predictors of high rates of ED use. This study examines Florida Medicaid claims (2011–2012) for children age 0–18 who were seen in an emergency department (ED) for behavioral health (BH) conditions. A logistic regression model was used to explore factors associated with frequent ED use and patterns of psychotropic medication utilization. The majority (95%) of patients with at least one BH-related ED visit had three or fewer of these visits, but 5% had four or more. Seventy-four percent of ED visits were not associated with psychotropic medication, including over half (54%) of visits for attention deficit hyperactivity disorder (ADHD). Frequent ED use was higher among older children and those with substance use disorders. The implementation of interventions that reduce non-emergent ED visits through the provision of care coordination, social work services, and/or the use of community health workers as care navigators may address these findings.     

Family structure, socioeconomic status, and access to health care for children

OBJECTIVE: To test the hypothesis that among children of lower socioeconomic status (SES), children of single mothers would have relatively worse access to care than children in two-parent families, but there would be no access difference by family structure among children in higher SES families. DATA SOURCES: The National Health Interview Surveys of 1993-95, including 63,054 children. STUDY DESIGN: Logistic regression was used to examine the relationship between the child's family structure (single-mother or two-parent family) and three measures of health care access and utilization: having no physician visits in the past year, having no usual source of health care, and having unmet health care needs. To examine how these relationships varied at different levels of SES, the models were stratified on maternal education level as the SES variable. The stratified models adjusted for maternal employment, child's health status, race and ethnicity, and child's age. Models were fit to examine the additional effects of health insurance coverage on the relationships between family structure, access to care, and SES. PRINCIPAL FINDINGS: Children of single mothers, compared with children living with two parents, were as likely to have had no physician visit in the past year; were slightly more likely to have no usual source of health care; and were more likely to have an unmet health care need. These relationships differed by mother's education. As expected, children of single mothers had similar access to care as children in two-parent families at high levels of maternal education, for the access measures of no physician visits in the past year and no usual source of care. However, at low levels of maternal education, children of single mothers appeared to have better access to care than children in two-parent families. Once health insurance was added to adjusted models, there was no significant socioeconomic variation in the relationships between family structure and physician visits or usual source of care, and there were no significant disparities by family structure at the highest levels of maternal education. There were no family structure differences in unmet needs at low maternal education, whereas children of single mothers had more unmet needs at high levels of maternal education, even after adjustment for insurance coverage. CONCLUSIONS: At high levels of maternal education, family structure did not influence physician visits or having a usual source of care, as expected. However, at low levels of maternal education, single mothers appeared to be better at accessing care for their children. Health insurance coverage explained some of the access differences by family structure. Medicaid is important for children of single mothers, but children in two-parent families whose mothers are less educated do not always have access to that resource. Public health insurance coverage is critical to ensure adequate health care access and utilization among children of less educated mothers, regardless of family structure.     

Predictors of GP service use: a community survey of an elderly Australian sample

As part of a study of an elderly community-dwelling Australian population, predictors of general practitioner (GP) service use were identified. The sample of 897 persons, aged 70 years or older and living in Canberra and Queanbeyan, were interviewed about their health and well-being. Data on the number of GP visits in the following 12-month period were obtained from the Health Insurance Commission. There were important gender differences in the prediction of both contact and volume of service use. Need variables (physical health in men, and disability and anxiety in women) were the most important predictors. Men who were older or who had lower occupational status used more medical services, as did women with less education or higher levels of extraversion. Men with lower social support were less likely to contact a GP, but social support was not related to volume of service use for either men or women. Since at most 21% of the variance in the volume of GP service use could be explained, despite the wide range of predictors considered and the different statistical approaches adopted, better measures of service use and predictors need to be developed.     

Food Insecurity,Dietary Quality,and Health Care Utilization in Lower-Income Adults: A Cross-Sectional Study

BackgroundFood insecurity and poor nutrition are prevalent in the United States and associated with chronic diseases. Understanding relationships among food insecurity, diet, and health care utilization can inform strategies to reduce health disparities.ObjectiveOur aim was to determine associations between food security status and inpatient and outpatient health care utilization and whether they differed by dietary quality in lower-income adults.DesignThis was a cross-sectional study of data from the 2009-2016 National Health and Nutrition Examination Survey.Participants/settingParticipants were 13,956 lower-income (<300% federal poverty level) adults 18 years and older in the United States.Main outcome measuresSelf-reported health care utilization in the past 12 months included no usual source of care, any outpatient visit, any mental health service use, and any hospitalization.Statistical analysesMultiple logistic regression was used to study the association between food insecurity and health care utilization. Analyses were stratified by diet-related comorbidities to account for potential confounding and mediation of health care utilization, and by dietary quality.ResultsIn a sample of lower-income adults <300% federal poverty level, 4,319 participants (27.4%) were food insecure, 2,208 (15.0%) were marginally food secure, and 7,429 (57.6%) were food secure. Food insecurity was associated with having no usual source of care (adjusted odds ratio [aOR] 1.30; 95% CI 1.11 to 1.52), any mental health service use (aOR 2.02; 95% CI 1.61 to 2.52), and any hospitalization (aOR 1.19; 95% CI 1.01 to 1.41). Food-insecure adults were more likely to report no outpatient visits if they had diet-related comorbidities (aOR 1.45; 95% CI 1.10 to 1.92) or the lowest dietary quality (aOR 1.53; 95% CI 1.06 to 2.23). Marginal food security was associated with having no usual source of care (aOR 1.22; 95% CI 1.04 to 1.44).ConclusionsAdults with food insecurity were more likely to be hospitalized, use mental health services, and have no usual source of care. Food-insecure participants with diet-related comorbidities or poor diet were less likely to have outpatient visits. Hospitalizations and mental health visits represent underused opportunities to identify and address food insecurity and dietary intake in lower-income patients.     

Physician Visits in a Farming-dependent County

Physician visits in a farming-dependent county in the upper-Midwest were studied using a mail questionnaire. A 16 percent random sample of households yielded 426 surveys (60 percent response rate). The dependent variable was the natural log (plus one) of the number of times the respondent had seen a physician in the prior 12 months. Predisposing, enabling, and medical need variables were tested as potential predictors of medical care usage. Self-rated health status proved to be an important predictor, as was a history of hospitalization and being married. However, health insurance coverage and family income were not associated with increased physician visits. Implications for modifying the conceptual model employed to analyze medical care utilization in similar populations are discussed.     

What's said and what's done: the reality of sexually transmitted disease consultations

OBJECTIVE: Indirect data collection methods, or approaches which disturb usual practice, are generally used in health care evaluation. We have compared what doctors report at interview what is observed by an identified researcher with an unobtrusive measure of their usual practice. DESIGN: Private practitioners who provide a service to sexually transmitted disease (STD) patients were interviewed regarding their usual case management. An identified researcher carried out structured observations of consultations between physicians and patients. Simulated clients then sought consultations, presenting a standardised history and symptom profile. Structured reporting of the history taking, examination, treatment and counselling aspects of these consultations was undertaken. SUBJECTS: Eighteen private practitioners in Madras (now Chennai), India. MAIN OUTCOME MEASURES: Comparisons between interviews, observations by identified researchers and the experiences of simulated clients were carried out. RESULTS: Interviews with physicians and observations by identified researchers indicated more favourable practice than was seen during simulated client visits. These differences were substantial and would lead to a severe misrepresentation of the actual situation-and thus of intervention needs, if data from interviews or observations were relied upon. CONCLUSIONS: The usual methods used in the evaluation of medical services and in carrying out medical audit may produce highly unreliable findings. STD services in the study area are failing to realise their potential of improving the sexual health of populations. The methodological and substantive findings of this study could be combined through the introduction of simulated client visits in the monitoring, improvement and licensing of STD (and perhaps other medical) services.     

Correlates of underutilization of gynecological cancer screening among lesbian and heterosexual women

BACKGROUND: Study aims were to examine cervical cancer risk factors, screening patterns, and predictors of screening adherence in demographically similar samples of lesbian (N=550) and heterosexual women (N=279). METHODS: Data are from a multisite survey study of women's health conducted from 1994 to 1996. RESULTS: Differences in sexual behavior risk factors for cervical cancer were observed with lesbians reporting earlier onset of sexual activity (P<0.05), more sexual partners (P<0.001), and lower use of safer sex activities (P<0.01). Lesbian and heterosexual women were equally likely to have ever had a Pap test; however, lesbians were less likely to report annual (P<0.001) or routine (P<0.001) testing. Multivariate analyses were used to determine the associations between demographics, health care factors, health behaviors, and worry about health and screening behaviors. Individual predictors of never screening included younger age, lower income, and lack of annual medical visits. Independent predictors of both recent and annual screenings included history of an abnormal Pap test, being heterosexual, and annual medical visits. CONCLUSION: Data indicate that lesbians are at risk for cervical cancer, yet underutilize recommended screening tests. Findings have implications for research, education, and cancer control among lesbians.     

Cold/flu knowledge, attitudes and health care practices: results of a two-city telephone survey.

The purpose of this paper is to describe knowledge, attitudes and practices of cold and flu self-care and health care utilization, and to identify the predictors of health care utilization for the cold and flu among residents of London and Windsor. Using a random digit dialing survey method, 417 residents were interviewed between November-December, 1993 and February-March, 1994. This survey revealed good knowledge about colds and flu and understanding of appropriate physician visits. Only seven percent reported a doctor visit for their last cold. Socio-demographic, health status, attitude and knowledge level variables were subjected to a logistic regression analysis to identify which variables predicted self-reported physician visits. Only attitudes and health status showed statistically significant log odds (3.6 and 1.5, respectively). In summary, consistent with other studies, attitude and health status, not knowledge, appear to be significant predictors of physician visits for colds/flu.     

A Primary Care Intervention for Depression

To assess a guideline-based intervention's impact on depression care provided in rural vs. urban primary care settings, 12 community primary care practices (four rural, eight urban) were randomized to enhanced (i.e., intervention) and usual care study conditions. The study enrolled 479 depressed patients, with 432 (90.2 percent) completing telephone follow-up at six months. Multilevel analytic models revealed that rural enhanced care patients had 2.70 times the odds (P = 0.02) of rural usual care patients of taking a three-month course of antidepressant medication at recommended dosages in the six months following baseline; urban enhanced care patients had 2.43 times the odds compared with their urban usual care counterparts (P = 0.007). Rural enhanced care patients had 3.00 times the odds of rural usual care patients of making eight or more visits to a mental health specialist for counseling in the six months following baseline (P = 0.03). Comparisons of patients in enhanced care practices showed that rural enhanced care patients had 2.00 times the odds (P = 0.12) of urban enhanced care patients of making at least one visit to a mental health specialist for counseling in the six months following baseline and had comparable odds to urban enhanced care patients (odds ratio [OR] = 1.06, P = 0.77) of making eight or more visits to such specialists during that interval. The study's intervention improved the care received by both rural and urban depressed primary care patients. Moreover, the intervention's effect appears to have been greater in rural settings, particularly in terms of increasing depressed rural patients' use of mental health specialists for counseling.     

A randomized trial of telenursing to reduce hospitalization for heart failure: patient-centered outcomes and nursing indicators

This trial compared 3 post-hospitalization nursing care models for reducing congestive heart failure (CHF) readmission charges during 180-days of follow-up. Subjects received in-person visits at baseline and 60 days plus 1 of 3 care modalities in the interim: (a) video-based home telecare; (b) telephone calls; and (c) usual care. CHF-related readmission charges were > 80% lower in the telenursing groups compared to usual care, and these groups also had significantly fewer CHF-related emergency visits. In-person visits were more than 3 times longer than telenursing visits (p < 0.0001), only partially due to added travel time. Patient self-care adherence, medications, health status, and satisfaction did not significantly differ between groups. Telenursing can reduce CHF hospitalizations and allow increased frequency of communication with patients.     

Gesundheitsberatung Und Motivation Zu VerhaltensäNderungen Nach Dem Check Up 35 Bei Risikopatienten

Since 1989 a biannual health examination has been available to the members of public insurance funds in Germany. To provide some evaluation of the measure, we studied the process and effectiveness of health counselling for participants of the regular health check-up. Participating primary care practitioners in the lands of Hessen and Thüringen were randomized to received either instruction for health counselling (intervention group) or no training (control group). The former received also printed materials for their patients covering diet, smoking, stress and exercise. The control goup practiced usual care. Only patients with previously untreated risk factors were to be included in the study. Patients’ health behaviors as assessed by standard instruments and cardiovascular risk profiles evaluated after one year’s follow-up served as endpoints. We also studied the frequency and intensity of counselling visits. Both groups improved with regard to their general subjective health status and wellbeing. There were no differences between intervention and control groups in cardiovascular risk-profile, health behaviours, or counselling visits. A one day teaching session for primary care practitioners and printed materials did not induce the desired change in provider behavior, at least not to the degree that patients’ behaviors or risk factors were improved. At the same time, health status improved considerably.     

Workplace health promotion and utilization of health services

This article reports findings from a workplace substance abuse prevention program designed to investigate best practices. The study sought to assess the effects of the worksite wellness program and employee assistance program (EAP) on healthcare utilization and costs, identify predictors of outpatient costs and visits, and assess the effect of the intervention on health attitudes, behaviors, and behavioral health-related costs and visits. Results indicated that visits to the EAP increased as did overall healthcare visits, that utilization of healthcare services and costs were higher in the population receiving substance abuse prevention intervention, and that employees in the substance abuse prevention intervention reported lower heavy drinking and binge drinking. Data suggest that substance abuse prevention may result in higher healthcare costs and utilization in the short term, but a reduction in health risk behaviors such as heavy drinking may result in lower healthcare costs and utilization in the long term.     

Predictors of health care utilization in the chronically ill: a review of the literature

The objective of this paper is to identify predictors of health care utilization in the chronically ill. This paper reviews 53 studies on hospitalizations and physician visits, published between 1966 and 1997 and identified by MEDLINE and ClinPSYCH databases. Studies with both univariate and multivariate analyses were included. On the basis of the Andersen-Newman model of health care utilization, the effects of predisposing, enabling and need variables are examined. Most studies reviewed indicate that predisposing factors such as age, sex, and marital status are not predictors of hospital utilization in the chronically ill. The enabling factors income, insurance and social support have not been shown to affect health care utilization, but characteristics of the hospitals could have an effect. Need factors such as disease severity, symptom severity and complications adversely affected health care utilization in the chronically ill, while disease duration and comorbidity do not have such an effect. Quality of life and perceived health might affect hospital utilization and physician use. Finally, depression and psychological distress proved to be among the strongest predictors of hospitalizations and physician visits. In conclusion, both disease severity and psychological well-being are most important in health care utilization. Intervention programs to support depressed or psychologically distressed patients should be considered. These could both help the patient and reduce health care utilization costs.     

Usual sources, patterns of utilization, and foregone health care among Hispanic adolescents

Purpose: To describe and differentiate the usual sources of health care, patterns of utilization of services, and reasons for foregone health care among Hispanic adolescents by place of birth (U.S. mainland versus Puerto Rico or other country) and gender.

Methods: All subjects who identified themselves as Hispanic (n = 717) in a larger survey of 10,059 students in 7th (n = 3596), 9th (n = 3691), and 11th (n = 2772) grades in the state of Connecticut in 1996 were included in this secondary analysis. Data were analyzed using Pearson product-moment coefficients, Chi-squares, and logistic regression.

Results: The majority of usual sources of medical care services were community clinics or private doctors’ offices. Subjects born in Puerto Rico or countries other than the United States were more likely to use a doctor’s office. About 5% reported no usual source of care. Over 25% reported not going to a doctor or other health care provider when they thought they should (foregone care). There were significant gender differences in reasons given for foregone care. Feeling connected to others was a significant predictor of having had a physical examination and negatively associated with foregone care for girls. For boys, connectedness and use of alcohol were negative predictors of foregone care.

Conclusions: The majority of Hispanic youth in this sample report having a usual source of medical care and the source differs by place of birth. Adolescents who do not report high levels of connectedness are more likely to have foregone care. The most frequent explanation given for not having sought care was that subjects thought the problem would go away. Socialization about how to access and use health care services, as well as what to expect, is needed by Hispanic adolescents who may be at risk.     

Impact of community health centers and Medicaid on the use of health services.

The impact of improved access to health care through the Federal community health center (CHC) and Medicaid programs was examined in five urban low-income areas. Data on access to care and physician, hospital, and dental services utilization were collected by baseline and followup health surveys in the CHCs'' services areas. There was a shift in use from hospital clinics to CHCs. Followup surveys indicated that 23 percent of the population reported CHCs as usual source of care. Travel time to source of care was reduced for users of CHCs. Medicaid coverage of the population in the survey areas increased from 16 to 37 percent between the baseline and followup surveys, an interval of 4 to 7 years. Increases occurred in the use of physicians and dental care between the baseline and followup surveys, but the rates scarcely kept pace with the national rates. Respondents who reported CHCs as their usual source of care, however, had a higher rate of physician visits and a lower rate of hospitalization compared with those using private physicians or hospital clinics as the usual source of care. Respondents with Medicaid coverage usually had higher physician and hospital use, irrespective of usual source of care. Both CHC and Medicaid programs contributed to increased use of dental care by providing financial and dental care resources. Although these two programs greatly facilitated the use of health services, disparity in physician and dental utilization remains between the five low-income areas and the averages for the nation.     

Effect of case mix on provider continuity

A random sample of 265 patient charts was selected to assess the degree of provider continuity at the University of North Carolina Family Practice Center from July 1, 1983, to June 30, 1984. Continuity was measured using usual provider continuity, the ratio of the number of visits with the assigned physician divided by total visits. Usual provider continuity rates varied as predicted for three types of visits: acute illness (0.55), chronic illness (0.76), and health maintenance (0.86). The average rate of usual provider continuity was 0.68. Case mix had a statistically significantly effect on provider continuity when comparing acute care with either chronic or health maintenance care (P less than .01). Because case mix is relevant and varies from site to site, a method of rate standardization was suggested using data on case mix from the National Ambulatory Medical Care Survey. Direct rate adjustment, a standard epidemiologic technique, would make continuity rates directly comparable for sites with different case mixes.     

Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers

Federally qualified health centers, also known as community health centers, play an essential role in providing health care to millions of Americans. In return for providing primary care to underserved, homeless, and migrant populations, these centers are reimbursed at a higher rate than other providers by public programs such as Medicaid. Under the Affordable Care Act of 2010, the role of the centers is expected to grow. To examine the quality of care that the centers provide, the Colorado Department of Health Care Policy and Financing compared the use of costly hospital-related services by Medicaid clients whose usual source of care was a community health center with the use by clients whose usual source of care was a private, fee-for-service provider. The study found that community health center users were about one-third less likely than the other group to have emergency department visits, inpatient hospitalizations, or preventable hospital admissions. Public funders such as states should work with community health centers to improve the quality and reduce the cost of care even further.     

Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English proficiency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ significantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONS The mailing of FOBT kits directly to patients was efficacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English proficiency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened.     

A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services.

Randomized controlled trials of case management in primary care have been infrequent and contradictory. The aim of this study was to determine if a clinic-based ambulatory case management intervention, Primary Intensive Care (PIC), would reduce hospital utilization and total cost and/or improve health outcomes among primary care patients with a recent history of high use of inpatient services. Current patients with > or =2 hospital admissions per year in the 12-18 months prior to recruitment in an urban primary care clinic were enrolled in a randomized clinical trial. Patients were randomized to the PIC intervention or usual care. PIC patients underwent a comprehensive multidisciplinary assessment with the result being a team-generated plan. The PIC team nurse practitioner served as case manager for the 12 months of follow-up and provided services designed to implement the care plan for those in the experimental group. Health care use, function, and a medication adherence scale were measured at baseline and at 12 months. There were no significant differences when either comparing the number of admissions pre and post enrollment within groups or the followup results post intervention between groups. A similar result was noted for the number of emergency department visits. The number of clinic visits increased in the intervention group by 1.5 visits per year which was statistically significant when compared to the control group. Overall functional status, health outcomes, and the Mental Health Functional Status subscore did not change significantly in either group during the study. We were unable to detect a difference in hospital use or functional status, mental health function, or medication adherence among patients who require frequent hospital admissions using our intervention.     

A case study of early experience with implementation of collaborative care in the Veterans Health Administration

Primary care remains critically important for those who suffer from mental disorders. Although collaborative care, which integrates mental health services into primary care, has been shown to be more effective than usual care, its implementation has been slow and the experience of providers and patients with collaborative care is less well known. The objective of this case study was to examine the effects of collaborative care on patient and primary care provider (PCP) experiences and communication during clinical encounters. Participating physicians completed a self-administered visit reconstruction questionnaire in which they logged details of patient visits and described their perceptions of the visits and the influence of collaborative care. Audio recordings of visits were analyzed to assess the extent of discussion about colocated mental health services and visit time devoted to mental health topics. The main outcome measures were the extent of discussion and recommendation for collaborative care during clinical visits and providers' experiences based on their responses to the visit reconstruction questionnaire. Providers surveyed expressed enthusiasm about collaborative care and cited the time constraint of office visits and lack of specialty support as the main reasons for limiting their discussion of mental health topics with patients. Despite the availability of mental health providers at the same clinic, PCPs missed many opportunities to address mental health issues with their patients. Ongoing education for PCPs regarding how to conduct a "warm handoff" to colocated providers will need to be an integral part of the implementation of collaborative care.