Impact of health maintenance organizations and fee‐for‐service on health care utilization among people with systemic lupus erythematosus

Objective

To compare health care utilization in people with systemic lupus erythematosus (SLE) in health maintenance organizations (HMOs) and fee‐for‐service (FFS).

Methods

A structured survey was administered to a cohort of 982 people with SLE who were assembled between 2002 and early 2005. A total of 2,656 person‐years of observation were completed by the end of 2005. In each year, respondents reported their health care utilization and whether they had HMO or FFS coverage. We compared health care utilization of those in HMOs and FFS, with and without adjustment for socioeconomic, demographic, and health characteristics using repeated‐measures regression techniques.

Results

Compared with people with SLE who were in FFS, those in HMOs were younger (3.3 years), received a diagnosis at an earlier age (3.6 years), had slightly less disease activity (0.4 on a 10‐point scale), were more likely to be nonwhite (8.8%), were less likely to be below the poverty line (7.8%), and were less likely to have public insurance (29.7%). The 2 groups did not differ in other characteristics. On an unadjusted basis, subjects with SLE in HMOs had significantly fewer physician visits (3.1; 95% confidence interval [95% CI] 1.7, 4.5) and were less likely to report one or more outpatient surgical visits (6.3%; 95% CI 2.5, 10.0), and hospital admissions (5.5%; 95% CI 1.7, 9.3) than those in FFS. Adjustment reduced the differences in physician visits (2.3; 95% CI 1.1, 3.5), outpatient surgical rates (4.4%; 95% CI 0.6, 8.1), and hospital admission rates (4.0%, 95% CI 0.4, 7.7).

Conclusion

Subjects with SLE in HMOs utilized substantially less ambulatory care and were less likely to have outpatient surgery and hospital admissions than those in FFS; the effects were not completely explained by socioeconomic, demographic, and health characteristics.

     

The impact of managed care on health care utilization among adults with asthma.

STUDY OBJECTIVES: To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. DESIGN: Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. MEASUREMENTS: Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. RESULTS: Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI -5.4, -0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = -16.5, 95% CI -27.8, -5.3). The two groups did not differ significantly in the proportion with asthma-related or nonasthma hospital admissions. CONCLUSIONS: Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in nonasthma care.     

Outcome and utilization differences for older persons with stroke in HMO and fee-for-service systems

OBJECTIVES: To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) systems. DESIGN: Inception cohort stratified by payer and followed for 1 year. SETTING: Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States. PARTICIPANTS: A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995. MEASUREMENTS: Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits. RESULTS: At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37-1.09). At 1 year, there was no difference in ADL recovery (difference, -0.24 ADL; 95% CI, -0.64-0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1-3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1-5.5). CONCLUSION: Study findings suggest that short-term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee‐for‐service settings. Design. Cross‐sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist‐immunologists, family practitioners, and from a random sample of the non‐institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee‐for‐service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta‐agonists, home nebulized beta‐agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI ? 5.4, ? 0.1), principally because those in MC had many fewer visits to allergist‐immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = ? 16.5, 95% CI ? 27.8–5.3). The two groups did not differ significantly in the proportion with asthma‐related or non asthma hospital admissions. Conclusions. Persons with asthma in fee‐for‐service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist‐immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

Elderly patients with congestive heart failure under prepaid care

PURPOSE: Because of concern about the quality of care received by Medicare patients in health maintenance organizations (HMOs), the care of patients with congestive heart failure (CHF) in eight HMOs was compared with the care of fee-for-service (FFS) Medicare cases. PATIENTS AND METHODS: We compared the care of 170 patients with CHF enrolled in one of eight Medicare HMOs with the care of 191 similar FFS patients. Panels of expert physicians developed criteria for evaluating quality of care, and specially trained nurse clinicians abstracted medical records. RESULTS: Outpatient evaluation and management were similar in both settings, although HMO patients were significantly more likely to be advised to restrict salt intake. However, FFS patients with uncontrolled hypertension were more likely to have their medication regimens changed (62% versus 36%, p less than 0.01). Ejection fractions were obtained equally as often, and inpatient management was similar for both groups. Nonetheless, HMO providers scheduled follow-up visits within 1 week of hospital discharge more often (42% versus 27%, p less than 0.01). CONCLUSIONS: This study suggests that financial incentives of prepaid care are not detrimental to most aspects of care for CHF patients. More rapid follow-up after hospital discharge for patients with CHF suggests that HMOs may be more effective in delivering continuity of care for patients with chronic illness.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. Design. Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI - 5.4, - 0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = - 16.5, 95% CI - 27.8-5.3). The two groups did not differ significantly in the proportion with asthma-related or non asthma hospital admissions. Conclusions. Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

Frequent use of the hospital emergency department is indicative of high use of other health care services

STUDY OBJECTIVE: We sought to determine the proportion of emergency department patients who frequently use the ED and to compare their frequency of use of other health care services at non-ED sites. METHODS: A computerized patient database covering all ambulatory visits and hospital admissions at all care facilities in the county of Stockholm, Sweden, was used. Frequent ED patients were defined as those making 4 or more visits in a 12-month period. RESULTS: Frequent users comprised 4% of total ED patients, accounting for 18% of the ED visits. The ED was the only source of ambulatory care for 13% of frequent versus 27% of rare ED users (1 ED visit). Primary care visits were made by 72% of frequent ED users versus 57% by rare ED visitors. The corresponding figures for hospital admission were 80% and 36%, respectively. Frequent ED visitors were also more likely to use other care facilities repeatedly: their odds ratio (adjusted for age and sex) was 3.43 (95% confidence interval [CI] 3.10 to 3.78) for 5 or more primary care visits and 29.98 (95% CI 26.33 to 34.15) for 5 or more hospital admissions. In addition, heavy users had an elevated mortality (standardized mortality ratio 1.55; 95% CI 1.26 to 1.90). CONCLUSION: High ED use patients are also high users of other health care services, presumably because they are sicker than average. A further indication of serious ill health is their higher than expected mortality. This knowledge might be helpful for care providers in their endeavors to find appropriate ways of meeting the needs of this vulnerable patient category.     

The management of geriatric hypertension in health maintenance organizations

OBJECTIVE: To evaluate the quality of medical care received by Medicare enrollees with hypertension in health maintenance organizations (HMOs) compared to that received by a similar group of elderly hypertensives in a fee-for-service (FFS) setting. DESIGN: A quasi-experimental design was used to study an historical cohort of newly evaluated hypertensive patients over a 2-year period. SETTING: Medicare HMO and FFS practice settings. PARTICIPANTS: Eight Medicare HMOs and 87 FFS primary care physicians in the same communities were selected. A sample of 685 elderly hypertensive patients was studied, 336 in FFS settings and 349 in HMOs. MEASUREMENTS AND MAIN RESULTS: An expert panel of physicians selected standards of care for the management of geriatric hypertension, and medical records were reviewed. The results showed significant differences (P less than 0.01) in recording medications (94.5% HMO versus 88% FFS) and smoking histories (75.8% HMO versus 64.7% FFS), checking orthostatic blood pressures (9.5% HMO versus 3.3% FFS), performing funduscopy (44.4% HMO versus 27% FFS), completing cardiac examinations (90.8% HMO versus 79.8% FFS), and obtaining chest x-rays (72.8% HMO versus 64.3% FFS, P less than 0.05). Treatment and follow-up were similar between the two groups, except that FFS hypertensives were more likely to have medications adjusted and electrolytes ordered. CONCLUSIONS: The results suggest that elderly hypertensives in HMOs received equal or better quality of care for most criteria compared to elderly hypertensives in FFS settings.     

Health care resource utilization in inflammatory bowel disease.

BACKGROUND & AIMS: The aim of this study was to quantify temporal changes in health care utilization by a population-based cohort of IBD. METHODS: By using the University of Manitoba IBD Epidemiology Database we assessed utilization of outpatient and hospital services, estimating relative risk (RR) of utilization for IBD cases compared with a matched cohort of non-IBD controls and for CD versus UC. We tested differences in utilization between prevalence cohorts 1990-1991 and 2000-2001. Also, utilization of the 1987-1988 incidence cohort was followed forward 15 years from diagnosis. The probability, intensity, and volume of utilization were estimated. RESULTS: In 2000-2001, IBD patients compared with controls were more likely to have an outpatient visit (RR, 1.18; 95% confidence interval [CI], 1.17-1.19) and an overnight hospital stay (RR, 2.32; 95% CI, 2.16-2.49). CD cases were more likely than UC cases to be hospitalized (RR, 1.26; 95% CI, 1.11-1.43) and had a greater number of outpatient visits. From 1990-1991 to 2000-2001, IBD cases experienced a significant decrease in the likelihood of an outpatient surgical visit relative to non-IBD controls (P < .05), and for those cases who were hospitalized, CD cases tended to be less likely than UC cases to experience IBD-specific inpatient surgery (P < .07). Of the 1987-1988 incidence cohort, 80% of admissions that occurred during the follow-up period were during the first 5 years after diagnosis. CONCLUSIONS: In 2000-2001, health care utilization continued to be higher in IBD versus controls and CD versus UC; however, the gap in costly service utilization appeared to narrow between the latter pair.     

Variation in participation in health care settings associated with race and ethnicity

OBJECTIVE: To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN: 1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting. SETTING: Physicians’ offices, outpatient clinics, hospital emergency departments, hospitals, and people’s homes. MAIN MEASUREMENT: Number of people per 1,000 per month who had at least one contact in a health care setting. RESULTS: Fewer blacks and Hispanics than whites received care in physicians’ offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians’ offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home. CONCLUSIONS: Fewer blacks and Hispanics than whites received health care in physicians’ offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.     

Impact of managed care on the use of biologic agents for rheumatoid arthritis

OBJECTIVE: To compare the use of biologic agents among persons with rheumatoid arthritis (RA) in managed care and fee-for-service settings. METHODS: The present study uses data from the University of California, San Francisco RA Panel Study in which 529 patients with RA from a random sample of northern California rheumatologists were interviewed annually between 1999 and 2002 using a structured survey instrument. Linear and logistic regression were used to compare current utilization, initiation, and cessation of biologic agents and other treatments among patients with RA in managed care and fee-for-service settings, with and without adjustment for differences in demographic and health characteristics. RESULTS: After adjustment, patients with RA in health maintenance organizations (HMOs) were significantly less likely to use biologic agents than those in other managed care settings (difference of -6.6%; 95% confidence interval [95% CI] -11.4%, -1.7%) or than those in fee-for-service settings (difference of -12.5%; 95% CI -19.0%, -5.9%); patients in other managed care settings and fee-for-service did not differ significantly in their use of biologic agents. Patients with RA in HMOs were significantly less likely than those in other managed care settings to initiate the use of biologic agents (difference of -7.3%; 95% CI -11.5%, -3.1%); there were no other differences between patients in HMOs and those in other managed care and fee-for-service settings in rates of initiation or cessation of these agents. Patients with RA in HMOs were less likely to use methotrexate, cyclooxygenase 2 (COX-2) inhibitors, and corticosteroids than those in other managed care settings; they were also less likely to use COX-2 inhibitors than those in fee-for-service settings. CONCLUSION: Patients with RA in HMOs were significantly less likely to use biologic agents than those in other managed care and fee-for-service settings, primarily due to lower rates of initiation.     

Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic

OBJECTIVES: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care. DESIGN: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996. SETTING: Nonprofit group model HMO. PARTICIPANTS: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic. INTERVENTION: Monthly group meetings held by patients' primary care physicians. MEASUREMENT: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs). RESULTS: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients' costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups. CONCLUSION: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status.     

Frequency of health service use in the year prior to asthma death

Objective: High frequency health service use (HSU) is associated with poorly controlled asthma, and is a recognized risk factor for near-fatal or fatal asthma. The objective of this study was to describe the frequency of HSU in the year prior to asthma death. Methods: Individuals aged 0–99 years who died from asthma from April 1996 to December 2011 in Ontario, Canada were identified as cases. Cases were matched to 4–5 live asthma controls by age, sex, rural/urban residence, socioeconomic status, duration of asthma and a co-diagnosis of COPD. HSU records in the year prior to death [hospitalization, emergency department (ED) and outpatient visits] were assembled. The association of prior HSU and asthma death was measured by conditional logistic regression models. Results: From 1996 to 2011, 1503 individuals died from asthma. While the majority of cases did not have increased HSU as defined in the study, compared to matched live asthma controls, the cases were 8-fold more likely to have been hospitalized two or more times (OR?=?7.60; 95% CI: 4.90, 11.77), 13-fold more likely to have had three or more ED visits (OR?=?13.28; 95% CI: 7.55, 23.34) and 4-fold more likely to have had five or more physician visits for asthma (OR?=?4.41; 95% CI: 3.58, 5.42). Conclusions: Frequency of HSU in the year prior was substantially higher in those died from asthma. Specifically, more than one asthma hospital admission, three ED visits or five physician visits increased the asthma mortality risk substantially and exponentially.     

Effects of cost containment on the care of elderly diabetics

OBJECTIVE--Because of rising costs in the Medicare program, the elderly have been encouraged to enroll in health maintenance organizations (HMOs). To evaluate the quality of care in these HMOs, detailed criteria on the treatment of elderly diabetics were established by an expert panel. DESIGN--Approximately 20 months of care for elderly diabetics was reviewed by medical record abstractions with a historical cohort design. SETTING--The care of elderly diabetics in eight HMOs was compared with the care received in fee-for-service (FFS) settings located in similar geographic areas. PATIENTS--Elderly diabetics enrolled in HMOs (n = 158) were compared with similar diabetics (n = 134) in FFS settings. RESULTS--Diabetic HMO enrollees were more likely to have funduscopic examinations (48% in HMOs vs 30% FFS) and urinalyses (89% in HMOs vs 74% FFS) performed. Enrollees with poor diabetic control were also more likely than FFS diabetics to be referred to an ophthalmologist (45% in HMOs vs 11% FFS). However, influenza vaccinations were administered to diabetics more often in FFS settings than to diabetic enrollees (19% in HMOs vs 62% FFS). One fifth of diabetics in both groups were treated with insulin and two thirds were treated with oral hypoglycemic agents, though HMO enrollees were more likely to have medication changes. CONCLUSION--We conclude that most aspects of the quality of diabetic care were similar in HMO and FFS settings and were unaffected by this effort at cost containment.     

Socioeconomic status and utilization of health care services among asthmatic children.

We evaluated the relation between socioeconomic factors and hospitalization as well as emergency department (ED) visits among asthmatic children who had universal access to health care. Newly diagnosed asthmatic children 3-4 years of age were followed up for a period of 6 years. Information on hospitalization and ED visits was obtained by interviewing parents. Socioeconomic status (SES) was measured by paternal occupation, race, type of dwelling, and an index of crowding. After adjusting for asthma severity, logistic regression analysis showed that children with fathers in the economically least advantaged occupations were more likely to be hospitalized due to their asthma [father's occupation group 3 (FOG3), odds ratio (OR)=2.1, 95% confidence interval (95% CI)=0.2-19.8; father's occupation group 4 (FOG4), OR=13.9, 95% CI=1.1-181.4]. The probability of emergency department visits was not significantly different according to the studied variables. Emergency department visits were not influenced by SES variables, probably due to the absence offinancial barriers to access health care. However, SES differences in hospitalization may suggest differential management and/or treatment practices according to socioeconomic status at the emergency departments.     

Relationship between avoidable hospitalizations for diabetes mellitus and income level

BACKGROUND: Acute diabetic emergencies are potentially avoidable or amenable to timely and effective outpatient therapy. OBJECTIVE: To evaluate the relationship between socioeconomic status (SES) and acute complications of diabetes mellitus in Ontario. METHODS: We used a population-based cohort of persons with diabetes mellitus (N = 605 825) derived from hospital and physician service claims between April 1, 1992, and March 31, 1999. Socioeconomic status was estimated using neighborhood-level data from the 1996 Canadian Census. Outcome events were defined as 1 or more hospitalizations or emergency department visits for hyperglycemia or hypoglycemia. RESULTS: There was a clear inverse gradient between income level and event rates. Individuals in the lowest income quintile were 44% more likely to have an event than those in the highest quintile (16.4% vs 11.4%; P<.001) and had a greater propensity toward recurrent emergency department admissions (1.9 vs 1.6 episodes per patient; P<.001). The gradient was most marked in 45- to 64-year-olds (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.69-1.82) and less apparent in children (OR, 1.06; 95% CI, 0.99-1.13). The relationship between SES and events persisted after adjusting for age, sex, urban vs rural residence, comorbidity, frequency of physician visits, continuity of care, physician specialty, and geographic region (adjusted OR, 1.09 [95% CI, 1.08-1.10] per quintile level). In contrast, admission rates for non-ambulatory care-sensitive conditions (appendicitis and hip fracture) were unaffected by SES. CONCLUSION: Even when some economic barriers to accessing care are removed, patients from low-SES neighborhoods still experience an excess number of hospitalizations for conditions that should be prevented by optimal care in the ambulatory setting.     

The Association Between Life Chaos,Health Care Use,and Health Status Among HIV-Infected Persons

Background Whether having a stable and predictable lifestyle is associated with health care use and health status among HIV patients is unknown. Objective To develop and test the reliability and validity of a measure of life chaos for adults with HIV and examine its association with health care use and health status. Design Prospective cohort study. Participants Two hundred twenty HIV-infected persons recruited from those who tested positive in a mobile testing van and from HIV clinics serving low-income populations. Measurements Participants completed a survey every 6 months, assessing their health care use, SF-12 mental and physical health status and life chaos. Results Cronbach’s alpha for the six-item measure of chaos was .67. Those without a spouse or partner and those with one or more unmet social service needs, such as housing or transportation, had higher chaos scores. Compared to those with less chaos, those with more chaos were less likely to have two or more outpatient visits (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI]: 0.24–0.98), more likely to have two or more missed visits (adjusted OR 2.30, 95%CI: 1.20–4.41) in the 6 months before study enrollment and had lower mental health status at enrollment and at follow-up. Life chaos was not associated with emergency department visits or physical health status. Conclusions We created a new measure of life chaos, which was associated with outpatient visits and mental health status. Chaos may be an important barrier to regular medical care. Future studies need to test this measure in more diverse populations and those with other diseases.     

Postpartum mental health service utilization in women with Human Immunodeficiency Virus (HIV): a population-based study

ABSTRACT

Women with HIV have higher rates of psychiatric disorders than HIV-negative women, yet little is known about their postpartum mental health and associated service use. The purpose of this study was to characterize HIV-positive women’s use of ambulatory and acute mental health services in the first year postpartum, relative to HIV-negative women. Using health administrative data, we identified 861,365 women who had a live birth delivery from April 1, 2002 to March 31, 2012 in Ontario, Canada, of whom 530 were identified to be HIV-positive. We described their use of mental health services, including outpatient mental health visits, psychiatric emergency department (ED) visits and hospitalizations using adjusted odds ratios (aORs) and 95% confidence intervals (CIs). HIV-positive women were more likely to access outpatient mental health services (31.5% vs. 21.0%, aOR, 1.26; 95% CI, 1.03–1.55), but more likely to remain engaged in psychiatrist services only (15.6% vs. 6.5%, aOR, 2.35; 95% CI, 1.41–3.72). They were also more likely to require a psychiatric ED visit or hospitalization (3.3% vs. 1.1%, aOR, 2.74; 95% CI, 1.72–4.12). Our findings highlight the importance of considering postpartum mental health as part of comprehensive reproductive health care for women with HIV.     

Influence of Payor on Use of Invasive Cardiac Procedures and Patient Outcome After Myocardial Infarction in the United States

Objectives. We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures.

Background. The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status.

Methods. We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events.

Results. Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01).

Conclusions. Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.     

Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians

PURPOSE: State legislatures have increased the prescribing capabilities of nurse practitioners and physician assistants and broadened the scope of their practice roles. To determine the impact of these changes, we compared outpatient antibiotic prescribing by practicing physicians, nonphysician clinicians, and resident physicians. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), we conducted a cross-sectional study of patients >/=18 years of age receiving care in 3 outpatient settings: office practices, hospital practices, and emergency departments, 1995-2000. We measured the proportion of all visits and visits for respiratory diagnoses where antibiotics are rarely indicated in which an antibiotic was prescribed by practitioner type. RESULTS: For all patient visits, nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians for visits in office practices (26.3% vs 16.2%), emergency departments (23.8% vs 18.2%), and hospital clinics (25.2% vs 14.6%). Similarly, for the subset of visits for respiratory conditions where antibiotics are rarely indicated, nonphysician clinicians prescribed antibiotics more often than practicing physicians in office practices (odds ratio [OR] 1.86, 95% confidence intervals [CI]: 1.05 to 3.29), and in hospital practices (OR 1.55, 95% CI: 1.12 to 2.15). In hospital practices, resident physicians had lower prescribing rates than practicing physicians for all visits as well as visits for respiratory conditions where antibiotics are rarely indicated (OR 0.56, 95% CI: 0.36 to 0.86). CONCLUSION: Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. These differences suggest that general educational campaigns to reduce antibiotic prescribing have not reached all providers.