Food Insecurity Is Associated with Greater Acute Care Utilization among HIV-Infected Homeless and Marginally Housed Individuals in San Francisco

Background

Food insecurity, or the uncertain availability of nutritionally adequate, safe foods, has been associated with poor HIV outcomes. There are few data on the extent to which food insecurity impacts patterns of health-care utilization among HIV-infected individuals.

Objective

We examined whether food insecurity was associated with hospitalizations, Emergency Department (ED) visits, and non-ED outpatient visits.

Methods

HIV-infected, homeless and marginally housed individuals participating in the San Francisco Research on Access to Care in the Homeless (REACH) cohort underwent quarterly structured interviews and blood draws. We measured food insecurity with the validated Household Food Insecurity Access Scale, and categorized participants as food secure, mild/moderately food insecure, and severely food insecure. Primary outcomes were: (1) any hospitalizations, (2) any ED visits, and (3) any non-ED outpatient visits. Generalized estimating equations were used to estimate model parameters, adjusting for socio-demographic (age, sex, ethnicity, education, income, housing status, health insurance) and clinical variables (CD4 nadir, time on antiretroviral therapy, depression, and illicit drug use).

Results

Beginning in November 2007, 347 persons were followed for a median of 2 years. Fifty-six percent of participants were food insecure at enrollment. Compared with food-secure persons, those with severe food insecurity had increased odds of hospitalizations [adjusted odds ratio (AOR)?=?2.16, 95 % confidence interval (CI)?=?1.50–3.09] and ED visits (AOR?=?1.71, 95 % CI?=?1.06–2.30). While the odds of an outpatient visit were 41 % higher for severely food insecure individuals, the effect was not statistically significant (AOR?=?1.41, 95 % CI?=?0.99–2.01). Mild/moderate food insecurity was also associated with increased hospitalizations (AOR?=?1.56, 95 % CI?=?1.06–2.30), ED visits (AOR?=?1.57, 95 % CI?=?1.22–2.03), and outpatient visits (AOR?=?1.68, 95 % CI?=?1.20–2.17).

Conclusions

Food insecurity is associated with increased health services utilization among homeless and marginally housed HIV-infected individuals in San Francisco. Increased ED visits and hospitalizations are not related to fewer ambulatory care visits among food-insecure individuals. Addressing food insecurity should be a critical component of HIV treatment programs and may reduce reliance on acute care utilization.     

Health-care use among Puerto Rican and African-American children with asthma

STUDY OBJECTIVES: To compare the rates of emergency department (ED) visits, hospitalizations, hospital days, and outpatient clinic visits for asthma among children in two ethnic minority groups that are disproportionately affected by asthma (Puerto Ricans and African Americans). Study design: This cross-sectional study was part of an asthma intervention program in Hartford, CT, in which 6,554 children were screened for asthma by primary care providers using a parental survey. Medicaid and the supplementary State Children's Health Insurance Plan data about health-care utilization for asthma were obtained for each child for the 12 months preceding completion of the screening survey. RESULTS: Among 2,304 children in whom asthma had been diagnosed, Puerto Ricans had more severe asthma than African Americans. In analyses adjusted for asthma severity and other potential confounders, Puerto Rican children had more clinic visits for asthma (rate ratio [RR], 1.31; 95% confidence interval [CI], 1.12 to 1.53) but spent fewer days in the hospital for asthma (RR, 0.36; 95% CI, 0.24 to 0.53) than African-American children. There were no differences in the rates of ED visits or hospitalizations between the two groups. CONCLUSIONS: Puerto Rican children had more severe asthma but were less likely than African-American children to have prolonged hospitalizations for asthma. This finding may be due to the frequent clinic visits for asthma made by Puerto Rican children. Further research is needed to understand the cultural factors that contribute to different approaches to health-care utilization among ethnic minorities.     

Reasons for home care clients’ unplanned Hospital admissions and their associations with patient characteristics

BackgroundUnplanned hospitalizations and emergency room visits occur frequently among home care clients The aim of this study was to identify typical discharge diagnoses and their associations with patient characteristics among a total of 6812 Finnish home care clients aged ≥63 years who were hospitalized within one year of their first home care assessment.MethodsA register-based study based on Resident Assessment Instrument-Home Care (RAI−HC) assessments and nationwide hospital discharge records. The RAI−HC assessments were linked to the hospital discharge records of the participants’ first unplanned hospitalization. Univariate and multivariable regression analyses were used to evaluate the association of RAI−HC determinants with discharge diagnoses.ResultsThe most common reason for the first hospitalization was an infectious disease (21%; n = 1446). When hospitalizations were classified according to the main diagnosis, chronic skin ulcers, functional impairment and daily urinary incontinence were associated with hospitalization due to infectious diseases; impaired cognitive capacity, Alzheimer’s disease or other dementia and polypharmacy (protective effect) were associated with hospitalizations due to dementia; age of ≥90 years, congestive heart failure, coronary artery disease and using ≥10 drugs with hospitalizations due to heart diseases; and moderate or strong pain with hospitalization due to musculoskeletal disorders. Previous falls, female sex and an earlier hip fracture were associated with injury-related hospitalizations. Feelings of loneliness increased the odds of hospitalization due to geriatric symptoms without a specific diagnosis.ConclusionPatient characteristics and geriatric syndromes identified using RAI−HC predict the reasons for future hospitalizations among new home care clients.     

Health-related quality of life predicts future health care utilization and mortality in veterans with self-reported physician-diagnosed arthritis: the veterans arthritis quality of life study

OBJECTIVE: To investigate whether health-related quality of life (HRQOL) measures predict health care utilization and mortality in a cohort of veterans with self-reported physician-diagnosed arthritis. METHODS: A cohort of veterans from the Upper Midwest Veterans Integrated Service Network (VISN) was mailed a self-administered questionnaire that was composed of the SF-36V (modified from SF-36 for use in veterans) and questions regarding demographics, current smoking status, limitation of activities of daily living (ADLs), and preexisting physician-diagnosed medical conditions, including arthritis. Within subjects reporting physician-diagnosed arthritis, we analyzed the associations between the SF-36V component summary scales (physical and mental component summary, PCS and MCS, respectively) and the occurrence of any hospitalization, number of hospitalizations, number of outpatient visits, and mortality, for the year after survey administration, using multivariable regression analyses. RESULTS: Of 34,440 survey responders who answered a question regarding arthritis, 18,464 (58%) subjects reported physician-diagnosed arthritis. Arthritic patients in the lowest tertile of PCS scores had significantly higher odds of any hospitalization (Odds ratio (OR) 1.49, 95% confidence interval (CI) [1.25-1.76]) and mortality (OR 1.69, 95% CI [1.18-2.42]), and a significantly higher number of hospitalizations/year (Rate ratio (RR) 1.09, 95% CI [1.05-1.13]) and outpatient visits/year (RR 1.07, 95% CI [1.03-1.11]). Arthritic patients in the lowest tertile of MCS scores had significantly higher odds of any hospitalization (OR 1.20, 95% CI [1.02-1.41]), mortality (OR 2.14, 95% CI [1.56-2.94]), and a significantly higher number of hospitalizations/year (RR 1.05, 95% CI [1.02-1.09]) and outpatient visits/year (RR 1.07, 95% CI [1.03-1.11]). CONCLUSIONS: HRQOL, as assessed by the SF-36V, predicts future inpatient and outpatient health care utilization and mortality in veterans with self-report of physician-diagnosed arthritis.     

China: the aging giant

This article examines the changing demographics of China, with particular attention paid to the effect of the one-child policy in relation to long-term care of older people. It also examines the current state of health care for older people. Long-term stays characterize hospital care. Most geriatric syndromes are less common in hospitalized older people (e.g., delirium, falls), but some (e.g., polypharmacy) are more common. A high volume of patients and brief targeted visits characterize outpatient care. Nursing homes exist in China, but relatively fewer than in the most developed countries. Geriatric departments in university-based hospitals primarily have developed out of a need to care for retired government officials and workers. There are no formal geriatric fellowships or national board certifications in geriatrics Health care is primarily based on fee for service. Not all elderly have healthcare insurance. Although costs of health care and medications are less expensive than in the United States, they are relatively high for lower- and middle-class Chinese and have increased more quickly than has the standard of living in the past 20 years. Family and community support for older people is strong in China. Some older people have one-to-one care from a baomu (literally "protection" (bao) "mother" (mu)), a type of live-in maid who also provides care for the older person. Some of the challenges facing China in the care of its aging population are how to increase geriatric research and training, how to care for the uninsured or underinsured, and how to handle the inevitable growth of disabled and frail older people.     

Evaluating the impact of integrated behavioral health intervention: Evidence from Rhode Island

There has been a historic separation between systems that address behavioral health problems and the medical care system that addresses other health issues. Integration of the 2 has the potential to improve care.The aim of this study was to evaluate the impact of Integrated Behavioral Health program on health care utilization and costs.Claims data between 2015 and 2018 from Rhode Island''s All Payers Claims Database representing 42,936 continuously enrolled unique patients.Retrospective study based on propensity score–matched difference-in-differences framework.Utilization (emergency department visits, office visits, and hospitalizations) and costs (total, inpatient, outpatient, professional, and pharmacy).Integrated Behavioral Health intervention in Rhode Island was associated with reduction in healthcare utilization. Emergency department visits reduced by 6.4 per 1000 people per month and office visits reduced by 29.8 per 1000 people per month, corresponding to a reduction of 7% and 6%, respectively. No statistically significant association was observed between the intervention and hospitalizations. The evidence was mixed for cost outcomes, with negative association recorded between the intervention and the likelihood of incurring non-zero cost but no significant association was observed between the intervention and the level of costs. This relationship held true for most of the cost measures considered.Integrated Behavioral Health intervention in Rhode Island was associated with significant reductions in emergency department visits and office visits, with no effects on hospitalizations. In terms of the cost outcomes, we found evidence that the intervention negatively affected the likelihood of incurring any non-zero costs but did not affect the level of costs.     

Patterns and predictors of asthma-related emergency department use in Harlem

STUDY OBJECTIVES: To assess the roles of poor access to care, psychological risk factors, and asthma severity in frequent emergency department (ED) use. DESIGN: A cross-sectional survey. SETTING: Harlem Hospital Center ED and outpatient chest clinic. PARTICIPANTS: Three hundred seventy-five adult residents of Harlem, a predominantly African-American community in New York City. MEASUREMENTS: Asthma severity was assessed by self-reported symptoms using National Asthma Education and Prevention Program guidelines, health-care utilization, and psychometric scales. RESULTS: Respondents with more severe asthma were more likely to have a primary asthma care provider, and to have had more scheduled office visits for asthma in the year prior to the interview (mean number of visits for patients with severe asthma, 3.6 visits; moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Despite having a regular source of care, 69% of respondents identified the ED as their preferred source of care; 82% visited the ED more than once in the year prior to interview (median, four visits). Persons with moderate or severe asthma were 3.8 times more likely to be frequent ED users compared to those with mild asthma (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2 to 6.6). This was the strongest predictor of frequent ED use. Other predictors of ED use were number of comorbid disorders (OR, 1.5; 95% CI, 1.1 to 2.1) and self-reported global health in the year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7). Psychological characteristics were not predictive of frequent ED use when controlling for disease severity. CONCLUSIONS: Frequent ED users present with serious medical conditions. They do not substitute physician care with ED care; they augment it to address serious health needs.     

Health care resource utilization associated with a diabetes center and a general medicine clinic

OBJECTIVE: Studies have proposed that the features of diabetes clinics may decrease hospital utilization and costs by reducing complications and providing more efficient outpatient care. We compared the health care utilization associated with a diabetes center (DC) and a general medicine clinic (GMC). DESIGN: Retrospective cohort study. SETTING: An urban academic medical center. PATIENTS/PARTICIPANTS: Type 2 diabetes patients (N = 601) under care in a DC and GMC before March 1996. MEASUREMENTS AND MAIN RESULTS: We compared baseline patient characteristics and outpatient care for the period of March 1996 to August 1997. Using administrative data from March 1996 to October 2000, we compared the probability of a hospitalization, length of stay, costs of hospitalizations, the probability of an emergency room visit, and costs of emergency room visits. Diabetes center patients had a longer mean duration of diabetes (12 years vs 6 years, P <.01), more baseline microvascular disease (65% vs 44%, P <.01), and higher baseline glucose levels (hemoglobin A1c 8.6% vs 7.9%, P <.01) than GMC patients. Diabetes center patients received more intensive outpatient care directed toward glucose monitoring and control. In all crude and adjusted analyses of hospitalizations and emergency room visits, we found no statistically significant differences for inpatient utilization or cost outcomes comparing clinic populations. CONCLUSIONS: Diabetes center attendance did not have a definitive positive or negative impact on inpatient resource utilization over a 4-year period. However, DC patients had more severe diabetes but no greater hospital utilization compared with GMC patients. Clear demonstration of the clinical and financial benefits of features of diabetes centers will require long-term controlled trials of interventions that promote comprehensive diabetes care, including cardiovascular prevention.     

Depression,medication adherence,and service utilization in systemic lupus erythematosus

Objective

Forgetting to take medications is an important cause of nonadherence. This study evaluated factors associated with forgetting to take medications in a large cohort of persons with systemic lupus erythematosus (SLE) participating in the University of California, San Francisco Lupus Outcomes Study (LOS). Relationships among adherence problems and service utilization (outpatient visits, emergency department visits, and hospitalizations) were also evaluated.

Methods

The cohort consisted of 834 LOS participants who provided self‐reported frequency of forgetting to take medications as directed. Predictors of adherence and service utilization patterns included self‐reported sociodemographics, disease‐related characteristics (e.g., disease activity, recent SLE flare), and mental health characteristics (Center for Epidemiologic Studies Depression Scale and cognitive function screen). Health care utilization patterns included the presence and quantity of visits to rheumatologists, primary care physicians, other care providers, emergency departments, and hospitalizations.

Results

Forty‐six percent of the LOS cohort reported forgetting to take medications at least some of the time. Depressive symptom severity was a strong predictor of adherence difficulties (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02–1.05; P < 0.0001) after accounting for all other predictors. Persons reporting adherence difficulties had significantly greater numbers of outpatient rheumatology and primary care visits, and were more likely to visit the emergency department (OR 1.45, 95% CI 1.04–2.04; P = 0.03).

Conclusion

Depression may be an important cause of medication adherence problems, and difficulties with adherence are significantly associated with high‐cost service utilization, specifically emergency department visits. In an era of rapidly evolving treatments for lupus, identifying patients at risk for adherence problems may decrease medical expenditures and improve patient outcomes in SLE.     

Body Mass Index Trajectories and Healthcare Utilization in Young and Middle-aged Adults

The obesity epidemic is a significant public health issue with adverse impact on health and costs. Applying a life-course perspective to obesity may advance our understanding of the influence of obesity over time on patterns of healthcare utilization in young and middle-aged United States (US) adults.We identified baseline body mass index (BMI) and BMI trajectories, and assessed their association with outpatient visits, emergency department (ED) visits, and hospitalizations in a well-defined population of young and middle-aged US adults.Using the Rochester Epidemiology Project resources, we conducted a retrospective cohort study of adults (N = 23,254) aged 18 to 44 years, with at least 3 BMI measurements, residing in Olmsted County, MN from January 1, 2005 through December 31, 2012.We observed that 27.5% of the population was obese. Four BMI trajectories were identified. Compared to under/normal weight, obese class III adults had higher risk of outpatient visits (adjusted rate ratio [RR], 1.86; 95% confidence intervals [CIs], 1.67–2,08), ED visits (adjusted RR, 3.02; 95% CI, 2.74–3.34), and hospitalizations (adjusted RR, 1.67; 95% CI, 1.59–1.75). BMI trajectory was positively associated with ED visits after adjustment for age, sex, race, and Charlson Comorbidity Index (P < 0.001 for trend).Among young and middle-aged US adults, baseline BMI is positively associated with outpatient visits, ED visits, and hospitalizations, while BMI trajectory is positively associated with ED visits. These findings extend our understanding of the longitudinal influence of obesity on healthcare utilization in early to mid-adulthood.     

Agreement between Caregiver Reported Healthcare Utilization and Administrative Data for Children with Asthma

In asthma, healthcare utilization is frequently an outcome measure and can come from several sources. Asthma-related hospitalizations, emergency department (ED) visits, oral steroid bursts, and outpatient visits were compared between caregiver report and administrative data over 2 years. The difference between sources (caregiver minus administrative) was as follows: hospitalizations = -0.02 (95% limits of agreement, -0.66 to 0.61), ED visits = 0.18 (-1.16 to 1.52), steroid bursts = 0.26 (-3.98 to 4.49), and outpatient visits = 0.29 (-6.10 to 6.64). The percent of individuals with disagreement between sources was hospitalizations = 6.1%; ED visits = 20.2%; steroid bursts = 34.3%; and outpatient visits = 83.6%. The data sources resulted in similar estimates on the population level; however, there were pronounced differences for outpatient visits on an individual level. Importantly, the individual level disagreement between the data sources could negatively affect the perceived quality of care provided by a physician and reduce their compensation in a pay-for-performance system when physicians are rated using administrative data, yet they provide treatment based on patient-reported information.     

Agreement between Caregiver Reported Healthcare Utilization and Administrative Data for Children with Asthma

In asthma, healthcare utilization is frequently an outcome measure and can come from several sources. Asthma-related hospitalizations, emergency department (ED) visits, oral steroid bursts, and outpatient visits were compared between caregiver report and administrative data over 2 years. The difference between sources (caregiver minus administrative) was as follows: hospitalizations = ?0.02 (95% limits of agreement, ?0.66 to 0.61), ED visits = 0.18 (?1.16 to 1.52), steroid bursts = 0.26 (?3.98 to 4.49), and outpatient visits = 0.29 (?6.10 to 6.64). The percent of individuals with disagreement between sources was hospitalizations = 6.1%; ED visits = 20.2%; steroid bursts = 34.3%; and outpatient visits = 83.6%. The data sources resulted in similar estimates on the population level; however, there were pronounced differences for outpatient visits on an individual level. Importantly, the individual level disagreement between the data sources could negatively affect the perceived quality of care provided by a physician and reduce their compensation in a pay-for-performance system when physicians are rated using administrative data, yet they provide treatment based on patient-reported information.     

Five-day telithromycin once daily is as effective as 10-day clarithromycin twice daily for the treatment of acute exacerbations of chronic bronchitis and is associated with reduced health-care resource utilization

STUDY OBJECTIVES: To demonstrate equivalence in the clinical efficacy of telithromycin vs clarithromycin treatment of outpatients with acute exacerbations of chronic bronchitis (AECB), and to compare the tolerability and respiratory-related health-care resource utilization associated with these treatment regimens. DESIGN AND PATIENTS: A randomized, double-blind, multicenter, clinical study was conducted at 105 centers in 14 countries. Adult outpatients (age > or = 30 years) received oral telithromycin, 800 mg qd for 5 days (n = 270), or oral clarithromycin, 500 mg bid for 10 days (n = 282), for the treatment of AECB. Clinical and bacteriologic outcomes were assessed at the posttherapy/test-of-cure (TOC) visit (days 17 to 24; per-protocol population). Health-care resource utilization data were collected for each patient by investigators blinded to study medication up to the late posttherapy visit (days 31 to 36). RESULTS: Clinical cure rates at the posttherapy/TOC visit were comparable between the groups (telithromycin, 193 of 225 patients [85.8%]; clarithromycin, 206 of 231 patients [89.2%]); bacteriologic outcome was satisfactory for 59 of 72 telithromycin-treated patients (81.9%) vs 63 of 76 clarithromycin-treated patients (82.9%). Health-care resource utilization assessed up to the late posttherapy visit was lower in the telithromycin treatment group than the clarithromycin treatment group, with significantly fewer hospitalizations for respiratory-related causes (one hospitalization vs eight hospitalizations for a total of 4 inpatient days vs 39 inpatient days, respectively), significantly fewer AECB-related emergency department visits (0 vs 8), and fewer unscheduled outpatient visits (11 vs 18). Fewer telithromycin-treated patients reported days lost from work (21 of 91 patients [23.1%]; 133 days) compared with those receiving clarithromycin (30 of 98 patients [30.6%]; 141 days). Telithromycin was well tolerated; adverse events considered possibly related to study medication were reported by 61 of 269 patients (22.7%) and 100 of 280 patients (35.7%) receiving telithromycin and clarithromycin, respectively. CONCLUSIONS: In this study, 5-day telithromycin treatment was as effective and well tolerated as 10-day clarithromycin treatment for patients with AECB, and was associated with a reduced utilization of health-care resources.     

Housing instability and food insecurity as barriers to health care among low-income americans

BACKGROUND: Homelessness and hunger are associated with poor health outcomes. Housing instability and food insecurity describe less severe problems securing housing and food. OBJECTIVE: To determine the association between housing instability and food insecurity and access to ambulatory health care and rates of acute health care utilization. DESIGN: Secondary data analysis of the National Survey of American Families. PARTICIPANTS: 16,651 low-income adults. MEASUREMENT: Self-reported measures of past-year access: (1) not having a usual source of care, (2) postponing needed medical care, or (3) postponing medication; and past-year utilization: (1) not having an ambulatory care visit, (2) having emergency department (ED) visits, or (3) inpatient hospitalization. RESULTS: 23.6% of subjects had housing instability and 42.7% had food insecurity. In multivariate logistic regression models, housing instability was independently associated with not having a usual source of care (adjusted odds ratio [AOR] 1.31, 95% confidence interval [CI] 1.08 to 1.59), postponing needed medical care (AOR 1.84, 95% CI 1.46 to 2.31) and postponing medications (AOR 2.16, 95% CI 1.70 to 2.74), increased ED use (AOR: 1.43, 95% CI 1.20 to 1.70), and hospitalizations (AOR 1.30, 95% CI 1.01 to 1.67). Food insecurity was independently associated with postponing needed medical care (AOR 1.74, 95% CI 1.38 to 2.21) and postponing medications (AOR 2.15, 95% CI 1.62 to 2.85), increased ED use (AOR 1.39, 95% CI 1.17 to 1.66), and hospitalizations (AOR 1.42, 95% CI 1.09 to 1.85). CONCLUSIONS: Housing instability and food insecurity are associated with poor access to ambulatory care and high rates of acute care. These competing life demands may lead to delays in seeking care and predispose to acute care.     

Effect of Advanced Access Scheduling on Processes and Intermediate Outcomes of Diabetes Care and Utilization

BACKGROUND  The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied. OBJECTIVE  To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits). METHODS  We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics. Using a generalized linear model framework, data were modeled with linear regression for continuous, logistic regression for dichotomous, and Poisson regression for utilization outcomes. RESULTS  Patients in the OA clinics were older, with a higher percentage being African American (51% vs 34%) and on insulin. In multivariate analyses, for A1c testing, the odds ratio for African-American patients in OA clinics was 0.47 (CI: 0.29-0.77), compared to non-African Americans [OR 0.27 (CI: 0.21-0.36)]. For urine microablumin, the odds ratio for non-African Americans in OA clinics was 0.37 (CI: 0.17-0.81). At 1 year, in adjusted analyses, patients in OA clinics had significantly higher SBP (mean 6.4 mmHg, 95% CI 5.4 – 7.5). There were no differences by clinic type in any of the three health-care utilization outcomes. CONCLUSION  OA scheduling was associated with worse processes of care and SBP at 1 year. OA clinic scheduling should be examined more critically in larger systems of care, multiple health-care settings, and/or in a randomized controlled trial. Support: This study was jointly funded by Program Announcement no. 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases.     

Clinic nonattendance is associated with increased emergency department visits in adults with congenital heart disease

Objective: To determine the prevalence and predictors of nonattendance in an ACHD outpatient clinic, and to examine the relationship between nonattendance and emergency department (ED) visits, hospitalizations, and death.
Methods: Patients ≥ 18 years who had scheduled appointments at an ACHD outpatient clinic between August 1, 2014 and December 31, 2014 were included. The primary outcome of interest was nonattendance of the first scheduled appointment of the study period, defined as “no-show” or “same-day cancellation.” Secondary outcomes of interest were ED visits, hospitalizations, and death until December 2017.
Results: Of 527 scheduled visits, 55 (10.4%) were nonattended. Demographic and socioeconomic characteristics such as race, income, and insurance type were associated with non-attendance (all P values < .05), whereas age, gender, and disease complexity were not. On multivariable analysis, predictors of nonattendance were black race (adjusted odds ratio [AOR] 4.95; P < .001), other race (AOR 3.54; P = .003), and history of no-show in the past (AOR 4.95; P < .001). Compared to patients who attended clinic, patients with a nonattended visit had a threefold increased odds of multiple ED visits and a significantly lower rate of ED-free survival over time. There were no significant differences in hospitalizations or death by attendance.
Conclusion: ACHD clinic nonattendance is associated with race and prior history of no-show, and may serve as a marker of higher ED utilization for patients with ACHD.     

Transition to Managed Care Impacts Health Care Service Utilization by Children Insured by Medicaid

Purpose. To evaluate the impact of transition to managed care from fee for service on asthma service utilization among Maryland Medicaid insured children. Methods. Healthcare claims from 1997-2000 for children with asthma insured by Maryland Medicaid were extracted and analyzed. Results. Between 1997-2000, inhaled corticosteroid use increased as a proportion of all asthma medications. Outpatient asthma visits increased from 4.2% to 5.9% of all outpatient claims as both asthma-related hospitalizations and emergency department visits decreased. Conclusions. Restructuring of Maryland Medicaid for children from fee for service to managed care was associated with improvement in asthma-related healthcare utilization claims.     

Gender Differences in Health Care Utilization Among Veterans with Chronic Pain

Background Previous research reports that 48% of veterans regularly experience and express concern over pain. Outpatient service use is higher for veterans with pain than for veterans without pain. Our study objective was to identify differences in outpatient utilization between men and women veterans with chronic pain. Methods We identified all men and women veterans at the Durham Veterans Affairs Medical Center in fiscal year (FY) 2002 between the ages of 21 and 60 that had two visits for the same pain location at least 6 weeks apart as determined by ICD-9 coding. Men and women were age-matched at a 2:1 ratio. We then compared the number of outpatient visits between genders in FY 2003. Results We identified 406 female and 812 male veterans. The mean number of clinic visits for women was 25.2 (SD 30.2) and for men 17.6 (SD 24.1). After adjusting for multiple pain sites, psychiatric diagnoses, age, and comorbidities, women veterans had a 27% higher rate of outpatient visits than men (incidence rate ratio [RR] 1.27, 95% confidence [CI] 1.15 to 1.41). Specifically, women had higher rates of visits to primary care (RR 1.36, 95% CI 1.24 to 1.50), physical therapy (RR 1.67, 95% CI 1.20 to 2.33), and other clinics (RR 1.28, 95% CI 1.14 to 1.44), and had a higher rate of visits to address pain (RR 1.15, 95% CI 1.02 to 1.30) than men. Conclusions This is the first study to examine gender differences in chronic pain and utilization in the veteran population. Women veterans with chronic pain may need more resources to adequately manage chronic pain conditions as well as associated comorbidities and psychiatric disease. Portions of this research were presented at the annual Society of General Internal Medicine conference, May, 2005, as well as the Women’s Health Congress, June, 2005.     

Transition to Managed Care Impacts Health Care Service Utilization by Children Insured by Medicaid

Purpose. To evaluate the impact of transition to managed care from fee for service on asthma service utilization among Maryland Medicaid insured children. Methods. Healthcare claims from 1997–2000 for children with asthma insured by Maryland Medicaid were extracted and analyzed. Results. Between 1997–2000, inhaled corticosteroid use increased as a proportion of all asthma medications. Outpatient asthma visits increased from 4.2% to 5.9% of all outpatient claims as both asthma-related hospitalizations and emergency department visits decreased. Conclusions. Restructuring of Maryland Medicaid for children from fee for service to managed care was associated with improvement in asthma-related healthcare utilization claims.