Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

Mental Health and High‐Cost Health Care Utilization: New Evidence from Axis II Disorders

Objective

To analyze the associations between Axis II (A2) disorders and two measures of health care utilization with relatively high cost: emergency department (ED) episodes and hospital admissions.

Data Source/Study Setting

Wave I (2001/2002) and Wave II (2004/2005) of the National Longitudinal Survey on Alcohol and Related Conditions (NESARC).

Study Design

A national probability sample of adults. Gender-stratified regression analysis adjusted for a range of covariates associated with health care utilization.

Data Collection

The target population of the NESARC is the civilian noninstitutionalized population aged 18 years and older residing in the United States. The cumulative survey response rate is 70.2 percent with a response rate of 81 percent (N = 43,093) in Wave I and 86.7 percent (N = 34,653) in Wave II.

Principal Findings

Both men and women with A2 disorders are at elevated risk for ED episodes and hospital admissions. Associations are robust after adjusting for a rich set of confounding factors, including Axis I (clinical) psychiatric disorders. We find evidence of a dose–response relationship, while antisocial and borderline disorders exhibit the strongest associations with both measures of health care utilization.

Conclusions

This study provides the first published estimates of the associations between A2 disorders and high-cost health care utilization in a large, nationally representative survey. The findings underscore the potential implications of these disorders on health care expenditures.     

The Effect of Medicaid Primary Care Provider Reimbursement on Access to Early Childhood Caries Preventive Services

Objective

To examine receipt of early childhood caries preventive services (ECCPS) in two states'' Medicaid programs before and after the implementation of reimbursement to medical primary care providers (M-PCPs).

Data Sources

Enrollment and claims data from the Florida and Texas Medicaid programs for children ≤54 months of age during the period 2006–2010.

Study Design

We conducted time trend-adjusted, difference-in-differences analyses by using modified Poisson regressions combined with generalized estimating equations (GEEs) to analyze the effect of M-PCP reimbursement on the likelihood that an enrollee had an ECCPS visit after controlling for age, sex, health status, race/ethnicity, geographic location, and enrollment duration.

Data Extraction Methods

Enrollment data were linked to claims data to create a panel dataset with child-month observations.

Principal Findings

Reimbursement to M-PCPs was associated with an increased likelihood of ECCPS receipt in general and topical fluoride application specifically in both states.

Conclusions

Reimbursement to M-PCPs can increase access to ECCPS. However, ECCPS receipt continues to fall short of recommended care, presenting opportunities for performance improvement.     

Leveraging Electronic Health Records to Develop Measurements for Processes of Care

Objectives

To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.

Data Sources/Study Setting

EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.

Study Design/Methods

Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.

Principal Findings

Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach''s alpha = 0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR = 1.13, p < .05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR = 1.02, p < .01) and LDL control (OR = 1.01, p < .01) among patients with diabetes, and better BP control (OR = 1.04, p < .01) among patients with hypertension.

Conclusions

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.     

Peer Reviewed: Managed-Medicare Health Club Benefit and Reduced Health Care Costs Among Older Adults

Introduction

Our study was undertaken to determine the association between use of a health plan-sponsored health club benefit by older adults and total health care costs over 2 years.

Methods

This retrospective cohort study used administrative and claims data from a Medicare Advantage plan. Participants (n = 4766) were enrolled in the plan for at least 1 year before participating in the plan-sponsored health club benefit (Silver Sneakers). Controls (n = 9035) were matched to participants by age and sex according to the index date of Silver Sneakers enrollment. Multivariate regression models were used to estimate health care use and costs and to make subgroup comparisons according to frequency of health club visits.

Results

Compared with controls, Silver Sneakers participants were older and more likely to be male, used more preventive services, and had higher total health care costs at baseline. Adjusted total health care costs for Silver Sneakers participants and controls did not differ significantly in year 1. By year 2, compared with controls, Silver Sneakers participants had significantly fewer inpatient admissions (−2.3%, 95% confidence interval, −3.3% to −1.2%; P < .001) and lower total health care costs (−$500; 95% confidence interval, −$892 to −$106; P = .01]. Silver Sneakers participants who averaged at least two health club visits per week over 2 years incurred at least $1252 (95% confidence interval, −$1937 to −$567; P < .001) less in health care costs in year 2 than did those who visited on average less than once per week.

Conclusion

Regular use of a health club benefit was associated with slower growth in total health care costs in the long term but not in the short term. These findings warrant additional prospective investigations to determine whether policies to offer health club benefits and promote physical activity among older adults can reduce increases in health care costs.     

A Decade in Dental Care Utilization among Adults and Children (2001–2010)

Objective

To decompose the change in pediatric and adult dental care utilization over the last decade.

Data

2001 through 2010 Medical Expenditure Panel Survey.

Study Design

The Blinder-Oaxaca decomposition was used to explain the change in dental care utilization among adults and children. Changes in dental care utilization were attributed to changes in explained covariates and changes due to movements in estimated coefficients. Controlling for demographics, overall health status, and dental benefits variables, we estimated year-specific logistic regression models. Outputs from these models were used to compute the Blinder-Oaxaca decomposition.

Principal Findings

Dental care utilization decreased from 40.5 percent in 2001 to 37.0 percent in 2010 for adults and increased from 43.2 percent in 2001 to 46.3 percent in 2010 for children (p < .05). Among adults, changes in insurance status, race, and income contributed to a decline in adult dental care utilization (−0.018, p < .01). Among children, changes in controlled factors did not substantially change dental care utilization, which instead may be explained by changes in policy, oral health status, or preferences.

Conclusions

Dental care utilization for adults has declined, especially among the poor and uninsured. Without further policy intervention, disadvantaged adults face increasing barriers to dental care.     

Racial/Ethnic Disparities in Health and Health Care among U.S. Adolescents

Objective

To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.

Data Source

Secondary data analysis of the 2003 National Survey of Children''s Health. The survey focus was children 0–17 years old.

Study Design

Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.

Principal Findings

Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.

Conclusions

U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.     

Location of cancer surgery for older veterans with cancer

Objective

Many veterans undergo cancer surgery outside of the Veterans Health Administration (VHA). We assessed to what extent these patients obtained care in the VHA before surgery.

Data Sources

VHA-Medicare data, VHA administrative data, and Veterans Affairs Central Cancer Registry data.

Study Design

We identified patients aged ≥65 years in the VHA-Medicare cohort who underwent lung or colon cancer resection outside the VHA and assessed VHA visits in the year before surgery.

Principal Findings

Over 60% of patients in the VHA-Medicare cohort who received lung or colon cancer surgeries outside the VHA did not receive any care in VHA before surgery.

Conclusions

Veterans’ receipt of major cancer surgery outside the VHA probably reflects usual private sector care among veterans who are infrequent VHA users.     

Using Quantile Regression to Examine Health Care Expenditures during the Great Recession

Objective

To examine the association between the Great Recession of 2007–2009 and health care expenditures along the health care spending distribution, with a focus on racial/ethnic disparities.

Data Sources/Study Setting

Secondary data analyses of the Medical Expenditure Panel Survey (2005–2006 and 2008–2009).

Study Design

Quantile multivariate regressions are employed to measure the different associations between the economic recession of 2007–2009 and health care spending. Race/ethnicity and interaction terms between race/ethnicity and a recession indicator are controlled to examine whether minorities encountered disproportionately lower health spending during the economic recession.

Principal Findings

The Great Recession was significantly associated with reductions in health care expenditures at the 10th–50th percentiles of the distribution, but not at the 75th–90th percentiles. Racial and ethnic disparities were more substantial at the lower end of the health expenditure distribution; however, on average the reduction in expenditures was similar for all race/ethnic groups. The Great Recession was also positively associated with spending on emergency department visits.

Conclusion

This study shows that the relationship between the Great Recession and health care spending varied along the health expenditure distribution. More variability was observed in the lower end of the health spending distribution compared to the higher end.     

Total Cost of Care Lower among Medicare Fee‐for‐Service Beneficiaries Receiving Care from Patient‐Centered Medical Homes

Objective

To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition.

Data Sources

Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare''s Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file.

Study Design

This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008–June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition.

Data Collection Methods

Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008.

Principal Findings

Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.

Conclusions

This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care.     

Effects of the Ten Percent Cap in Medicare Home Health Care on Treatment Intensity and Patient Discharge Status

Objective

To estimate the effect of the 10 percent cap introduced to Medicare home health care on treatment intensity and patient discharge status.

Data Sources

Medicare Denominator, Medicare Home Health Claims, and Medicare Provider of Services Files from 2008 through 2010.

Study Design

We used agency-level variation in the proportion of outlier payments prior to the implementation of the 10 percent cap to identify how home health agencies adjusted the number of home health visits and patient discharge status under the new law.

Principal Findings

Under the 10 percent cap, agencies dramatically decreased the number of service visits. Agencies also dropped relatively healthy patients and sent sicker patients to nursing homes.

Conclusions

The drastic reduction in the number of service visits and discontinuation of relatively healthy patients from home health care suggest that the 10 percent cap improved the efficiency of home health services as intended. However, the 10 percent cap increased other types of health care expenditures by pushing sicker patients to use more expensive health services.     

Health Care Utilization and Costs Associated with Adherence to Clinical Practice Guidelines for Early Magnetic Resonance Imaging among Workers with Acute Occupational Low Back Pain

Objective

To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP).

Data Sources

Washington State Disability Risk Identification Study Cohort (D-RISC), consisting of administrative claims and patient interview data from workers’ compensation claimants (2002–2004).

Study Design

In this prospective, population-based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags).

Data Collection/Extraction Methods

We identified workers (age >18) with work-related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury.

Principal Findings

Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52–54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18 percent).

Conclusions

Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.     

Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges

Objective

Compare health care utilization and charges for low‐back‐pain (LBP) patients receiving advanced imaging or physical therapy as a first management strategy following a new primary care consultation.

Data Source

Electronic medical record (EMR) and insurance claims data.

Study Design

Retrospective analysis of propensity‐matched groups.

Data Collection/Extraction

Claims and EMR data were used. Utilization and LBP‐related charges over a 1‐year period were extracted from claims data.

Principal Findings

In the propensity‐matched sample (n = 406), advanced imaging recipients had higher odds of all utilization outcomes. Charges were higher with advanced imaging by an average $4,793 (95 percent CI: $3,676, $5,910).

Conclusions

For patients with LBP whom newly consulted primary care referred for additional management, advanced imaging as a first management was associated with higher health care utilization and charges than physical therapy.     

Determinants of Mental Health Care Utilization in a Suicide High-risk Group With Suicidal Ideation

Objectives:

The suicide rate in Korea is increasing every year, and is the highest among the Organization for Economic Cooperation and Development countries. Psychiatric patients in particular have a higher risk of suicide than other patients. This study was performed to evaluate determinants of mental health care utilization among individuals at high risk for suicide.

Methods:

Korea Health Panel data from 2009 to 2011 were used. Subjects were individuals at high risk of suicide who had suicidal ideation, a past history of psychiatric illness, or had utilized outpatient services for a psychiatric disorder associated with suicidal ideation within the past year. The chi-square test and hierarchical logistic regression were used to identify significant determinants of mental health care utilization.

Results:

The total number of subjects with complete data on the variables in our model was 989. Individuals suffering from three or more chronic diseases used mental health care more frequently. Mental health care utilization was higher in subjects who had middle or high levels of educational attainment, were receiving Medical Aid, or had a large family size.

Conclusions:

It is important to control risk factors in high-risk groups as part of suicide prevention strategies. The clinical approach, which includes community-based intervention, entails the management of reduction of suicidal risk. Our study identified demographic characteristics that have a significant impact on mental health care utilization and should be considered in the development of suicide prevention strategies. Further studies should examine the effect of mental health care utilization on reducing suicidal ideation.     

A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy

Objective

To compare patient profiles and health care use for physician-referred and self-referred episodes of outpatient physical therapy (PT).

Data Source

Five years (2003–2007) of private health insurance claims data, from a Midwest insurer, on beneficiaries aged 18–64.

Study Design

Retrospective analyses of health care use of physician-referred (N = 45,210) and self-referred (N = 17,497) ambulatory PT episodes of care was conducted, adjusting for age, gender, diagnosis, case mix, and year.

Data Collection/Extraction

Physical therapy episodes began with the physical therapist initial evaluation and ended on the last date of service before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of PT.

Principal Findings

The self-referred group was slightly younger, but the two groups were very similar in regard to diagnosis and case mix. Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00), after covariate adjustment, but did not differ in related health care utilization after PT.

Conclusions

Health care use during PT episodes was lower for those who self-referred, after adjusting for key variables, but did not differ after the PT episode.     

Ambulatory subspecialty visits in a large pediatric primary care network

Objective

To determine patterns of subspecialty utilization within a pediatric primary care network.

Data Sources/Study Setting

Paid claims from a large not-for-profit health plan for patients of The Pediatric Physicians'' Organization at Children''s, a network of private pediatric practices affiliated with Children''s Hospital Boston.

Principal Findings

The subspecialty visit rate was 1.01 visits per subject-year. In 2007, 56.8 percent of subjects had no subspecialty visits, whereas 4.2 percent had ≥5 visits; the corresponding figures in 2008 were 54.1 and 4.5 percent, respectively. The most frequently visited subspecialties were Ophthalmology, Orthopedics, Dermatology, Otorhinolaryngology, and Allergy/Immunology. Visit rates varied sevenfold by practice.

Conclusions

Wide practice variability in pediatric subspecialty utilization suggests an opportunity for reducing unnecessary visits. Better integration between primary care and the most commonly used subspecialties will be needed to meaningfully reduce unnecessary visits and enhance value.     

The Patterns of Health Care Utilization by Elderly Europeans: Frailty and Its Implications for Health Systems

Objective

To examine the patterns of health care utilization by the elderly and test the influence of functional decline.

Data Source and Study Design

We used the three regular waves of the SHARE survey to estimate the influence of frailty on health care utilization in 10 European countries. We controlled for the main correlates of frailty and unobserved individual effects.

Results

The frail elderly increase their primary and hospital care utilization before the onset of disability. Multimorbidity moderates the effect of frailty on care utilization.

Conclusions

The prevalence of frailty is high in most countries and is expected to increase. This renders frailty prevention and remediation efforts imperative for two complementary reasons: to promote healthier aging and to reduce the burden on health systems.     

Home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review

Objective

To determine whether home visits for neonatal care by community health workers can reduce infant and neonatal deaths and stillbirths in resource-limited settings.

Methods

We conducted a systematic review up to 2008 of controlled trials comparing various intervention packages, one of them being home visits for neonatal care by community health workers. We performed meta-analysis to calculate the pooled risk of outcomes.

Findings

Five trials, all from south Asia, satisfied the inclusion criteria. The intervention packages included in them comprised antenatal home visits (all trials), home visits during the neonatal period (all trials), home-based treatment for illness (3 trials) and community mobilization efforts (4 trials). Meta-analysis showed a reduced risk of neonatal death (relative risk, RR: 0.62; 95% confidence interval, CI: 0.44–0.87) and stillbirth (RR: 0.76; 95% CI: 0.65–0.89), and a significant improvement in antenatal and neonatal practice indicators (> 1 antenatal check-up, 2 doses of maternal tetanus toxoid, clean umbilical cord care, early breastfeeding and delayed bathing). Only one trial recorded infant deaths (RR: 0.41; 0.30–0.57). Subgroup analyses suggested a greater survival benefit when home visit coverage was ≥ 50% (P < 0.001) and when both preventive and curative interventions (injectable antibiotics) were conducted (P = 0.088).

Conclusion

Home visits for antenatal and neonatal care, together with community mobilization activities, are associated with reduced neonatal mortality and stillbirths in southern Asian settings with high neonatal mortality and poor access to facility-based health care.