Health services use in women with a history of bulimia nervosa or binge eating disorder

OBJECTIVE: The current study examined health services use during the past 12 months in a sample of young women with a history of an adolescent eating disorder (bulimia nervosa [BN] or binge eating disorder [BED]). METHOD: A community sample of 1,582 young women (mean age = 21.5 years) was classified, based on a screening interview (and, for eating disorder diagnosis, confirmatory diagnostic interview), into one of three groups: BN or BED (n = 67), other psychiatric disorder (n = 443), and no adolescent psychiatric disorder (n = 1,072). RESULTS: A history of BN/BED in adolescence was associated with elevated health services use, but this was a general effect associated with having a psychiatric disorder, not an effect specific to the diagnosis of an eating disorder. Total service days, outpatient psychotherapy visits, and emergency department visits were elevated in the combined group of BN/BED and other psychiatric disorder participants relative to the healthy comparison group. The women with BN/BED did not differ significantly from the women with a non-eating-related psychiatric disorder in the use of these services. DISCUSSION: The similarity of health services use in young women with BN or BED and those with other psychiatric disorders underscores the clinical and economic impact of these eating disorders.     

Factors associated with health service utilization patterns in low-income women

Little is known about the relationship of demographic, health, and psychosocial factors with health services utilization over time among low-income female heads of household. In a case-control study conducted between 1991 and 1997, 273 homeless and low-income housed mothers living in Worcester, Massachusetts were interviewed at baseline and at a two-year follow-up. The use of outpatient and emergency department care in this study sample was examined. High usage patterns were found at baseline. At the two-year follow-up, poor health status, non-White race, and fewer supportive relationships were significantly associated with frequent emergency department visits. Women with higher rates of ongoing outpatient medical care visits were more likely to have fewer social supports and more bodily pain than women with lower rates of ambulatory care usage. Mental health and victimization were not associated with service use patterns. In order to address poor women's needs in a more effective and potentially less costly way, health programs must understand their need for social support and culturally responsive services.     

Circulating levels of neuroactive steroids in patients with binge eating disorder: a comparison with nonobese healthy controls and non-binge eating obese subjects

OBJECTIVES: Increased plasma levels of allopregnenolone (3alpha,5alpha-tetrahydroprogesterone [3alpha,5alpha-THP]), dehydroepiandrosterone (DHEA), and DHEA sulphate (DHEA-S) have been reported in patients with anorexia nervosa or bulimia nervosa. To assess whether those changes are related to malnutrition, we investigated plasma levels of neuroactive steroids in women with binge eating disorder (BED) who compulsively binge as bulimic patients, but do not incur malnutrition. METHODS: Sixty-eight women participated in the study (31 nonobese healthy controls, 9 nonobese patients with BED, 16 obese patients with BED, and 12 obese non-binge eating women). Blood samples were collected in the morning for determination of plasma levels of 3alpha,5alpha-THP, DHEA, DHEA-S, and cortisol. RESULTS: Nonobese BED women had significantly higher plasma levels of DHEA, DHEA-S, and 3alpha,5alpha-THP than nonobese healthy women. Similarly, obese individuals with BED exhibited significantly higher neurosteroid plasma levels than non-binge eating obese subjects. No significant differences in plasma cortisol levels were observed among the groups. DISCUSSION: This study shows increased plasma levels of neuroactive steroids in BED patients. These findings could have been influenced by methodologic limitations (e.g., the absence of diurnal sampling). However, they suggest that if malnutrition is involved in the determination of increased plasma levels of neuroactive steroids in people with anorexia or bulimia nervosa, then different factors may induce similar effects in people with BED. Alternatively, common unknown factors could be responsible for neurosteroid changes in anorexia nervosa, bulimia nervosa, and BED.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

Relationship between body mass index and the use of healthcare services in Australia

OBJECTIVE: To examine the relationship between body mass index (BMI) and the use of medical and preventive health services. RESEARCH METHODS AND PROCEDURES: This study involved secondary analysis of weighted data from the Australian 1995 National Health Survey. The study was a population survey designed to obtain national benchmark information about a range of health-related issues. Data were available from 17,033 men and 17,174 women, > or =20 years or age. BMI, based on self-reported weight and height, was analyzed in relation to the use of medical services and preventive health services. RESULTS: A positive relationship was found between BMI and medical service use, such as medication use, visits to hospital accident and emergency departments (for women only); doctor visits, visits to a hospital outpatient clinics; and visits to other health professionals (for women only). A negative relationship was found in women between BMI and preventive health services. Underweight women were found to be significantly less likely to have Papanicolaou smear tests, breast examinations, and mammograms. DISCUSSION: This research shows that people who fall outside the healthy weight range are more likely to use a range of medical services. Given that the BMI of industrialized populations appears to be increasing, this has important ramifications for health service planning and reinforces the need for obesity prevention strategies at a population level.     

Utilization of mental health services by low-income pregnant and postpartum women on medical assistance

This paper examines mental health service use among publicly insured white and African-American pregnant and postpartum women who live in a metropolitan area. The study examines the extent to which ethnicity, physical health problems, and behavioral health risk factors are associated with the probability of service use during the prenatal-postpartum period. It also analyzes the patterns of service utilization for those women who used mental health services. Medicaid claims and eligibility data, County Reporting System claims and admissions data, and Pennsylvania State Vital Birth Records were integrated using a unique algorithm. Logistic regression was employed to estimate the probability of mental health service use among 3,841 low-income women residing in Philadelphia who were continuously enrolled in Medicaid for 9 months preceding delivery and 6 months postpartum. Analyses were also conducted on the intensity and location of service use, as well as psychiatric diagnosis, during pregnancy and the postpartum period. About 10% of the women used mental health services during the study period. Women were more likely to use services if they were Caucasian, had a number of chronic diseases, had a number of pregnancy complications, and smoked. Among users, the same proportion (ca. 6%) used services during pregnancy and postpartum, with the average number of outpatient visits slightly higher during pregnancy than during the postpartum period. Most outpatient services (86%) were delivered in the specialty sector. Most women who used mental health services (84%) were diagnosed with minor psychiatric disorders including minor depression and anxiety disorders. Women who used services during the postpartum only were more likely to be diagnosed with major depression, whereas women who used services throughout the perinatal period were more likely to be diagnosed with severe mental disorders. Health providers can use information generated in this study to identify women who are likely to have a need for mental health services.     

Plasma pyridoxal 5'-phosphate concentrations in obese and nonobese black women residing near Petersburg, VA

The vitamin B-6 status of 15 obese and 15 nonobese black women aged 21-51 y who were not taking vitamin supplements was assessed by using plasma pyridoxal 5'-phosphate (PLP) measurements. Ages, heights, and ideal body weights of the two groups were similar as were reported energy, protein, and vitamin B-6 intakes obtained by using 24-h intake data collected on two nonconsecutive days separated by at least 1 wk. The reported vitamin B-6 intakes were 1.18 +/- 0.44 mg/d (means +/- SD). Plasma PLP levels in the obese and nonobese black women were similar; these levels were also similar to those observed previously for white obese and nonobese women having similar physical characteristics. All subjects had plasma PLP levels indicative of adequate status with one possible exception. Obesity did not affect the plasma PLP levels in these black women.     

Racial and ethnic differences in utilization of health services in patients with diabetes enrolled in medicaid

We evaluated racial and ethnic differences in use of medical care between patients with diabetes enrolled in Medicaid and explored whether differences varied by state Medicaid program. Using data from 137,006 patients we created a multivariable Poisson regression model to examine the effect of race on ambulatory care visits, emergency ward visits, and hospitalization rates for patients with diabetes mellitus enrolled in three state Medicaid programs. We found significant differences in service use between groups, which varied depending on state. For example, black patients compared with whites had significantly fewer outpatient visits but more hospitalizations in New Jersey; by contrast, blacks had higher outpatient visit rates and lower hospitalization rates in Georgia. Racial and ethnic differences in health service use among Medicaid enrollees were not consistent across states, suggesting that local factors, including varied Medicaid policies, may affect racial and ethnic differences in use of health care services.     

Obesity and the use of health care services

OBJECTIVE: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. RESEARCH METHODS AND PROCEDURES: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self-reported health status using the Medical Outcomes Study Short Form-36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. RESULTS: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. DISCUSSION: Obesity is a chronic condition requiring long-term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity-related diseases will continue to grow, resulting in escalating use of health care services.     

Impact of a school-based health center on emergency department use by elementary school students

While school-based health centers (SBHC) improve student access to health services, it remains unclear if use of the centers can reduce hospital emergency department visits. This study evaluated the impact of an elementary school SBHC on emergency department visits by children enrolled in the center. Major reasons for visits included trauma (32%), otitis media (15%), upper respiratory infections (9%), and gastroenteritis (6%). Implementation of an elementary SBHC resulted in a significant decrease (p < 0.03) in non-urgent emergency department visits. No difference existed in urgent emergency department visits. Medicaid-insured children were more likely to use the emergency department than privately insured or uninsured children. Reducing emergency department visits can decrease medical costs and support the cost effectiveness of SBHCs.     

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

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

Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as?≥?4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n?=?75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having?≥?1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

     

National Hospital Ambulatory Medical Care Survey: 1998 outpatient department summary

OBJECTIVE: This report describes ambulatory care visits to hospital outpatient departments in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. METHODS: The data presented in this report were collected from the 1998 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to hospital outpatient and emergency departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1998, an estimated 75.4 million visits were made to hospital outpatient departments in the United States, an overall rate of 28.0 per 100 persons. Visit rates did not vary by age except in a comparison of the 15-24 year old group with the 75 years and over age group. Black persons had higher rates of visits than white persons as did women compared with men. Of all visits made to hospital outpatient departments in 1998, 33.8 percent and 25.9 percent, respectively, listed private insurance and Medicaid as the primary expected source of payment, and 21.9 percent were made by patients belonging to a health maintenance organization. There were an estimated 7.1 million injury-related outpatient department visits during 1998.     

Health needs and health care utilization among rural, low-income women

This study examined the correlates of health service utilization in a sample of low-income, rural women. Self-reported data were from Rural Families Speak (N = 275), a multi-state study of low-income, rural families in the U.S. collected in 2002. Findings indicated that women with health insurance, a regular doctor, and poorer overall physical health had higher incident rates of physician visits. Women who were divorced, separated or widowed and had more chronic health problems had higher incidence rates of emergency department (ED) use, while women living in counties with higher primary care physician rates had lower incidence rates of ED use. Future research and policies should focus on improved access to health insurance, increasing physician availability in rural areas, and providing rural women with a usual source of care, so as to reduce emergency services utilization for non-emergent needs and improve health status for this population.     

Depression, service utilization, and treatment costs among Medicare elderly: gender differences.

OBJECTIVE: To compare gender differences in mood disorders, service utilization, and health care costs among a random sample of Medicare elderly beneficiaries of Tennessee. DATA SOURCES: Medicare expenditure data from a 5% random sample of Tennessee Medicare beneficiaries (n = 35,673) were examined for 1991-1993. The physician reimbursement files provided data relative to ICD-9 diagnostic codes, physician visits, and the cost of physician services provided. Other service utilization and cost data were obtained for the sample from the outpatient, home health, skilled nursing, hospice and inpatient files. STUDY DESIGN: The dependent variables were: (i) patients with ICD-9 diagnosis for a mood disorder (major depression and other depression), (ii) service utilization (number of outpatient visits, skilled nursing visits, home health visits, physician visits, emergency visits, and inpatient days), and (iii) health care costs (dollar amount of physician cost, outpatient cost, inpatient cost, total mental health cost, total health cost, and other cost). The independent variable was gender. PRINCIPLE FINDINGS: Chi-square tests showed that among the patients with a mood disorder, females had a significantly higher incidence than males of major depression (1.3% vs. .4%, respectively, p < .001) and other depression (1.6% vs. .6%, respectively, p < .001). Further, t-test results indicated that females diagnosed with major depression utilized significantly more outpatient services than males (3.2 vs. 2.6, respectively, p < .04). Total health care costs for those with other depression were significantly higher for males than females ($15,060 vs. $10,240, respectively, p < .002). CONCLUSIONS: The results indicate that mood disorders, outpatient services, and total mental health costs are higher for females than males; however, total health care costs are higher for males than females.     

Health care utilization among homeless adults prior to death

This study characterizes health care utilization prior to death in a group of 558 homeless adults in Boston. In the year before death, 27 percent of decedents had no outpatient visits, emergency department visits, or hospitalizations except those during which death occurred. However, 21 percent of homeless decedents had a health care contact within one month of death, and 21 percent had six or more outpatient visits in the year before death. Injection drug users and persons with HIV infection were more likely to have had contact with the health care system. This study concludes that homeless persons may be underusing health care services even when they are at high risk of death. Because a subset of homeless persons had extensive health care contacts prior to death, opportunities to prevent deaths may have been missed, and some deaths may not have been preventable through medical intervention.     

Women and outpatient mental health services: Use by black,Hispanic, and white women in a national insured population

Factors affecting ethnic differences in women’s use of outpatient mental health services were analyzed to determine whether lower use by black and Hispanic women occurred when socioeconomic and other factors are controlled. Employing the Andersen and Newman model of health use, insurance claims of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed to identify significant predictors of use. Results revealed that black and Hispanic women had lower probabilities and amounts of use when compared to white women even after controlling for a number of variables. Further research is needed to examine cultural and gender-related factors that may underlie ethnic differences; attitudinal factors and service system barriers are also implicated. Such findings have policy implications in the current climate of health care reform for which efforts are needed to increase access to care for ethnic minority women and other underserved populations.