The impact of recent changes in public health insurance on community‐based health‐care in the USA

Recent changes in US government‐funded healthcare insurance are having profound impacts on all types of community‐based health‐care, reducing access to care by vulnerable populations. This article traces the impacts of recent policies on a range of community institutions in which nurses play a critical role, such as health centers, highlighting the effects on access to care and the survival of non‐profit services in less‐advantaged communities. In general, the new policies shifted revenues into fixed payment per client contracts (capitation) paid to for‐profit managed care organizations and away from non‐profit community services. The full impact of this competitive, market‐oriented system of health services has just begun to be felt. The uncertainties and dissatisfactions assure continued activity to change current conditions, including efforts by groups that seek greater access to health services for all populations and security for committed providers and personnel, including nurses.     

A population‐based cohort study of ambulatory care service utilization among older adults

Rationale, aims and objectives Age‐related effects on ambulatory care service utilization are not well understood. We aim to measure the utilization patterns of ambulatory health care services (i.e. family physician visits, specialist physician visits and emergency room visits) in the late life course (65 years and older). Methods A population‐based retrospective cohort study was conducted for the period 1 April 2005 to 31 March 2006. All Ontario, Canada, residents aged 65+ and eligible for government health insurance were included in the analysis. Results This population‐based cohort study demonstrates considerable increase in utilization rates and variability of ambulatory services as age increases. Variations in utilization were observed by gender as overall women were more likely to consult a family physician, and men more likely to visit specialists and the emergency room. A small group of high users, constituting 5.5% of the total population, accounted for 18.7% of total ambulatory visits. Finally, we report socio‐economic status (SES) based disparity for specialist services in which high users were more likely to have higher SES. Conclusions There is increasing utilization and variability in ambulatory service utilization with increase in age. Further research is required to explain the gender and SES differences reported in this study.     

The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review

ObjectiveTo synthesize literature about the effect of early physical therapy (PT) for acute low back pain (LBP) on subsequent health services utilization (HSU), compared to delayed PT or usual care.Data SourcesElectronic databases (MEDLINE, CINAHL, Embase) were searched from their inception to May 2018.Study SelectionStudy selection included randomized control trials and prospective and retrospective cohort studies that investigated the association between early PT and HSU compared to delayed PT or usual care. Two independent authors screened titles, abstracts, and full-text articles for inclusion based on eligibility criteria, and a third author resolved discrepancies. Eleven out of 1146 articles were included.Data ExtractionTwo independent reviewers extracted data on participants, timing of PT, comparisons to delayed PT or usual care, and downstream HSU, and a third reviewer assessed the information to ensure accuracy and reach consensus. Risk of bias was assessed with the Downs and Black checklist using the same method.Data SynthesisEleven studies met eligibility criteria. Early PT is within 30 days of the index visit for acute LBP. Five out of 6 studies that compared early PT to delayed PT found that early PT reduces future HSU. Random effects meta-analysis indicated a significant reduction in opioid use, spine injection, and spine surgery. Five studies compared early PT to usual care and reported mixed results.ConclusionsEarly PT for acute LBP may reduce HSU, cost, and opioid use, and improve health care efficiency. This review may assist patients, health care providers, health care systems, and third-party payers in making decisions for the treatment of acute LBP.     

Disparities in Telemedicine Access: A Cross-Sectional Study of a Newly Established Infrastructure during the COVID-19 Pandemic

Background  The COVID-19 pandemic led to dramatic increases in telemedicine use to provide outpatient care without in-person contact risks. Telemedicine increases options for health care access, but a “digital divide” of disparate access may prevent certain populations from realizing the benefits of telemedicine. Objectives  The study aimed to understand telemedicine utilization patterns after a widespread deployment to identify potential disparities exacerbated by expanded telemedicine usage. Methods  We performed a cross-sectional retrospective analysis of adults who scheduled outpatient visits between June 1, 2020 and August 31, 2020 at a single-integrated academic health system encompassing a broad range of subspecialties and a large geographic region in the Upper Midwest, during a period of time after the initial surge of COVID-19 when most standard clinical services had resumed. At the beginning of this study period, approximately 72% of provider visits were telemedicine visits. The primary study outcome was whether a patient had one or more video-based visits, compared with audio-only (telephone) visits or in-person visits only. The secondary outcome was whether a patient had any telemedicine visits (video-based or audio-only), compared with in-person visits only. Results  A total of 197,076 individuals were eligible (average age = 46 years, 56% females). Increasing age, rural status, Asian or Black/African American race, Hispanic ethnicity, and self-pay/uninsured status were significantly negatively associated with having a video visit. Digital literacy, measured by patient portal activation status, was significantly positively associated with having a video visit, as were Medicaid or Medicare as payer and American Indian/Alaskan Native race. Conclusion  Our findings reinforce previous evidence that older age, rural status, lower socioeconomic status, Asian race, Black/African American race, and Hispanic/Latino ethnicity are associated with lower rates of video-based telemedicine use. Health systems and policies should seek to mitigate such barriers to telemedicine when possible, with efforts such as digital literacy outreach and equitable distribution of telemedicine infrastructure.     

Utilization of medical healthcare among people receiving long‐term care at home or in special accommodation

Scand J Caring Sci; 2010; 24; 404–413
Utilization of medical healthcare among people receiving long‐term care at home or in special accommodation Aim: To investigate the utilization of medical healthcare, hospital care and outpatient care, during a 1‐year period in relation to informal care, multimorbidity, functional status and health complaints and to long‐term care at home or in special accommodation among people aged 65+, with one or more hospital admissions and receiving long‐term care. Method: A total of 694 people receiving long‐term care during the year 2001 were studied. Data were collected by means of the administrative registers Patient Administrative Support in Skåne and PrivaStat and through the study Good Ageing in Skåne. Those at home and those in special accommodation were compared regarding utilization of medical healthcare, informal care, multimorbidity, functional status and health complaints. Multiple logistic regression analysis was performed using at home vs. in special accommodation as the dependent variable and also two multiple linear regression analyses using the number of hospital stays and the number of contacts with the physician in outpatient care separately as dependent variables. Findings: Those at home were significantly younger (mean age: 81 vs. 84 years) and less dependent in personal and instrumental activities of daily living (PADL/IADL) than those in special accommodation. A larger proportion of those at home was admitted to hospital three times or more (21 vs. 14%) and they had significantly more contacts with physicians in outpatient care (md: 10 vs. md: 7). Informal care was associated with care at home (OR = 0.074) and with utilization of outpatient care (B = 2.045). Dependency in PADL was associated with care in special accommodation (OR = 1.375) and with utilization of hospital care (B = ?0.060) and outpatient care (B = ?0.581). Conclusion: Medical healthcare seems more accessible to those who live at home are younger, less dependent and who have access to informal caregivers.     

Alcohol Use and Medical Care Utilization among Health Maintenance Organization Patients in the Emergency Department

Objective: To determine the association of an alcohol–related ED visit with medical care utilization during a two–year period surrounding the ED visit in an HMO.
Methods: A probability sample of ED patients were interviewed and underwent breath analysis in a large HMO in a Northern California county. Based on recent alcohol intake or documentation of an alcohol–related ED visit, the patients were assigned to an alcohol group ( n = 91) or a non–alcohol group ( n = 897). A 10% random sample of the health plan membership of the same county ( n = 19, 968) served as a comparison group. Utilization data were obtained from computerized files. Multiple linear regression was used to determine differences in subsequent outpatient visit rates between the alcohol and the non–alcohol groups. Logistic regression was used to compare the risks of hospitalization in the two groups.
Results: Annual outpatient visit rates were 7. 8 in the alcohol group and 8. 3 in the non–alcohol group (p = 0. 65), controlling for gender, age, and injury status, and were significantly different from the visit rate of 5. 5 for the random health plan sample (p = 0. 0001). No difference was found between the alcohol and the non–alcohol groups for risk of hospitalization; however, those in the health plan sample were less than half as likely to be hospitalized as were those in the non–alcohol group (odds ratio 0. 44, p = 0. 002).
Conclusions: No difference was found in utilization of medical services between the alcohol and the nonalcohol groups in this predominantly white, well–educated HMO ED population. However, both groups used significantly more inpatient and outpatient services than did the general HMO membership.     

GP group profiles and involvement in mental health care

Rationale and objectives Mental health is one of the leading causes of morbidity worldwide. Its impact in terms of cost and loss of productivity is considerable. Improving the efficiency of mental health care system has thus been a high priority for decision makers. In the context of current reforms that privilege the reinforcement of primary mental health care and integration of services, this article brings new lights on the role of general practitioners (GPs) in managing mental health, and shared‐care initiatives developed to deal with more complex cases. The study presents a typology of GPs providing mental health care, by identifying clusters of GP profiles associated with the management of patients with common or serious mental disorders (CMD or SMD). Methods GPs in Quebec (n = 398) were surveyed on their practice, and socio‐demographic data were collected. Results Cluster analysis generated five GP profiles, including three that were closely tied to mental health care (labelled, respectively: group practice GPs, traditional pro‐active GPs and collaborative‐minded GPs), and two not very implicated in mental health (named: diversified and low‐implicated GPs, and money‐making GPs). Conclusion The study confirmed the central role played by GPs in the treatment of patients with CMD and their relative lack of involvement in the care of patients with SMD. Study results support current efforts to strengthen collaboration among primary care providers and mental health specialists, reinforce GP training, and favour multi‐modal clinical and collaborative strategies in mental health care.     

Disparities in Health Care: An Overview

The most important predictor of quality of health care across all racial and ethnic groups is access, especially insurance status and the ability to pay for health care. If we consider populations with equal access to health care, two groups emerge with differing qualities of health care: non-minority and minority populations. When studies control for the stage of disease at presentation, comorbidities, severity of illness, and other variables, substantial differences in health care based on race and ethnicity can still be found. Raising the consciousness of this issue is an important step toward recognizing and eliminating health care disparities.     

Trends in mental health: implications for advanced practice nurses

PURPOSE: To examine current trends in mental health care for vulnerable populations and suggest how advanced practice nurses (APNs) can incorporate mental health care into primary care practice. DATA SOURCES: Original research and evidence-based clinical articles, government publications, and professional practice guidelines. CONCLUSIONS: Vulnerable populations, such as racial and ethnic minorities, adults with chronic mental illness, the elderly, the incarcerated, and those living in rural areas have long been ignored as recipients of quality, integrated health care services. There is a compelling need for APNs to participate in the integrated delivery of physical and mental health care to all Americans, especially to vulnerable populations. IMPLICATIONS FOR PRACTICE: Under the umbrella of advanced practice nursing, a variety of nurse practitioners (NPs) and clinical nurse specialists (CNSs) can offer a holistic approach to the provision of evidence-based health care in a wide variety of settings to an array of vulnerable and underserved people. By serving on provider panels, partnering with consumer groups, and advocating for the unmet health needs of vulnerable populations, APNs can have a positive impact on the health care delivery system.     

A Cost-Analysis of an Interdisciplinary Pediatric Chronic Pain Clinic

Chronic pain is characterized by high rates of functional impairment, health care utilization, and associated costs. Research supports the use of comprehensive, interdisciplinary treatment approaches. However, many hospitals hesitate to offer this full range of services, especially to Medi-Cal/Medicaid patients whose services are reimbursed at low rates. This cost analysis examines the effect on hospital and insurance costs of patients' enrollment in an interdisciplinary pediatric pain clinic, which includes medication management, psychotherapy, biofeedback, acupuncture, and massage. Retrospective hospital billing data (inpatient/emergency department/outpatient visits, and associated costs/reimbursement) from 191 consecutively enrolled Medi-Cal/Medicaid pediatric patients with chronic pain were used to compare 1-year costs before initiating pain clinic services with costs 1 year after. Pain clinic patients had significantly fewer emergency department visits, fewer inpatient stays, and lower associated billing, compared with the year before without interdisciplinary pain management services. Cost savings to the hospital of $36,228 per patient per year and to insurance of $11,482 per patient per year were found even after pain clinic service billing was included. Analyses of pre-pain clinic costs indicate that these cost reductions were likely because of clinic participation. Findings provide economic support for the use of interdisciplinary care to treat pediatric chronic pain on an outpatient basis from a hospital and insurance perspective.

Loneliness and health care consumption among older people

Few studies have investigated loneliness in relation to health care consumption among frail older people. The aim of this study was to examine loneliness, health‐related quality of life (HRQoL), and health complaints in relation to health care consumption of in‐ and outpatient care among frail older people living at home. The study, with a cross‐sectional design, comprised a sample of 153 respondents aged from 65 years (mean age 81.5 years) or older, who lived at home and were frail. Data was collected utilising structured interviews in the respondent's home assessing demographic data, loneliness, HRQoL and health complaints. Patient administrative registers were used to collect data on health care consumption. Loneliness was the dependent variable in the majority of the analyses and dichotomised. For group comparisons Student′s t‐test, Mann–Whitney U‐test and Chi‐square test were used. The results showed that 60% of the respondents had experienced loneliness during the previous year, at least occasionally. The study identified that lonely respondents had a lower HRQoL (p = 0.022), with a higher total number of reported health complaints (p = 0.001), and used more outpatient services including more acute visits at the emergency department, compared to not lonely respondents (p = 0.026). Multiple linear regression analysis showed that a depressed mood was independently associated to total use of outpatient care (B = 7.4, p < 0.001). Therefore, it might not be loneliness, per se, that is the reason for seeking health care. However, reasons for using health care services are difficult to determine due to the complex situation for the frail older person. To avoid emergency department visits and to benefit the well‐being of the frail older person, interventions targeting the complex health situation, including loneliness, are suggested.     

Emergency Department Utilization in the United States and Ontario, Canada

Objectives: The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics.
Methods: This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year.
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada.
Conclusions: ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.     

农村老年人健康状况及卫生保健需求调查

目的了解农村老年人的健康状况和卫生保健需求。方法采用自设问卷对528名60岁及以上的农村老年人进行调查。结果59．28％的老年人患有一种或几种慢性疾病,56．82％的老年人常有孤独感、衰老感、抑郁感、无能为力感等负性情绪;65．63％的老年人支付医疗费用困难。卫生保健需求依次是定期体格检查、急救处理、上门服务、健康教育、定期家访。结论农村老年人存在不同程度的身心健康问题,对卫生保健有较大需求,应根据老年人的经济状况和需求提供多种形式、多层次的卫生保健服务。     

Building a Culture of Oral Health Care

Poor oral health afflicts many low-income and other vulnerable populations. Poor oral health can lead to unnecessary tooth decay, periodontal disease, plaque buildup, pain, and even the quiet and deadly advancement of oral cancer. It also leads to unnecessary and expensive visits to the emergency department to treat pain of tooth decay and periodontal disease but not the causal conditions. Finding ways to improve oral health in low-income communities is essential to good health and helping individuals move from poverty to middle class status. It requires a collaborative effort of a diverse array of health care workers.     

The impact of specialist care for low back pain on health service utilization in primary care patients: A prospective cohort study

Guidelines portray low back pain (LBP) as a benign self‐limiting disease which should be managed mainly by primary care physicians. For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment. This is a longitudinal prospective cohort study. General practitioners recruited consecutive adult patients presenting with LBP. Data on physical function, on depression, and on utilization of health services were collected at the first consultation and at follow‐up telephone interviews for a period of 12 months. Logistic regression models were calculated to investigate predictors for specialist consultations and use of specific health care services. Large proportions (57%) of the 1342 patients were seeking additional specialist care. Although patients receiving specialist care had more often chronic LBP and a positive depression score, the association was weak. A total of 623 (46%) patients received some form of imaging, 654 (49%) physiotherapy and 417 (31%) massage. Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions while disease‐related and socio‐demographic factors were less important. Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection. The high dependence of health care service utilization on providers rather than clinical factors indicates an unsystematic and probably inadequate management of LBP.     

Important Attributes of Quality Health Care: Consumer Perspectives

Purpose: Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables.
Design: Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations.
Methods: Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas.
Findings: The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status.
Conclusions: The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.     

Referral of Medically Uninsured Emergency Department Patients to Primary Care

OBJECTIVE: To examine the impact primary care referral has on subsequent emergency department (ED) utilization. METHODS: Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital-based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral. RESULTS: Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self-pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p < 0.001). There was no significant difference in pre- or post-ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001). CONCLUSIONS: For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.     

Enhancing oral health for better mental health: Exploring the views of mental health professionals

The association between oral health, self‐esteem and quality of life is well established yet there is limited research on the impact of addressing the poor oral health of people living with mental health disorders. Greater consideration is warranted on how enhancing oral health in the course of mental healthcare might reduce the burden of a person's ill health. The role of mental health professionals is important in this regard yet uncertainty persists about the role these providers can and should play in promoting oral health care for people with mental health disorders. This qualitative study explored the issue of oral health and mental health with community based mental health professionals in Perth, Western Australia. It examined their views on the oral health status and experiences of their clients, and the different and alternative ways to improve access to care, knowledge and preventative regimens. Findings indicated participants’ ambivalence, reluctance and lack of training in raising oral health issues, despite its acknowledged importance, indicating a siloed approach to care. Findings offer an opportunity to reflect on whether a more integrated approach to oral health care for people with mental health disorders would improve health outcomes.     

CA4-01: Obesity and Health Care Utilization

Background/Aims Maternal obesity (BMI > 30) is associated with increased prenatal health care utilization and puts infants at risk for macrosomia and delivery complications. Our aim was to investigate whether obese women and their infants have higher rates of health care utilization in the first year postpartum. Methods We extracted EMR data of 1663 women who had singleton, live births in 2006-2009, height and weight measurements for BMI, known delivery and discharge dates, and continuous health insurance coverage for 12 months post-partum. We used multivariate regression analyses to evaluate associations between maternal pre-pregnancy BMI category and maternal and infant outpatient visits and hospitalizations. Results During the first year post-partum, women made an average of 7.0 + 7.3 ambulatory visits, including a wide variety of ancillary services as well as primary and specialty care. Thirty percent (492/1663) were hospitalized at least once, 19% (311/1663) had at least one emergency department visit and 25% (421/1663) visited urgent care. When adjusted for age, race/ethnicity, insurance status and delivery type, women with BMIs > 30 had significantly more ambulatory, urgent care and emergency visits. Women with BMIs > 40 had significantly more hospitalizations and outpatient visits of all types compared to women with normal BMIs. There were 1427 infants with adequate data for inclusion. During the first year of life, 21% (299 of 1427) were hospitalized, 32% (454/1427) had at least one emergency visit, and 47% (676/1427) visited urgent care. Essentially all infants (99.7%) had an ambulatory visit. Maternal BMI was not significantly associated with infant hospitalization, emergency or urgent care visits. However, infants whose mothers had BMIs >30 had significantly fewer ambulatory visits compared to infants of mothers with normal BMIs (p=.008). Discussion During the first year post-partum, obese women had more ambulatory care and emergency visits than normal weight women, the greatest differences occurring between extreme obesity and normal BMI categories. In contrast, infants of obese women have fewer ambulatory visits. This finding merits investigation to determine whether the obese mother's need for medical services after delivery competes with her ability to bring her infant for recommended care.