Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis.

Patients with inflammatory bowel disease (IBD) suffer physical dysfunction and impaired quality of life (QOL), and need frequent health care. They often lack knowledge about their disease and desire more education. Educational interventions for other chronic diseases have demonstrated reduced health care use and increased knowledge, medication adherence and QOL. Sixty-nine participants were randomly assigned to formal IBD education and standard of care (pamphlets and ad hoc physician education) or standard of care alone. Assessment of IBD knowledge and QOL occurred at baseline, immediately posteducation and eight weeks posteducation. Participants documented medication adherence and health care use in diaries. Patient satisfaction was assessed at the end of the study. The education group had higher knowledge scores (P=0.000), perceived knowledge ratings (P=0.01) and patient satisfaction (P=0.001). There was a lower rate of medication nonadherence and health care use for the education group, but the differences were not significant. QOL indices did not change. Significant correlations were found for increased health care use in patients with poorer medication adherence (P=0.01) and lower perceived health (P=0.05). Formal IBD patient education improves knowledge, perceived knowledge and patient satisfaction. Further study of long-term effects may better demonstrate potential benefits for QOL, medication adherence and health care use.

BackgroundMany patients encounter a variety of problems after discharge from hospital and many discharge (planning and support) interventions have been developed and studied. These primary studies have already been synthesized in several literature reviews with conflicting conclusions. We therefore set out a systematic review of the reviews examining discharge interventions. The objective was to synthesize the evidence presented in literature on the effectiveness of interventions aimed to reduce post-discharge problems in adults discharged home from an acute general care hospital.MethodsA comprehensive search of seventeen literature databases and twenty-five websites was performed for the period 1994–2004 to find relevant reviews. A three-stage inclusion process consisting of initial sifting, checking full-text papers on inclusion criteria, and methodological assessment, was performed independently by two reviewers. Data on effects were synthesized by use of narrative and tabular methods.ResultsFifteen systematic reviews met our inclusion criteria. All reviews had to deal with considerable heterogeneity in interventions, populations and outcomes, making synthesizing and pooling difficult.Although a statistical significant effect was occasionally found, most review authors reached no firm conclusions that the discharge interventions they studied were effective.We found limited evidence that some interventions may improve knowledge of patients, may help in keeping patients at home or may reduce readmissions to hospital. Interventions that combine discharge planning and discharge support tend to lead to the greatest effects. There is little evidence that discharge interventions have an impact on length of stay, discharge destination or dependency at discharge. We found no evidence that discharge interventions have a positive impact on the physical status of patients after discharge, on health care use after discharge, or on costs.ConclusionBased on fifteen high quality systematic reviews, there is some evidence that some interventions may have a positive impact, particularly those with educational components and those that combine pre-discharge and post-discharge interventions. However, on the whole there is only limited summarized evidence that discharge planning and discharge support interventions have a positive impact on patient status at hospital discharge, on patient functioning after discharge, on health care use after discharge, or on costs.

Opioid use disorder is a significant cause of morbidity, mortality, and health care costs. A transitional pain service (TPS) approach to perioperative pain management has been shown to reduce opioid use among patients undergoing orthopedic joint surgery. However, whether TPS also leads to lower health care use and costs is unknown. We designed this study to estimate the effect of TPS implementation relative to standard care on health care use and associated costs of care following orthopedic surgery. We evaluated postoperative health care use and costs for patients who underwent orthopedic joint surgery at 6 US Department of Veterans Affairs medical centers (VAMCs) between 2018 and 2019 using difference-in-differences analysis. Patients enrolled in the TPS at the Salt Lake City VAMC were matched to control patients undergoing the same surgeries at 5 different VAMCs without a TPS. We stratified patients based on history of preoperative opioid use into chronic opioid use (COU) and nonopioid use (NOU) groups and analyzed them separately. For NOU patients, TPS was associated with a mean increase in the number of outpatient visits (6.9 visits; P < .001), no change in outpatient costs, and a mean decrease in inpatient costs (-$12,170; P = .02) during the 1-year follow-up period. TPS was not found to increase health care use or costs for COU patients. Although TPS led to an increase in outpatient visits for NOU patients, there was no increase in outpatient costs and a decrease in inpatient costs after orthopedic surgery. Further, there was no added cost for managing COU patients with a TPS. These findings suggest that TPS can be implemented to reduce opioid use following joint surgery without increasing health care costs.

Context Patients treated with maintenance hemodialysis experience significant symptom burden resulting in impaired quality of life. However, the association of patient reported symptom burden and the risk of healthcare use for patients with end stage kidney disease on hemodialysis has not been fully explored. Objectives To investigate if higher symptom burden, assessed by the Edmonton Symptom Assessment System-revised (ESASr), is associated with increased healthcare use in patients with end stage kidney disease on hemodialysis. Methods Prospective, single-center, study of adult patients on HD. Participants completed the ESASr questionnaire at enrollment. Baseline demographic, clinical information as well as healthcare use events during the 12-month following enrollment were extracted from medical records. The association between symptom burden and healthcare use was examined with a multivariable adjusted negative binomial model. Results Mean (SD) age of the 80 participants was 71 (13) years, 56% diabetic, and 70% male. The median (IQR) dialysis vintage was 2 (1–4) years. In multivariable adjusted models, higher global [incident rate ratio (IRR) 1.02, 95% confidence interval (CI) 1.00–1.04, p = .025] and physical symptom burden score [IRR 1.03, CI 1.00–1.05, p = .034], but not emotional symptom burden score [IRR 1.05, CI 1.00–1.10, p = .052] predicted higher subsequent healthcare use. Conclusions Our preliminary evidence suggests that higher symptom burden, assessed by ESASr may predict higher risk of healthcare use amongst patients with end stage kidney disease on hemodialysis. Future studies need to confirm the findings of this preliminary study and to assess the utility of ESASr for systematic symptom screening.

Both attention-deficit/hyperactivity disorder (ADHD) and insomnia have been independently related to poorer quality of life (QoL), productivity loss, and increased health care use, although most previous studies did not take the many possible comorbidities into account. Moreover, ADHD and insomnia often co-occur. Symptoms of ADHD and insomnia together may have even stronger negative effects than they do separately. We investigated the combined effects of symptoms of ADHD and insomnia, in addition to their independent effects, on QoL, productivity, and health care use, thereby controlling for a wide range of possible comorbidities and confounders. Data from the third wave of the Netherlands Mental Health Survey and Incidence Study-2 were used, involving N = 4618 from the general population. Both the inattention and the hyperactivity ADHD symptom dimensions were studied, assessed by the ASRS Screener. Mental functioning and productivity were negatively associated with the co-occurrence of ADHD and insomnia symptoms, even after adjusting for comorbidity and confounders. The results show no indication of differences between inattention and hyperactivity. Poorer physical functioning and health care use were not directly influenced by the interaction between ADHD and insomnia. People with both ADHD and sleep problems have increased risk for poorer mental functioning and productivity loss. These results underscore the importance of screening for sleep problems when ADHD symptoms are present, and vice versa, and to target both disorders during treatment.

BackgroundHealthcare use is increasing, and health anxiety (HA) is recognized as an important associated factor. Previous research on the association between HA and healthcare use has mostly explored HA as a dichotomous construct, which contrasts the understanding of HA as a continuous construct, and compared healthcare use to non-use. There is a need for studies that examine the association between healthcare use and the continuum of HA in a general population.AimTo explore the association between HA and primary, somatic specialist and mental specialist healthcare use and any differences in the association by level of healthcare use.MethodsThis study used cross-sectional data from the seventh Tromsø study. Eighteen thousand nine hundred sixty-seven participants aged 40 years or older self-reported their primary, somatic specialist and mental specialist healthcare use over the past 12 months. Each health service was categorized into 5 groups according to the level of use. The Whiteley Index-6 (WI-6) was used to measure HA on a 5-point Likert scale, with a total score range of 0–24. Analyses were conducted using unconstrained continuation-ratio logistic regression, in which each level of healthcare use was compared with all lower levels. Morbidity, demographics and social variables were included as confounders.ResultsHA was positively associated with increased utilization of primary, somatic specialist and mental specialist healthcare. Adjusting for confounders, including physical and mental morbidity, did not alter the significant association. For primary and somatic specialist healthcare, each one-point increase in WI-6 score yielded a progressively increased odds ratio (OR) of a higher level of use compared to all lower levels. The ORs ranged from 1.06 to 1.15 and 1.05 to 1.14 for primary and somatic specialist healthcare, respectively. For mental specialist healthcare use, the OR was more constant across levels of use, ranging between 1.06 and 1.08.ConclusionsIn an adult general population, HA, as a continuous construct, was significantly and positively associated with primary, somatic specialist and mental healthcare use. A small increase in HA was associated with progressively increased healthcare use across the three health services, indicating that the impact of HA is more prominent with higher healthcare use.

Longitudinal study with a 6-month follow-up. To investigate whether demographic, work-related physical and psychosocial risk factors involved in the occurrence of musculoskeletal symptoms also determine subsequent health care use and sick leave. Preventing the socioeconomic consequences of disability from musculoskeletal symptoms may be a goal separate from that of eliminating the symptoms themselves; thus, other factors may need to be addressed in intervention. A questionnaire provided data on demographics and work-related factors, musculoskeletal symptoms, and ensuing health care use and sick leave among 407 industrial workers. The 12-month prevalence of low back pain (LBP) and neck/upper extremity symptoms was 52% and 56%, respectively. Of those individuals with symptoms at baseline, 68% had a recurrence of LBP, and 62% a recurrence of neck/upper extremity symptoms during a 6-month follow-up. The recurrence of sick leave for a particular musculoskeletal complaint was approximately 30%, while recurrence of health care use was more than 40%. Recurrence of symptoms, health care use, and sick leave were strongly associated with a history of severe symptoms. Physical load, high job strain, and low social support at work determined the occurrence of LBP, related health care use, and sick leave. Older age and living alone were also important risk factors, especially for sick leave. High job strain determined the occurrence of neck/upper extremity symptoms, related health care use, and sick leave. Being female and living alone increased the probability of the occurrence of all 3 endpoints, especially the occurrence of sick leave. Work-related factors that were associated with the occurrence of musculoskeletal symptoms were quite similar to those associated with health care use and sick leave. However, for LBP, older age and living alone, and, for neck/upper extremity symptoms, living alone and being female more strongly determined whether subjects with these complaints took sick leave. These results imply that prevention strategies aimed at minimizing the risks of the occurrence of work-related musculoskeletal symptoms and prevention programs aimed at reducing sick leave may need to emphasize different sets of risk factors.

BackgroundGiant cell arteritis (GCA), a medium and large vessel vasculitis remains a formidable disease. Through feed-forward loops and a multitude of vascular complications, GCA impacts seriously negatively on both the...

Alexithymia has been related to adult health care use. We investigated the association between alexithymia and the utilization of primary health care services by adolescents and young adults. The participants (n = 751, aged 13-18 years) in this 5-year follow-up study were assessed with the 20-item Toronto Alexithymia Scale (TAS-20) and its three subscales, difficulty identifying feelings (DIF), difficulty describing feelings (DDF) and externally oriented thinking (EOT), and the 21-item Beck Depression Inventory (BDI). Primary health care data were gathered from health care centre registers in 2005-10. Generalized linear models and mediation analyses were used. An increase in the TAS-20 total score correlated with a higher number of primary health care and emergency care visits, but in multivariate general linear models, TAS-20 total scores were no longer significant. Younger age, female gender and an increase in the baseline EOT score are associated with a higher number of both primary health care and emergency room visits. In females, a smaller change in the EOT score from baseline to follow-up was associated with a higher number of primary health care visits. In mediation analyses, EOT had a direct effect on a higher number of primary health care and emergency room visits, whereas the BDI score mediated the incremental effect of DIF and DDF on visit numbers. The results suggest that an EOT style independently increases health care use by adolescents, whereas the effects of difficulties identifying and describing feelings on health care use are mediated by symptoms of depression.

Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers. To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending. This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending. Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial. Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility. This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03). This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending. ClinicalTrials.gov Identifier: NCT03952728.

With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer. To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP). This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020. Type of surgical procedure: ORP vs RARP. Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use. Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits. Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes. Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors. Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13). Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

Air pollution is a worldwide public health issue that has been exacerbated by recent wildfires, but the relationship between wildfire-associated air pollution and inflammatory skin diseases is unknown. To assess the associations between wildfire-associated air pollution and clinic visits for atopic dermatitis (AD) or itch and prescribed medications for AD management. This cross-sectional time-series study assessed the associations of air pollution resulting from the California Camp Fire in November 2018 and 8049 dermatology clinic visits (4147 patients) at an academic tertiary care hospital system in San Francisco, 175 miles from the wildfire source. Participants included pediatric and adult patients with AD or itch from before, during, and after the time of the fire (October 2018 through February 2019), compared with those with visits in the same time frame of 2015 and 2016, when no large wildfires were near San Francisco. Data analysis was conducted from November 1, 2019, to May 30, 2020. Wildfire-associated air pollution was characterized using 3 metrics: fire status, concentration of particulate matter less than 2.5 μm in diameter (PM2.5), and satellite-based smoke plume density scores. Weekly clinic visit counts for AD or itch were the primary outcomes. Secondary outcomes were weekly numbers of topical and systemic medications prescribed for AD in adults. Visits corresponding to a total of 4147 patients (mean [SD] age, 44.6 [21.1] years; 2322 [56%] female) were analyzed. The rates of visits for AD during the Camp Fire for pediatric patients were 1.49 (95% CI, 1.07-2.07) and for adult patients were 1.15 (95% CI, 1.02-1.30) times the rate for nonfire weeks at lag 0, adjusted for temperature, relative humidity, patient age, and total patient volume at the clinics for pediatric patients. The adjusted rate ratios for itch clinic visits during the wildfire weeks were 1.82 (95% CI, 1.20-2.78) for the pediatric patients and 1.29 (95% CI, 0.96-1.75) for adult patients. A 10-μg/m3 increase in weekly mean PM2.5 concentration was associated with a 7.7% (95% CI, 1.9%-13.7%) increase in weekly pediatric itch clinic visits. The adjusted rate ratio for prescribed systemic medications in adults during the Camp Fire at lag 0 was 1.45 (95% CI, 1.03-2.05). This cross-sectional study found that short-term exposure to air pollution due to the wildfire was associated with increased health care use for patients with AD and itch. These results may provide a better understanding of the association between poor air quality and skin health and guide health care professionals' counseling of patients with skin disease and public health practice.

Objective: To evaluate health care use and outcomes among patients who experienced a non-medical switch of their prescribed anti-tumor-necrosis-factor biological agent (anti-TNF) for cost containment reasons.Methods: Retrospective evaluation of Humedica electronic health records of patients ≥18 years old with anti-TNF treatment for immune conditions. Using natural language processing, stable patients who experienced a non-medical switch (for cost reasons) of their anti-TNF between 2007 and 2013 were identified (NMS cohort, n = 158) and matched to patients who did not (control cohort, n = 4804). Rates of office visits, emergency department visits, and hospitalizations at 30, 90, and 365 days following were evaluated. Medication-related adverse events, defined as subsequent medication change due to a side effect and/or efficacy-related reason were also compared.Results: Adjusted rates of office visits were higher among the NMS cohort than the control cohort at 30 (46.4% vs. 31.7%, p < .001), 90 (71.0% vs. 57.0%, p < .001), and 365 days (87.8% vs. 76.8%, p < .001). Rates of emergency department use and hospitalization were comparable between cohorts. The NMS cohort had higher adjusted rates of medication-related adverse consequences (both increased side effects and diminished efficacy) than the control cohort at 30 (13.8% vs. 4.0%, p = .003), 90 (31.6% vs 9.6%, p < .001), and 365 days (54.7% vs. 20.3%, p < .001). Compared with controls, the NMS cohort had higher adjusted rates of subsequent medication change within 1 year (27.82% vs. 13.9%, p = .001).Conclusion: Non-medical switching among patients prescribed anti-TNFs was associated with increased health care use, medication-related side effects, and reports of diminished efficacy.

Does Retirement Impact Health Care Utilization?