Opioid Access among Advanced Cancer Patients in Low- and Middle-Income Countries in Asia.

CONTEXT: Most cancer-associated pain is experienced in low- and middle-income countries (LMICs) due to inequitable access to opioids. OBJECTIVE: To determine opioid access as estimated by both patients and providers and to understand patient and facility-level factors influencing access among patients with advanced cancer in LMICs in Asia using the Behavioral Model of Health Services Use. METHODS: The APPROACH cross-sectional study was conducted in seven LMICs in Asia, involving in-depth surveys with providers and advanced cancer patients. A hierarchical logistic regression model was used to assess predisposing (i.e. individual factors), enabling (i.e. health care system and facility-level resources) and need (i.e. pain severity) factors predicting opioid access. RESULTS: Among patient participants (n=1,933), approximately 40% reported opioid use. Meanwhile 80% of facilities, as reported by providers, indicated at least half of their advanced cancer patients receive oral morphine prescriptions. Predisposing characteristics factored in the least in the model, with patient education positively associated with access (Odds ratio (OR): 1.01; 95% CI=1.00, 1.03). Facility-level enabling resources, factoring the most, included oral morphine prescription duration >14 days (OR: 1.27; 95% CI=1.05, 1.53) and the extent of physician palliative care training (extensive (>160 hours) OR: 3.95; CI=3.19, 4.88; basic (up to 40 hours) OR: 1.03; CI=1.03, 1.04). Patient need as indicated by greater pain severity predicted access (OR: 1.55; CI=1.47, 1.64). CONCLUSION: Study findings emphasize the importance of palliative care training-even a minimal amount-in supporting access to opioids for advanced cancer patients. This study also highlights pragmatic site-level policies, such as extended morphine prescription durations, enabling access.

Salud sin Fronteras: Identifying Determinants of Frequency of Healthcare Use among Mexican immigrants in Southern Arizona.

BACKGROUND: Guided by Andersen's Behavioral Model of Health Services Use (BMHSU), this study aimed to identify determinants of post-migration healthcare use among a sample of Mexican immigrants in a US-Mexico border region in Southern Arizona, while considering pre-migration health and healthcare experiences. METHODS: A non-probabilistic convenience sample of 300 adult Mexican immigrants completed a telephone survey to assess healthcare practices. Multivariable logistic regressions were fitted to determine adjusted relationships between frequency of care and predisposing, enabling, need, and contextual factors as well as personal health practices. RESULTS: Overall, participants had a 79% probability of receiving healthcare "at least once a year" after migrating to Southern Arizona. Receiving post-migration healthcare was associated with predisposing, enabling, need, contextual factors, and personal health practices (p < 0.05). DISCUSSION: Consistent with BMHSU, our findings suggest that frequency of healthcare is not only a function of having post-migration health insurance but is also shaped by a complex array of other factors. The results of this study shed light onto potential areas to be leveraged by multifactorial sociocultural interventions to increase Mexican immigrants' frequency of healthcare services use.

Non-use and inadequate use of cervical cancer screening among a representative sample of women in the United States.

Introduction: Women's adherence to the United States (U.S.) Preventive Services Task Force guidelines for cervical cancer screening was determined by examining predisposing, enabling, and needs factors from Andersen's Behavioral Model of Health Services Use conceptual framework. Methods: The outcome was operationalized as cervical cancer screening use, non-use, and inadequate-use. Multinomial logistic regression was conducted on data from the 2019 National Health Interview Survey of 7,331 eligible women aged 21-65. Results: Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Non-Users than those aged 21-29. Hispanic, Asian, and American Indian/Alaska Native (AIAN) women were more likely to be Non-Users than White women. More educated women were less likely to be Non-Users. Foreign-born women <10 years in the U.S. were more likely to be Non-Users than U.S.-born women. Women with financial hardship were less likely to be Non-Users. Poorer women and uninsured women were more likely to be Non-Users. Women with children in their household were less likely to be Non-Users than those without children. Women who had a well-visit in the past year were less likely to be Non-Users. Women with a history of human papillomavirus (HPV) vaccination were less likely to be Non-Users. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Inadequate-Users. AIAN women were more likely to be Inadequate-Users. Women of other races were less likely to be Inadequate-Users. Employed women were less likely to be Inadequate-Users. Uninsured women were more likely to be Inadequate-Users. Women who had a well-visit within a year were less likely to be Inadequate-Users. Women with past HPV vaccination were more likely to be Inadequate-Users. Smokers were less likely to be Inadequate-Users. Discussion: Predisposing, enabling, and needs factors are differently associated with non-use and inadequate use of cervical cancer screening. Understanding factors associated with the use, non-use, and inadequate use of cervical cancer screening is crucial to avoid or curb unnecessary tests, increased costs to both society and individuals, and the ill-allocation of limited resources.

The effects of a large-scale home visiting programme for child development on use of health services in Brazil.

Partnership between early childhood development interventions and primary health care services can help catalyse health care uptake by socially vulnerable families. This study aimed to assess the real-life effects of a large-scale home visiting programme [Primeira Infância Melhor (PIM)] in Brazil on the use of preventive (prenatal visits, well child visits, dentist visits and vaccination) and recovery (emergency room visits and hospitalization) health services. A quasi-experiment nested in a population-based birth cohort study was conducted. The intervention group was firstly defined as all children enrolled in PIM up to age 6 months, and afterwards stratified between those enrolled during pregnancy or after birth up to 6 months. Children receiving PIM were matched with controls on propensity scores based on 27 confounders to estimate effects on health service use from prenatal to age 2 years. Double adjustment was applied in outcome Quasi-Poisson regressions. No evidence was found for effects of PIM starting anytime up to 6 months (262 pairs), or for the children enrolled only after birth (133 pairs), on outcomes occurring after age 6 months. When the programme started during pregnancy (129 pairs), there was a 13% higher prevalence of adequate prenatal visits (prevalence ratio = 1.13; 95% confidence interval 1.01-1.27), but no effect on use of any other health service. Sensitivity analyses suggested longer participation in the programme with reduced visitor turnover might improve its impact on prenatal visits. Integration between PIM and primary health care was not adequate to affect overall patterns of contacts with health services. Nevertheless, prenatal home visits showed potential to increase health service contact during a sensitive period of development, indicating the need to start such programmes before birth, when there is more time for maternal care, and family engagement in a network of services is facilitated.

Effects of Medicare Part D medication therapy management on racial/ethnic disparities in adherence to antidementia medications among patients with Alzheimer's disease and related dementias: An observational study.

Background: Evidence is sparse on the effects of Medicare medication therapy management (MTM) on racial/ethnic disparities in medication adherence among patients with Alzheimer's disease and related dementias. Objectives: This study examined the Medicare MTM program's effects on racial/ethnic disparities in the adherence to antidementia medications among patients with Alzheimer's disease and related dementias. Methods: This is a retrospective analysis of 100% of 2010-2017 Medicare Parts A, B, and D data linked to Area Health Resources Files. The study outcome was nonadherence to antidementia medications, and intervention was defined as new MTM enrollment in 2017. Propensity score matching was conducted to create intervention and comparison groups with comparable characteristics. A difference-in-differences model was employed with logistic regression, including interaction terms of dummy variables for the intervention group and racial/ethnic minorities. Results: Unadjusted comparisons revealed that Black, Hispanic, and Asian/Pacific Islander patients were more likely to be nonadherent than non-Hispanic White (White) patients in 2016. Differences in odds of nonadherence between Black and White patients among the intervention group were lower in 2017 than in 2016 by 27% (odds ratios [OR]: 0.73, 95% confidence interval [CI]: 0.65-0.82). A similar lowering was seen between Hispanic and White patients by 26% (OR: 0.74, 95% CI: 0.63-0.87). MTM enrollment was associated with reduced disparities in nonadherence for Black-White patients of 33% (OR: 0.67, 95% CI: 0.57-0.78) and Hispanic-White patients of 19% (OR: 0.81, 95% CI: 0.67-0.99). Discussion: The Medicare MTM program was associated with lower disparities in adherence to antidementia medications between Black and White patients, and between Hispanic and White patients in the population with Alzheimer's disease and related dementias. Conclusions: Expanding the MTM program may particularly benefit racial/ethnic minorities in Alzheimer's disease and related dementia care.

Impact of Guideline-Based Asthma Treatment on Health Services Use in Singapore Before and During COVID-19 Outbreak.

Introduction: To date, the role of standard asthma care in reducing asthma-related health services use (HSU) during the COVID-19 pandemic remains unclear. This study examined the impact of guideline-based asthma treatment on the use of asthma-related emergency department (ED) visits, polyclinic visits (total visits and urgent visits characterized by nebuliser use) before and during the pandemic. Methods: Data from April 2017 to October 2020 was obtained from the National University Health System, one of the three healthcare clusters in Singapore. Using generalized linear models, we estimated the joint effects of the ratio of preventer to reliever dispensations (PRR) and COVID-19 on asthma-related ED visits per hospital per month, total asthma-related polyclinic visits and asthma-related urgent polyclinic visits per clinic per month. Results: Findings show that before the onset of COVID-19, for every 0.5 unit increase in PRR, the number of asthma-related ED visits and urgent polyclinic visits decreased by 12.9% (95% CI: -13.0% to -12.9%) and 6.8% (95% CI: -6.9% to -6.7%), respectively, whereas total asthma-related polyclinic visits increased by 1.0% (95% CI: 0.9% to 1.0%). During the pandemic, a 0.5 unit increase of PRR decreased the number of asthma-related ED visits, urgent and total polyclinic visits by 16.9% (95% CI: -17.0% to - 16.9%), 9.3% (95% CI: -9.5% to -9.2%) and 0.7% (95% CI: -0.8% to -0.7%), respectively. Discussion: These findings suggest that regardless of the COVID-19 pandemic, an increase in PRR consistently reduced the frequency of asthma-related urgent and emergent care, although it barely influenced routine asthma follow-up visits.

Estimating the effects of COVID-19 on essential health services utilization in Uganda and Bangladesh using data from routine health information systems.

Background: Since March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country. Methods: We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services. Results: The time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services. Conclusion: Our analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers.

Unlocking big data to understand health services usage and government funding during pregnancy and early childhood, evidence in Australia.

BACKGROUND: Maternity care is a high-volume and high-cost area of health care, which entails various types of service use throughout the course of the pregnancy. Thus, the aim of this study was to explore the most common reasons and related costs of health services used by women and babies from pregnancy to 12-month postbirth. METHODS: We used linked administrative data from one state of Australia, which contained all births in Queensland between 01/07/2017 and 30/06/2018. Descriptive analyses were used to identify the 10 most frequent reasons and related costs for accessing inpatient, outpatient, emergency department, and Medicare services. These are reported separately for women and babies in different periods. RESULTS: We included 58,394 births in our data set. The results have highlighted that there was relatively uniform use of inpatient, outpatient, and Medicare services by women and babies, with the 10 most common services accounting for more than half of the total services accessed. However, the emergency department service use was more diverse. Medicare services accounted for the greatest volume (79.21%) of service events but only 10.21% of the overall funding, compared with inpatient services, which accounted for less volume (3.62%) but the highest amount of overall funding (75.19%). CONCLUSION: Study findings provide empirical evidence about the full spectrum of services used by birthing families and their babies, and could assist health providers and managers to understand the services women and infants actually access during pregnancy, birth, and postbirth.

Factors associated with breast cancer screening services use among women in the United States: An application of the Andersen's Behavioral Model of Health Services Use.

This study applied Andersen's Behavioral Model of Health Services Use to examine predisposing, enabling, and need factors associated with adherence to the United States Preventive Services Task Force (USPSTF) guidelines for breast cancer screening (BCS). Multivariable logistic regression was used to determine factors of BCS services utilization among 5484 women aged 50-74 from the 2019 National Health Interview Survey. Predisposing factors significantly associated with use of BCS services were: being a Black (odds-ratios [OR]:1.49; 95% confidence interval [CI]:1.14-1.95) or a Hispanic woman (OR:2.25; CI:1.62-3.12); being married/partnered (OR:1.32, CI:1.12-1.55); having more than a bachelor's degree (OR: 1.62; CI:1.14-2.30); and living in rural areas (OR:0.72; CI:0.59-0.92). Enabling factors were: poverty level [≤138% federal poverty level (FPL) (OR:0.74; CI:0.56-0.97), >138-250% FPL (OR:0.77; CI:0.61-0.97), and > 250-400% FPL (OR:0.77; CI:0.63-0.94)]; being uninsured (OR:0.29; CI:0.21-0.40); having a usual source of care at a physician office (OR:7.27; CI:4.99-10.57) or other healthcare facilities (OR:4.12; CI:2.68-6.33); and previous breast examination by a healthcare professional (OR:2.10; CI:1.68-2.64). Need factors were: having fair/poor health (OR:0.76; CI:0.59-0.97) and being underweight (OR:0.46; CI:0.30-0.71). Disparities in BCS services utilization by Black and Hispanic women have been reduced. Disparities still exist for uninsured and financially restrained women living in rural areas. Addressing disparities in BCS uptake and improving adherence to USPSTF guidelines may require revamping policies that address disparities in enabling resources, such as health insurance, income, and health care access.

Change in Homeless and Health Services Use Following Migration Among Veterans with Experience of Homelessness.

BACKGROUND: Homelessness is associated with poor health outcomes, including lack of access to care. Homelessness experienced in rural areas is understudied but likely associated with difficulty accessing needed services. Prior studies have assessed the extent to which Veterans experiencing homelessness in rural areas "migrate" to urban areas, but have not focused on changes in services utilization following migration. OBJECTIVE: To determine whether Veterans with a history of homelessness experience changes in the use of homeless and health services following a migration from a rural to urban residence, and vice versa, and to assess the magnitude of those changes. DESIGN: Longitudinal retrospective analysis of services use among Veterans identified as experiencing homelessness and migrating at least 40 miles or from an urban to a rural area or vice versa. PARTICIPANTS: A total of 81,620 Veterans with incident homelessness who experienced a migration and for whom we could establish 2 quarters of both pre-migration and post-migration service utilization. MAIN MEASURES: In addition to sociodemographic and health-related factors, we assessed index location and destination using geographic descriptors both residential address and Veteran Affairs (VA) facility where Veterans were identified as experiencing homelessness. Outcomes included continuous measures of homeless services and outpatient care and dichotomous measures of emergency department use and inpatient admissions. KEY RESULTS: Regardless of a Veteran's index location, migration to or within a rural area was associated with a significant decrease in the number of homeless and outpatient services and reduced risk of emergency department use or inpatient admission relative to migration to or within an urban area. CONCLUSION: Controlling for sociodemographic and health-related factors, Veterans experiencing homelessness who had a residential migration to or within a rural area had a significant reduction in their use of VA health and homeless services compared to those who migrated to or within an urban area.

Time intervals to care and health service use experiences of uninsured cancer patients treated under public financing in Mexico City.

BACKGROUND: The present study assesses the time intervals from symptom discovery to treatment start and describes the health service use experiences of uninsured patients with cancer of the breast, cervix uteri, testicle, and prostate before their arrival to the cancer hospital. METHODS: This cross-sectional study included 1468 patients who were diagnosed between June 2016 and May 2017 and received treatment for the selected cancers in two of the largest public cancer hospitals in Mexico City, financed through Seguro Popular. Data was collected through a survey administered via face-to-face interviews with patients and a review of their medical files. RESULTS: The median time between detection (symptom discovery or first abnormal screening test) and treatment start was 6.6 months. For all types of cancer, the longest interval was the diagnostic interval -between the first use of healthcare services and the confirmation of cancer. Less than 20% cancer patients were diagnosed in the earliest stages that are associated with the best chances of long-term survival. The participants described a high use of private services for their first consultation, the use of several different types of health services and multiple consultations before arrival to the cancer centers, and 35% perceived being misdiagnosed by the first doctor they consulted. CONCLUSIONS: Most cancer patients treated in the two largest public institutions available for the uninsured faced long delays to get diagnosed and started treatment at advanced stages. Strengthening quality and access for effective early cancer diagnosis and treatment is key to improve patient outcomes in low and middle-income settings.

Vaping and Health Service Use: A Canadian Health Survey and Health Administrative Data Study.

Rationale: Emerging research suggests that e-cigarette (EC) use may have detrimental health effects, increasing the burden on healthcare systems. Objectives: To determine whether young EC users had increased asthma, asthma attacks, and health services use (HSU). Methods: This cohort study used the linked Canadian Community Health Survey (cycles 2015-16 and 2017-18) and health administrative data (January 2015-March 2018). A propensity score method matched self-reported EC users to up to five control subjects. Matched multivariable logistic and negative binomial regressions were used to calculate odds ratios, rate ratios (RRs), and 95% confidence intervals (CIs) with EC use as the exposure and asthma, asthma attacks, and all-cause HSU as the outcomes. Results: Analyses included 2,700 matched Canadian Community Health Survey participants (15-30 yr), 505 (2.4% of 20,725 participants) EC users matched to 2,195 nonusers. After adjusting for confounders, EC users with asthma had over twofold higher odds of having an asthma attack in the last 12 months (odds ratio, 2.30; 95% CI, 1.29-4.12). Dual EC and conventional tobacco users had a twofold increased all-cause HSU rate compared with nonusers who never smoked tobacco (RR, 2.13; 95% CI, 1.53-2.98). This rate was greater than that for EC users who never smoked tobacco (RR, 1.73; 95% CI, 1.00-3.00) and non-EC users who regularly smoke tobacco (RR, 1.72; 95% CI, 1.29-2.29). Compared with male nonusers, female EC users had the highest increased all-cause HSU (RR, 1.94; 95% CI, 1.39-2.69) over male EC users and female nonusers (RR, 1.13; 95% CI, 0.86-1.48; RR, 1.41; 95% CI, 1.16-1.71, respectively). Conclusions: Current EC use is associated with significantly increased odds of having an asthma attack. Furthermore, concurrent EC use and conventional cigarette smoking are associated with a higher rate of all-cause HSU. The odds of asthma attack and all-cause HSU were highest among women. Thus, EC use may be an epidemiological biomarker for youth and young adults with increased health morbidity.

Disparities and determinants of maternal health services utilization among women in poverty-stricken rural areas of China: a cross-sectional study.

BACKGROUND: Reducing maternal mortality ratio (MMR) has been a worldwide public health challenge for a long time. Utilization of maternal health services including antenatal care (ANC), institutional delivery (ID), and postnatal care (PNC) is vital to prevent maternal mortality. China has made significant improvements in maternal health during the past 30 years, however, disparities in maternal health service utilization still exist among regions and the western rural areas had the lowest utilization rate. This study aims to assess the inequality and determinants of maternal health service utilization in western poverty-stricken rural areas based on Anderson's Behavioral Model of Health Service Use and provide evidence-based suggestions to improve equity and coverage of maternal service utilization in China. METHODS: A cross-sectional study was conducted in Gansu and Yunnan Province, Western China using primary data (n = 996) collected by the research team. A multistage, judgment, quota sampling procedure was employed to select the participants of the survey. Trained local health staff formed an interview team to help respondents answer a structured, pre-tested questionnaire designed based on Anderson's model. Data collected through interviews were used for descriptive analysis, range analysis, and univariate and multivariate binary logistic analysis to identify influencing factors of 5 + ANC, 8 + ANC, ID, and 2 + PNC utilization. RESULTS: Place of residence, age, education level, annual income, and health education during ANC were influencing factors of 5 + ANC; place of residence, education level, per capita household income, conditional cash transfer (CCT) participation, and distance to health facilities were influencing factors of 8 + ANC; place of residence, education level, and availability of financial incentive programs were influencing factors of ID; number of children, health education during ANC, CCT projects participation, and self-rated health status were influencing factors of 2 + PNC. CONCLUSIONS: Inequalities in maternal service utilization exist between Yunnan and Gansu provinces. This study shows a strong association between both predisposing and enabling factors and maternal services utilization. Predisposing factors such as place of residence, education level, and number of children, enabling factors such as CCT participation, annual income, health education during ANC, and distance to health facilities along with need factor self-rated health status all contribute to maternal services utilization. We conclude that many factors influence maternal service utilization and interventions targeted at various levels should be considered. Therefore, we suggest more health resources should be invested in underutilized areas, financial incentive projects targeting pregnant women should be implemented, and health education should be provided to improve women's health literacy.

A Home-Care Service for Frail Older Adults: Findings from a Quasi-Experiment in Milan.

Population aging is particularly pronounced in Italy. Recently, home-care services emerged as one of the desirable strategy when dealing with such situations of fragility. In this framework, we present the evaluation of a home-care service which was experimentally implemented by Fondazione Sacra Famiglia and Casa di Cura Ambrosiana in the 2017-2018 biennium. The service consisted of a twice-weekly nursing visit intended to monitor patient health conditions and to gather data constantly supervised by a geriatrician. The eligible population consisted of the users of San Carlo Hospital Emergency Department (91 individuals). Twenty of these individuals had access to the experimental home-care service. The results show the smaller probability of mortality for the treatment group compared to the control group, but similar probabilities in admissions to ER and in hospitalizations. These findings suggest that health home-care policies could reduce mortality by lessening the negative effects of relational isolation.

Patient Reported Outcomes and Unscheduled Health Services use During Oral Anti-Cancer Treatment.

CONTEXT: People on oral anti-cancer agents must self-manage their symptoms with less interaction with oncology providers compared to infusion treatments. Symptoms and physical function are key patient-reported outcomes (PROs) and may lead to unscheduled health services uses (urgent care and emergency department [ED] visits, hospitalizations), which in turn lead to increased health care costs. OBJECTIVES: To evaluate the prediction of unscheduled health services uses using age, sex, and comorbidity, then determine the extent to which PRO data (symptoms and functioning) improve that prediction. METHODS: This post-hoc exploratory analysis was based on data from the control group of a trial of medication adherence reminder and symptom self-management intervention for people starting a new oral anti-cancer agent (n = 117 analyzed). Severity and interference with daily life for 18 symptoms, physical function, and depressive symptoms were assessed at intake (oral agent start), and four, eight, and 12 weeks later. Unscheduled health services use during three four-week periods after the start of oral agents was analyzed using generalized mixed effects models in relation to age, sex, comorbidity, and PROs at the beginning of each time period. RESULTS: The summed severity index of 18 symptoms and physical function were significant predictors of hospitalizations in the four weeks following PRO assessment. The addition of PROs improved areas under the receiver operating characteristic curves to be over .70 in most time periods. CONCLUSION: Monitoring of PROs has the potential of reducing unscheduled health services use if supportive care interventions are deployed based on their levels.

An informatics-driven intelligent system to improve healthcare accessibility for vulnerable populations.

Broad disparities persist in access to healthcare and health outcomes in the United States, especially among vulnerable populations. An important step towards improving their healthcare access is to ensure "having access", or "accessibility". Drawing together the Behavioral Model of Health Services Use, social determinants of health (SDOH), and spatial healthcare accessibility literature, the research attempts to create an integrative accessibility measure to support the improvement of "having access" for vulnerable populations. A Vulnerable Population Healthcare Accessibility Framework (VPHAF) is proposed to systematically integrate vulnerable population characteristics, health behavior, customer satisfaction, and other SDOH factors to measure healthcare accessibility using advanced analytics. The qualitative and quantitative evaluation of VPHAF demonstrates that it enhances the existing spatial accessibility methods. An intelligent spatial decision support system (SDSS) instantiates the framework to support the decision making in improving healthcare accessibility for vulnerable populations in a regional healthcare plan. The system was evaluated by decision makers from a real-world organization as a useful tool with high usability. The intelligent SDSS enables the collection of SDOH data from multiple sources and uses analytics to measure healthcare accessibility focusing on characteristics of vulnerable populations. Policymakers and health plan providers can use the system to increase awareness of social risks and advocate for better policy decisions in creating equitable healthcare access and reducing health disparity.

Hospital emergency department visits made by developmentally disabled adolescents with oral complications.

Purpose: We used Andersen's Behavioral Model in a cross-sectional study to determine the factors associated with utilization of the emergency department (ED), controlling for whether an adolescent has a developmental disability (DD) and one or more oral complications (toothaches, decayed teeth, bleeding gums, eating or swallowing problems). Methods: Data from the 2016-2019 National Survey of Children's Health (NSCH) was used for this secondary data analysis study. We used frequencies and percentages to describe the sample characteristics. Chi-square tests were used for bivariate analyses. Multivariable logistic regression modeling was conducted to predict ED visits by adolescents aged 10-17 controlling for predisposing, enabling, and need variables. Results: The sample consisted of 68,942 adolescents who were primarily male, non-Hispanic White, and born in the U.S. Parents reported that 69% of the adolescents had neither a DD nor an oral complication; 10% had no DD but experienced one or more oral complication; 16% had a DD but no oral complication; and 5% had both DDs and one or more oral complication. Adolescents with both a DD and an oral complication reported the highest level of ED visits at 33%, compared to 14% of adolescents with neither DD nor oral complication. Regression analysis showed that adolescents with a DD and oral complication (OR: 2.0, 95% CI: 1.64-2.54, p < 0.0001), and those with DDs but no oral complications (OR: 1.45, 95% CI: 1.25-1.68, p < 0.0001) were at higher odds of having an ED visit compared to those with neither a DD nor an oral complication. Not having a Medical Home increased the likelihood of ED visits by 14% (p = 0.02). Those with private insurance (OR: 0.63, 95% CI: 0.53-0.75, p < 0.0001) and those from a family where the highest level of education was some college and above (OR: 0.85, 95% CI: 0.73-0.98, p = 0.03) were less likely than their counterparts to have had an ED visit. Conclusion: Adolescents with DDs and oral complications utilize ED visits more frequently than those with neither DDs nor oral complications. Integrating the dental and medical health systems and incorporating concepts of a Patient-Centered Medical Home could improve overall health care and reduce ED visits for adolescents.

Utilisation of supplementary prenatal screening and diagnostics in Germany: cross-sectional study using data from the KUNO Kids Health Study.

BACKGROUND: Appropriate health system utilisation during pregnancy is fundamental for maintaining maternal and child's health. To study the use and determinants of supplementary prenatal screening and diagnostics in Germany this study provides comprehensive data. METHODS: We obtained data from a recently established prospective German birth cohort study, the KUNO Kids Health Study. Analyses are based on Andersen's Behavioural Model of health system use, which distinguishes between predisposing (e.g. country of birth), enabling (e.g. health insurance) and need factors (e.g. at-risk pregnancy). We examined bi- and multivariate association with the use of supplementary prenatal screening and diagnostics using logistic regression. RESULTS: The study has a sample size of 1886 participating mothers. One fifth of the mothers investigated did not use any supplementary prenatal screening or diagnostics. Notably, the chance of using supplementary prenatal screening and diagnostics more than doubled if the pregnant woman had a private health insurance (OR 2.336; 95% CI 1.527-3.573). Higher maternal age (OR 1.038; 95% CI 1.006-1.071) and environmental tobacco smoke exposure (OR 1.465 95% CI 1.071-2.004) increased the use of supplementary prenatal screening and diagnostics. However, regarding need factors only having an at-risk-pregnancy (OR 1.688; 95% CI 1.271-2.241) showed an independent association. CONCLUSION: The important role of the type of health insurance and the relatively small influence of need factors was surprising. Especially with respect to equity in accessing health care, this needs further attention.

The impact of the COVID-19 pandemic on the continuity of care for at-risk patients in Swiss primary care settings: A mixed-methods study.

Continuity of care is important for the health of aging individuals with comorbidities. When initial coronavirus mitigation campaigns involved messaging such as "Stay at home-stay safe," and banned provision of non-urgent care, at-risk patients depending upon regular consultations with general practitioners (GPs) faced confusion about the possibility of seeking non-COVID-19 related healthcare. We employed a sequential explanatory mixed-methods design, consisting of a quantitative component followed by a qualitative component, to understand at-risk patients' health services use during the COVID-19 pandemic in Switzerland. Quantitatively, we used electronic medical records data from 272 GPs and 266,796 patients. Based on pre-pandemic data, we predicted weekly consultation counts as well as weekly measurement counts (blood pressure, glycated hemoglobin, and low-density lipoprotein cholesterol) per 100 patients that would be expected in 2020 in absence of a pandemic and compared those to actual observed values. Qualitatively, we conducted 23 semi-structured interviews with 24 GPs (∼45 min) and 37 interviews with at-risk patients (∼35 min). Quantitative results demonstrate a significant decrease in consultation and measurement counts during the first shutdown period, with consultation counts quickly returning to normal and moving within expected values for the rest of 2020. Qualitative data contextualize these findings with GPs describing constantly implementing material, administrative, and communication changes. GPs reported communication gaps with the authorities and noted a lack of clear guidelines delineating how to define "at-risk patients" and what cases were "urgent" to treat during shutdowns. Patient interviews show that patient-level factors, such as fear of contracting coronavirus, perceptions that GPs were overburdened, and a sense of solidarity, influenced patients' decisions to consult less at the beginning of the pandemic. Findings demonstrate communication gaps during pandemic periods and provide valuable lessons for future pandemic preparedness, particularly the need for contingency plans for the overall healthcare system instead of plans focusing only on the infectious agent itself.

Mental health services use among Canadian Armed Forces members and Veterans: Data from the 2018 Canadian Armed Forces members and Veterans mental health follow-up survey (CAFMVHS).

Background: Differences in healthcare delivery systems and pathways to mental healthcare for Canadian Armed Forces (CAF) members and Veterans may contribute to variations in mental health services use (MHSU) and the factors associated with it. We: (1) estimated the prevalence of past 12-month MHSU (≥1 visit with a medical or mental health professional); and (2) identified sociodemographic, military-, trauma-, and health-related variables associated with MHSU among CAF members and Veterans. Methods: The current study used data from the 2018 CAF Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Model variables were selected a priori, and their respective associations with MHSU were estimated among (1) CAF members and (2) Veterans using separate multivariable logistic regression models. Results: Similar proportions of CAF members and Veterans reported past 12-month MHSU (26.9 vs. 27.5%, respectively). For both CAF members and Veterans, meeting criteria for at least one past 12-month MH disorder was associated with past 12-month MHSU [adjusted odds ratio (AOR) = 7.80, 95% confidence interval (CI) = 7.18-8.46; and AOR = 11.82, 95% CI: 11.07-12.61, respectively). Past-year suicide ideation, a history of sexual trauma, and endorsement of adverse childhood experiences were also significantly associated with MHSU among CAF members and Veterans. Significance: Similar to previous research, meeting screening criteria for a past 12-month MH disorder was strongly associated with MHSU among both samples. This study extends our existing knowledge about factors associated with MHSU among CAF members and Veterans, and offers direction for future research to increase MHSU.