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Objective To investigate patterns of use of general practitioners (GPs) and/or mental health professionals (MHPs) for mental health reasons, across six European countries, and the extent to which these patterns of use are associated with differences in mental health-care delivering systems. Methods Data are based on the European Study of the Epidemiology of Mental Disorders (ESEMeD): a cross-sectional survey of a representative sample of 8,796 non-institutionalized adults from six European countries, conducted between 2001 and 2003 using computer-assisted interviews with the CIDI-3.0. Countries were classified into: MHP− for countries where access to medical professionals tends to predominate (Belgium, France, Italy), and MHP+ where access to non-medical MHPs predominates (Germany, Spain, The Netherlands). Results Among respondents consulting GPs and/or MHPs in the past year ( n  = 1,019), respondents from the MHP− group more often consulted GPs (68 vs. 55 % in MHP+ group), GPs and psychiatrists (23 vs. 14 %). People from the MHP+ group more often used MHPs only (45 vs. 32 %), GPs and non-medical MHPs (16 vs. 8 %). GPs from the MHP+ group were more inclined to refer patients to MHPs. Factors associated with use of GPs versus MHPs were: being over 49 years, not highly educated, lower income and suffering from mood or severe mental disorders. Conclusions Differences in the use of GPs versus MHPs are markedly linked to individual as well as organizational factors. Interventions are needed, in countries fostering medical access, to reimburse sessions with non-medical MHPs and improve cooperation between professionals to obtain better practice in access to care.

ABSTRACT BACKGROUND Because pregnancy complications, including gestational diabetes mellitus (GDM) and hypertensive disorders in pregnancy, are risk factors for diabetes and cardiovascular disease, post-delivery follow-up is recommended. OBJECTIVE To determine predictors of post-delivery primary and obstetric care utilization in women with and without medical complications. RESEARCH DESIGN Five-year retrospective cohort study using commercial and Medicaid insurance claims in Maryland. SUBJECTS 7,741 women with a complicated pregnancy (GDM, hypertensive disorders and pregestational diabetes mellitus [DM]) and 23,599 women with a comparison pregnancy. MEASURES We compared primary and postpartum obstetric care utilization rates in the 12 months after delivery between the complicated and comparison pregnancy groups. We conducted multivariate logistic regression to assess the association between pregnancy complications, sociodemographic predictor variables and utilization of care, stratified by insurance type. RESULTS Women with a complicated pregnancy were older at delivery ( p  < 0.001), with higher rates of cesarean delivery ( p  < 0.0001) and preterm labor or delivery ( p  < 0.0001). Among women with Medicaid, 56.6 % in the complicated group and 51.7 % in the comparison group attended a primary care visit. Statistically significant predictors of receiving a primary care visit included non-Black race, older age, preeclampsia or DM, and depression. Among women with commercial health insurance, 60.0 % in the complicated group and 49.5 % in the comparison group attended a primary care visit. Pregnancy complication did not predict a primary care visit among women with commercial insurance. CONCLUSIONS Women with pregnancy complications were more likely to attend primary care visits post-delivery compared to the comparison group, but overall visit rates were low. Although Medicaid expansion has potential to increase coverage, innovative models for preventive health services after delivery are needed to target women at higher risk for chronic disease development.

Low-income and minority communities are disproportionately affected by incarceration, which exacerbates health disparities. Through enhanced primary care, the Transitions Clinic Network (TCN) seeks to improve the health of people with chronic conditions who return to their communities from prison. Using TCN data, we assessed the impact of early engagement in primary care and referral from correctional systems to TCN on the use of acute care (emergency department visits and hospitalizations) and recidivism. Of 751 patients, 29.8 percent were referred by correctional partners, and 52.7 percent were engaged in TCN care within one month after release. In the twelve months after release, patients referred by correctional partners had fewer acute care visits, compared to those referred by community-based partners, while early engagement was associated with more acute care visits. Neither referral by correctional partners nor early engagement was significantly associated with recidivism. Our findings suggest that health equity for this vulnerable population could be achieved through improved coordination between correctional and community health care systems.

Objectives. Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care–based care management program with a community health worker, versus expedited primary care. Methods. We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit). Results. Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04). Conclusions. Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care–based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.

Newly insured people will most likely use more health care across settings, including the emergency department, for at least 2 years, rather than substituting office visits for ED use, according to an analysis of additional data from Oregon's Medicaid lottery. The effect of Medicaid coverage on health and the use of health care services is of first-order policy importance, particularly as policymakers consider expansions of public health insurance. Estimating the effects of expanding Medicaid is challenging, however, because Medicaid enrollees and the uninsured differ in many ways that may also affect outcomes of interest. Oregon’s 2008 expansion of Medicaid through random-lottery selection of potential enrollees from a waiting list offers the opportunity to assess Medicaid’s effects with a randomized evaluation that is not contaminated by such confounding factors. In a previous examination of the Oregon Health Insurance Experiment, we found . . .

Objective To assess whether continuity of care with a general practitioner is associated with hospital admissions for ambulatory care sensitive conditions for older patients.Design Cross sectional study.Setting Linked primary and secondary care records from 200 general practices participating in the Clinical Practice Research Datalink in England.Participants 230 472 patients aged between 62 and 82 years and who experienced at least two contacts with a general practitioner between April 2011 and March 2013.Main outcome measure Number of hospital admissions for ambulatory care sensitive conditions (those considered manageable in primary care) per patient between April 2011 and March 2013.Results We assessed continuity of care using the usual provider of care index, which we defined as the proportion of contacts occurring between April 2011 and March 2013 that were with the most frequently seen general practitioner. On average, the usual provider of care index score was 0.61. Continuity of care was lower among practices with more doctors (average score 0.59 in large practices versus 0.70 in small practices). Higher continuity of care was associated with fewer admissions for ambulatory care sensitive conditions. When modelled, controlling for demographic and clinical patient characteristics, an increase in the usual provider of care index of 0.2 for all patients would reduce these admissions by 6.22% (95% confidence interval 4.87% to 7.55%). There was greater evidence for an association among patients who were heavy users of primary care. Heavy users also experienced more admissions for ambulatory care sensitive conditions than other patients (0.36 admissions per patient for those with ≥18 contacts with a general practitioner, compared with 0.04 admissions per patient for those with 2-4 contacts).Conclusions Strategies that improve the continuity of care in general practice may reduce secondary care costs, particularly for the heaviest users of healthcare. Promoting continuity might also improve the experience of patients and those working in general practice.

Objective To study and compare the utilisation of primary health care services among 46-year-old current smokers, ex-smokers and never-smokers, and to estimate the corresponding costs. Methods This population-based cohort study is based on the Northern Finland Birth Cohort 1966, which is a longitudinal research program in Finland's two northernmost provinces. The study is based on data collected at the 46-year follow-up, during which a total of 4997 individuals completed questionnaires on their primary health care service utilisation. Primary health care covered visits to both occupational and public health care (typically community health centres). Results Current smokers visited primary health care professionals more often per year than never-smokers, regardless of gender (RR 1.24, 95 % confidence interval 1.10-1.43 for men; RR 1.10, 1.01-1.22 for women). When primary health care services were categorised based on the type of service provided, current smokers of both genders were more likely to visit a dentist (RR 1.56, 1.32-1.84 for men; RR 1.34, 1.15-1.55 for women) or a physician (RR 1.20, 1. 03-1.40 for men; RR 1.15, 1.02-1.30 for women) than their never-smoking counterparts (BMI adjusted for). For men, the total annual costs of primary health care visits were 28 % higher for current smokers versus neversmokers (P < 0.001). For women, the difference was 21 % (P < 0.01). Conclusions Smokers visit primary health care professionals more often already at the age of 46, before the expected diagnosis of fatal smoking-related illnesses. This phenomenon not only predicts an elevated incidence of serious illnesses in later life (such as cardiovascular disease), but also causes an economic burden on the health care system.

Using data from multiple health systems (2009–2010) and the largest sample to date, this study compares health services use among youth with and without an autism spectrum disorder (ASD)—including preventive services not previously studied. To examine these differences, we estimated logistic and count data models, controlling for demographic characteristics, comorbid physical health, and mental health conditions. Results indicated that youth with an ASD had greater health care use in many categories, but were less likely to receive important preventive services including flu shots and other vaccinations. An improved understanding of the overall patterns of health care use among this population could enable health systems to facilitate the receipt of appropriate and effective health care.

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users. Adapted from the source document.

Background China, like other countries, is facing a growing burden of chronic disease but the prevalence of multimorbidity and implications for the healthcare system have been little researched. We examined the epidemiology of multimorbidity in southern China in a large representative sample. The effects of multimorbidity and other factors on usual source of healthcare were also examined. Methods We conducted a large cross-sectional survey among approximately 5% (N = 162,464) of the resident population in three prefectures in Guangdong province, southern China in 2011. A multistage, stratified random sampling was adopted. The study population had many similar characteristics to the national census population. Interviewer-administered questionnaires were used to collect self-report data on demographics, socio-economics, lifestyles, healthcare use, and health characteristics from paper-based medical reports. Results More than one in ten of the total study population (11.1%, 95% confidence interval (CI) 10.6 to 11.6) had two or more chronic conditions from a selection of 40 morbidities. The prevalence of multimorbidity increased with age (adjusted odds ratio (aOR) = 1.36, 95% CI 1.35 to 1.38 per five years). Female gender (aOR = 1.70, 95% CI 1.64 to 1.76), low education (aOR = 1.26, 95% CI 1.23 to 1.29), lack of medical insurance (aOR = 1.79, 95% CI 1.71 to 1.89), and unhealthy lifestyle behaviours were independent predictors of multimorbidity. Multimorbidity was associated with the regular use of secondary outpatient care in preference to primary care. Conclusions Multimorbidity is now common in China. The reported preferential use of secondary care over primary care by patients with multimorbidity has many major implications. There is an urgent need to further develop a strong and equitable primary care system.