The current study was designed to examine the relationship between childhood anxiety and depression and children's rate of medical care utilization. Additionally, the model examined considered family and parental factors (family conflict, parental anxiety, parental depression, and parental somatization) as well as children's level of negative affectivity and demographic variables (age and sex). A hierarchical regression analysis was used to examine the effects of each of these variables on rate of physician utilization and to control for the effects of demographic factors, parent/family variables and negative affectivity while examining childhood anxiety and depression. Results revealed that parental anxiety and depression and family conflict contribute significantly to the explanation of children's health care utilization. Additionally, child anxiety also explained number of physician visits but only when considered in the absence of child depression. / Master of Science

Infant health care use has rarely been examined empirically. A growing literature links maternal health and psychosocial variables to broadly defined pediatric health care use. The Common Sense Model of health and illness behaviors (CSM) provides a framework from which to view the role of the maternal psychosocial variables examined (i.e. maternal negative affect, lay consultation and parenting self-efficacy) in infant health care decision-making. Findings for infant health care use are reported specific to referral source (i.e. mother versus physician initiated infant health care). Physician initiated visits were not significantly predicted by the models tested, consistent with the independence of predictor variables from initiation source (i.e. mothers versus physicians). Mother initiated visits were significantly predicted by the model containing the Lay Consultation worry item, which was also the only variable that significantly predicted infant health care use in the model. The main dissertation study finding is the independence of infant health care use decision-making from most of the maternal psychosocial, demographic and enabling variables examined. The finding is positive for the health care system as it suggests that mothers generally do not seek infant health care for their own emotional regulation and/or reassurance in their parenting competency. The contextual component of the CSM, as measured by lay consultation, received support from the findings, suggesting that mothers' perceived worry of her lay consults results in greater infant health care use. Implications for mothers and infants include community psychoeducation programs and home visiting programs focusing on infant health and development psychoeducation.

Introduction: Studies show that women living in Sweden treated for coeliac disease have lower subjective health than other women. After showing signs of remission, adults who have coeliac disease and follow a gluten-free diet, are expected to handle the treatment without any further planned follow-up by health care. Aim: The overall aim of this thesis was to study aspects of living with coeliac disease in adults in the years beyond the diagnosis. Methods: Quantitative methods were used in Studies I, II and III. A qualitative content analysis was performed in Study IV. Results: The results show that women with coeliac disease have a lower level of well-being than men with coeliac disease. The women who have coeliac disease reported a high rate of gastrointestinal symptoms, although they followed a gluten-free diet, and they visited health care services more frequently than women who did not have coeliac disease. A low rate of gastrointestinal symptoms, a positive self-image and few comorbidity emerged as factors that positively affected well-being. Worries also seemed to be a companion of women diagnosed with coeliac disease in adulthood, typically evident when socializing with others. Conclusion: This thesis may provide evidence questioning the validity of declaring all women with coeliac disease showing a normalized intestinal mucosa to be in remission, and thus leaving them to self-management. Clinical implications: Health care professionals need to be aware of that the transition to a gluten-free life may vary for individuals. It does not seem enough to follow a gluten-free diet to reach a state of good well-being for all women. A major task for health care providers is therefore to support women with CD in reaching better subjective treatment outcomes. The results may also contribute to that health care system develops routines in order to optimise the care and treatment of these patients.

L’arthrose est la maladie articulaire la plus fréquente pouvant être responsable d’une perte d’autonomie et d’un handicap fonctionnel majeur. Du fait du vieillissement de la population et de la prévalence de l’obésité, le nombre de personnes ayant une arthrose des membres inférieurs va augmenter dans les années à venir et entrainer une explosion des dépenses de santé. La cohorte « Knee and Hip OsteoArthritis Long-term Assessment » (KHOALA) est une cohorte française multicentrique représentative de patients atteints d’arthrose symptomatique de hanche et/ou de genou.Les objectifs de ce projet étaient d’établir une revue de la littérature sur les conséquences économiques de l'arthrose de hanche et/ou du genou. Puis à partir de la cohorte KHOALA, nous avons décrit la consommation de soins ; identifié les facteurs associés aux trajectoires d'utilisation des ressources de santé et estimé les coûts annuels totaux. Enfin nous avons réalisé une analyse systématique de la littérature sur les analyses coût-efficacité des anti-arthrosiques d’action lente et de l’acide hyaluronique intra articulaire dans l’arthrose de genoux.La revue systématique a objectivé une hétérogénéité des couts totaux par patient (de 0,7 à 12 k€/an). Les données de KHOALA ont démontré que la majorité des patients consultait son médecin généraliste et une minorité de patients consultait un spécialiste. Le seul facteur clinique indépendant prédictif des consultations des professionnels de la santé était l'état de santé mentale. Le coût total annuel moyen par patient sur la période d'étude de 5 ans était de 2180 ± 5 305 €. En France, les coûts médians pourraient atteindre 2 milliards € / an (IQR 0,7–4,3). / Osteoarthritis is the most common joint disease that can be responsible for a loss of autonomy and a major functional disability. With the aging of the population and the prevalence of obesity, the number of people with lower limb osteoarthritis will increase in the coming years and lead to an explosion of health spending. The "Knee and Hip OsteoArthritis Long-term Assessment" cohort (KHOALA) is a representative French multicenter cohort of patients with symptomatic hip and / or knee osteoarthritis.The aims of this thesis were to provide an overview of the economic consequences of hip and knee osteoarthritis worldwide. Then from the KHOALA cohort, we described health care resources use in the KHOALA cohort, we identified factors associated with trajectories of healthcare use and we estimated the annual total costs. Finally, we conducted a systematic review of the literature on the cost effectiveness of intra-articular hyaluronic acid and disease-modifying osteoarthritis drugs used in the treatment of knee OA.The systematic review showed a heterogeneity of the total costs per patient (from 0.7 to 12 k € / year). KHOALA data showed that primary care physicians have a central role in osteoarthritis care, mental health state was the only independent predictive factor of healthcare professional consultations. The mean annual total cost per patient over 5 years was 2180 ± 5,305 €. In France, median annual total costs would be approximately 2 billion €/year (IQR 0.7-4.3).

Integrated behavioral health care within primary care has become a popular style of health care delivery within the United States. However, individuals with a behavioral health concern face several barriers in using these services. The purpose of this quantitative study was to identify key factors accounting for individuals' utilization and intensity of behavioral health services. Andersen's behavioral model of health care use and the integrated theory of health behavior change served as the theoretical framework. It was hypothesized that gender, age, race, ethnicity, family size, payer type, poverty level, and certain preexisting medical conditions (obesity, diabetes, hypertension, and tobacco use) would determine behavioral health care utilization and intensity. A secondary data analysis of 315 individuals who used behavioral health services within primary care was performed; the study setting was at the Center for Health, Education, Medicine, and Dentistry, located in Lakewood, New Jersey. Among the individual variables examined, only a preexisting condition of hypertension reached statistical significance, showing that those individuals were more likely to attend multiple sessions, Ï?2 (1) = 5.77, p = .02. Payer type was also found to be predictive of behavioral health care intensity. Medicare recipients were more likely to attend multiple behavioral health care sessions (74%) than were Medicaid recipients (59%) and those who were uninsured (25%). By providing insights about the barriers faced by individuals, study findings may help patient advocates and health care professionals to provide individuals with better health care. This study has implications for positive social change, as study findings may assist the United States health care system in its shift toward an integrated behavioral health care style of health care delivery.

Bakgrund Celiaki är en autoimmun sjukdom som ger inflammation i tunntarmsslemhinnan vid intag av gluten. Symtom hos vuxna kan vara diffusa och därför svåra att koppla till celiaki. I Sverige är genomsnittstiden från första symtom till celiakidiagnos ungefär 10 år och det finns luckor i kunskapen om vilka konsekvenser fördröjningen till diagnos ger. Syfte Studiens syfte är att överblicka hur fördröjd diagnos av celiaki hos vuxna påverkar samhällets resurser, hur dessa individer upplever att symptomen påverkat deras sociala liv före och efter diagnos, samt om diagnostiken behöver effektiviseras. Metod I Sverige, september 2012, skickades en Internetbaserad enkät ut till 4337 medlemmar i Svenska Celiakiförbundet varav 611 kvarstod efter bortfall. Enkätens fokus var främst sjukfrånvaro, vårdkontakter och social påverkan p.g.a. symtom av celiaki. Enkäterna analyserades i SPSS (v.20.0) med p<0,05. Resultat Efter diagnos sjönk både sjukfrånvaro och vårdkontakter. Deltagarna undvek också sociala aktiviteter i mindre utsträckning och majoriteten upplevde förbättrad livskvalité. En stor del (39 %, n=238) uppgav att de fått diagnos först 10 år eller mer efter symtomdebut, varav majoriteten var äldre. Det var framför allt de som uppgav en fördröjning på fyra år eller mer från första symtom till diagnos som upplevde att deras livskvalité förbättrades av diagnosen. Slutsats Det är viktigt att celiakidiagnos ställs tidigt för att bespara kostnader som annars kommer av sjukfrånvaro och vårdkonsumtion, samt minska den negativa påverkan av symtom på det sociala livet och livskvalitén. Då mer än hälften av deltagarna i studien haft symtom i minst 5 år innan diagnos anser vi att åtgärder måste sättas in. Tidigare diagnos kräver antingen screening av befolkningen eller nya vårdplaner där diffusa symtom av celiaki uppmärksammas mer. Mer studier behövs för att avgöra vilken åtgärd som är mest hållbar. / Background Coeliac disease is an autoimmune disease where gluten causes inflammation in the mucosa of the small intestine. Symptoms in adults may be vague and therefore difficult to associate with coeliac disease. In Sweden, the average delay from first symptom to diagnosis is about 10 years. There are gaps in the knowledge of the consequences of a delayed diagnose. Objective The purpose of this study is to review the effect of the delay of coeliac diagnosis among adults on society’s resources, how the symptoms may have affected these individuals social life and the need of improved diagnosis. Method In Sweden, September 2012, an online questionnaire was distributed to 4,337 members of the Swedish Coeliac Society of which 611 was included in the study. The survey focus was mainly sick leave, health care contacts and social impacts due to symptoms of coeliac disease. The questionnaires were analyzed in SPSS (v.20.0) with p<0,05. Results Both sick leave and health care contacts decreased after diagnosis. The participants also avoided social activities to a lower extent and the majority experienced an improved quality of life. A large proportion (39%, n=238) reported that diagnosis delayed at least 10 years from the onset of symptoms, the majority of whom were older than the average. It was mainly those who reported a long delay from first symptom to diagnosis who experienced an improvement in quality of life due to diagnosis. Conclusion Early diagnosis is important in order to reduce costs that would otherwise derive from health care consumption and sick leave. Early diagnosis would also reduce the negative impact of symptoms on social life and quality of life. Since the majority of the participants reported a delay of at least 5 years from onset of symptoms to diagnosis, we believe that it is necessary to take action. In order to diagnose individuals with coeliac disease at an earlier stage it is necessary to apply effective methods such as screening or new care plans with more attention on vague symptoms. To determine which method is most sustainable, more studies needs to be done.

This research investigated physician and emergency room use among representative samples of children in the Dallas metropolitan area (N = 1606) and among patients who used Children's Medical Center of Dallas' First Care services (N = 612). Through telephone interviewing, caregivers to children under fifteen years of age were asked about an array of health service use behaviors, social-psychological issues related to acquiring health care for their children, and demographic characteristics as outlined by the Andersen & Newman model of health care service use. Children's use of physician services is best predicted by whether or not they have medical insurance, their level of income, and whether or not they have medical homes. Although having commercial managed care and fee-for-service Medicaid insurance consistently predicted increased physician use, neither independently reduced reliance on emergency rooms for non-emergent care. Managed care insurance and Medicaid did, however, significantly improve the odds that children would have medical homes, which significantly decreased emergency room use for non-emergent care. Further, increasing physician use and reducing reliance on hospital emergency rooms for non-emergent care will require ensuring that children have medical homeseither private physicians or community health centersat which they can readily and consistently receive sick and well care. Although some ethnic differences were observed, few of the broad array of factors in the Behavioral Model significantly predicted either physician or emergency room use. Moreover, educational levels and health beliefs rarely, and if significant negligibly, influenced physician and emergency room use. Health policy for children would best be served by focusing on programs that facilitate parent's ability to secure health insurance for their children and allocating children to medical homes where they can readily and consistently access sick and well care.

Background: Obesity has been associated with increased health care use, but it is unclear whether this is consistent across all measures of obesity. The objectives of this thesis were to compare obesity defined by four anthropometric measures, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and percent body fat (%BF), and to estimate their associations with health care use among Canadian adults. Methods: A secondary data analysis was conducted from 30,097 individuals aged 45-85 years from the Canadian Longitudinal Study on Aging. Anthropometric measures were collected by trained research assistants and %BF, the reference standard, was measured using dual-energy x-ray absorptiometry. Obesity was defined as BMI≥30.0 kg/m2, WC≥88cm for females and ≥102cm for males, WHR≥0.85 for females and ≥0.90 for males, and %BF>35% for females and >25% for males. Approximately 18 months after baseline data collection, self-reported health care use in the past 12 months was collected, including any contact with a general practitioner, medical specialist, emergency department, and being a patient in a hospital overnight. Pearson correlation coefficients and sensitivity and specificity analyses were conducted to compare anthropometric measures to %BF. Relative risks and risk differences were calculated for measures of health care use, adjusted for sex, age, education, income, urban/rural, marital status, smoking status, and alcohol use. Secondary analyses were also stratified by sex and age. Results: The prevalence of obesity defined by BMI was 29%, by WC was 42%, by WHR was 62%, and by %BF was 73%. BMI and WC were highly correlated with %BF (r=0.75 and r=0.70, respectively) and WHR was weakly correlated with %BF (r=0.29). BMI and WC cut points demonstrated high specificity (>93%) and lower sensitivity (<58%) in predicting obesity defined by %BF. WHR cut points demonstrated high sensitivity (95%) and lower specificity (28%) in males, but lower sensitivity (44%) and high specificity (83%) in females in predicting %BF- defined obesity. There was an increased relative and absolute risk of health care use for all measures of obesity and all health care services. For example, WC-defined obesity was associated with increased relative risk (RR) of hospital overnight stay (RR: 1.40, 95% CI: 1.28- 1.54) and the risk difference (per 100) was 2.6 (95% CI:1.9-3.3). The risk of health care use was similar amongst females and males with obesity although relative risks and risk differences attenuated in the oldest adult group aged 75 and older compared to the youngest group aged 45- 54. Conclusion: The prevalence of obesity among Canadian adults varied substantially by anthropometric measure. BMI and WC have stronger correlations and concordance with %BF than does WHR, however all measures were positively associated with increased health care use. Further research should be conducted on obesity cut points to discern the best measure to predict health care use. / Thesis / Master of Public Health (MPH)

Objective: The aim of this study was to investigate the longitudinal impact of depressive symptoms on utilization of healthcare in terms of GP visits as well as specialist visits and hospital admission in late life among community-dwelling individuals. Methods: Longitudinal data (baseline and follow-up) were derived from the German multicentre, prospective cohort study “Late-life depression in primary care: needs, health care utilization and costs” study (AgeMooDe). At baseline, n = 1,230 patients aged 75 years and older were recruited from primary care practices. Main outcomes of interest were use of health care services: the number of GP visits, the number ofmedical specialist visits, and hospital admission. We used the Geriatric Depression Scale (GDS-15) to measure depression. Outcomes were analyzed with multilevel random intercept negative binominal regression and logistic random-effects models. Results: At baseline (n = 1,191), mean age was 80.7 (SD 4.6) years, 62.9% were female, and 196 individuals (16.5%) had depression (GDS-15 6). Our longitudinal analyses indicated that older individuals with more depressive symptoms visited their GP more often (IRR=1.03; CI [1.01-1.04], p < 0.001), were visiting medical specialists more frequently (IRR=1.03; CI [1.01-1.04], p < 0.01), and had higher odds of being hospitalized (OR=1.08; CI [1.02-1.13], p < 0.01). Conclusions: Based on this large longitudinal study we showed that, after adjustment for important covariates, older individuals with more depressive symptoms had higher health care utilization over time. They visited their GP and specialists more frequently and they had higher odds of being hospitalized. This may suggest that higher utilization of specialist care and increased likelihood of being hospitalized may be also attributable to unspecific symptoms or symptoms that are elevated through depressive symptoms