Barriers to health care access among the elderly and who perceives them

Educational Attainment and Perceived Need for Urgent Care

While lower educational attainment is associated with worse health status, education may also affect one's ability to identify need for urgent care. Using data from the 2010 Medicare CAHPS survey, we estimated multivariate logistic models to test the relationship between self-reported educational attainment and the perceived need for urgent care, controlling for health status and other factors. As expected, lower educational attainment was associated with greater reported need for urgent care in bivariate analyses because of poorer health. However, lower educational attainment was associated with less perceived need for urgent care after controlling for health status, particularly for those in poor health. These findings suggest the need for interventions to improve the likelihood that people with less education recognize the need for urgent care, particularly those in poor health and in most need of urgent care.

Forgotten patients: ACO attribution omits those with low service use and the dying

OBJECTIVES

Alternative payment models, such as accountable care organizations, hold provider groups accountable for an assigned patient population, but little is known about unassigned patients. We compared clinical and utilization profiles of patients attributable to a provider group with those of patients not attributable to any provider group.

STUDY DESIGN

Cross-sectional study of 2012 Medicare fee-for-service beneficiaries 21 years and older.

METHODS

We applied the Medicare Shared Savings Program attribution approach to assign beneficiaries to 2 mutually exclusive categories: attributable or unattributable. We compared attributable and unattributable beneficiaries according to demographics, dual eligibility for Medicaid, nursing home residency, clinical comorbidities, annual service utilization, annual spending, and 1- and 2-year mortality. We estimated multivariate regression models describing correlates of attribution status.

RESULTS

Most beneficiaries (88%) were attributable to a provider group. The remaining 12% were unattributable. Beneficiaries unattributable to any provider group were more likely to be younger, male, and from a minority group; to have disability as the basis for enrollment; and to live in high-poverty areas. Unattributable beneficiaries included 3 distinct subgroups: nonusers of care, decedents, and those with healthcare service use but no qualifying evaluation and management visits. Many unattributable Medicare beneficiaries had minimal use of healthcare services, with the exception of a small subgroup of beneficiaries who died within the attribution year.

CONCLUSIONS

Attribution approaches that more fully capture unattributable patients with low service use and patients near the end of life should be considered to reward population health efforts and improve end-of-life care.

Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges

There have been many advances in management of cerebrovascular diseases. However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This review summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation units, and types of rehabilitation resources and services available in Singapore. We also present the challenges faced by the elderly stroke survivors in the local setting and propose strategies to overcome the barriers to rehabilitation in this aging population.

Differences in Referral Access to Care Between Gastrointestinal Subspecialty Patients: Barriers and Opportunities

Purpose: Referral access to subspecialty care for patients with gastrointestinal (GI) diseases is not well defined, but has significant importance to patients. We hypothesized that patients experience barriers to care in two common gastroenterology subspecialties, Hepatology and Motility, in a university medical center. Methods: Two hundred thirteen clinic patients (mean age 46.5 years; 66.5% female; 85.6% Caucasians) completed a formatted questionnaire on access to care. Hepatology patients were older (49.7 years, p=0.008); motility patients predominantly female (76.8%, p<0.001). Gender distribution was even for hepatology (51.2% female). Both groups were overweight (mean body mass index 28.4). Results: Patients waited a mean 89.5 days to be seen by a subspecialist. There were differences by subspecialty (107.6 days for motility vs. 64.3 days for hepatology, p=0.022). A larger percentage of motility patients were told nothing was wrong with them (16.8%, p<0.01) and could not be helped (42.1%, p=0.000). Conclusions: Access to care for subspecialty gastroenterology patients in a university center appears to be impacted by a number of variables. While there are similarities, differences exist between these two subspecialties. Motility patients were more likely to have been told they have nothing wrong with them, suffer setbacks financially, and suffer mood problems. Their wait time for appointments was also greater than hepatology patients. Further investigations of referral access for gastroenterology patients may yield additional insights into disease-specific barriers to accessing subspecialty care.

Self-Perceptions of Aging and Perceived Barriers to Care: Reasons for Health Care Delay

Background and Objectives

Self-perceptions of aging (SPA), or attitudes toward one's aging experience, have been linked to health through multiple pathways. Few studies, however, have investigated how older adults' views on aging influence their care-seeking behaviors.

Research Design and Methods

Using two independent subsamples from the Health and Retirement Study (2011 Health Care Mail Survey: N = 2,866; 2013 Health Care and Nutrition Study: N = 2,474), logistic regression and negative binomial regression were used to examine the association between SPA and health care delay over the next 12 months. Subsequently, we used latent class analysis to identify subgroups reporting different reasons for delay. With multinomial logistic regression, we then examined if, compared with the no delay group, SPA differentiated membership in the delay subgroups.

Results

In both samples, more negative aging self-perceptions were associated with a higher likelihood of health care delay and more perceived barriers to care, after adjusting for predisposing, enabling, and need factors. Latent class analysis revealed three subgroups characterized by different reasons for delay: (a) limited health care access, (b) too busy to go to the doctor, and (c) dislike of going to the doctor. In fully adjusted models, individuals with more negative SPA were more likely to belong to "limited-access" and "dislike" subgroups compared with the no delay group.

Discussion and Implications

SPA may affect decision-making processes regarding whether to seek care for worrisome symptoms. Efforts to promote more positive SPA may encourage older adults to be more proactive in addressing their health care needs.

Too old to test? Prevalence and correlates of HIV testing among sexually active older adults

Older adults account for 17% of new HIV diagnoses in the US and are more likely to be diagnosed with HIV later in the course of the disease compared to younger people. We calculated the prevalence and associated factors of having ever been tested for HIV among sexually active older adults. We analyzed data from the 2008-2016 General Social Survey Limited to respondents ≥65 years of age who reported more than one sex partner(s) in past 12 months (n = 757). HIV testing prevalence, prevalence ratios, and 95% confidence intervals were calculated by demographic variables and HIV-related risk behaviors. An estimated 16.3% of sexually active older adults have tested for HIV, and 15.9% were at increased risk for HIV infection (reported injection drug and/or crack-cocaine use, exchanging money for sex, more than three sex partners in the past year, or men who reported having sex with another man). In the adjusted model, adults aged 65-70, not married, self-identified as gay/bisexual, and at increased risk for HIV infection were more likely to have tested for HIV. An estimated 83.7% of sexually active older adults never tested for HIV. Strategies are needed to increase HIV awareness and testing among potentially high-risk older adults.

Providing no-cost transport to patients in an underserved area: Impact on access to physical therapy

Background: Barriers to accessing outpatient health care services are common and contribute to poor health outcomes. We describe the efforts of a private practice physical therapy (PT) clinic to reduce these barriers by offering a door-to-door van service at no cost to patients. Methods: Clinic records and national census databases were retrospectively reviewed to explore the impact of offering no-cost van rides to patients attending outpatient PT appointments. We used descriptive statistics and linear regression to describe volume of utilization of the van service over a 40-month period. Paired t-tests compared PT clinic attendance rates (percentage of scheduled visits that were attended) before and after implementation of the van service. Results: Use of the van service increased significantly over time, from a mean of 83 riders per month in 2010 to 205 riders per month in 2013 (p < 0.001). Overall clinic attendance rate increased from 80.1% to 84.1% after implementation of the service (p = 0.002). Following introduction of the van service, 48% of patients using the van, compared to 25% of clinic patients overall, were uninsured or insured by Medicaid. Conclusion: Use of the van service increased over time, and availability of no-cost van transportation was associated with increased visit attendance for patients at an outpatient PT clinic.

Using Information Technology in the Assessment and Monitoring of Geriatric Oncology Patients

PURPOSE OF REVIEW

Older adults with cancer have complex medical needs and often experience higher rates of treatment-related toxicities compared to their younger counterparts. The advent of health information technologies can address multiple gaps in the care of this population. We review the role of existing and emerging technologies in facilitating the use of comprehensive geriatric assessment (CGA) in routine clinics, promoting symptom reporting, and monitoring medication adherence.

RECENT FINDINGS

Increasingly, studies demonstrate the feasibility of implementing electronic CGA in routine oncology practices. Evidence also suggests that electronic symptom reporting can improve outcomes in patients with cancer. In addition, technology devices can be used to promote adherence to cancer therapy. There are many opportunities for information technology to be integrated into the management and treatment of older adults with cancer. However, further evaluation of these technologies is needed to ensure that they meet the needs of the targeted end users.

Randomized controlled trial evaluating a novel community eye care programme for elderly individuals with visual impairment

IMPORTANCE

The novel intervention was effective at improving compliance to appropriate tertiary eye care after community eye screening.

BACKGROUND

Elderly individuals from low socio-economic background with visual impairment (VI) often do not attend tertiary care, even if significant eye diseases are detected while in the community. We evaluate a novel incentive care scheme (ICS) to improve compliance to appropriate follow-up after community eye screening.

DESIGN

Randomized controlled trial in a population-based setting was conducted.

PARTICIPANTS

A total of 140 elderly individuals with VI (visual acuity <6/12, mean age ± SD = 66.6 ± 8.9 years, 46.4% female) were included.

METHODS

Participants were randomized to either ICS (N = 72) or usual care (UC; N = 68). ICS incorporated patient education, social support and financial assistance to assist individuals in attending tertiary eye care. UC comprised of a standard referral letter and advice.

MAIN OUTCOME MEASURE

Primary outcome included compliance to eye care referral. Secondary outcomes included best-corrected visual acuity and vision-related quality of life assessed at baseline and 3 months.

RESULTS

Participants receiving the ICS intervention had higher rates of compliance to tertiary eye care attendance compared to UC (31.9% vs. 16.2%, respectively, P = 0.027). While we observed an overall significant improvement in best-corrected visual acuity at 3 months in both groups (P < 0.05), we found no significant differences in Rasch-transformed vision-related quality of life scores between groups (all P > 0.05). Identified barriers for tertiary healthcare access included patient attitudes and financial- and health-related barriers.

CONCLUSION AND RELEVANCE

Our pilot RCT found that ICS improved adherence to appropriate tertiary eye care referrals after community eye screening in elderly people with VI.

The Social Determinants of Healthcare Access for Rural Elderly Women - A Systematic Review of Quantitative Studies

Objective:

This review aimed to explore and analyze the social determinants that impact rural women’s aged 60 years and older healthcare access in low or middle income and high income countries.

Methods:

Major healthcare databases including MEDLINE and MEDLINE In-Process, PsycINFO, PubMed, ProQuest, Web of Science, CINAHL and ERIC were searched from April 2016 to August 2016 and a manual search was also conducted. A rigorous selection process focusing on the inclusion of rural elderly women in study population and the social determinants of their healthcare access resulted in 38 quantitative articles for inclusion. Data were extracted and summarized from these studies, and grouped into seven categories under upstream and downstream social determinants.

Results:

Prevailing healthcare systems in combination with personal beliefs and ideas about ageing and healthcare were identified as significant determinants. Socioeconomic and cultural determinants also had a statistically significant negative impact on the access to healthcare services, especially in developing countries.

Conclusion:

Potentially, improvements to healthcare access can be achieved through consideration of rural elderly women’s overall status including healthcare needs, socioeconomic determinants and cultural issues rather than simply establishing healthcare centers.

Depression and Anxiety Among Emergency Department Patients: Utilization and Barriers to Care

BACKGROUND

Anxiety and depression rates among emergency department (ED) patients are substantially higher than those in the general population. Additionally, those with mental health issues often have difficulty accessing care. Unfortunately, issues of anxiety and depression are frequently not addressed in the ED due to competing care priorities. This may lead to increased burden and overcrowding in EDs.

OBJECTIVE

This study related anxiety and depression with ED utilization and perceived barriers to care.

METHODS

To limit the impact of insurance coverage on ED utilization and access to care, a convenience sample of adults 45 to 85 years of age in the ED were surveyed. The Generalized Anxiety Disorder 7 and Patient Health Questionnaire 9 were used to measure anxiety and depression.

RESULTS

A total of 251 subjects were enrolled. Severe anxiety was observed in 10% of patients, while moderately severe or severe depression was observed in 12%. Patients who were both severely anxious and depressed visited the ED nearly twice as often as nonanxious and nondepressed patients. The majority of patients cited at least one moderate barrier to care, and greater anxiety and depression scores were related to greater perceived barriers to care. Perceived barriers to care were more than three times higher among patients who were both anxious and depressed compared to those in patients who were neither depressed nor anxious and twice as high as in those who were either depressed or anxious (p < 0.001).

CONCLUSION

Patients identified with internalizing mental health concerns utilize the ED at elevated rates while also reporting the greatest difficulties accessing care. These findings highlight the need for ED interventions aimed at identifying patient mental health concerns, as well as perceived barriers to care, to design interventions to effectively improve continuity of care.

Nuances in the Management of Older People With Multiple Myeloma

Multiple myeloma is a disease of the elderly, with about a third of patients at diagnosis older than 75 years of age. Yet, the population of elderly patients is heterogeneous: older patients are more likely to have comorbidities and frailties complicating both their initial diagnosis and subsequent management, but these are not consistent across the group. Furthermore, patients with comorbidities and frailty are generally underrepresented in clinical trials. Despite the survival of myeloma patients increasing following the introduction of novel agents, older patients continue to have worse outcomes with increased treatment-related toxicity. Treatment tolerability is not defined by age alone, rather a combination of age, physical function, cognitive function, and comorbidities. These factors all influence patients' tolerability of treatment and therefore treatment efficacy and should also be considered when reviewing the results of clinical trials. It is the nuances of determining how these factors interact that should influence initial treatment and ongoing management decisions and these will be discussed here.

Effects of ambient PM1 air pollution on daily emergency hospital visits in China: an epidemiological study

BACKGROUND

China is experiencing severe ambient air pollution. However, few studies anywhere have examined the health effects of PM₁ (particulate matter with aerodynamic diameter <1 μm), which are a major part of PM_2·5 (particulate matter with aerodynamic diameter <2·5 μm) and even potentially more harmful than PM_2·5. We aimed to estimate the effects of ambient daily PM₁ and PM_2·5 concentrations on emergency hospital visits in China.

METHODS

In this epidemiological study, we collected daily counts of emergency hospital visits from the 28 largest hospitals in 26 Chinese cities from Sept 9, 2013, to Dec 31, 2014. Ground-based monitoring data for PM₁ and PM_2·5 and meteorological data were also collected. Hospital-specific emergency hospital visits associated with PM₁ or PM_2·5 were evaluated with a time-series Poisson regression. The effect estimates were then pooled at the country level using a random-effects meta-analysis.

FINDINGS

The mean daily concentration of PM₁ in all cities was 42·5 μg/m³ (SD 34·6) and of PM_2·5 was 51·9 μg/m³ (41·5). The mean daily number of emergency hospital visits in all hospitals was 278 (SD 173). PM₁ and PM_2·5 concentrations were significantly associated with an increased risk of emergency hospital visits at lag 0-2 days (cumulative relative risk [RRs] 1·011 [95% CI 1·006-1·017] for a 10 μg/m³ increase in PM₁ and 1·010 [1·005-1·016] for a 10 μg/m³ increase in PM_2·5). Slightly higher RRs of ambient PM₁ and PM_2·5 pollution were noted among women and children than among men and adults, respectively, but without statistical significance. Given a cause-effect association, 4·47% (95% CI 2·05-6·79) and 5·05% (2·23-7·75) of daily emergency hospital visits in China could be attributed to ambient PM₁ and PM_2·5 pollution, respectively.

INTERPRETATION

Exposure to both ambient PM₁ and PM_2·5 were significantly associated with increased emergency hospital visits. The results suggest that most of the health effects of PM_2·5 come from PM₁.

FUNDING

None.

What is the gap in activity and participation between people with disability and the general population in Taiwan?

BACKGROUND

In 2010, the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) was developed, based on the concept of the International Classification of Functioning, Disability and Health (ICF). The ICF provides a common language and framework for health and health-related status and attempts to integrate the biopsychosocial model as a multidimensional perspective in understanding functioning. Activities and participation (AP) is one salient component of the ICF refers to the execution of a task by an individual, and how such tasks are involved in their daily life. It is essential to examine the gap between the general adult population and adults with disabilities. This gap may be attributed to health status, personal factors, and natural and social environments, which include social and health services and policies. The purposes: (1) To develop a normative activity and participation (AP) value for the adult population and people with disabilities; and (2) to compare the gap in AP normative values between the two groups in Taiwan.

METHODS

We use the WHODAS 2.0 to survey and develop a normative AP value for the general adult population, and used secondary data from National Disability Eligibility Determination System (NDEDS) of Taiwan to describe the AP functioning distribution of adult with disability. There were 1100 participants, selected by stratified proportional sampling from two cities. There were also 144,850 participants who were adults with disability, selected from the secondary database in Taiwan.

RESULTS AND CONCLUSIONS

The AP curve for the disabled population increased rapidly at the beginning. The summary score was 13.21 in the performance at 90 percentile for the general population and 82.61 score for disabled adults that the similar gap in every domain, its means that there are significant functioning difference and health equality in general adults population and adults with disabilities. This presents a substantial challenge for both the government and the whole population of Taiwan, to begin considering how to reduce the gap in AP functioning and promote equality for people with disabilities, using social welfare policy. It is important to make sure disabled people have the same rights to be included in society as anybody else and better access to things in all areas of life that are according to Convention on the Rights of Persons with Disabilities (CRPD).

Characterizing Time to Diagnostic Resolution After an Abnormal Cancer Screening Exam in Older Adult Participants in the Ohio Patient Navigation Research Program

OBJECTIVE

This study aims to test the effectiveness of a patient navigation (PN) intervention to reduce time to diagnostic resolution among older adults age ≥65 years versus those <65 years with abnormal breast, cervical, or colorectal cancer screening exams participating in the Ohio Patient Navigation Research Program (OPNRP).

METHOD

The OPNRP utilized a nested cohort group-randomized trial design to randomize 862 participants ( n = 67 for ≥65 years; n = 795 for <65 years) to PN or usual care conditions. A shared frailty Cox model tested the effect of PN on time to resolution.

RESULTS

Older adult participants randomized to PN achieved a 6-month resolution rate that was 127% higher than those randomized to usual care ( p = .001). This effect was not significantly different from participants <65 years.

DISCUSSION

PN significantly reduced time to diagnostic resolution among older adults beginning 6 months after an abnormal cancer screening exam. Health care systems should include this population in PN programs to reduce cancer disparities.

Comparison of 30-Day and Long-Term Outcomes and Hospital Complications Among Patients Aged <75 Versus ≥75 Years With ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Our aim was to evaluate the mortality rate and occurrence of complications in patients aged <75 versus ≥75 years with ST-elevation myocardial infarction (STEMI). We studied 1,657 consecutive patients with STEMI hospitalized in the cardiac intensive care unit during 2008 to 2014. All patients underwent primary percutaneous intervention, of which 292 (18%) were aged ≥75 years. Patient records were evaluated for in-hospital complications, 30-day mortality, and long-term mortality over a mean period of 3.4 ± 2.1 years. Compared with younger patients, patients aged ≥75 years had a significantly higher rate of coronary disease risk factors, prolonged symptom duration (512 ± 640 vs 333 ± 545 minutes, p <0.01) and door-to-balloon time (51.1 ± 24 vs 45.6 ± 38, p = 0.02). Patients aged ≥75 years had more in-hospital noncardiac and cardiac complications, including cardiogenic shock and arrhythmia, and had higher 30-day and long-term mortalities. Cardiogenic shock was associated with increased short- and long-term mortality in the older group but was not incremental over the noncardiogenic shock cohort. In conclusion, in patients aged ≥75 years who underwent primary percutaneous intervention for STEMI, the short- and long-term mortality rate was greater than fourfold higher compared with younger patients.

Reaching the Unreachable: Novel Approaches to Telemedicine Screening of Underserved Populations for Vitreoretinal Disease

Telemedicine involves electronic communication between a physician in one location and a patient in another location to provide remote medical care. Ophthalmologists are increasingly employing telemedicine, particularly in retinal disease screening and monitoring. Telemedicine has been utilized to decrease barriers to care and yield greater patient satisfaction and lower costs, while maintaining high sensitivity and specificity. This review discusses common patient barriers to eye care, innovative approaches to retinal disease screening and monitoring using telemedicine, and eye care policy initiatives needed to enact large-scale telemedicine eye disease screening programs.

Socioeconomic determinants of access to health services among older adults: a systematic review

OBJECTIVE

The objective of this study was to analyze the association between the socioeconomic characteristics and the access to or use of health services among older adults.

METHODS

This is a systematic review of the literature. The search has been carried out in the databases PubMed, LILACS and Web of Science, without restriction of dates and languages; however we have included only articles published in Portuguese, English, and Spanish. The inclusion criteria were: observational design, socioeconomic factors as variables of interest in the analysis of the access to or use of health services among older adults, representative sample of the target population, adjustment for confounding factors, and no selection bias.

RESULTS

We have found 5,096 articles after deleting duplicates and 36 of them have been selected for review after the process of reading and evaluating the inclusion criteria. Higher income and education have been associated with the use and access to medical appointments in developing countries and some developed countries. The same association has been observed in dental appointments in all countries. Most studies have shown no association between socioeconomic characteristics and the use of inpatient and emergency services. We have identified greater use of home visits in lower-income individuals, with the exception of the United States.

CONCLUSIONS

We have observed an unequal access to or use of health services in most countries, varying according to the type of service used. The expansion of the health care coverage is necessary to reduce this unequal access generated by social inequities.

Quality Indicator for Epilepsy Treatment 15 (QUIET-15): Intervening after recurrent seizures in the elderly

In this study, we examined the provision of care to older adults with epilepsy and compliance with the "Quality Indicator for Epilepsy Treatment 15" (QUIET-15) measure. We analyzed 2008-2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African-Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27-1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57-0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57-1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22-1.51). The probability of AED change after a seizure was higher for patients with ≥4 comorbidities (OR 1.69, 95%CI 1.25-2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30-1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27-1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.

Dental and Oral Problem Patterns and Treatment Seeking Behavior of Geriatric Population

Background:

The manifestations of oral changes and disorders affecting the geriatric population are different from the rest of the population. Inaccessibility to dental care is a compelling impediment to avail oral health services.

Objective:

The aims were to assess the dental and oral problems and to find out the determinants of oral health seeking behaviour among elderly population of Al-Jouf province, Saudi Arabia.

Methods:

The present cross sectional study included geriatric patients of 60 years and above, who visited the College of Dentistry, Al-Jouf University. A simple pre-structured questionnaire was filled by the patients, which comprised of demographic details and the different oral complaints of elderly and the type of health care utilized for those complaints.

Results:

Out of total 892 elderly persons included, 51.79% were males and 48.21 were females. The most common oral problem was missing tooth (78.69%) followed by gum problems (74.21%). 39.5% males and 28.0% females visited general dental practitioners for oral health care. Majority of the participants (32.8%) suggested accessibility as a basic factor in determining the health care source. The difference in the distribution of male and females or association between the type of care and gender and distribution for choosing a health care source was found to be statistically significant (p < 0.05).

Conclusion:

Inaccessibility to dental care emerged as an important barrier to avail oral health services. Adequate access to medical and dental care can reduce premature morbidity and mortality, preserve function, and enhance overall quality of life.

Correlates of subjective transportation deficiency among older adults attending outpatient clinics in a tertiary care hospital in Mexico City

AIM

Older adults frequently report problems of transportation. Little is known about the correlates of transportation deficiency in Latin America. Therefore, the aim of the present study was to determine the correlates of subjective transportation deficiency (STD) among community-dwelling older adults attending a tertiary care hospital in Mexico City.

METHODS

Cross-sectional study of 228 participants aged ≥70 years being followed in any of the outpatient clinics of a tertiary care hospital in Mexico City. Data were obtained through a structured questionnaire. Univariate and multivariate logistic regression analyses were carried out in order to identify the correlates of STD.

RESULTS

The mean age of the participants was 79.8 years (SD 6.4) and 67.1% were women. STD was present in 46% of participants. The multivariate logistic regression model showed that female sex, illiteracy, mobility disability and the use of an assistive walking device had an independent and statistically significant association with STD.

CONCLUSIONS

Female sex, illiteracy, mobility disability and the use of an assistive walking device were independent correlates of STD in the present study. Identifying the frequency and correlates of transportation deficiency in vulnerable populations will allow for the identification and implementation of useful public policies, as well as for the optimization of prevention and treatment strategies in an attempt to preserve mobility and autonomy, especially in low- and middle-income countries where previous work on transportation deficiency is lacking. Geriatr Gerontol Int 2017; 17: 1893-1898.

Health Care Utilization Among Elderly Medicare Beneficiaries With Coexisting Dementia and Cancer

Objective: The goal of this research is to delineate health care utilization among elderly Medicare beneficiaries with coexisting dementia and cancer compared with those with dementia alone, cancer alone, or neither condition. Method: The study cohort included 96,124 elderly patients aged 65 years and older who resided in the Mid-South region of the United States and were enrolled in Medicare during 2009. Multivariate regression analyses were used to examine health care utilizations while adjusting for sociodemographic characteristics. Results: Those with coexisting dementia and cancer diagnoses had higher rates of hospitalizations, hospital readmissions within 30 days, intensive care unit use, and emergency department visits compared with those with dementia only, cancer only, and those with neither condition. Patients with coexisting dementia and cancer also had a higher number of primary care visits and specialist visits. Conclusion: There is a greater need for developing tailored care plans for elderly with these two degenerative health conditions to address their unique health care needs and to reduce financial burden on the patients and the health care system.

Access to Care and Depression among Emergency Department Patients

BACKGROUND

The prevalence of depression among patients in the emergency department (ED) is significantly higher than in the general population, making the ED a potentially important forum for the identification of depression and intervention. Concomitant to the identification of depression is the issue of patient access to appropriate care.

OBJECTIVE

This study sought to establish prevalence estimates of potential barriers to care among ED patients and relate these barriers with symptoms of depression.

METHODS

Two medical students conducted brief surveys on all ED patients ≥ 18 years on demographics, perceived access to care, and depression.

RESULTS

A total of 636 participants were enrolled. The percentage of participants with mild or greater depression was 42%. The majority of patients reported experiencing some barriers to care, with the most prominent being difficulty finding transportation, work responsibilities, and the feeling that the doctor is not responsive to their concerns. Higher depression scores were bivariately associated with higher overall barriers to care mean scores (r = 0.44; p < 0.001), suggesting that greater symptoms of depression are associated with greater difficulties accessing care. Particularly strong associations were observed between symptoms of depression and difficulty finding transportation, the feeling that the doctor is not responsive to patients' concerns, embarrassment about a potential illness, and confusion trying to schedule an appointment.

CONCLUSIONS

Across all barriers analyzed, there was a greater incidence of depression associated with a greater perception of barriers. These barriers may be used as potential targets for intervention to increase access to health care resources.

Public pensions and unmet medical need among older people: cross-national analysis of 16 European countries, 2004-2010

Background

Since the onset of the Great Recession in Europe, unmet need for medical care has been increasing, especially in persons aged 65 or older. It is possible that public pensions buffer access to healthcare in older persons during times of economic crisis, but to our knowledge, this has not been tested empirically in Europe.

Methods

We integrated panel data on 16 European countries for years 2004–2010 with indicators of public pension, unemployment insurance and sickness insurance entitlement from the Comparative Welfare Entitlements Dataset and unmet need (due to cost) prevalence rates from EuroStat 2014 edition. Using country-level fixed-effects regression models, we evaluate whether greater public pension entitlement, which helps reduce old-age poverty, reduces the prevalence of unmet medical need in older persons and whether it reduces inequalities in unmet medical need across the income distribution.

Results

We found that each 1-unit increase in public pension entitlement is associated with a 1.11 percentage-point decline in unmet medical need due to cost among over 65s (95% CI −0.55 to −1.66). This association is strongest for the lowest income quintile (1.65 percentage points, 95% CI −1.19 to −2.10). Importantly, we found consistent evidence that out-of-pocket payments were linked with greater unmet needs, but that this association was mitigated by greater public pension entitlement (β=−1.21 percentage points, 95% CI −0.37 to −2.06).

Conclusions

Greater public pension entitlement plays a crucial role in reducing inequalities in unmet medical need among older persons, especially in healthcare systems which rely heavily on out-of-pocket payments.

Assessing the Associations Between Awareness of Myocardial Infarction Symptoms, Socioeconomic Factors, and Cardiovascular Disease Risk Factors Through Regression Models

There are few studies that consider the association between awareness of symptoms of acute myocardial infarction (MI), socioeconomic factors (household income, sex, race/ethnicity, and educational attainment), and cardiovascular (CVD) risk factors. It is important to understand these associations because there is evidence that suggests that disparities in the awareness of MI symptoms lead to disparities in delays in receiving treatment and outcomes of patients with MI. The study was to determine if there are disparities in the awareness of different MI symptoms among different groups with respect to self-reported race, ethnicity, education, age, and income (i.e., various SES factors) in the presence/absence of modifiable cardiovascular disease risk factors. We utilized the 2003-2009 Behavioral Risk Factor Surveillance Survey, a nationally representative telephone-based survey, to evaluate the relationships between five common symptoms of MI, socioeconomic factors, and four major modifiable CVD risk factors. We found that being college-educated, a higher household income, making $75,000 a year or more, being female, being non-Hispanic White, having hypertension, and exercising regularly were generally associated with a higher probability of being aware of the MI symptoms evaluated in this study. Additionally, awareness that jaw/back/neck pain and feeling weak/light-headed/faint are symptoms of MI were found to be consistently lower compared to that of other MI symptoms, ranging from 50 to 75%, across all SES factors and CVD risk factors. The findings from this study can serve as a useful guide to facilitating targeted educational efforts aimed at improving awareness of MI symptoms that may ultimately reduce disparities in the outcomes of patients at risk for MI.

Access to Health Care and Hospitalization for Ambulatory Care Sensitive Conditions

Hospitalization for Ambulatory Care Sensitive Conditions (ACSH) is an accepted indicator of access to health care and avoidable morbidity. Accessible care of reasonable quality should reduce ACSH. Little research has examined the indicator’s external validity. We calculated standardized ACSH rates for 32 areas of Victoria, Australia (population 4.4 million). A representative survey measured access, disease prevalence, propensity to seek care, disease burden, social determinants of health services use, and behavioral risk factors. Regression analyses compared self-rated access with ACSH rates. Independent of prevalence, propensity to seek care, disease burden, and physician supply, better access was associated with lower ACSH rates. Results provide support for the ACSH indicator. When rural residence was considered, the covariate measuring access was not significant. However, rural residence also may contribute importantly to access. Results suggest both the complexity of the meaning of access and the desirability of further research to validate the ACSH indicator.

Access to transportation for Chittenden County Vermont older adults

BACKGROUND

Aging often leads to decreased independence and mobility, which can be detrimental to health and well-being. The growing population of older adults will create a greater need for reliable transportation.

AIMS

Explore whether and how lack of transportation has compromised areas of daily lives in older adults.

METHODS

1221 surveys with 36 questions assessing transportation access, usage, and impact on activities were distributed to Chittenden County, Vermont older adults; 252 met criteria for analysis.

RESULTS

Older adults reported overwhelming difficulty getting to activities considered important, with 69 % of participants delaying medical appointments due to transportation barriers. Although family and friends represent a primary method of transportation, older adults reported difficulty asking them for help.

DISCUSSION

Lack of accessible transportation leads to missed healthcare appointments and social isolation, which may have detrimental effects on older adults' quality of life.

CONCLUSION

Many older adults face significant transportation challenges that negatively affect their health and well-being.

Telephone communication between practice nurses and older patients with long term conditions - a systematic review

Background and aims Long term conditions are a significant health problem faced by older people worldwide. Telephone communication is often used to deliver health care to patients and is an important tool in improving access to care. Previous research has shown that primary health care nurses communicate with patients by telephone, but little is known about the way in which telephone communication can be used to benefit older patients with long term conditions. The aims of this review were to identify the range and scope of telephone use between practice nurses working in primary health care and older people with long term conditions, explore which elements of this communication has been successful, and determine whether older people see telephone communication as useful for their needs. Methods A systematic search of the literature was conducted through CINAHL, Medline, Web of Science and EMBASE between July and August 2015. Included were English language articles containing older adults, primary care nurses and both qualitative and quantitative designs. Results Five studies met the inclusion criteria. All were intervention studies, and none looked at routine telephone communication between nurse and patient. Most studies showed that telephone based interventions were successful in improving pre-determined disease-specific health indicators. Conclusions All telephone communication interventions in this review focused on a specific long term condition, which they aimed to help patients self-manage. While all studies' samples included older patients, they did not consider them separately in relation to the effectiveness of the intervention. What was also lacking was the patient perspective regarding effectiveness in all but one study.

Nursing Program Partners With Community to Implement Neighborhood Influenza Immunization Clinics

Service-learning projects provide a valuable service to the community and a valuable clinical experience for nursing students. There are several national studies and initiatives that highlight the importance of partnerships in care and service delivery. This article describes how these were considered and incorporated into the development of a community partnership by multiple service providers to offer influenza immunizations in neighborhood stores. This article is a discussion of a multidisciplinary, community-wide influenza immunization clinic.

Evaluating equality in psoriasis healthcare: a cohort study of the impact of age on prescription of biologics

BACKGROUND

Inequality in healthcare has been identified in many contexts. To the best of our knowledge, this is the first study investigating age inequality in the form of prescription patterns of biologics in psoriasis care.

OBJECTIVES

To determine whether patients with psoriasis have equal opportunities to receive biological medications as they age. If patients did not receive equal treatment, a subsequent objective was to determine the magnitude of the disparity.

METHODS

A cohort of biologic-naive patients with psoriasis was analysed using Cox proportional hazards models to measure the impact of each additional year of life on the likelihood of initiating biological treatment, after controlling for sex, body mass index, comorbidities, disease activity and educational level. A supporting analysis used a nonparametric graphical method to study the proportion of patients initiating biological treatment as age increased, after controlling for the same covariates.

RESULTS

The Cox proportional hazards model resulted in hazard ratios of a 1-year increase in age of 0·96-0·97 depending on calendar-year stratification, which implies that an increase in age of 30 years corresponds to a reduced likelihood of initiating biological treatment by 61·3-67·6%. The estimated proportion of patients initiating biological medication always decreased as age increased, at a statistically significant level.

CONCLUSIONS

Patients with psoriasis have fewer opportunities to access biological medications as they age. This result was shown to be applicable at all stages in a patient's life course and was not only restricted to the elderly, although it implies greater disparities as the age difference between patients increases. These results show that inequality in access to biological treatments due to age is prevalent in clinical practice today. Further research is needed to investigate the extent to which this result is influenced by patient preferences.

Familiarity with and intentions to use Internet-delivered mental health treatments among older rural adults

OBJECTIVES

Older adults are the fastest growing age group in Australia, necessitating an increase in appropriate mental health services in the coming years. While Internet-delivered mental health treatments have been established as acceptable and efficacious among younger samples, little research has explored whether they would be similarly useful in older populations.

METHODS

The participants were part of the Australian Rural Mental Health study, which explores mental health and well-being in residents of non-metropolitan New South Wales. A postal survey was used to assess knowledge of and intentions to use Internet-delivered mental health treatments. Demographics, mental health, and frequency of Internet use were also measured.

RESULTS

The survey was completed by 950 adults aged 50-93. The sample was largely unfamiliar with Internet mental health services, with 75% reporting that they had never heard of them and a further 20% not knowing any details of what they involved. Intentions to use these services were also low, at 13.5%; however, this increased with level of familiarity. Respondents with higher psychological distress, higher education, and more frequent Internet use were significantly more likely to consider using Internet treatments.

CONCLUSIONS

Among older adults, overall awareness of Internet-delivered mental health treatments appears to be limited; however, higher familiarity contributes to higher intentions to use these treatments. Importantly, respondents with higher distress and greater computer literacy were more likely to consider mental health treatments delivered via the Internet. Future research exploring strategies to increase the promotion of these services to older samples may further improve their perceptions and use.

The Emerging Business Models and Value Proposition of Mobile Health Clinics

Mobile health clinics are increasingly used to deliver healthcare to urban and rural populations. An estimated 2000 vehicles in the United States are now delivering between 5 and 6 million visits annually; however, despite this growth, mobile health clinics represent an underutilized resource that could transform the way healthcare is delivered, especially in underserved areas. Preliminary research has shown that mobile health clinics have the potential to reduce costs and improve health outcomes. Their value lies primarily in their mobility, their ability to be flexibly deployed and customized to fit the evolving needs of populations and health systems, and their ability to link clinical and community settings. Few studies have identified how mobile health clinics can be sustainably utilized. We discuss the value proposition of mobile health clinics and propose 3 potential business models for them-adoption by accountable care organizations, payers, and employers.

The Effect of Telemedicine on Access to Acute Stroke Care in Texas: The Story of Age Inequalities

Background. Ischemic stroke is a time sensitive disease with the effectiveness of treatment decreasing over time. Treatment is more likely to occur at Primary Stroke Centers (PSC); thus rapid access to acute stroke care through stand-alone PSCs or telemedicine (TM) is vital for all Americans. The objective of this study is to determine if disparities exist in access to PSCs or the extended access to acute stroke care provided by TM. Methods. Data from the US Census Bureau and the 2010 Neilson Claritas Demographic Estimation Program, American Hospital Association annual survey, and The Joint Commission list of PSCs and survey response data for all hospitals in the state of Texas were used. Results. Over 64% of block groups had 60-minute ground access to acute stroke care. The odds of a block group having 60-minute access to acute stroke care decreased with age, despite adjustment for sex, race, ethnicity, socioeconomic status, urbanization, and total population. Conclusion. Our survey of Texas hospitals found that as the median age of a block group increased, the odds of having access to acute stroke care decreased.

New indices for home nursing care resource disparities in rural and urban areas, based on geocoding and geographic distance barriers: a cross-sectional study

BACKGROUND

Aging in place is the crucial object of long-term care policy worldwide. Approximately 15.6-19.4% of people aged 15 or above live with a disability, and 15.3% of them have moderate or severe disabilities. The allocation of home nursing care services is therefore an important issue. Service providers in Taiwan vary substantially across regions, and between rural and urban areas. There are no appropriate indices for describing the capacity of providers that it is due to the distances from care recipients. This study therefore aimed to describe and compare distance barriers for home nursing care providers using indices of the "profit willing distance" and the "tolerance limited distance".

METHODS

This cross-sectional study was conducted during 2012 and 2013 using geocoding and a geographic information system to identify the distance from the providers' locations to participants' homes in urban (Taipei City) and rural (Hualien County) areas in Taiwan. Data were collected in-person by professionals in Taiwanese hospitals using the World Health Organization Disability Assessment Schedule 2.0. The indices were calculated using regression curves, and the first inflection points were determined as the points on the curves where the first and second derivatives equaled 0.

RESULTS

There were 5627 participants from urban areas and 956 from rural areas. In urban areas, the profit willing distance was 550-600 m, and we were unable to identify them in rural areas. This demonstrates that providers may need to supply services even when there is little profit. The tolerance limited distance were 1600-1650 m in urban areas and 1950-2000 m in rural areas. In rural areas, 33.3% of those living inside the tolerance limited distance and there was no provider within this distance, but this figure fell to just 13.9% in urban areas. There were strong disparities between urban and rural areas in home nursing care resource allocation.

CONCLUSIONS

Our new "profit willing distance" and the "tolerance limited distance" are considered to be clearer and more equitable than other evaluation indices. They have practical application in considering resource distribution issues around the world, and in particular the rural-urban disparities for public resource.

Bridging barriers to health promotion: a feasibility pilot study of the 'Promoting Aging Migrants' Capabilities study'

RATIONALE, AIMS AND OBJECTIVES

Improving the possibilities for ageing persons to take control over their health is an increasingly important public health issue. Health promotion has previously been visualized to succeed with this goal, but research has primarily focused on ageing persons who are native-born, leaving the generalizability to persons who are foreign-born unexplored. Therefore, as part of the development of a larger health promotion initiative for ageing persons who have experienced migration, this study aimed to assess the feasibility of an adapted protocol. The specific feasibility objectives were to assess recruitment procedure, retention rates, study questionnaire administration and variability of collected data.

METHOD

Forty persons who were ≥70 years, and who had migrated from Finland, Bosnia and Herzegovina, Croatia, Montenegro or Serbia to Sweden were randomly allocated to a health promotion programme or a control group. The programme was linguistically adapted with regard to translated information material, bilingual health professionals and evaluators, and a person-centred approach was applied to both programme development and provision. The data analysis was explorative and descriptive.

RESULTS

The results visualized structural and linguistic barriers to recruitment and study questionnaire administration, and describe strategies for how to bridge them. Retention rates and data variability were satisfying.

CONCLUSIONS

Calling for iterative and pragmatic programme design, the findings describe how to move towards a more inclusive health care environment. Person-centred and bilingual approaches with attention to the possibilities for building authentic relationships between participants and providers are emphasized, and a structured methodology for developing study questionnaires is suggested.

CircleRides: developing an older adult transportation application and evaluating feedback

The purpose of the current study was to assess perceptions of CircleRides, a paper prototype of a service website designed to meet older adult transportation needs. Researchers used purposive sampling to conduct two focus groups comprised of older adults to obtain feedback on the CircleRides prototype at the beginning of its iterative design process. One focus group was conducted in a continuing care retirement community (n = 13) and the other in an independent living community for older adults (n = 11). The study assessed perceptions of the CircleRides prototype as well as self-reported older adult transportation preferences and needs. Three themes emerged from the data: (a) trust and concern, (b) socialization, and (c) flexibility and options. Researchers found that participants are interested in transportation options; however, concern exists about trusting a new system or prototype that has not established a reputation. Findings from the current study offer lessons learned for future iterations and for creating transportation prototypes for older adults.

Burden of undetected and untreated glaucoma in the United States

PURPOSE

To determine the burden of undetected and untreated glaucoma in the noninstitutionalized population over the age of 40 years in the United States of America (US).

DESIGN

Cross-sectional study.

METHODS

setting: US civilian, noninstitutionalized population from the 2005-2006 and 2007-2008 administrations of the National Health and Nutrition Examination Survey that were 40 years old or older with completed retinal photographs, completed interview question regarding prior diagnosis of glaucoma, and a negative response to questions regarding comorbidities. main outcome measures: Prevalence of self-reported glaucoma history; signs of glaucoma damage seen in retinal photographs and perimetry; prevalence of undiagnosed glaucoma; and comparison of demographic factors using odds ratios to identify populations with highest burden of previously undiagnosed glaucoma.

RESULTS

The study population included 3850 participants who met the inclusion criteria. The 99.5th percentile of the vertical cup-to-disc ratio was 0.67 and the 99.5th percentile of the vertical cup-to-disc ratio asymmetry between eyes was 0.26. Prevalence of undiagnosed glaucoma was 2.9%, increasing with age to 6.6% of the population over 70 years old. Among those with glaucoma, 78% were previously undiagnosed and untreated. Blacks have roughly 4.4 times (95% confidence interval [CI]: 2.9-6.7; P < .0001) and Hispanics have roughly 2.5 times (95%CI: 1.5-4.3; P = .0012) greater odds of having undiagnosed and untreated glaucoma than non-Hispanic whites.

CONCLUSIONS

Approximately 2.4 million persons in the US have undetected and untreated glaucoma. Overall, prevalence of both diagnosed and undiagnosed glaucoma is much higher in minorities and the elderly. Among those with definite glaucoma, individuals younger than 60 years of age have a greater proportion of undetected disease.

Disparities in access to care among US adults with self-reported hypertension

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease. Access to care has been identified as a significant factor affecting hypertension treatment and control. We examined disparities in access to care among US adults with self-reported hypertension.

METHODS

Using Behavioral Risk Factor Surveillance System 2011 data, we identified US adults with self-reported hypertension. Access to care was assessed based on responses to questions about health insurance, having an identified personal doctor, and cost barriers to visiting a doctor. We assessed access to care by geographic location (ie, US state) and selected sociodemographic characteristics.

RESULTS

Overall, 159,947 eligible participants reported having hypertension. Among them, 19.1% had no health insurance, 18.1% had no personal doctor, and 23.6% could not visit a doctor because of cost. Among those with hypertension by state, age-standardized prevalence of no health insurance ranged from 6.3% in Hawaii to 28.1% in Texas. The prevalence of those without a personal doctor ranged from 9.2% in Massachusetts to 32.7% in Nevada, and the prevalence of cost barrier to visiting a doctor ranged from 10.8% in North Dakota to 35.1% in Tennessee. By sociodemographic characteristics, the prevalence with no health insurance was highest among those aged 18-44 years (25.9%), Hispanics (28.1%), those with less than a high school education (32.8%), and those with a household income of less than $25,000 (31.6%). Similar disparity patterns were noted for estimates of the other access-to-care variables.

CONCLUSIONS

Among US hypertensive adults, approximately 20% reported access-to-care challenges, with significant geographic and sociodemographic variations.

Negative feelings and help seeking among older adults with chronic conditions

Older adults with chronic conditions are at greater risk of negative affect, though few studies have focused on older adults' perspectives on how chronic conditions affect their mental well-being. This study involved in-depth interviews that explored how older adults describe their feelings about chronic conditions, the context within which they experience these feelings, and their experiences with help-seeking for negative feelings. Participants reported that older adults experience a range of negative feelings related to their conditions and are only comfortable talking to people who understand their everyday experiences with managing chronic conditions. The findings have implications for health self-management.

Geriatric outcomes for trauma patients in the state of Florida after the advent of a large trauma network

BACKGROUND

Florida State has one of the largest geriatric populations in the United States. However, recent data show that up to the year 2010, geriatric trauma patients were least served by designated trauma centers (TCs). One existing TC and five provisional Level 2 TCs were combined to create a large-scale trauma network (TN). The new TCs were placed in those areas with the lowest ratios of TC to residents based on census data. The aim of this study was to measure the TN impact on the population of geriatric trauma patients.

METHODS

Data from the Florida State Agency for Health Care Administration were used to determine mortality, length of stay, and complication rates for geriatric trauma patients (≥ 65 years). The potential effect of the TN was measured by comparing outcomes before and after the initiation of the TN. A total of 165,640 geriatric patients were evaluated. Multivariate regression methods were used to match and adjust for age, injury status (penetrating vs. nonpenetrating), sex, race, comorbidity, and injury severity (DRG International Classification of Diseases-9th Rev. Injury Severity Score).

RESULTS

Since the advent of the TN, an additional 1,711 geriatric patients were treated compared with the previous period. The TN was responsible 86% of these new patients. There was a temporal association with a decrease in both mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) and length of stay (p < 0.0001) for geriatric patients since the advent of the TN. The improved access was associated with a significant decrease in mortality in the regions serviced by the TN.

CONCLUSION

Geriatric patients make up a significant proportion of trauma patients within the TN. The temporal improvement in outcomes may be associated with the increased proportion of patients being treated in state-designated TCs as a result of the addition of the TN.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Geographic variations in access and utilization of cancer screening services: examining disparities among American Indian and Alaska Native Elders

Background

Despite recommendations for cancer screening for breast and colorectal cancer among the Medicare population, preventive screenings rates are often lower among vulnerable populations such as the small but rapidly growing older American Indian and Alaska Native (AIAN) population. This study seeks to identify potential disparities in the availability of screening services, distance to care, and the utilization of cancer screening services for Medicare beneficiaries residing in areas with a higher concentration of AIAN populations.

Methods

Using the county (n =3,225) as the level of analysis, we conducted a cross-sectional analysis of RTI International’s Spatial Impact Factor Data (2012) to determine the level of disparities for AIAN individuals. The outcomes of interest include: the presence of health care facilities in the county, the average distance in miles to the closest provider of mammography and colonoscopy (analyzed separately) and utilization of screening services (percent of adults aged 65 and older screened by county).

Results

Counties with higher concentrations of AIAN individuals had greater disparities in access and utilization of cancer screening services. Even after adjusting for income, education, state of residence, population 65 and older and rurality, areas with higher levels of AIAN individuals were more likely to see disparities with regard to health care services related to mammograms (p ≤ .05; longer distance, lower screening) and colonoscopies (p ≤ .05; longer distance, lower screening).

Conclusions

These findings provide evidence of a gap in service availability, utilization and access facing areas with higher levels of AIAN individuals throughout the US. Without adequate resources in place, these areas will continue to have less access to services and poorer health which will be accelerated as the population of older adults grows.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

Missed or Delayed Medical Care Appointments by Older Users of Nonemergency Medical Transportation

PURPOSE OF THE STUDY

This study identified factors associated with canceling nonemergency medical transportation appointments among older adult Medicaid patients.

DESIGN AND METHODS

Data from 125,913 trips for 2,913 Delaware clients were examined. Mediation analyses, as well as, multivariate logistic regressions were conducted.

RESULTS

Over half of canceled trips were attributed to client reasons (e.g., no show, refusal). Client characteristics (e.g., race, sex, functional status) were associated with cancelations; however, these differed based on the cancelation reason. Regularly scheduled trips were less likely to be canceled.

IMPLICATIONS

The evolving American health care system may increase service availability. Additional policies can improve service accessibility and overcome utilization barriers.

Geographic residency status and census tract socioeconomic status as determinants of colorectal cancer outcomes

OBJECTIVES

We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.

METHODS

This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.

RESULTS

For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).

CONCLUSIONS

Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.

Sociodemographic Correlates of Choice of Health Care Services in Six Rural Communities in North Central Nigeria

Household expenditure on health has increasingly remained a major source of health care financing in Nigeria despite the introduction of several social health scheme policies provided by the government for meeting the health care costs of patients. Recognizing these limitations, this study assessed the type of health care services people commonly use in various illnesses and the sociodemographic correlates of the preferred health care services by household heads in six rural communities of North Central Nigeria. A cross-sectional community-based descriptive study design was used to study 154 household heads in the settlements using a multistage sampling method. Multiple logistic regressions were performed to investigate independent predictors that had significant chi-square atP<0.05. The leading causes of illness experienced by respondents were medical conditions (42.0%) and 41.7% of them sought treatment from patent medicine vendors. The dominant reasons for health-seeking preferences were financial access (53.7%) and proximity (48.6%). Age had a higher impact (Beta = 0.892) on the health-seeking preferences of the respondents as compared to their occupation and religion (Beta = 0.368 and −0.746, resp.). Therefore, in order to meet the health care of patients, it is pertinent that the unmet needs of patients are properly addressed by appropriate agencies.

Defining a comprehensive verotype using electronic health records for personalized medicine

The burgeoning adoption of electronic health records (EHR) introduces a golden opportunity for studying individual manifestations of myriad diseases, which is called 'EHR phenotyping'. In this paper, we break down this concept by: relating it to phenotype definitions from Johannsen; comparing it to cohort identification and disease subtyping; introducing a new concept called 'verotype' (Latin: vere = true, actually) to represent the 'true' population of similar patients for treatment purposes through the integration of genotype, phenotype, and disease subtype (eg, specific glucose value pattern in patients with diabetes) information; analyzing the value of the 'verotype' concept for personalized medicine; and outlining the potential for using network-based approaches to reverse engineer clinical disease subtypes.