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Obikane E, Nishi D, Ozaki A, Shinozaki T, Kawakami N, Tabuchi T. Association between Poverty and Refraining from Seeking Medical Care during the COVID-19 Pandemic in Japan: A Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2682. [PMID: 36768046 PMCID: PMC9915459 DOI: 10.3390/ijerph20032682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
This limited study examined how low household income affected avoidant behaviors to seek medical care during the pandemic. We investigated an association between household income below the relative poverty line and refraining from seeking medical care (RSMC) in a longitudinal study during the COVID-19 pandemic. We conducted an analysis of a population-based internet cohort in Japan. Individuals aged 20 to 79 years old living in Japan participated in the internet surveys between 2020 and 2021. The primary outcome was the RSMC of regular visits and new symptoms in 2021. A total of 19,672 individuals were included in the analysis. Household income below the relative poverty line in 2020 was significantly associated with refraining from seeking regular medical visits for men and women (for men, odds ratio: 1.28; confidence interval: 1.19, 1.83; for women, odds ratio: 1.42; confidence interval: 1.14, 1.82) in 2021, after accounting for RSMC in 2020. Relative poverty in 2020 was also associated with the RSMC of new symptoms among men (for males, odds ratio: 1.32; confidence interval: 1.05, 1.66) in 2021 after adjusting for covariates. The study suggested the need to alleviate the financial burden of vulnerable people seeking medical care and advocate for making necessary medical visits, even in a pandemic.
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Affiliation(s)
- Erika Obikane
- Department of Social Medicine, National Center for Child Health and Development, Tokyo 157-0074, Japan
- Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Daisuke Nishi
- Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
- Department of Public Mental Health Research, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
| | - Akihiko Ozaki
- Department of Breast and Thyroid Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki 972-8322, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo 162-8601, Japan
| | - Norito Kawakami
- Department of Digital Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Takahiro Tabuchi
- Department of Cancer Control Center, Osaka International Cancer Institute, Osaka 541-8567, Japan
- The Tokyo Foundation for Policy Research, Tokyo 106-6234, Japan
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Zhao J, Zheng Z, Nogueira L, Yabroff KR, Han X. Preexisting Condition Protections Under the Affordable Care Act: Changes in Insurance Coverage, Premium Contributions, and Out-of-Pocket Spending. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1360-1370. [PMID: 35304035 DOI: 10.1016/j.jval.2022.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 12/01/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES In January 2014, the Affordable Care Act (ACA) preexisting condition protections prohibited coverage denials, premium increases, and claim denials on the basis of preexisting conditions. This study aimed to examine changes in coverage and premiums and out-of-pocket spending after the implementation of the preexisting condition protections under the ACA. METHODS We identified adults aged 18 to 64 years with (n = 59 041) and without preexisting conditions (n = 61 970) from the 2011-2013 and 2015-2017 Medical Expenditure Panel Survey. We used a difference-in-differences and a difference-in-difference-in-differences approach to assess the associations of preexisting condition protections and changes in insurance coverage, premium contributions, and out-of-pocket spending after the ACA. Simple and multivariable logistic or multivariable 2-part models were fitted for the full sample and stratified by family income (low ≤138% federal poverty level [FPL]; middle 139%-400% FPL; and high > 400 FPL). RESULTS The ACA increased nongroup insurance coverage to a similar extent for individuals with or without preexisting conditions at all income levels. Decreases in premium contributions were observed to a similar extent among families with nongroup private coverage regardless of declinable preexisting condition status, whereas no significant changes were observed among families with group coverage. We found greater decreases in out-of-pocket spending for individuals with preexisting conditions than those without conditions among both individuals covered by nongroup and group insurance, and a greater difference was observed among those covered by nongroup insurance (difference-in-difference-in-differences -$279; 95% confidence interval -$528 to -$29). CONCLUSIONS The ACA protections were associated with decreases in out-of-pocket spending among adults with preexisting conditions.
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Affiliation(s)
- Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA.
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
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Nguyen OT, Watson AK, Motwani K, Warpinski C, McDilda K, Leon C, Khanna N, Nall RW, Turner K. Patient-Level Factors Associated with Utilization of Telemedicine Services from a Free Clinic During COVID-19. Telemed J E Health 2021; 28:526-534. [PMID: 34255572 DOI: 10.1089/tmj.2021.0102] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Disparities in telemedicine use by race, age, and income have been consistently documented. To date, research has focused on telemedicine use among patients with adequate insurance coverage. To address this gap, this study identifies patient-level factors associated with telemedicine use during the coronavirus (COVID-19) pandemic among one free clinic network's patients who are underinsured or uninsured. Materials and Methods: Electronic health record data were reviewed for patient-level data on patients seen from March 2020 to September 2020. Patients were grouped by telemedicine use history. We controlled for sociodemographic factors (e.g., age, race/ethnicity) and comorbidities. Logistic regression analyses were conducted. Results: Across 198 adult patients, 56.6% received telemedicine care. Of these, 99.1% elected for audio-only telemedicine instead of video telemedicine. Telemedicine use was more likely among those living within 15 miles of their clinic (adjusted odds ratio [aOR] = 4.43, 95% confidence interval [CI] 1.70-11.53). It was less likely to be used by older patients (aOR = 0.97, 95% CI 0.94-1.00), patients of male sex (aOR = 0.85, 95% CI 0.18-0.92), and those establishing care as a new patient (aOR = 0.01, 95% CI 0.00-0.07). Conclusion: The moderate usage of telemedicine suggests that its implementation in free clinics may be feasible. Solutions specific to patients with smartphone-only internet access are needed to improve the use of video telemedicine as smartphone-specific factors (e.g., data use limits) may influence the ability for underserved patients to receive video telemedicine.
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Affiliation(s)
- Oliver T Nguyen
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Amelia K Watson
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kartik Motwani
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Chloe Warpinski
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA
| | - Katelin McDilda
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Carlos Leon
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,Department of Psychology, University of Florida, Gainesville, Florida, USA
| | - Neel Khanna
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Ryan W Nall
- Department of Community Health and Family Medicine and University of Florida, Gainesville, Florida, USA.,Division of General Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Oncological Sciences, University of South Florida, Tampa, Florida, USA
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Kane T, Flood C, Oluwato T, Pan Q, Zilbermint M. Expanding legal treatment options for medical marijuana in the State of Louisiana. J Community Hosp Intern Med Perspect 2021; 11:343-349. [PMID: 34234903 PMCID: PMC8118431 DOI: 10.1080/20009666.2021.1890339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The use of cannabis for ‘medical’ purposes has expanded throughout the USA. Despite the limited peer-reviewed medical research, medical marijuana therapy has been to treat chronic pain, stimulate appetite, treat nausea, and ameliorate muscle spasticity. Challenge: In the state of Louisiana, this potential treatment is strictly controlled. The ability of the individual patient to receive this therapy is limited since any prescribing provider had to be both licensed by the state medical board and registered with the board to prescribe medical marijuana. Medical cannabis could be used only for limited medical disorders. The ‘Medical Marijuana’ HB819 bill authorizes the recommendation of medical marijuana for additional conditions and allows any state-licensed physician to recommend/prescribe medical marijuana. Alternative options: The government may consider working with the state medical board to lessen its regulation allowing a collaborative effort to formalize protocols for safe prescribing of medical marijuana. A more liberal option would be to make it available to the consumer over the counter, while a state tracking mechanism is set in place to limit the amount purchased. Conclusions: Two stakeholders pertaining to this new legislation to focus on are the Louisiana State government and healthcare providers. This law probably has the biggest impact on healthcare providers and their relationship to patients. This legislation may allow providers to have more ‘freedom in medical marijuana treatment plans’. These benefits would be monitored using such criteria as cost, access to care, as well as patient and healthcare provider satisfaction.
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Affiliation(s)
- Theresa Kane
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA
| | - Christopher Flood
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Department of Quality, Suburban Hospital, Johns Hopkins Medicine, Bethesda, USA
| | - Tobi Oluwato
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Department of Quality, Suburban Hospital, Johns Hopkins Medicine, Bethesda, USA.,Department of OB Hospitalists, Sutter East Bay Medical Group, Berkeley, CA, USA
| | - Qinshi Pan
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, MD, USA.,Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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5
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Kenney A, Cox N, Bryan MA, Cochran G. Brief intervention medication therapy management: Establishment of an opioid misuse intervention model delivered in a community pharmacy. Am J Health Syst Pharm 2021; 78:310-319. [PMID: 33386733 PMCID: PMC7868881 DOI: 10.1093/ajhp/zxaa389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Medication expertise and close patient contact position community pharmacists to make significant contributions to combatting the opioid epidemic. This position facilitated the development and initial implementation of the Brief Intervention Medication Therapy Management (BIMTM) model to detect and address patient opioid misuse. BIMTM is an intervention consisting of 9 sessions. One medication management session is delivered by a pharmacist in a community pharmacy setting, and the remaining sessions are delivered telephonically by a patient navigator to follow up with goals established with the pharmacist and address concomitant health concerns that increase risk for misuse. METHODS We employed the Consolidated Framework for Implementation Research (CFIR) to summarize and present key findings from 4 distinct studies. CFIR domains addressed were (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) process, and (5) characteristics of individuals. The study results show sequential development of evidence for BIMTM. RESULTS A multistate cross-sectional pharmacist survey (n = 739) demonstrated limited pharmacist training and/or resources to address misuse, suggesting the need for external intervention development. Our multistakeholder intervention planning project showed limitations of current evidence-based models of care and of intervention implementation, which resulted in construction of the BIMTM. A multisite cross-sectional screening survey of patients (n = 333) established an electronic misuse screening protocol within 4 community pharmacies and identified opioid misuse in 15% of screened patients; among those patients, 98% had concomitant health conditions that contribute to the risk of opioid misuse. Presentation of study results to pharmacy leaders produced commitment for intervention implementation and a partnership to develop a grant proposal supporting this action. Our small-scale randomized trial evinced success in recruitment and retention and BIMTM patient benefit. The small-scale randomized trial likewise showed high levels of satisfaction with BIMTM. CONCLUSION The establishment of BIMTM supports community pharmacist identification and intervention with patients engaged in misuse. Continued use of this research-based strategy may further empower pharmacists to address the opioid epidemic.
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Affiliation(s)
- Amy Kenney
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nicholas Cox
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - M Aryana Bryan
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Gerald Cochran
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Barriers to Care Affecting Presentation to Urogynecologists in a Community Setting. Female Pelvic Med Reconstr Surg 2021; 27:e368-e371. [PMID: 33105343 DOI: 10.1097/spv.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings. METHODS Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care. RESULTS One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01). CONCLUSION This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care.
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7
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Implementation of the Affordable Care Act: A Comparison of Outcomes in Patients With Severe Sepsis and Septic Shock Using the National Inpatient Sample*. Crit Care Med 2020; 48:783-789. [DOI: 10.1097/ccm.0000000000004310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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8
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Choi W. Older adults' health information behavior in everyday life settings. LIBRARY & INFORMATION SCIENCE RESEARCH 2019. [DOI: 10.1016/j.lisr.2019.100983] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Self-Identified Social Determinants of Health during Transitions of Care in the Medically Underserved: a Narrative Review. J Gen Intern Med 2018; 33:1959-1967. [PMID: 30128789 PMCID: PMC6206338 DOI: 10.1007/s11606-018-4615-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/15/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Medically underserved or low socioeconomic status (SES) patients face significant vulnerability and a high risk of adverse events following hospital discharge. The environmental, social, and economic factors, otherwise known as social determinants, that compound this risk have been ineffectually described in this population. As the underserved comprise 30% of patients discharged from the hospital, improving transitional care and preventing readmission in this group has profound quality of care and financial implications. METHOD EMBASE and MEDLINE searches were conducted to examine specific barriers to care transitions in underserved patients following an episode of acute care. Articles were reviewed for barriers and categorized within the context of five general themes. RESULTS This review yielded 17 peer-reviewed articles. Common factors affecting care transitions were cost of medications, access to care, housing instability, and transportation. When categorized within themes, social fragility and access failures, as well as therapeutic misalignment, disease behavior, and issues with accountability were noted. DISCUSSION Providers and health systems caring for medically underserved patients may benefit through dedicating increased resources and broadening collaboration with community partners in order to expand health care access and enhance coordination of social services within this population. Future studies are needed to identify potential interventions targeting underserved patients to improve their post-hospital care.
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10
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The relationship between health services standardized costs and mortality is non-linear: Results from a large HMO population. Health Policy 2017; 121:1008-1014. [PMID: 28751033 DOI: 10.1016/j.healthpol.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 11/22/2022]
Abstract
Older age, male gender, and poor socioeconomic status have been found to predict mortality. Studies have also documented an elevation in health services standardized costs (HSSC) and expenditures in the last years of life. We examined the contribution of HSSC in the last years of life in predicting mortality beyond predictors that have been established in the literature, and whether the impact of HSSC on mortality is linear. Vulnerability, operationalized as being exempt from co-payments due to poverty, being a holocaust survivor, or other reasons, was examined as potentially mediating the relationship between HSSC and mortality. We used longitudinal data obtained from the largest Health Maintenance Organization in Israel. Subjects were insured persons who were over age 65 in 2006 (n=423,140). Predictors included demographics, co-morbidity, and HSSC. All factors significantly predicted time to death. For HSSC, high levels displayed the highest Hazard Ratios (HR), with medium levels having the lowest HRs. The higher mortality rate in the low HSSC group might indicate a risk of underutilizing health services. Vulnerable status remained a predictor of mortality even within a system of universal access to healthcare. There is a need for establishing mechanisms to identify those underutilizing health services. A universal health care system is insufficient for providing equal health care, indicating a need for additional means to increase equality.
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Vina ER, Ran D, Ashbeck EL, Kaur M, Kwoh CK. Relationship Between Knee Pain and Patient Preferences for Joint Replacement: Health Care Access Matters. Arthritis Care Res (Hoboken) 2017; 69:95-103. [PMID: 27636123 DOI: 10.1002/acr.23084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To determine if severity of osteoarthritis-related knee pain is associated with a willingness to undergo total knee replacement (TKR) and whether this association is confounded or modified by components of socioeconomic status and health care coverage. METHODS Cross-sectional analysis was conducted among 3,530 Osteoarthritis Initiative study participants. Logistic regression models were used to assess the effect of knee pain severity (where 0 = none, 1-3 = mild, 4-7 = moderate, and 8-10 = severe) on willingness to undergo TKR. Stratified analyses were conducted to evaluate whether socioeconomic status and health care coverage modify the effect of knee pain severity on willingness. RESULTS Participants with severe knee pain, compared to participants without pain, were less willing to undergo TKR (odds ratio [OR] 0.73, 95% confidence interval [95% CI] 0.57-0.93). This association was attenuated when adjusted for age, sex, comorbidity, depression, health insurance coverage, prescription medicine coverage, health care source, education, income, employment, race, and marital status (adjusted OR 0.92, 95% CI 0.68-1.24). The odds of willingness to undergo TKR were significantly lower in those with the highest level of pain, compared to those without pain, among participants without health insurance (adjusted OR 0.08, 95% CI 0.01-0.56), but not among those with health insurance (adjusted OR 1.03, 95% CI 0.73-1.38), when adjusted for demographic, clinical, health care access, and socioeconomic factors (P = 0.015). However, <5% of participants were without health insurance. CONCLUSION Among participants without health insurance, severe knee pain was paradoxically associated with less willingness to undergo TKR. Policies that improve access to quality health care may affect patient preferences and increase utilization of TKR surgery among vulnerable populations.
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Affiliation(s)
| | - Di Ran
- University of Arizona, Tucson
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Stecker EC, Reinier K, Rusinaru C, Uy-Evanado A, Jui J, Chugh SS. Health Insurance Expansion and Incidence of Out-of-Hospital Cardiac Arrest: A Pilot Study in a US Metropolitan Community. J Am Heart Assoc 2017; 6:JAHA.117.005667. [PMID: 28659263 PMCID: PMC5586291 DOI: 10.1161/jaha.117.005667] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health insurance has many benefits including improved financial security, greater access to preventive care, and better self-perceived health. However, the influence of health insurance on major health outcomes is unclear. Sudden cardiac arrest prevention represents one of the major potential benefits from health insurance, given the large impact of sudden cardiac arrest on premature death and its potential sensitivity to preventive care. METHODS AND RESULTS We conducted a pre-post study with control group examining out-of-hospital cardiac arrest (OHCA) among adult residents of Multnomah County, Oregon (2015 adult population 636 000). Two time periods surrounding implementation of the Affordable Care Act were evaluated: 2011-2012 ("pre-expansion") and 2014-2015 ("postexpansion"). The change in OHCA incidence for the middle-aged population (45-64 years old) exposed to insurance expansion was compared with the elderly population (age ≥65 years old) with constant near-universal coverage. Rates of OHCA among middle-aged individuals decreased from 102 per 100 000 (95% CI: 92-113 per 100 000) to 85 per 100 000 (95% CI: 76-94 per 100 000), P value 0.01. The elderly population experienced no change in OHCA incidence, with rates of 275 per 100 000 (95% CI: 250-300 per 100 000) and 269 per 100 000 (95% CI: 245-292 per 100 000), P value 0.70. CONCLUSIONS Health insurance expansion was associated with a significant reduction in OHCA incidence. Based on this pilot study, further investigation in larger populations is warranted and feasible.
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Affiliation(s)
- Eric C Stecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | | | - Carmen Rusinaru
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Jon Jui
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Sumeet S Chugh
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Affiliation(s)
- Richard L Kravitz
- Division of General Medicine, University of California Davis, Sacramento, CA, USA.
| | - Mitchell D Feldman
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
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14
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Megwalu UC. Impact of County-Level Socioeconomic Status on Oropharyngeal Cancer Survival in the United States. Otolaryngol Head Neck Surg 2017; 156:665-670. [PMID: 28195022 DOI: 10.1177/0194599817691462] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective To evaluate the impact of county-level socioeconomic status on survival in patients with oropharyngeal cancer in the United States. Study Design Retrospective cohort study via a large population-based cancer database. Methods Data were extracted from the SEER 18 database (Surveillance, Epidemiology, and End Results) of the National Cancer Institute. The study cohort included 18,791 patients diagnosed with oropharyngeal squamous cell carcinoma between 2004 and 2012. Results Patients residing in counties with a low socioeconomic status index had worse overall survival (56.5% vs 63.0%, P < .001) and disease-specific survival (62.7% vs 70.3%, P < .001) than patients residing in counties with a high socioeconomic status index. On multivariable analysis, residing in a county with a low socioeconomic status index was associated with worse overall survival (hazard ratio, 1.21; 95% CI, 1.14-1.29; P < .001) and disease-specific survival (hazard ratio, 1.21; 95% CI, 1.12-1.30; P < .001), after adjusting for race, age, sex, marital status, year of diagnosis, site, American Joint Committee on Cancer stage group, presence of distant metastasis, presence of unresectable tumor, histologic grade, surgical resection of primary site, treatment with neck dissection, and radiation therapy. Conclusion Residing in a county with a low socioeconomic status index is associated with worse survival. Further research is needed to elucidate the mechanism by which socioeconomic status affects survival in oropharyngeal cancer.
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Affiliation(s)
- Uchechukwu C Megwalu
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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Kan AWG, Hussain T, Carson KA, Purnell TS, Yeh HC, Albert M, Cooper LA. The Contribution of Age and Weight to Blood Pressure Levels Among Blacks and Whites Receiving Care in Community-Based Primary Care Practices. Prev Chronic Dis 2015; 12:E161. [PMID: 26402051 PMCID: PMC4584478 DOI: 10.5888/pcd12.150069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We examined whether race and age, risk factors for obesity and hypertension, affect the association of obesity with elevated blood pressure (BP). Using electronic medical record data, we conducted a cross-sectional study of adult patients seen at 6 Maryland primary care clinics from September 2011 through June 2012. The risk for higher BP among patients younger than 65 years and in an elevated weight category was greater for both races but was higher for whites than blacks. For patients aged 65 years or older, weight had little impact on systolic BP, suggesting that approaches involving weight loss to address elevated BP should focus on populations younger than 65.
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Affiliation(s)
| | - Tanvir Hussain
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathryn A Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Tanjala S Purnell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hsin-Chieh Yeh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael Albert
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lisa A Cooper
- 2024 E. Monument St, Room 2-515, Baltimore, MD 21287. . Dr Cooper is affiliated with the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, and the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Rivera-Hernandez M, Galarraga O. Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico. J Aging Health 2015; 27:962-82. [PMID: 25804897 PMCID: PMC4720256 DOI: 10.1177/0898264315569457] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico. METHOD Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012. RESULTS After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears. DISCUSSION Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.
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Affiliation(s)
| | - Omar Galarraga
- Department of Health Services, Policy and Practice Brown University, Providence, RI, USA
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Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med 2015; 30:290-7. [PMID: 25387439 PMCID: PMC4351276 DOI: 10.1007/s11606-014-3089-1] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/24/2014] [Accepted: 10/20/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Many studies have examined barriers to health care utilization, with the majority conducted in the context of specific populations and diseases. Less research has focused on why people avoid seeking medical care, even when they suspect they should go. OBJECTIVE The purpose of the study was to present a comprehensive description and conceptual categorization of reasons people avoid medical care. DESIGN Data were collected as part of the 2008 Health Information National Trends Survey, a cross-sectional national survey. PARTICIPANTS Participant-generated reasons for avoiding medical care were provided by 1,369 participants (40% male; M age =48.9; 75.1% non-Hispanic white, 7.4% non-Hispanic black, 8.5% Hispanic or Latino/a). MAIN MEASURES Participants first indicated their level of agreement with three specific reasons for avoiding medical care; these data are reported elsewhere. We report responses to a follow-up question in which participants identified other reasons they avoid seeking medical care. Reasons were coded using a general inductive approach. KEY RESULTS Three main categories of reasons for avoiding medical care were identified. First, over one-third of participants (33.3% of 1,369) reported unfavorable evaluations of seeking medical care, such as factors related to physicians, health care organizations, and affective concerns. Second, a subset of participants reported low perceived need to seek medical care (12.2%), often because they expected their illness or symptoms to improve over time (4.0%). Third, many participants reported traditional barriers to medical care (58.4%), such as high cost (24.1%), no health insurance (8.3%), and time constraints (15.6%). We developed a conceptual model of medical care avoidance based on these results. CONCLUSIONS Reasons for avoiding medical care were nuanced and highly varied. Understanding why people do not make it through the clinic door is critical to extending the reach and effectiveness of patient care, and these data point to new directions for research and strategies to reduce avoidance.
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Impact of Subsidized Health Insurance Coverage on Emergency Department Utilization by Low-income Adults in Massachusetts. Med Care 2015; 53:38-44. [DOI: 10.1097/mlr.0000000000000279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Watanabe JH, Ney JP. Association of increased emergency rooms costs for patients without access to necessary medications. Res Social Adm Pharm 2014; 11:499-506. [PMID: 25487421 DOI: 10.1016/j.sapharm.2014.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 10/15/2014] [Accepted: 10/15/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prescription medications are an important component of chronic disease management. They are vital in preventing unnecessary ER visits. However, few studies have examined the association between patients' self-reported inability to receive necessary medications and emergency room costs. OBJECTIVES The study objectives were to: 1) determine differences in ER costs based on self-reported ability to obtain necessary medications. 2) identify differences in ER costs based on self-reported ability to obtain necessary medications among medication users. The association was also examined by insurance category. METHODS Respondent data from 10 years (2002-2011) of the U.S. Medical Expenditure Panel Survey was analyzed. The models employed estimated the association of respondents reporting being 'unable to receive necessary medications' on ER expenditures. Secondarily, the relationship was assessed by insurance category: private, public, and uninsured. Two-part cost regression models with bootstrapped estimates to produce 95% confidence intervals of cost differences were applied for these analyses. Significance was set at α = 0.05. Analyses were completed using SAS 9.4 (Cary, NC) and Stata 13 (College Station, TX). Estimates were in 2011 US dollars. RESULTS People unable to receive necessary medications experienced increased average annual ER costs of $46.62 with 95% a confidence interval [CI] of 34.76-58.49) compared to patients able to receive necessary medications. By insurance category, respondents unable to receive necessary medications experienced increased ER costs of $104.80 (95% CI: 60.57-149.03), $42.16 (95% CI: 24.65-59.68), and $33.18 (95% CI: 18.54-47.82), for Publically Insured, Privately Insured, and Uninsured, respectively. Findings were similar for those already using medications. CONCLUSIONS Inability to obtain necessary medications is associated with increased emergency room costs. Those with public insurance have a larger increase in ER costs if they are without necessary medications compared to those insured privately or without insurance.
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Affiliation(s)
- Jonathan Hirohiko Watanabe
- University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, La Jolla, CA 92093-0714, USA.
| | - John P Ney
- University of Washington, Comparative Effectiveness, Cost and Outcomes Research Center, Box 359736, PSB Suite 5076, 325 Ninth Ave, Seattle, WA 98104, USA
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Kotagal M, Carle AC, Kessler LG, Flum DR. Limited impact on health and access to care for 19- to 25-year-olds following the Patient Protection and Affordable Care Act. JAMA Pediatr 2014; 168:1023-9. [PMID: 25200181 PMCID: PMC4218866 DOI: 10.1001/jamapediatrics.2014.1208] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Patient Protection and Affordable Care Act (PPACA) allowed young adults to remain on their parents' insurance until 26 years of age. Reports indicate that this has expanded health coverage. OBJECTIVE To evaluate coverage, access to care, and health care use among 19- to 25-year-olds compared with 26- to 34-year-olds following PPACA implementation. DESIGN, SETTING, AND PARTICIPANTS Data from the Behavior Risk Factor Surveillance System and the National Health Interview Survey, which provide nationally representative measures of coverage, access to care, and health care use, were used to conduct the study among participants aged 19 to 25 years (young adults) and 26 to 34 years (adults) in 2009 and 2012. EXPOSURE Self-reported health insurance coverage. MAIN OUTCOMES AND MEASURES Health status, presence of a usual source of care, and ability to afford medications, dental care, or physician visits. RESULTS Health coverage increased between 2009 and 2012 for 19- to 25-year-olds (68.3% to 71.7%). Using a difference-in-differences (DID) approach, after adjustment, the likelihood of having a usual source of care decreased in both groups but more significantly for 26- to 34-year-olds (DID, 2.8%; 95% CI, 0.45 to 5.15). There was no significant change in health status for 19- to 25-year-olds compared with 26- to 34-year-olds (DID, -0.5%; 95% CI, -1.87 to 0.87). There was no significant change for 19- to 25-year-olds compared with 26- to 34-year-olds in the percentage who reported receiving a routine checkup in the past year (DID, 0.3%; 95% CI, -2.25 to 2.85) or in the ability to afford prescription medications (DID, -0.4%; 95% CI, -2.93 to 1.93), dental care (DID, -2.6%; 95% CI, -5.61 to 0.61), or physician visits (DID, -1.7%; 95% CI, -3.66 to 0.26). There was also no change in the percentage who reported receiving a flu shot (DID, 1.9; 95% CI, -1.93 to 4.93). Insured individuals were more likely to report having a usual source of care and a recent routine checkup and were more likely to be able to afford health care than uninsured individuals. CONCLUSIONS AND RELEVANCE Implementation of the PPACA was associated with increased health insurance coverage for 19- to 25-year-olds without significant changes in perceived health care affordability or health status. Although the likelihood of having a usual source of care declined between 2009 and 2012 for all, this decrease was smaller among 19- to 25-year-olds, and younger adults were more likely than 26- to 34-year-olds to have a usual source of care.
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Affiliation(s)
- Meera Kotagal
- Department of Surgery, University of Washington, Seattle2Surgical Outcomes Research Center, University of Washington, Seattle3Centers for Comparative Health Systems Effectiveness Alliance, University of Washington, Seattle
| | - Adam C. Carle
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio5Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Larry G. Kessler
- Centers for Comparative Health Systems Effectiveness Alliance, University of Washington, Seattle6Department of Health Services, University of Washington, Seattle
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle2Surgical Outcomes Research Center, University of Washington, Seattle3Centers for Comparative Health Systems Effectiveness Alliance, University of Washington, Seattle
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Alang SM, McAlpine DD, Henning-Smith CE. Disability, Health Insurance and Psychological Distress among US Adults: An Application of the Stress Process. SOCIETY AND MENTAL HEALTH 2014; 4:164-178. [PMID: 25767740 PMCID: PMC4352711 DOI: 10.1177/2156869314532376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Structural resources, including access to health insurance, are understudied in relation to the stress process. Disability increases the likelihood of mental health problems, but health insurance may moderate this relationship. We explore health insurance coverage as a moderator of the relationship between disability and psychological distress. A pooled sample from 2008-2010 (N=57,958) was obtained from the Integrated Health Interview Series. Chow tests were performed to assess insurance group differences in the association between disability and distress. Results indicated higher levels of distress associated with disability among uninsured adults compared to their peers with public or private insurance. The strength of the relationship between disability and distress was weaker for persons with public compared to private insurance. As the Affordable Care Act is implemented, decision-makers should be aware of the potential for insurance coverage, especially public, to ameliorate secondary conditions such as psychological distress among persons who report a physical disability.
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Affiliation(s)
- Sirry M. Alang
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Donna D. McAlpine
- Division of Health Policy and Management, University of Minnesota School of Public Health
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Misky GJ, Carlson T, Thompson E, Trujillo T, Nordenholz K. Implementation of an acute venous thromboembolism clinical pathway reduces healthcare utilization and mitigates health disparities. J Hosp Med 2014; 9:430-5. [PMID: 24639293 DOI: 10.1002/jhm.2186] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/24/2014] [Accepted: 02/28/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute venous thromboembolism (VTE) is prevalent, expensive, and deadly. Published data at our institution identified significant VTE care variation based on payer source. We developed a VTE clinical pathway to standardize care, decrease hospital utilization, provide education, and mitigate disparities. METHODS Target population for our interdisciplinary pathway was acute medical VTE patients. The intervention included order sets, system-wide education, follow-up phone calls, and coordinated posthospital care. Study data (n = 241) were compared to historical data (n = 234), evaluating outcomes of hospital admission, length of stay (LOS), and reutilization, stratified by payer source. RESULTS A total of 241 patients entered the VTE clinical care pathway: 107 with deep venous thrombosis (44.4%) and 134 with a pulmonary embolism (55.6%). Within the pathway, uninsured VTE patients were admitted at a lower rate than insured patients (65.9 vs 79.1%; P = 0.032). LOS decreased from 4.4 to 3.1 days (P < 0.001) for admitted VTE patients and from 5.9 to 3.1 days among uninsured patients (P = 0.0006). Overall, 30-day emergency department recidivism remained 11%, but declined (17.9% to 13.6%) among uninsured patients (P = 0.593). Fewer pathway patients (5.8%) were readmitted compared to historical patients (9.4%, P = 0.254). Individual cost of care decreased from $7610 to $5295 (P < 0.005) for any VTE patient, and from $9953 to $4304 (P = 0.001) per uninsured patient. CONCLUSIONS Implementing an interdisciplinary, clinical pathway standardized care for VTE patients and dramatically reduced hospital utilization and cost, particularly among uninsured patients. Results of this novel study demonstrate a model for improving transitional care coordination with local community health clinics and delivering care to vulnerable populations. Other disease populations may benefit from the development of a similar model.
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Affiliation(s)
- Gregory J Misky
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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The association of lacking insurance with outcomes of severe sepsis: retrospective analysis of an administrative database*. Crit Care Med 2014; 42:583-91. [PMID: 24152590 DOI: 10.1097/01.ccm.0000435667.15070.9c] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Patients with severe sepsis have high mortality that is improved by timely, often expensive, treatments. Patients without insurance are more likely to delay seeking care; they may also receive less intense care. DESIGN We performed a retrospective analysis of administrative database-Healthcare Costs and Utilization Project's Nationwide Inpatient Sample-to test whether mortality is more likely among uninsured patients hospitalized for severe sepsis. PATIENTS None. INTERVENTIONS We used International Classification of Diseases-9th Revision, Clinical Modification, codes indicating sepsis and organ system failure to identify hospitalizations for severe sepsis among patients aged 18-64 between 2000 and 2008. We excluded patients with end-stage renal disease or solid organ transplants because very few are uninsured. We performed multivariate logistic regression modeling to examine the association of insurance status and in-hospital mortality, adjusted for patient and hospital characteristics. We performed subgroup analysis to examine whether the impact of insurance status varied by geographical region; by patient age, sex, or race; or by hospital characteristics such as teaching status, size, or ownership. We used similar methods to examine the impact of insurance status on the use of certain procedures, length of stay, and discharge destination. MEASUREMENTS AND MAIN RESULTS There were 1,600,269 discharges with severe sepsis from 2000 through 2008 in the age group 18-64 years. Uninsured people, who accounted for 7.5% of admissions with severe sepsis, had higher adjusted odds of mortality (odds ratio, 1.43; 95% CI, 1.37-1.47) than privately insured people. The higher mortality in uninsured was present in all subgroups and was similar in each year from 2000 to 2008. After adjustment, uninsured individuals had a slightly shorter length of stay than insured people and were less likely to receive five of the six interventions we examined. They were also less likely to be discharged to skilled nursing facilities or with home healthcare after discharge. CONCLUSIONS Uninsured are more likely to die following admission for severe sepsis than patients with insurance, even after adjusting for potential confounders. This was not due to a hospital effect or demographic or clinical factors available in our administrative database. Further research should examine the mechanisms that lead to this association.
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Slack T, Myers CA, Martin CK, Heymsfield SB. The geographic concentration of US adult obesity prevalence and associated social, economic, and environmental factors. Obesity (Silver Spring) 2014; 22:868-74. [PMID: 23630100 DOI: 10.1002/oby.20502] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/17/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This study used spatial statistical methods to test the hypotheses that county-level adult obesity prevalence in the United States is (1) regionally concentrated at significant levels, and (2) linked to local-level factors, after controlling for state-level effects. METHODS Data were obtained from the Centers for Disease Control and Prevention and other secondary sources. The units of analysis were counties. The dependent variable was the age-adjusted percentage of adults who were obese in 2009 (body mass index >30 kg/m2). RESULTS The prevalence of county-level obesity varied from 13.5% to 47.9% with a mean of 30.3%. Obesity prevalence across counties was not spatially random: 15.8% belonged to high-obesity regions and 13.5% belonged to low-obesity regions. Obesity was positively associated with unemployment, outpatient healthcare visits, physical inactivity, female-headed families, black populations, and less education. Obesity was negatively correlated with physician numbers, natural amenities, percent ≥65 years, Hispanic populations, and larger population size. A number of variables were notable for not reaching significance after controlling for other factors, including poverty and food environment measures. CONCLUSIONS The findings demonstrate the importance of local-level factors in explaining geographic variation in obesity prevalence, and thus hold implications for geographically targeted interventions to combat the obesity epidemic.
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Affiliation(s)
- Tim Slack
- Louisiana State University, Baton Rouge, Louisiana, USA
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Ye J, Shim R, Rust G. Health care avoidance among people with serious psychological distress: analyses of 2007 Health Information National Trends Survey. J Health Care Poor Underserved 2014; 23:1620-9. [PMID: 23698676 DOI: 10.1353/hpu.2012.0189] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Using data of 2007 Health Information National Trends Survey, we investigated the association between individuals' psychological distress and their reported avoidance of medical care and assessed whether people with serious psychological distress (SPD) were more likely to report psychosocial barriers to care. After controlling for demographic and health characteristics, individuals with SPD were more likely than those without SPD to report having avoided visiting a doctor even when they suspected they should (OR=1.64, 95% CI=1.08-2.48). The distressed individuals were also more likely to agree that they avoided a doctor because of fear of having a serious illness (OR=1.99, 95% CI=1.15-3.44) or thinking about dying (OR=2.15, 95% CI=1.12-4.11). Further understanding of the mechanism under which an individuals' mental health status may influence their perceived need for health and their use of medical services would improve the interface between mental health and primary care services.
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Affiliation(s)
- Jiali Ye
- Department of Community Health & Preventive Medicine, Morehouse School of Medicine, 720 Westview Dr., Atlanta, GA 30310, USA.
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de Heer HD, Balcázar HG, Morera OF, Lapeyrouse L, Heyman JM, Salinas J, Zambrana RE. Barriers to care and comorbidities along the U.S.-Mexico border. Public Health Rep 2014; 128:480-8. [PMID: 24179259 DOI: 10.1177/003335491312800607] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities. METHODS We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009-2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions. RESULTS Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥ 2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers. CONCLUSION A substantial proportion of adults reported comorbidities. Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.
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Affiliation(s)
- Hendrik Dirk de Heer
- Northern Arizona University, Department of Physical Therapy and Athletic Training, Flagstaff, AZ
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Independent associations of childhood and current socioeconomic status with risk of self-reported doctor-diagnosed arthritis in a family-medicine cohort of North-Carolinians. BMC Musculoskelet Disord 2013; 14:327. [PMID: 24256740 PMCID: PMC3907039 DOI: 10.1186/1471-2474-14-327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 11/13/2013] [Indexed: 12/31/2022] Open
Abstract
Background Associations of socioeconomic status (SES) with the prevalence of various forms of arthritis are well documented. Increasing evidence suggests that SES during childhood is a lasting determinant of health, but its association with the onset of arthritis remains unclear. Methods Cross-sectional data on 1276 participants originated from 22 family practices in North-Carolina, USA. We created 4-level (high, medium, low, lowest) current SES and childhood SES summary scores based on parental and participant education, occupation and homeownership. We investigated associations of individual SES characteristics, summary scores and SES trajectories (e.g. high/low) with self-reported arthritis in logistic regression models progressively adjusted for race and gender, age, then BMI, and clustered by family practice. Results We found evidence for independent associations of both childhood and current SES with the reporting of arthritis across our models. In covariate-adjusted models simultaneously including current and childhood SES, compared with high SES participants in the lowest childhood SES category (OR = 1.39 [95% CI = 1.04, 1.85]) and those in the low (OR = 1.66 [95% CI = 1.14, 2.42]) and lowest (OR = 2.08 [95% CI = 1.16, 3.74]) categories of current SES had significantly greater odds of having self-reported arthritis. Conclusions Current SES and childhood SES are both associated with the odds of reporting arthritis within this primary-care population, although the possibly superseding influence of existing circumstances must be noted. BMI was a likely mechanism in the association of childhood SES with arthritis onset, and research is needed to elucidate further pathways linking the socioeconomic environment across life-stages and the development of rheumatic diseases.
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Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis. J Endod 2013; 39:1104-10. [PMID: 23953280 DOI: 10.1016/j.joen.2013.04.042] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/15/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Root canal therapy is a highly successful in-office treatment and preventive measure against periapical abscesses. Left untreated, periapical abscesses can have serious consequences that can lead to hospitalization. This study observes the trends of hospitalizations attributed to periapical abscesses. METHODS A retrospective analysis of the Nationwide Inpatient Sample (years 2000-2008) was used; we selected cases with a primary diagnosis of a periapical abscess with/without sinus involvement. The demographic characteristics and outcomes were examined. Each individual hospitalization was the unit of analysis. RESULTS During the 9-year study period, a total of 61,439 hospitalizations were primarily attributed to periapical abscesses in the United States. The average age was 37 years, and 89% of all hospitalizations occurred on an emergency/urgent basis. The mean length of stay was 2.96 days, and a total of 66 patients died in hospitals. Medicare, Medicaid, and private insurance plans paid for 18.7%, 25.2%, and 33.4% of hospitalizations, respectively. Uninsured patients accounted for 18.5% of hospitalizations. Significant predictors that influenced both hospital charges and length of stay included age, race, insurance status, a periapical abscess with sinus involvement, geographic region of country, the Charlson comorbidity index, and the year of study (P < .05). CONCLUSIONS The current study highlights the increasing burden of hospitalization of patients with periapical abscesses over a 9-year study period from 2000 to 2008. The high-risk groups likely to seek a hospital setting for the treatment of periapical abscesses were identified as were groups associated with higher hospital charges and a longer length of stay.
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Lavelle B, Smock PJ. Divorce and women's risk of health insurance loss. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2012; 53:413-31. [PMID: 23147653 PMCID: PMC3511592 DOI: 10.1177/0022146512465758] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
This article bridges the literatures on the economic consequences of divorce for women with that on marital transitions and health by focusing on women's health insurance. Using a monthly calendar of marital status and health insurance coverage from 1,442 women in the Survey of Income and Program Participation, we examine how women's health insurance changes after divorce. Our estimates suggest that roughly 115,000 American women lose private health insurance annually in the months following divorce and that roughly 65,000 of these women become uninsured. The loss of insurance coverage we observe is not just a short-term disruption. Women's rates of insurance coverage remain depressed for more than two years after divorce. Insurance loss may compound the economic losses women experience after divorce and contribute to as well as compound previously documented health declines following divorce.
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Sabik LM, Bradley CJ. Differences in mortality for surgical cancer patients by insurance and hospital safety net status. Med Care Res Rev 2012; 70:84-97. [PMID: 22951313 DOI: 10.1177/1077558712458158] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent research suggests hospitals serving low-income patients have poorer outcomes. However, safety net hospitals (SNHs) offering access to care regardless of insurance coverage may provide better care than low-income patients would otherwise receive. This study considers the association between insurance and mortality among surgical cancer patients and the role of SNHs. We estimate models of 1- and 5-year mortality on insurance, SNH status, patient characteristics, and hospital surgical volume for colorectal and breast cancer patients. Interaction terms between insurance and SNH status estimate how mortality differs by insurance source at SNHs. Medicaid and uninsurance are associated with significantly higher mortality for colorectal cancer patients. There is a statistically significant improvement in mortality for Medicaid colorectal cancer patients treated in SNHs relative to non-SNHs and a marginally significant improvement for uninsured breast cancer patients treated in SNHs. The results suggest a survival benefit for low-income patients treated in SNHs.
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Bonnar KK, McCarthy M. Health related quality of life in a rural area with low racial/ethnic density. J Community Health 2012; 37:96-104. [PMID: 21656020 DOI: 10.1007/s10900-011-9422-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to compare the self-reported quality of life of racial/ethnic minorities and Caucasians living in a rural, northern New York county, where 94% of the population is Caucasian. Participants completed a 79-item survey online and in-person assessing health status, health-related quality of life, perceptions of health information, and health care access/use. Frequencies, Chi-Square, and ANOVA were used to analyze the results. A total of 1,039 surveys were completed. Racial/ethnic minorities earned significantly less income, F (1, 1031) = 29.306, P = .000, relied more on public health insurance, X ( 2 )(7, 1033) = 47.827, P = .000, were significantly less likely to see a doctor because of the cost, F(1,990) = 17.042, P = .000, and reported using health-related services significantly less often when compared to Caucasians, F(1, 1032) = 17.051, P = .000. In terms of quality of life, while there were no significant differences in self-reported physical health, racial/ethnic minorities were more likely to feel sad/blue/depressed, F(1, 1031) = 7.193, P = .011 and worried/tense/anxious, F(1, 1031) = 5.550, P = .040. Findings from this study offer some initial evidence that, while perceived health status is generally good, rural racial/ethnic minorities residing in predominantly Caucasian rural areas may experience more mental health problems that are risk factors for chronic diseases. This coupled with lower use of health care services increases the need for culturally competent health programs and services for this population.
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Affiliation(s)
- Kelly K Bonnar
- School of Education and Professional Studies, Department of Community Health, State University of New York at Potsdam, Potsdam, NY, USA.
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Bradley CJ, Dahman B, Bear HD. Insurance and inpatient care: differences in length of stay and costs between surgically treated cancer patients. Cancer 2012; 118:5084-91. [PMID: 22415708 DOI: 10.1002/cncr.27508] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 02/01/2012] [Accepted: 02/03/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Early research demonstrated that patients' length-of-stay and inpatient costs varied according to their health insurance status. The authors of the current report studied a population-based sample of privately insured, Medicaid-insured, and uninsured inpatients ages 21 to 64 years who underwent surgical resection for either nonsmall cell lung cancer (NSCLC) (n = 781) or colorectal cancer (CRC) (n = 8190) or who underwent mastectomy (n = 6201) to compare length of stay and inpatient costs by insurance status. METHODS Data for this study were derived from all civilian, acute-care hospitals in Virginia from 1999 to 2005. Hierarchical generalized linear models were used to estimate the relation between the explanatory variables and lengths of stay and costs. All analyses controlled for patient characteristics and hospital random effects. RESULTS Medicaid-insured patients with NSCLC had longer lengths of stay (39% or 2.64 days longer) and higher inpatient costs (20% or $2479 higher costs). Uninsured and Medicaid-insured patients with CRC had longer lengths of stay and higher inpatient costs. In contrast, uninsured patients with breast cancer had 11% shorter lengths of stay and 12% lower inpatient costs than privately insured patients. Medicaid-insured patients had 10% lower inpatient costs than privately insured patients. Differences were no longer statistically significant when reconstruction was added to the models. CONCLUSIONS Health insurance affected the need for health care and the amount of health care received. Uninsured and Medicaid-insured patients with lung cancer and colon cancer who underwent resection had longer lengths of stay and higher inpatient costs than privately insured patients, but they had shorter lengths of stay when reconstruction was not provided. Among the patients with breast cancer, patients and/or providers economized on discretionary procedures.
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Affiliation(s)
- Cathy J Bradley
- Department of Healthcare Policy and Research, Massey Cancer Center, Richmond, VA 23298-0430, USA.
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English language proficiency and geographical proximity to a safety net clinic as a predictor of health care access. J Immigr Minor Health 2011; 13:260-7. [PMID: 21170588 PMCID: PMC3056133 DOI: 10.1007/s10903-010-9425-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Studies suggest that proximity to a safety net clinic (SNC) promotes access to care among the uninsured. Distance-based barriers to care may be greater for people with limited English proficiency (LEP), compared to those who are English proficient (EP), but this has not been explored. We assessed the relationship between distance to the nearest SNC and access in non-rural uninsured adults in California, and examined whether this relationship differs by language proficiency. Using the 2005 California Health Interview Survey and a list we compiled of California's SNCs, we calculated distance between uninsured interviewee residence and the exact address of the nearest SNC. Using multivariate regression to adjust for other relevant characteristics, we examined associations between this distance and interviewee's probability of having a usual source of health care (USOC) and having visited a physician in the prior 12 months. To examine differences by language proficiency, we included interactions between distance and language proficiency. Uninsured LEP adults living within 2 miles of a SNC were 9.3% less likely than their EP counterparts to have a USOC (P = 0.046). Further, distance to the nearest SNC was inversely associated with the probability of having a USOC among LEP, but not among EP; consequently, the difference between LEP and EP in the probability of having a USOC widened with increasing distance to the nearest SNC. There was no difference between LEP and EP adults living within 2 miles of a SNC in likelihood of having a physician visit; however, as with USOC, distance to the nearest SNC was inversely associated with the probability of having a physician visit among LEP but not EP. The effect sizes diminished, but remained significant, when we included county fixed effects in the models. Having LEP is a barrier to health care access, which compounds when combined with increased distance to the nearest SNC, among uninsured adults. Future studies should explore potential mechanisms so that appropriate interventions can be implemented.
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Thornton JD, Chandriani K, Thornton JG, Farooq S, Moallem M, Krishnan V, Auckley D. Assessing the prioritization of primary care referrals for polysomnograms. Sleep 2010; 33:1255-60. [PMID: 20857874 DOI: 10.1093/sleep/33.9.1255] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVE The mortality attributed to obstructive sleep apnea (OSA) is comparable to that of breast cancer and colon cancer. We sought to determine if patients at high risk for OSA were less likely to be referred by their primary care physician for polysomnograms (PSG) than mammograms or endoscopies. DESIGN Prospective cohort study; patients were recruited between January 2007 and April 2007. SETTING Academic public hospital system PATIENTS 395 patients waiting for family or internal medicine primary care appointments were administered the Berlin questionnaire. Chart abstraction or interview determined demographics; insurance and employment status; body mass index (BMI); comorbidities; and prior PSG, mammography, or endoscopy referrals. RESULTS Mean BMI was 30 +/- 7.4 kg/m2; 187 (47%) patients had high-risk Berlin scores. Overall, 19% of patients with high-risk Berlin scores were referred for PSG, compared to 63% of those eligible for mammograms and 80% of those eligible for endoscopies. Women (OR = 2.9, P = 0.02), COPD (OR = 4.6, P = 0.03), high-risk Berlin scores (OR = 3.4, P = 0.009), and higher BMI (OR = 1.1, P < 0.001) were positively associated with PSG referrals. Privately insured patients were less likely to be referred than uninsured patients (OR = 0.3, P = 0.04). There was no significant difference in referrals among those with other forms of insurance. Race was not associated with PSG referrals. CONCLUSION In a public hospital, primary care patients were less likely to be referred for PSG compared to mammogram and endoscopy. Uninsured patients were more likely to be referred for PSG than those with private insurance. Further studies are needed to address the low PSG referral rates in high-risk populations.
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Affiliation(s)
- J Daryl Thornton
- Center for Reducing Health Disparities, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH 44109, USA.
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Miller JE, Gaboda D, Nugent CN, Simpson TM, Cantor JC. Parental eligibility and enrollment in state children's health insurance program: the roles of parental health, employment, and family structure. Am J Public Health 2010; 101:274-7. [PMID: 21164085 DOI: 10.2105/ajph.2010.194654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We examined eligibility and enrollment among parents of children in New Jersey's State Children's Health Insurance Program following expansion of parental eligibility for NJ FamilyCare coverage. Data were from the 2003 NJ FamilyCare Family Health Survey (n = 416 families). Parental eligibility was higher in households without a full-time employed parent (odds ratio [OR] = 5.50; 95% confidence interval [CI] = 2.72, 11.14) and lower among single parents (OR = 0.38; 95% CI = 0.23, 0.61). Enrollment was higher among single parents (OR = 2.24; 95% CI = 1.17, 4.31). Roughly one third of eligible parents did not enroll, suggesting the need to increase awareness of parental eligibility and reduce barriers to enrollment.
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Affiliation(s)
- Jane E Miller
- Health, Health Care Policy and Aging Research, and the Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ 08901, USA.
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Kirby JB, Kaneda T. Unhealthy and uninsured: exploring racial differences in health and health insurance coverage using a life table approach. Demography 2010; 47:1035-51. [PMID: 21308569 PMCID: PMC3000037 DOI: 10.1007/bf03213738] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Millions of people in the United States do not have health insurance, and wide racial and ethnic disparities exist in coverage. Current research provides a limited description of this problem, focusing on the number or proportion of individuals without insurance at a single time point or for a short period. Moreover, the literature provides no sense of the joint risk of being uninsured and in need of medical care. In this article, we use a life table approach to calculate health- and insurance-specific life expectancies for whites and blacks, thereby providing estimates of the duration of exposure to different insurance and health states over a typical lifetime. We find that, on average, Americans can expect to spend well over a decade without health insurance during a typical lifetime and that 40% of these years are spent in less-healthy categories. Findings also reveal a significant racial gap: despite their shorter overall life expectancy, blacks have a longer uninsured life expectancy than whites, and this racial gap consists entirely of less-healthy years. Racial disparities in insurance coverage are thus likely more severe than indicated by previous research.
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Affiliation(s)
- James B Kirby
- The Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Rockville, MD, USA.
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Hasan O, Orav EJ, Hicks LS. Insurance status and hospital care for myocardial infarction, stroke, and pneumonia. J Hosp Med 2010; 5:452-9. [PMID: 20540165 DOI: 10.1002/jhm.687] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite widely documented variations in health care outcomes by insurance status, few nationally representative studies have examined such disparities in the inpatient setting. OBJECTIVE To determine whether there are insurance-related differences in hospital care for 3 common medical conditions. DESIGN AND SUBJECTS Retrospective database analysis of 154,381 adult discharges (age 18-64 years) with a principal diagnosis of acute myocardial infarction (AMI), stroke, or pneumonia from the 2005 Nationwide Inpatient Sample (NIS). MEASUREMENTS For each diagnosis, we compared in-hospital mortality, length of stay (LOS), and cost per hospitalization for Medicaid and uninsured patients with the privately insured. RESULTS Compared with the privately insured, in-hospital mortality among AMI and stroke patients was significantly higher for the uninsured (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] [1.24-1.85] for AMI and 1.49 [1.29-1.72] for stroke) and among pneumonia patients was significantly higher for Medicaid recipients (1.21 [1.01-1.45]). Excluding patients who died during hospitalization, LOS was consistently longer for Medicaid recipients for all 3 conditions (adjusted ratio 1.07, 95% CI [1.05-1.09] for AMI, 1.17 [1.14-1.20] for stroke, and 1.04 [1.03-1.06] for pneumonia), although costs were significantly higher for Medicaid recipients for only 2 of the 3 conditions (adjusted ratio 1.06, 95% CI [1.04-1.09] for stroke and 1.05 [1.04-1.07] for pneumonia). CONCLUSIONS In this nationally representative study of working-age Americans hospitalized for 3 common medical conditions, significantly lower in-hospital mortality was noted for privately insured patients compared with the uninsured or Medicaid recipients. Interventions to reduce insurance-related gaps in inpatient quality of care should be investigated.
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Affiliation(s)
- Omar Hasan
- Department of Medicine, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02120-1613, USA
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Lee C, Ayers SL, Kronenfeld JJ, Frimpong JA, Rivers PA, Kim SS. The importance of examining movements within the US health care system: sequential logit modeling. BMC Health Serv Res 2010; 10:269. [PMID: 20831805 PMCID: PMC2944276 DOI: 10.1186/1472-6963-10-269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 09/10/2010] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Although patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements. METHODS The sample included 6,772 adults aged 18 years and older who participated in the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. A sequential logit model was used to account for movement in all stages of utilization: use of any health services (i.e., first stage), having a perceived need for specialty care (i.e., second stage), and utilization of specialty care (i.e., third stage). In the sequential logit model, all stages are nested within the previous stage. RESULTS Gender, race/ethnicity, education and poor health had significant explanatory effects with regard to use of any health services and having a perceived need for specialty care, however racial/ethnic, gender, and educational disparities were not present in utilization of specialty care. After controlling for use of any health services and having a perceived need for specialty care, inability to pay for specialty care via income (AOR = 1.334, CI = 1.10 to 1.62) or health insurance (unstable insurance: AOR = 0.26, CI = 0.14 to 0.48; no insurance: AOR = 0.12, CI = 0.07 to 0.20) were significant barriers to utilization of specialty care. CONCLUSIONS Use of a sequential logit model to examine utilization of specialty care resulted in a detailed representation of utilization behaviors and patient characteristics that impact these behaviors at all stages within the health care system. After controlling for sequential movements within the health care system, the biggest barrier to utilizing specialty care is the inability to pay, while racial, gender, and educational disparities diminish to non-significance. Findings from this study represent how Americans use the health care system and more precisely reveals the disparities and inequalities in the U.S. health care system.
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Affiliation(s)
- Chioun Lee
- Department of Sociology, Rutgers University, New Brunswick, NJ 08901, USA
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Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health 2010; 100:1326-33. [PMID: 20466953 DOI: 10.2105/ajph.2009.180109] [Citation(s) in RCA: 306] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults. METHODS We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need. RESULTS Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications. CONCLUSIONS This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.
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Affiliation(s)
- Travis P Baggett
- General Medicine Division, Massachusetts General Hospital, Boston, MA 02114, USA.
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Compton MT, Ramsay CE, Shim RS, Goulding SM, Gordon TL, Weiss PS, Druss BG. Health services determinants of the duration of untreated psychosis among African-American first-episode patients. Psychiatr Serv 2009; 60:1489-94. [PMID: 19880467 PMCID: PMC5854470 DOI: 10.1176/ps.2009.60.11.1489] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The duration of untreated psychosis is associated with poor outcomes in multiple domains in the early course of nonaffective psychotic disorders, although relatively little is known about determinants of this critical period, particularly health services-level determinants. This study examined three hypothesized predictors of duration of untreated psychosis (lack of insurance, financial problems, and broader barriers) among urban, socioeconomically disadvantaged African Americans, while controlling for the effects of three patient-level predictors (mode of onset of psychosis, living with family versus alone or with others before hospitalization, and living above versus below the federally defined poverty level). METHODS Analyses included data from 42 patient-family member dyads from a larger sample of 109 patients with a first episode of nonaffective psychosis. The duration of untreated psychosis and all other variables were measured in a rigorous, standardized fashion in a study designed specifically to examine determinants of treatment delay. Survival analyses and Cox regression assessed the effects of the independent predictors on time from onset of psychosis to hospital admission for initial evaluation and treatment. RESULTS The median duration of untreated psychosis was 24.5 weeks. When the analyses controlled for the three patient-level covariates, patients without health insurance, with financial problems, or with barriers to seeking help had a significantly longer duration of untreated psychosis. CONCLUSIONS Health services-related factors, such as lack of insurance, are predictive of longer treatment delay. Efforts to eliminate uninsurance and underinsurance, as well as minimize barriers to treatment, would be beneficial for improving the prognosis of young patients with emerging nonaffective psychotic disorders.
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Affiliation(s)
- Michael T Compton
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA 30303, USA.
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Busch SH, Vigdor ER. Are Adults in Poor Health More Likely to Enroll in Public Insurance? INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2008; 45:380-94. [DOI: 10.5034/inquiryjrnl_45.04.380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Policies to reduce the number of uninsured people are rarely judged by whether they will increase insurance coverage rates among the chronically ill, despite evidence suggesting that the health benefits of coverage are greatest for these individuals. This paper examines the effect of public coverage expansions on insurance take-up and unmet need by low-income mothers in poor health. We find a 14.3-percentage-point reduction in unmet need among mothers reporting fair or poor health status. Our results suggest that some of this reduction is due to individuals moving from inadequate private coverage to public coverage.
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Danziger S, Davis MM, Orzol S, Pollack HA. Health Insurance and Access to Care among Welfare Leavers. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2008; 45:184-97. [DOI: 10.5034/inquiryjrnl_45.02.184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This analysis explores the effects of the 1996 welfare reform on health insurance coverage and access to care among former recipients of cash aid. Using panel data from the Women's Employment Study, which conducted five interviews between 1997 and 2003 in one Michigan county, we find that 25% of welfare leavers lacked health insurance coverage in fall 2003. Uninsured adults were significantly more likely than others to report that they could not afford a medical or dental visit during the year prior to the 2003 interview. Fixed-effect logistic regression analysis indicates that women who had been off the welfare rolls for at least 12 months (the duration of transitional Medicaid) were significantly more likely to be uninsured than women who had made more recent welfare exits, and were significantly more likely to report financial obstacles to the receipt of medical and dental care.
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Cristancho S, Garces DM, Peters KE, Mueller BC. Listening to rural Hispanic immigrants in the Midwest: a community-based participatory assessment of major barriers to health care access and use. QUALITATIVE HEALTH RESEARCH 2008; 18:633-46. [PMID: 18420537 DOI: 10.1177/1049732308316669] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Hispanic immigrants are increasingly residing in rural communities, including in the midwestern United States. Limitations in the ability of rural Hispanics to access and utilize health care contribute to patterns of poor health and health disparity. A conceptual model of "vulnerability" guides this community-based participatory assessment project designed to explore rural Hispanics' perceived barriers to accessing and utilizing health care. Findings from a series of 19 focus groups with 181 participants from three communities in the upper Midwest identified perceived barriers at the individual and health care system levels. The most commonly perceived barriers were the lack of and limitations in health insurance coverage, high costs of health care services, communication issues involving patients and providers, legal status/discrimination, and transportation concerns. Findings imply that these barriers could be addressed using multiple educational and health service delivery policy-related strategies that consider the vulnerable nature of this growing population.
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Affiliation(s)
- Sergio Cristancho
- University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
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Washington DL, Bowles J, Saha S, Horowitz CR, Moody-Ayers S, Brown AF, Stone VE, Cooper LA. Transforming clinical practice to eliminate racial-ethnic disparities in healthcare. J Gen Intern Med 2008; 23:685-91. [PMID: 18196352 PMCID: PMC2324135 DOI: 10.1007/s11606-007-0481-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 11/13/2007] [Accepted: 11/29/2007] [Indexed: 10/22/2022]
Abstract
Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices.
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Affiliation(s)
- Donna L. Washington
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA USA
| | - Jacqueline Bowles
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA USA
| | - Somnath Saha
- Section of General Internal Medicine, Portland Veterans Affairs Medical Center, Portland, OR USA
- Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - Carol R. Horowitz
- Departments of Health Policy and Medicine, Mount Sinai School of Medicine, New York, NY USA
| | - Sandra Moody-Ayers
- Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA USA
| | - Arleen F. Brown
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA USA
| | - Valerie E. Stone
- General Medicine Unit, Massachusetts General Hospital, Boston, MA USA
| | - Lisa A. Cooper
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Writing group for the Society of General Internal Medicine, Disparities in Health Task Force
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA USA
- Section of General Internal Medicine, Portland Veterans Affairs Medical Center, Portland, OR USA
- Department of Medicine, Oregon Health & Science University, Portland, OR USA
- Departments of Health Policy and Medicine, Mount Sinai School of Medicine, New York, NY USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA USA
- General Medicine Unit, Massachusetts General Hospital, Boston, MA USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Hoffman C, Paradise J. Health insurance and access to health care in the United States. Ann N Y Acad Sci 2007; 1136:149-60. [PMID: 17954671 DOI: 10.1196/annals.1425.007] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Health insurance, poverty, and health are all interconnected in the United States. This article synthesizes a large and compelling body of health services research, finding a strong association between health insurance coverage and access to primary and preventive care, the treatment of acute and traumatic conditions, and the medical management of chronic illness. Moreover, by improving access to care, health insurance coverage is also fundamentally important to better health care and health outcomes. Research connects being uninsured with adverse health outcomes, including declines in health and function, preventable health problems, severe disease at the time of diagnosis, and premature mortality.
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Affiliation(s)
- Catherine Hoffman
- Kaiser Commission on Medicaid and the Uninsured, Menlo Park, California 94025, USA.
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Cunningham PJ, Hadley J. Differences between symptom-specific and general survey questions of unmet need in measuring insurance and racial/ethnic disparities in access to care. Med Care 2007; 45:842-50. [PMID: 17712254 DOI: 10.1097/mlr.0b013e318053678f] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine differences in insurance and racial/ethnic disparities in access to care between a single-item measure of general unmet medical need and a multi-item measure of symptom-specific unmet medical need. DATA SOURCE The 2003 Community Tracking Study Household Survey, which included both a single question about any unmet medical needs over the last year, and a measure of unmet medical need keyed to the recent occurrence of 1 of 15 symptoms that a panel of physicians considered serious enough to warrant seeking medical care. STUDY DESIGN/METHODS We constructed 3 measures of unmet need (general perceived unmet need, perceived unmet need for a specific new symptom, and actual unmet need for the new symptom). We used multivariate logistic regression analysis to determine whether the measures have similar implications for access disparities by insurance status and by race/ethnicity, while controlling for income, health, and other sociodemographic characteristics. PRINCIPAL FINDINGS Uninsured people are consistently more likely than privately insured people to have unmet medical needs across the 3 measures of unmet need, and these differences were not due to differences in the perceived need for care. However, racial/ethnic disparities were apparent only for the symptom-specific measures of unmet need, and not the general measure of unmet need. CONCLUSIONS Using a symptom-specific measure of unmet medical need is probably not worth the added survey complexity and cost if the primary objective is to measure access disparities by insurance coverage. However, a general measure of unmet medical needs may not adequately capture racial/ethnic disparities in access.
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Neighbors CJ, Rogers ML, Shenassa ED, Sciamanna CN, Clark MA, Novak SP. Ethnic/Racial Disparities in Hospital Procedure Volume for Lung Resection for Lung Cancer. Med Care 2007; 45:655-63. [PMID: 17571014 DOI: 10.1097/mlr.0b013e3180326110] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ethnic/racial minorities experience poorer outcomes from lung cancer than non-Hispanic whites. Higher hospital procedure volume is associated with better survival from lung resection for lung cancer. OBJECTIVES We examined whether (1) ethnic/racial minorities are more likely to obtain lung resections at lower volume hospitals, (2) ethnicity/race is associated with inpatient mortality, (3) hospital volume mediates this association, and (4) hospital selection is mediated by racial/ethnic segregation, differences in insurance coverage, or limited hospital choice. METHODS Six years of data from the Nationwide Inpatient Sample (NIS 1998-2003, unweighted n = 50,245, weighted n = 129,506) were used in multivariate models controlling for sociodemographic factors, case complexity, and hospital characteristics. Additional analyses were conducted using the Area Resource File, which provided data on ethnic density and number of surgical hospitals in the hospital region. RESULTS Blacks/African Americans (odds ratio [OR] = 0.45; 0.34-0.58) and Latinos (OR = 0.44; 0.32-0.63) had lower odds of obtaining lung resection at a high-volume hospital than non-Hispanic whites. Blacks/African Americans (OR = 1.30; 1.01-1.67), Latinos (OR = 1.41; 1.02-1.94), and other racial/ethnic minorities (OR = 1.46; 1.04-2.06) also had higher odds of dying in hospital, but this association was statistically nonsignificant after controlling for hospital volume. Hospital location was not associated with lung resection procedure volume, nor did location mediate the association between ethnicity/race and hospital volume. CONCLUSIONS Ethnic/racial minorities are obtaining lung resection in lower volume hospitals and are more likely to die in hospital. Hospital volume is associated with higher mortality, but health insurance, segregation, and number of surgical hospitals within a county do not account for observed disparities.
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Affiliation(s)
- Charles J Neighbors
- National Center on Addiction and Substance Abuse at Columbia University, 633 Third Avenue, New York, NY 10017, USA.
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Ross JS, Ho V, Wang Y, Cha SS, Epstein AJ, Masoudi FA, Nallamothu BK, Krumholz HM. Certificate of Need Regulation and Cardiac Catheterization Appropriateness After Acute Myocardial Infarction. Circulation 2007; 115:1012-9. [PMID: 17283258 DOI: 10.1161/circulationaha.106.658377] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Certificate of need (CON) regulation was introduced to control healthcare costs and improve quality of care in part by limiting the number of facilities providing complex medical care. Our objective was to examine whether rates of appropriate cardiac catheterization after admission for acute myocardial infarction varied between states with and without CON regulation of cardiac catheterization. METHODS AND RESULTS We performed a retrospective analysis of chart-abstracted data for 137,279 Medicare patients admitted for acute myocardial infarction between 1994 and 1996 at 4179 US acute-care hospitals. Using 3-level hierarchical generalized linear modeling adjusted for patient sociodemographic and clinical characteristics and physician and hospital characteristics, we compared catheterization rates within 60 days of admission for states (and the District of Columbia) with (n=32) and without (n=19) CON regulation in the full cohort and stratified by catheterization appropriateness. Appropriateness was categorized as strongly, equivocally, or weakly indicated. We found CON regulation was associated with a borderline-significant lower rate of catheterization overall (45.8% versus 46.5%; adjusted risk ratio [RR] 0.91, 95% confidence interval 0.82 to 1.00, P=0.06). After stratification by appropriateness, CON regulation was not associated with a significantly lower rate of catheterization among 63,823 patients with strong indications (49.9% versus 50.3%; adjusted RR 0.94, 95% confidence interval 0.86 to 1.02, P=0.17). However, CON regulation was associated with significantly lower rates of catheterization among 65,077 patients with equivocal indication (45.0% versus 46.0%; adjusted RR 0.88, 95% confidence interval 0.78 to 1.00, P=0.05) and among 8379 patients with weak indications (19.8% versus 21.8%; adjusted RR 0.84, 95% confidence interval 0.71 to 0.98, P=0.04). Associations were weakened substantially after adjustment for hospital coronary artery bypass graft surgery or cardiac catheterization capability. CONCLUSIONS CON regulation was associated with modestly lower rates of equivocally and weakly indicated cardiac catheterization after admission for acute myocardial infarction, but no significant differences existed in rates of strongly indicated catheterization.
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Affiliation(s)
- Joseph S Ross
- Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, One Gustave L. Levy Pl, Box 1070, New York, NY 10029, USA.
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