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Mahmoudi E, Lin P, Rubenstein D, Guetterman T, Leggett A, Possin KL, Kamdar N. Use of preventive service and potentially preventable hospitalization among American adults with disability: Longitudinal analysis of Traditional Medicare and commercial insurance. Prev Med Rep 2024; 40:102663. [PMID: 38464419 PMCID: PMC10920729 DOI: 10.1016/j.pmedr.2024.102663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024] Open
Abstract
Objective Examine the association between traditional Medicare (TM) vs. commercial insurance and the use of preventive care and potentially preventable hospitalization (PPH) among adults (18+) with disability [cerebral palsy/spina bifida (CP/SB); multiple sclerosis (MS); traumatic spinal cord injury (TSCI)] in the United States. Methods Using 2008-2016 Medicare and commercial claims data, we compared adults with the same disability enrolled in TM vs. commercial insurance [Medicare: n = 21,599 (CP/SB); n = 7,605 (MS); n = 4,802 (TSCI); commercial: n = 11,306 (CP/SB); n = 6,254 (MS); n = 5,265 (TSCI)]. We applied generalized estimating equations to address repeated measures, comparing cases with controls. All models were adjusted for age, sex, race/ethnicity, and comorbid conditions. Results Compared with commercial insurance, enrolling in TM reduced the odds of using preventive services. For example, adjusted odds ratios (OR) of annual wellness visits in TM vs. commercial insurance were 0.31 (95% confidence interval (CI): 0.28-0.34), 0.32 (95% CI: 0.28-0.37), and 0.19 (95% CI: 0.17-0.22) among adults with CP/SB, TSCI, and MS, respectively. Furthermore, PPH risks were higher in TM vs. commercial insurance. ORs of PPH in TM vs. commercial insurance were 1.50 (95% CI: 1.18-1.89), 1.83 (95% CI: 1.40-2.41), and 2.32 (95% CI: 1.66-3.22) among adults with CP/SB, TSCI, and MS, respectively. Moreover, dual-eligible adults had higher odds of PPH compared with non-dual-eligible adults [CP/SB: OR = 1.47 (95% CI: 1.25-1.72); TSCI: OR = 1.61 (95% CI: 1.35-1.92), and MS: OR = 1.80 (95% CI: 1.55-2.10)]. Conclusions TM, relative to commercial insurance, was associated with lower receipt of preventive care and higher PPH risk among adults with disability.
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Affiliation(s)
- Elham Mahmoudi
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Dana Rubenstein
- Clinical and Translational Science Institute, Duke University School of Medicine, 701 West Main Street, Durham, NC, USA
| | - Timothy Guetterman
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amanda Leggett
- Institute of Gerontology & Department of Psychology, Wayne State University, Detroit, MI, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Rosella LC, Hurst M, O'Neill M, Pagalan L, Diemert L, Kornas K, Hong A, Fisher S, Manuel DG. A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT). Diagn Progn Res 2024; 8:2. [PMID: 38317268 PMCID: PMC10845544 DOI: 10.1186/s41512-024-00165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Avoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data. METHODS AND ANALYSIS The derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18-74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Abstract Database (1999/2000-2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000-2006 compared to 2007-2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell's concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement. ETHICS AND DISSEMINATION This study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.
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Affiliation(s)
- Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada.
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- ICES, Toronto, ON, M4N 3M5, Canada.
| | - Mackenzie Hurst
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
- ICES, Toronto, ON, M4N 3M5, Canada
| | - Meghan O'Neill
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Lief Pagalan
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Lori Diemert
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Andy Hong
- PEAK Urban Research Programme, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Department of City & Metropolitan Planning, University of Utah, Salt Lake City, UT, USA
- The George Institute for Global Health, Newtown, NSW, Australia
| | - Stacey Fisher
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Douglas G Manuel
- Ottawa Hospital Research Institute, Ottawa, Canada
- Statistics Canada, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
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Shilane D, Miller S, Fleming J, Bar J, Corbin Y, Garcia M, Gasner MR, Campbell KN, Brown S, Weber E. Barriers to Telehealth Utilization Among Patients of Limited Income with Chronic Conditions and a Gap in Care. Telemed J E Health 2023; 29:1659-1666. [PMID: 36944144 DOI: 10.1089/tmj.2022.0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Objective: This study assessed barriers and facilitators to telehealth utilization among patients living in New York City public housing with chronic conditions and a gap in clinical care. Methods: Community health workers performed outreach to eligible patients by telephone between January and March 2021. Consenting respondents answered questions about telehealth barriers, including internet and cell phone access, ownership of digital devices, comfort with using digital devices, comfort with telehealth, cost, awareness, and availability of written materials in patients' preferred language. We obtained demographic and medical information from patients' electronic health records. We used multivariable logistic regression to estimate the association of barriers with the odds of self-reported prior telehealth utilization. Results: A total of 304 consenting patients participated in the program. The average patient had 3.1 telehealth barriers; 76% reported at least one barrier. Regression analysis showed sizable reductions in prior telehealth utilization associated with the barriers of unlimited cell phone minutes (odds ratio [OR]: 0.21 [0.05-0.88], p = 0.033), technological comfort (OR: 0.33 [0.13-0.82], p = 0.016), conceptual comfort with telehealth (OR: 0.15 [0.04-0.54], p = 0.004), and materials in the patient's preferred language (OR: 0.23 [0.07-0.79], p = 0.02). Discussion: With a high prevalence of telehealth barriers, patients with limited income, a chronic condition, and a care gap may benefit from greater technological access and supportive programs for awareness, telehealth comfort, and navigation support. Addressing telehealth barriers could increase the quality of medical care and improve health outcomes for this population.
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Affiliation(s)
- David Shilane
- Program in Applied Analytics, Columbia University, New York, New York, USA
- AIRnyc, Bronx, New York, USA
| | - Sarah Miller
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Fleming
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jasmine Bar
- School of Global Public Health, New York University, New York, New York, USA
| | | | | | | | - Kirk N Campbell
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Ellerie Weber
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Ranjit A, Andriotti T, Madsen C, Koehlmoos T, Staat B, Witkop C, Little SE, Robinson J. Does Universal Coverage Mitigate Racial Disparities in Potentially Avoidable Maternal Complications? Am J Perinatol 2021; 38:848-856. [PMID: 31986540 DOI: 10.1055/s-0040-1701195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. STUDY DESIGN PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. RESULTS A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10). CONCLUSION Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.
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Affiliation(s)
- Anju Ranjit
- Department of Obstetrics and Gynecology, Howard University Hospital, Washington, District of Columbia
| | - Tomas Andriotti
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cathaleen Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barton Staat
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Catherine Witkop
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sarah E Little
- Department of Obstetrics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian Robinson
- Department of Obstetrics, Brigham and Women's Hospital, Boston, Massachusetts
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Rochlin DH, Lee CM, Scheuter C, Platchek T, Kaplan RM, Milstein A. Health Care Is Failing the Most Vulnerable Patients: Three Underused Solutions. Public Health Rep 2020; 135:711-716. [PMID: 32962512 DOI: 10.1177/0033354920954496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Danielle H Rochlin
- 6429 Clinical Excellence Research Center, Stanford University, Palo Alto, CA, USA.,Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Chuan-Mei Lee
- 6429 Clinical Excellence Research Center, Stanford University, Palo Alto, CA, USA
| | - Claudia Scheuter
- 6429 Clinical Excellence Research Center, Stanford University, Palo Alto, CA, USA.,Division of General Internal Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Terry Platchek
- 6429 Clinical Excellence Research Center, Stanford University, Palo Alto, CA, USA
| | - Robert M Kaplan
- 6429 Clinical Excellence Research Center, Stanford University, Palo Alto, CA, USA
| | - Arnold Milstein
- 6429 Clinical Excellence Research Center, Stanford University, Palo Alto, CA, USA
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Saunders MR, Ricardo AC, Chen J, Anderson AH, Cedillo-Couvert EA, Fischer MJ, Hernandez-Rivera J, Hicken MT, Hsu JY, Zhang X, Hynes D, Jaar B, Kusek JW, Rao P, Feldman HI, Go AS, Lash JP. Neighborhood socioeconomic status and risk of hospitalization in patients with chronic kidney disease: A chronic renal insufficiency cohort study. Medicine (Baltimore) 2020; 99:e21028. [PMID: 32664108 PMCID: PMC7360239 DOI: 10.1097/md.0000000000021028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients with chronic kidney disease (CKD) experience significantly greater morbidity than the general population. The hospitalization rate for patients with CKD is significantly higher than the general population. The extent to which neighborhood-level socioeconomic status (SES) is associated with hospitalization has been less explored, both in the general population and among those with CKD.We evaluated the relationship between neighborhood SES and hospitalizations for adults with CKD participating in the Chronic Renal Insufficiency Cohort Study. Neighborhood SES quartiles were created utilizing a validated neighborhood-level SES summary measure expressed as z-scores for 6 census-derived variables. The relationship between neighborhood SES and hospitalizations was examined using Poisson regression models after adjusting for demographic characteristics, individual SES, lifestyle, and clinical factors while taking into account clustering within clinical centers and census block groups.Among 3291 participants with neighborhood SES data, mean age was 58 years, 55% were male, 41% non-Hispanic white, 49% had diabetes, and mean estimated glomerular filtration rate (eGFR) was 44 ml/min/1.73 m. In the fully adjusted model, compared to individuals in the highest SES neighborhood quartile, individuals in the lowest SES neighborhood quartile had higher risk for all-cause hospitalization (rate ratio [RR], 1.28, 95% CI, 1.09-1.51) and non-cardiovascular hospitalization (RR 1.30, 95% CI, 1.10-1.55). The association with cardiovascular hospitalization was in the same direction but not statistically significant (RR 1.21, 95% CI, 0.97-1.52).Neighborhood SES is associated with risk for hospitalization in individuals with CKD even after adjusting for individual SES, lifestyle, and clinical factors.
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Affiliation(s)
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jinsong Chen
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Amanda H. Anderson
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VAMC, Chicago, IL
| | | | | | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Xiaoming Zhang
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Denise Hynes
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
- College of Public Health and Human Sciences, Oregon State University, and US Department of Veterans Affairs, Portland, OR
| | - Bernard Jaar
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - John W. Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Panduranga Rao
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
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Yaqoob M, Wang J, Sweeney AT, Wells C, Rego V, Jaber BL. Trends in Avoidable Hospitalizations for Diabetes: Experience of a Large Clinically Integrated Health Care System. J Healthc Qual 2020; 41:125-133. [PMID: 31094945 DOI: 10.1097/jhq.0000000000000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.
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Live Discharge From Hospice Due to Acute Hospitalization: The Role of Neighborhood Socioeconomic Characteristics and Race/Ethnicity. Med Care 2020; 58:320-328. [PMID: 31876664 DOI: 10.1097/mlr.0000000000001278] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute hospitalization is a frequent reason for live discharge from hospice. Although risk factors for live discharge among hospice patients have been well documented, prior research has not examined the role of neighborhood socioeconomic characteristics, or how these characteristics relate to racial/ethnic disparities in hospice outcomes. OBJECTIVE To examine associations between neighborhood socioeconomic characteristics and risk for live discharge from hospice because of acute hospitalization. The authors also explore the moderating role of race/ethnicity in any observed relationship. RESEARCH DESIGN Retrospective cohort study using electronic medical records of hospice patients (N=17,290) linked with neighborhood-level socioeconomic data (N=55 neighborhoods). Multilevel models were used to identify the independent significance of patient and neighborhood-level characteristics for risk of live discharge because of acute hospitalization. RESULTS Compared with the patients in the most well-educated and affluent sections of New York City [quartile (Q)4], the odds of live discharge from hospice because of acute hospitalization were greater among patients who resided in neighborhoods where lower proportions of residents held college degrees [Q1 adjusted odds ratio (AOR), 1.36; 95% confidence interval (CI), 1.06-1.75; Q2 AOR, 1.41; 95% CI, 1.07-1.84] and median household incomes were lower (Q1 AOR, 1.42; 95% CI, 1.10-1.85; Q2 AOR, 1.43; 95% CI, 1.10-1.85; Q3 AOR, 1.39; 95% CI, 1.07-1.80). However, these observed relationships were not equally distributed by patient race/ethnicity; the association of neighborhood socioeconomic disadvantage and risk for live discharge was significantly lower among Hispanic compared with white patients. CONCLUSIONS Findings demonstrate neighborhood socioeconomic disadvantage poses a significant risk for live discharge from hospice. Additional research is needed to clarify the social mechanisms underlying this association, including greater attention to the experiences of hospice patients from under-represented racial/ethnic groups.
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Wallar LE, De Prophetis E, Rosella LC. Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990-2018. Int J Equity Health 2020; 19:60. [PMID: 32366253 PMCID: PMC7197160 DOI: 10.1186/s12939-020-01160-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/09/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hospitalizations for chronic ambulatory care sensitive conditions are an important indicator of health system equity and performance. Chronic ambulatory care sensitive conditions refer to chronic diseases that can be managed in primary care settings, including angina, asthma, and diabetes, with hospitalizations for these conditions considered potentially avoidable with adequate primary care interventions. Socioeconomic inequities in the risk of hospitalization have been observed in several health systems globally. While there are multiple studies examining the association between socioeconomic status and hospitalizations for chronic ambulatory care sensitive conditions, these studies have not been systematically reviewed. The objective of this study is to systematically identify and describe socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions amongst adult populations in economically developed countries reported in high-quality observational studies published in the peer-reviewed literature. METHODS Peer-reviewed literature was searched in six health and social science databases: MEDLINE, EMBASE, PsycInfo, CINAHL, ASSIA, and IBSS using search terms for hospitalization, socioeconomic status, and chronic ambulatory care sensitive conditions. Study titles and abstracts were first screened followed by full-text review according to the following eligibility criteria: 1) Study outcome is hospitalization for selected chronic ambulatory care sensitive conditions; 2) Primary exposure is individual- or area-level socioeconomic status; 3) Study population has a mean age ± 1 SD < 75 years of age; 4) Study setting is economically developed countries; and 5) Study type is observational. Relevant data was then extracted, and studies were critically appraised using appropriate tools from The Joanna Briggs Institute. Results were narratively synthesized according to socioeconomic constructs and type of adjustment (minimally versus fully adjusted). RESULTS Of the 15,857 unique peer-reviewed studies identified, 31 studies met the eligibility criteria and were of sufficient quality for inclusion. Socioeconomic constructs and hospitalization outcomes varied across studies. However, despite this heterogeneity, a robust and consistent association between lower levels of socioeconomic status and higher risk of hospitalizations for chronic ambulatory care sensitive conditions was observed. CONCLUSIONS This systematic review is the first to comprehensively identify and analyze literature on the relationship between SES and hospitalizations for chronic ambulatory care sensitive conditions, considering both aggregate and condition-specific outcomes that are common to several international health systems. The evidence consistently demonstrates that lower socioeconomic status is a risk factor for hospitalization across global settings. Effective health and social interventions are needed to reduce these inequities and ensure fair and adequate care across socioeconomic groups. TRIAL REGISTRATION PROSPERO CRD42018088727.
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Affiliation(s)
- Lauren E Wallar
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
| | - Eric De Prophetis
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada.
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10
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Tsui J, Hirsch JA, Bayer FJ, Quinn JW, Cahill J, Siscovick D, Lovasi GS. Patterns in Geographic Access to Health Care Facilities Across Neighborhoods in the United States Based on Data From the National Establishment Time-Series Between 2000 and 2014. JAMA Netw Open 2020; 3:e205105. [PMID: 32412637 PMCID: PMC7229525 DOI: 10.1001/jamanetworkopen.2020.5105] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE The association between proximity to health care facilities and improved disease management and population health has been documented, but little is known about small-area health care environments and how the presence of health care facilities has changed over time during recent health system and policy change. OBJECTIVE To examine geographic access to health care facilities across neighborhoods in the United States over a 15-year period. DESIGN, SETTING, AND PARTICIPANTS Using longitudinal business data from the National Establishment Time-Series, this cross-sectional study examined the presence of and change in ambulatory care facilities and pharmacies and drugstores in census tracts (CTs) throughout the continental United States between 2000 and 2014. Between January and April 2019, multinomial logistic regression was used to estimate associations between health care facility presence and neighborhood sociodemographic characteristics over time. MAIN OUTCOMES AND MEASURES Change in health care facility presence was measured as never present, lost, gained, or always present between 2000 and 2014. Neighborhood sociodemographic characteristics (ie, CTs) and their change over time were measured from US Census reports (2000 and 2010) and the American Community Survey (2008-2012). RESULTS Among 72 246 included CTs, the percentage of non-US-born residents, residents 75 years or older, poverty status, and population density increased, and 8.1% of CTs showed a change in the racial/ethnic composition of an area from predominantly non-Hispanic (NH) white to other racial/ethnic composition categories between 2000 and 2010. The presence of ambulatory care facilities increased from a mean (SD) of 7.7 (15.9) per CT in 2000 to 13.0 (22.9) per CT in 2014, and the presence of pharmacies and drugstores increased from a mean (SD) of 0.6 (1.0) per CT in 2000 to 0.9 (1.4) per CT in 2014. Census tracts with predominantly NH black individuals (adjusted odds ratio [aOR], 2.37; 95% CI, 2.03-2.77), Hispanic/Latino individuals (aOR 1.30; 95% CI, 1.00-1.69), and racially/ethnically mixed individuals (aOR, 1.53; 95% CI, 1.33-1.77) in 2000 had higher odds of losing health care facilities between 2000 and 2014 compared with CTs with predominantly NH white individuals, after controlling for other neighborhood characteristics. Census tracts of geographic areas with higher levels of poverty in 2000 also had higher odds of losing health care facilities between 2000 and 2014 (aOR, 1.12; 95% CI, 1.05-1.19). CONCLUSIONS AND RELEVANCE Differential change was found in the presence of health care facilities across neighborhoods over time, indicating the need to monitor and address the spatial distribution of health care resources within the context of population health disparities.
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Affiliation(s)
- Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Rutgers, The State University of New Jersey, New Brunswick
- Rutgers Center for State Health Policy, Rutgers, The State University of New Jersey, New Brunswick
| | - Jana A. Hirsch
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Felicia J. Bayer
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - James W. Quinn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Jesse Cahill
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - David Siscovick
- Research, Evaluation & Policy, New York Academy of Medicine, New York, New York
| | - Gina S. Lovasi
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
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11
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Wallar LE, Rosella LC. Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study. PLoS One 2020; 15:e0229465. [PMID: 32182242 PMCID: PMC7077875 DOI: 10.1371/journal.pone.0229465] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/06/2020] [Indexed: 12/14/2022] Open
Abstract
Hospitalizations for certain chronic conditions are considered avoidable for adult Canadians given effective and timely primary care management. Individual-level risk factors such as income and health behaviours are not routinely collected in most hospital databases and as a result, are largely uncharacterized for avoidable hospitalization at the national level. The aim of this study was to identify and describe demographic, socioeconomic, and health behavioural risk factors for avoidable hospitalizations in Canada using linked data. A national retrospective cohort study was conducted by pooling eight cycles of the Canadian Community Health Survey (2000/2001-2011) and linking to hospitalization records in the Discharge Abstract Database (1999/2000–2012/2013). Respondents who were younger than 18 years and older than 74 years of age, residing in Quebec, or pregnant at baseline were excluded yielding a final cohort of 389,065 individuals. The primary outcome measure was time-to index avoidable hospitalization. Sex-stratified Cox proportional hazard models were constructed to determine effect sizes adjusted for various factors and their associated 95% confidence intervals. Demographics, socioeconomic status, and health behaviours are associated with risk of avoidable hospitalizations in males and females. In fully adjusted models, health behavioural variables had the largest effect sizes including heavy smoking (Male HR 2.65 (95% CI 2.17–3.23); Female HR 3.41 (2.81–4.13)) and being underweight (Male HR 1.98 (1.14–3.43); Female HR 2.78 (1.61–4.81)). Immigrant status was protective in both sexes (Male HR 0.83 (0.69–0.98); (Female HR 0.69 (0.57–0.84)). Adjustment for behavioural and clinical variables attenuated the effect of individual-level socioeconomic status. This study identified several risk factors for time-to-avoidable hospitalizations by sex, using the largest national database of linked health survey and hospitalization records. The larger effect sizes of several modifiable risk factors highlights the importance of prevention in addressing avoidable hospitalizations in Canada.
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Affiliation(s)
- Lauren E. Wallar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Laura C. Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
- * E-mail:
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