1
|
Morenz AM, Wong ES, Zhou L, Chen CP, Zerzan-Thul J, Liao JM. Neighborhood Socioeconomic Disadvantage and Acute Care Utilization in Washington State Medicaid: A Retrospective Cohort Study. J Gen Intern Med 2024:10.1007/s11606-024-09114-w. [PMID: 39394471 DOI: 10.1007/s11606-024-09114-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 09/30/2024] [Indexed: 10/13/2024]
Abstract
BACKGROUND Neighborhood disadvantage has been associated with potentially preventable acute care utilization among Medicare beneficiaries, but this association has not been studied in a Medicaid population, which is important for informing more equitable care and policies for this population. OBJECTIVE To describe the association between Area Deprivation Index (ADI) and acute care utilization (including potentially preventable utilization) among Medicaid beneficiaries in Washington State. DESIGN Retrospective cohort study of 100% Medicaid claims. Mixed effects logistic regression was applied to estimate the association between state-level ADI decile and acute care utilization, adjusting for age, sex, self-identified race and ethnicity, Charlson Comorbidity Index, primary spoken language, individual Federal Poverty Level, homelessness, and rurality. Standard errors were clustered at the Census block group level. PARTICIPANTS 1.5 million unique adult Medicaid beneficiaries enrolled for at least 11 months of a calendar year during the period 2017-2021. MAIN MEASURES Binary measures denoting receipt of ED visits, low-acuity ED visits, hospitalizations in a calendar year. KEY RESULTS Increasing levels of neighborhood socioeconomic disadvantage (by ADI decile) were associated with greater odds of any ED visits (adjusted odds ratio (aOR) 1.07, 95% confidence interval (CI) 1.06-1.07), low-acuity ED visits (aOR 1.08, CI 1.08-1.08), and any hospitalizations (aOR 1.02, CI 1.02-1.02). CONCLUSIONS Among Medicaid beneficiaries, greater neighborhood socioeconomic disadvantage was associated with increased acute care utilization, including potentially preventable utilization. These findings signal potential barriers to outpatient care access that could be amenable to future intervention by health systems and payers.
Collapse
Affiliation(s)
- Anna M Morenz
- Department of Medicine, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA.
- Program On Policy Evaluation and Learning-Northwest, Seattle, WA, USA.
| | - Edwin S Wong
- Program On Policy Evaluation and Learning-Northwest, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Lingmei Zhou
- Program On Policy Evaluation and Learning-Northwest, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher P Chen
- Department of Medicine, University of Washington, Seattle, WA, USA
- Washington State Health Care Authority, Olympia, WA, USA
| | - Judy Zerzan-Thul
- Department of Medicine, University of Washington, Seattle, WA, USA
- Washington State Health Care Authority, Olympia, WA, USA
| | - Joshua M Liao
- Program On Policy Evaluation and Learning-Northwest, Seattle, WA, USA
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Program On Policy Evaluation and Learning, Dallas, TX, USA
| |
Collapse
|
2
|
Weight N, Moledina S, Lawson CA, Van Spall HGC, Wijeysundera HC, Rashid M, Kontopantelis E, Mamas MA. The Intersection of Socioeconomic Differences and Sex in the Management and Outcomes of Acute Myocardial Infarction: A Nationwide Cohort Study. Angiology 2024:33197241273433. [PMID: 39295517 DOI: 10.1177/00033197241273433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024]
Abstract
Patients with lower socioeconomic status (SES) have poorer outcomes following acute myocardial infarction (AMI) than patients with higher SES; however, how sex modifies socioeconomic differences is unclear. Using the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP) registry, alongside Office of National Statistics (ONS) mortality data, we analyzed 736,420 AMI patients between 2005 and 2018, stratified by Index of Multiple Deprivation (IMD) score Quintiles (most affluent [Q1] to most deprived [Q5]). There was no significant difference in probability of in-hospital mortality in our adjusted model according to sex. The probability of 30-day mortality in our adjusted model was similar between men and women throughout Quintiles, ((Q5; Men 7.6%; 95% CI 7.3-7.8% (P < .001), Women; 7.0%; 95% CI 6.8-7.3%, P < .001)) ((Q1; Men 7.1%; 95% CI 6.8-7.4%, P < .001, Women; 6.9%; 95% CI 6.6-7.1%, P < .001)). The probability of one-year mortality in our adjusted model was higher in men throughout all Quintiles (Q1; Men 15.0%; 95% CI 14.8-15.6%), P < .001, Women; 14.5%; 95% CI 14.2-14.9%, P < .001) (Q5; Men 16.9%; 95% CI 16.5-17.3%, P < .001, Women; 15.5%; 95% CI 15.1-15.9 by %, P < .001). Overall, female sex did not significantly influence the effect of deprivation on AMI processes of care and outcomes.
Collapse
Affiliation(s)
- Nicholas Weight
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Saadiq Moledina
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Research Institute of St Joe's, Hamilton, ON, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
- Department of Cardiovascular Sciences, Glenfield Hospital, University Hospitals of Leicester NHS Trust Leicester United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, UK
| |
Collapse
|
3
|
Gill TM, Becher RD, Leo-Summers L, Gahbauer EA. Changes in neighborhood disadvantage over the course of 22 years among community-living older persons. J Am Geriatr Soc 2024. [PMID: 39206716 DOI: 10.1111/jgs.19172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/30/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Among older persons, neighborhood disadvantage is a granular and increasingly used social determinant of health and functional well-being. The frequency of transitions into or out of a disadvantaged neighborhood over time is not known. These transitions may occur when a person moves from one location to another or when the Neighborhood Atlas, the data source for the area deprivation index (ADI) that is used to identify disadvantaged neighborhoods at the census-block level, is updated. METHODS From a prospective longitudinal study of community-living persons, aged 70 years or older in South Central Connecticut, neighborhood disadvantage was ascertained every 18 months for 22 years (from March 1998 to March 2020). ADI scores higher than the 80th state percentile were used to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80). RESULTS At baseline, 205 (29.3%) of the 699 participants were living in a disadvantaged neighborhood. Changes in neighborhood disadvantage during 14 consecutive 18-month intervals were relatively uncommon, ranging from 1.5% to 11.8%. Nearly 80% of participants had no change in neighborhood disadvantage and less than 4% had more than one change over a median follow-up of more than 9 years. Overall, the rate of transitions into or out of neighborhood disadvantage was only 2.7 per 100 person-years. These transitions were most common when the Neighborhood Atlas was updated (2013, 2015, 2018, and 2020). Comparable results were observed when decile changes in ADI scores during the 18-month intervals were evaluated. CONCLUSIONS In longitudinal studies of older persons with extended follow-up, it may not be necessary to update information on disadvantaged neighborhoods in circumstances when it is possible, and the degree of misclassification of neighborhood disadvantage should be relatively low in circumstances when updated information cannot be obtained.
Collapse
Affiliation(s)
- Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Linda Leo-Summers
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Evelyne A Gahbauer
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
4
|
Lusk JB, Blass B, Mahoney H, Hoffman MN, Clark AG, Bae J, Mentz RJ, Wang TY, Patel M, Hammill BG. Neighborhood Socioeconomic Disadvantage and 30-Day Outcomes for Common Cardiovascular Conditions. J Am Heart Assoc 2024; 13:e036265. [PMID: 39119993 DOI: 10.1161/jaha.124.036265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/14/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Understanding the relationship between neighborhood environment and cardiovascular outcomes is important to achieve health equity and implement effective quality strategies. We conducted a population-based cohort study to determine the association of neighborhood socioeconomic deprivation and 30-day mortality and readmission rate for patients admitted with common cardiovascular conditions. METHODS AND RESULTS We examined claims data from fee-for-service Medicare beneficiaries aged ≥65 years between 2017 and 2019 admitted for heart failure, valvular heart disease, ischemic heart disease, or cardiac arrhythmias. The primary exposure was the Area Deprivation Index; outcomes were 30-day all-cause death and unplanned readmission. More than 2 million admissions were included. After sequential adjustment for patient characteristics (demographics, dual eligibility, comorbidities), area health care resources (primary care clinicians, specialists, and hospital beds per capita), and admitting hospital characteristics (ownership, size, teaching status), there was a dose-dependent association between neighborhood socioeconomic deprivation and 30-day mortality rate for all conditions. In the fully adjusted model for death, estimated effect sizes of residence in the most disadvantaged versus least disadvantaged neighborhoods ranged from adjusted odds ratio 1.29 (95% CI, 1.22-1.36) for the heart failure group to adjusted odds ratio 1.63 (95% CI, 1.36-1.95) for the valvular heart disease group. Neighborhood deprivation was associated with increased adjusted 30-day readmission rates, with estimated effect sizes from adjusted odds ratio 1.09 (95% CI, 1.05-1.14) for heart failure to adjusted odds ratio 1.19 (95% CI, 1.13-1.26) for arrhythmia. CONCLUSIONS Neighborhood socioeconomic disadvantage was associated with 30-day mortality rate and readmission for patients admitted with common cardiovascular conditions independent of individual demographics, socioeconomic status, medical risk, care access, or admitting hospital characteristics.
Collapse
Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine Durham NC USA
- Duke University Fuqua School of Business Durham NC USA
| | - Beau Blass
- Duke University School of Medicine Durham NC USA
| | - Hannah Mahoney
- Duke University Department of Population Health Sciences Durham NC USA
| | - Molly N Hoffman
- Duke University Department of Population Health Sciences Durham NC USA
| | - Amy G Clark
- Duke University Department of Population Health Sciences Durham NC USA
| | - Jonathan Bae
- Duke University Health System Durham NC USA
- Division of Cardiology Duke University Department of Medicine Durham NC USA
| | - Robert J Mentz
- Division of Cardiology Duke University Department of Medicine Durham NC USA
| | - Tracy Y Wang
- Patient Centered Outcomes Research Institute Durham NC USA
| | - Manesh Patel
- Division of Cardiology Duke University Department of Medicine Durham NC USA
| | - Bradley G Hammill
- Duke University School of Medicine Durham NC USA
- Duke University Department of Population Health Sciences Durham NC USA
| |
Collapse
|
5
|
Qu Q, Guo Q, Shi J, Chen Z, Sun J, Cheang I, Gao R, Zhou Y, Zhang H, Liao S, Yao W, Li X. Trends in cardiovascular risk factor prevalence, treatment, and control among US adolescents aged 12 to 19 years, 2001 to March 2020. BMC Med 2024; 22:245. [PMID: 38872207 PMCID: PMC11170826 DOI: 10.1186/s12916-024-03453-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Early-life cardiovascular risk factors (CVRFs) are known to be associated with target organ damage during adolescence and premature cardiovascular morbidity and mortality during adulthood. However, contemporary data describing whether the prevalence of CVRFs and treatment and control rates have changed are limited. This study aimed to examine the temporal trends in the prevalence, treatment, and control of CVRFs among US adolescents over the past 2 decades. METHODS This is a serial cross-sectional study using data from nine National Health and Nutrition Examination Survey cycles (January 2001-March 2020). US adolescents (aged 12 to 19 years) with information regarding CVRFs (including hypertension, elevated blood pressure [BP], diabetes, prediabetes, hyperlipidemia, obesity, overweight, cigarette use, inactive physical activity, and poor diet quality) were included. Age-adjusted trends in CVRF prevalence, treatment, and control were examined. Joinpoint regression analysis was performed to estimate changes in the prevalence, treatment, and control over time. The variation by sociodemographic characteristics were also described. RESULTS A total of 15,155 US adolescents aged 12 to 19 years (representing ≈ 32.4 million people) were included. From 2001 to March 2020, there was an increase in the prevalence of prediabetes (from 12.5% [95% confidence interval (CI), 10.2%-14.9%] to 37.6% [95% CI, 29.1%-46.2%]) and overweight/obesity (from 21.1% [95% CI, 19.3%-22.8%] to 24.8% [95% CI, 21.4%-28.2%]; from 16.0% [95% CI, 14.1%-17.9%] to 20.3% [95% CI, 17.9%-22.7%]; respectively), no improvement in the prevalence of elevated BP (from 10.4% [95% CI, 8.9%-11.8%] to 11.0% [95% CI, 8.7%-13.4%]), diabetes (from 0.7% [95% CI, 0.2%-1.2%] to 1.2% [95% CI, 0.3%-2.2%]), and poor diet quality (from 76.1% [95% CI, 74.0%-78.2%] to 71.7% [95% CI, 68.5%-74.9%]), and a decrease in the prevalence of hypertension (from 8.1% [95% CI, 6.9%-9.4%] to 5.5% [95% CI, 3.7%-7.3%]), hyperlipidemia (from 34.2% [95% CI, 30.9%-37.5%] to 22.8% [95% CI, 18.7%-26.8%]), cigarette use (from 18.0% [95% CI, 15.7%-20.3%] to 3.5% [95% CI, 2.0%-5.0%]), and inactive physical activity (from 83.0% [95% CI, 80.7%-85.3%] to 9.5% [95% CI, 4.2%-14.8%]). Sex and race/ethnicity affected the evolution of CVRF prevalence differently. Whilst treatment rates for hypertension and diabetes did not improve significantly (from 9.6% [95% CI, 3.5%-15.8%] to 6.0% [95% CI, 1.4%-10.6%]; from 51.0% [95% CI, 23.3%-78.7%] to 26.5% [95% CI, 0.0%-54.7%]; respectively), BP control was relatively stable (from 75.7% [95% CI, 56.8%-94.7%] to 73.5% [95% CI, 40.3%-100.0%]), while glycemic control improved to a certain extent, although it remained suboptimal (from 11.8% [95% CI, 0.0%-31.5%] to 62.7% [95% CI, 62.7%-62.7%]). CONCLUSIONS From 2001 to March 2020, although prediabetes and overweight/obesity increased, hypertension, hyperlipidemia, cigarette use, and inactive physical activity decreased among US adolescents aged 12 to 19 years, whereas elevated BP, diabetes, and poor diet quality remained unchanged. There were disparities in CVRF prevalence and trends across sociodemographic subpopulations. While treatment and control rates for hypertension and diabetes plateaued, BP control were stable, and improved glycemic control was observed.
Collapse
Affiliation(s)
- Qiang Qu
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qixin Guo
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jinjing Shi
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Ziqi Chen
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jinyu Sun
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Iokfai Cheang
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Rongrong Gao
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Yanli Zhou
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Haifeng Zhang
- Department of Cardiology, Gusu School, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Nanjing Medical University, 26 Daoqian Street, Suzhou, 215002, China
- Department of Cardiology, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Shengen Liao
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Wenming Yao
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Xinli Li
- State Key Laboratory for Innovation and Transformation of Luobing Theory, Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| |
Collapse
|
6
|
Wadhera RK, Secemsky EA, Xu J, Yeh RW, Song Y, Goldhaber SZ. Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019. Circ Cardiovasc Qual Outcomes 2024; 17:e010090. [PMID: 38597091 DOI: 10.1161/circoutcomes.123.010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 01/31/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades. METHODS Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries. RESULTS A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]). CONCLUSIONS Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.
Collapse
Affiliation(s)
- Rishi K Wadhera
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Eric A Secemsky
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Jiaman Xu
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Yang Song
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.Z.G.)
| |
Collapse
|
7
|
Henry CM, Oseran AS, Zheng Z, Dong H, Wadhera RK. Cardiovascular hospitalizations and mortality among adults aged 25-64 years in the USA. Eur Heart J 2024; 45:1017-1026. [PMID: 37952173 PMCID: PMC10972685 DOI: 10.1093/eurheartj/ehad772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/28/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND AND AIMS Declines in cardiovascular mortality have stagnated in the USA since 2011. There is growing concern that these patterns reflect worsening cardiovascular health in younger adults. However, little is known about how the burden of acute cardiovascular hospitalizations and mortality has changed in this population. Changes in cardiovascular hospitalizations and mortality among adults aged 25-64 years were evaluated, overall and by community-level income. METHODS Using the National Inpatient Sample, age-standardized annual hospitalization and in-hospital mortality rates for acute myocardial infarction (AMI), heart failure, and ischaemic stroke were determined among adults aged 25-64 years. Quasi-Poisson and quasi-binominal regression models were fitted to compare outcomes between individuals residing in low- and higher-income communities. RESULTS Between 2008 and 2019, age-standardized hospitalization rates for AMI increased among younger adults from 155.0 (95% confidence interval: 154.6, 155.4) per 100 000 to 160.7 (160.3, 161.1) per 100 000 (absolute change +5.7 [5.0, 6.3], P < .001). Heart failure hospitalizations also increased (165.3 [164.8, 165.7] to 225.3 [224.8, 225.8], absolute change +60.0 (59.3, 60.6), P < .001), as ischaemic stroke hospitalizations (76.3 [76.1, 76.7] to 108.1 [107.8, 108.5], absolute change +31.7 (31.2, 32.2), P < .001). Across all conditions, hospitalizations rates were significantly higher among younger adults residing in low-income compared with higher-income communities, and disparities did not narrow between groups. In-hospital mortality decreased for all conditions over the study period. CONCLUSIONS There was an alarming increase in cardiovascular hospitalizations among younger adults in the USA from 2008 to 2019, and disparities between those residing in low- and higher-income communities did not narrow.
Collapse
Affiliation(s)
- Chantal M Henry
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel
Deaconess Medical Center and Harvard Medical School, 375
Longwood Ave, 4th Floor, Boston, MA 02215, USA
- Meharry Medical College, Nashville,
TN, USA
| | - Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel
Deaconess Medical Center and Harvard Medical School, 375
Longwood Ave, 4th Floor, Boston, MA 02215, USA
- Division of Cardiology, Massachusetts General Hospital,
Boston, MA, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard
Medical School, 330 Brookline Avenue, Boston, MA
02215, USA
| | - ZhaoNian Zheng
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel
Deaconess Medical Center and Harvard Medical School, 375
Longwood Ave, 4th Floor, Boston, MA 02215, USA
| | - Huaying Dong
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel
Deaconess Medical Center and Harvard Medical School, 375
Longwood Ave, 4th Floor, Boston, MA 02215, USA
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel
Deaconess Medical Center and Harvard Medical School, 375
Longwood Ave, 4th Floor, Boston, MA 02215, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard
Medical School, 330 Brookline Avenue, Boston, MA
02215, USA
| |
Collapse
|
8
|
Alagh A, Ramm O, Lyon LL, Ritterman Weintraub ML, Shatkin-Margolis A. Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00183. [PMID: 38465980 PMCID: PMC11380043 DOI: 10.1097/spv.0000000000001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
IMPORTANCE Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation. OBJECTIVE The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status. METHODS This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI. RESULTS Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% (P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures (P = 0.01). When controlling for age, no clinically significant difference was demonstrated. CONCLUSIONS Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.
Collapse
Affiliation(s)
- Amy Alagh
- From the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente Oakland, Kaiser Permanente East Bay-University of California San Francisco Urogynecology Fellowship Training Program
| | - Olga Ramm
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of California San Francisco, Kaiser Permanente East Bay-University of California San Francisco Urogynecology Fellowship Training Program
| | - Liisa L Lyon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Abigail Shatkin-Margolis
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of California San Francisco, Kaiser Permanente East Bay-University of California San Francisco Urogynecology Fellowship Training Program
| |
Collapse
|
9
|
Malla G, Long DL, Cherrington A, Goyal P, Guo B, Safford MM, Khodneva Y, Cummings DM, McAlexander TP, DeSilva S, Judd SE, Hidalgo B, Levitan EB, Carson AP. Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Circ Cardiovasc Qual Outcomes 2024; 17:e009867. [PMID: 38328917 PMCID: PMC10950536 DOI: 10.1161/circoutcomes.123.009867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 11/14/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status. METHODS We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term. RESULTS The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes. CONCLUSIONS In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.
Collapse
Affiliation(s)
- Gargya Malla
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - D. Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrea Cherrington
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Boyi Guo
- Departments of Family Medicine and Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Monika M. Safford
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Yulia Khodneva
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Doyle M. Cummings
- Departments of Family Medicine and Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Tara P. McAlexander
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Shanika DeSilva
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Suzanne E. Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bertha Hidalgo
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily B. Levitan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - April P. Carson
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| |
Collapse
|
10
|
Kyalwazi AN, Narasimmaraj P, Xu J, Song Y, Wadhera RK. Medicare's Value-Based Purchasing And 30-Day Mortality At Hospitals Caring For High Proportions Of Black Adults. Health Aff (Millwood) 2024; 43:118-124. [PMID: 38190594 DOI: 10.1377/hlthaff.2023.00740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The care of Black adults is highly concentrated at a limited set of US hospitals that often have limited resources. In 2011, the Medicare Hospital Value-Based Purchasing (VBP) Program began financially penalizing or rewarding hospitals based on thirty-day mortality rates for target conditions (myocardial infarction, heart failure, and pneumonia). Because the VBP Program has disproportionately penalized resource-constrained hospitals caring for high proportions of Black adults since its implementation in 2011, clinicians, health system leaders, and policy makers have worried that the program may unintentionally be widening racial disparities in health outcomes. Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.
Collapse
Affiliation(s)
| | | | - Jiaman Xu
- Jiaman Xu, Beth Israel Deaconess Medical Center
| | - Yang Song
- Yang Song, Beth Israel Deaconess Medical Center
| | | |
Collapse
|
11
|
MADDOX KARENEJOYNT. THE ROLE OF HEALTH POLICY IN IMPROVING HEALTH OUTCOMES AND HEALTH EQUITY. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2024; 134:200-213. [PMID: 39135594 PMCID: PMC11316889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Despite higher per-capita health care spending than any other country, the United States lags far behind in health outcomes. Additionally, there are significant health inequities by race, ethnicity, socioeconomic position, and rurality. One set of potential solutions to improve these outcomes and reduce inequities is through health policy. Policy focused on improving access to care through insurance coverage, such as the Affordable Care Act's Medicaid expansion, has led to better health and reduced mortality. Policy aimed at improving health care delivery, including value-based payment and alternative payment models, has improved quality of care but has had little impact on population health outcomes. Policies that influence broader issues of economic opportunity likely have a strong influence on health, but lack the evidence base of more targeted interventions. To advance health outcomes and equity, further policy change is crucial.
Collapse
|
12
|
Lusk JB, Hoffman MN, Clark AG, Mahoney H, Blass B, Bae J, Ashana DC, Cox CE, Hammill BG. Neighborhood Socioeconomic Disadvantage, Healthcare Access, and Outcomes of Hospitalizations for Common Pulmonary Conditions: A National Study of Medicare Beneficiaries. Ann Am Thorac Soc 2023; 20:1416-1424. [PMID: 37343304 DOI: 10.1513/annalsats.202304-310oc] [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] [Received: 04/05/2023] [Accepted: 06/21/2023] [Indexed: 06/23/2023] Open
Abstract
Rationale: Understanding how systemic forces and environmental exposures impact patient outcomes is critical to advancing health equity and improving population health for patients with pulmonary disease. This relationship has not yet been assessed at the population level nationally. Objectives: To determine whether neighborhood socioeconomic deprivation is independently associated with 30-day mortality and readmission for hospitalized patients with pulmonary conditions, after controlling for demographics, access to healthcare resources, and characteristics of admitting healthcare facilities. Methods: This was a retrospective, population-level cohort study of 100% of United States nationwide Medicare inpatient and outpatient claims from 2016-2019. Patients were admitted for one of four pulmonary conditions (pulmonary infections, chronic lower respiratory disease, pulmonary embolism, and pleural and interstitial lung diseases), defined by diagnosis-related group. The primary exposure was neighborhood socioeconomic deprivation, measured by the area deprivation index. The main outcomes were 30-day mortality and 30-day unplanned readmission, defined by Centers for Medicare and Medicaid Services methodologies. Generalized estimating equations were used to estimate logistic regression models for the primary outcomes, addressing clustering by hospital. A sequential adjustment strategy was first adjusted for age, legal sex, Medicare-Medicaid dual eligibility, and comorbidity burden, then adjusted for metrics of access to healthcare resources, and finally adjusted for characteristics of the admitting healthcare facility. Results: After full adjustment, patients from low socioeconomic status neighborhoods had greater 30-day mortality after admission for pulmonary embolism (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13-1.40), respiratory infections (OR, 1.20; 95% CI, 1.16-1.25), chronic lower respiratory disease (OR, 1.31; 95% CI, 1.22-1.41), and interstitial lung disease (OR, 1.15; 95% CI, 1.04-1.27) when compared to patients from the highest SES neighborhoods. Low neighborhood socioeconomic status was also associated with 30-day readmission for all groups except the interstitial lung disease group. Conclusions: Neighborhood socioeconomic deprivation may be a key factor driving poor health outcomes for patients with pulmonary diseases.
Collapse
Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine
- Duke University Fuqua School of Business
| | | | - Amy G Clark
- Duke University Department of Population Health Sciences
| | - Hannah Mahoney
- Duke University Department of Population Health Sciences
| | | | - Jonathan Bae
- Duke University Health System, and
- Duke University Department of Medicine, Duke University, Durham, North Carolina
| | - Deepshikha C Ashana
- Duke University Department of Medicine, Duke University, Durham, North Carolina
| | - Christopher E Cox
- Duke University Department of Medicine, Duke University, Durham, North Carolina
| | - Bradley G Hammill
- Duke University School of Medicine
- Duke University Department of Population Health Sciences
| |
Collapse
|
13
|
Katayama O, Lee S, Bae S, Makino K, Chiba I, Harada K, Shinkai Y, Shimada H. Differential effects of lifestyle activities on disability incidence based on neighborhood amenities. BMC Geriatr 2023; 23:483. [PMID: 37563564 PMCID: PMC10416387 DOI: 10.1186/s12877-023-04170-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 07/13/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND This study examined the effect of neighborhood amenities on disability risk among community-dwelling older adults in Japan, based on lifestyle activities. METHOD This was an observational prospective cohort study. Participants comprised 13,258 older adults from the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes. We calculated participants' Walk Score using their home addresses and divided them into three groups: "car-dependent," "somewhat walkable," and "very walkable." We then calculated the average value of lifestyle activities. We divided the neighborhood amenity groups into two groups, "fewer lifestyle activities" and "more lifestyle activities," for a total of six groups. After identifying interactions between neighborhood amenities and lifestyle activities, Cox proportional hazard models to calculate hazard ratios for incident disability risk, based on neighborhood amenities and lifestyle activities. RESULTS An interaction occurred between neighborhood amenities and lifestyle activities (p < 0.05). Survival probabilities for incident disability based on lifestyle activities were estimated for each neighborhood amenity group: car-dependent, 1.62 (95% CI 1.07 to 2.46); somewhat walkable, 1.08 (95% CI 0.84 to 1.40); and very walkable, 1.05 (95% CI 0.87 to 1.27). Those with fewer lifestyle activities in the car-dependent group exhibited the highest risk of incident disability in the unadjusted and adjusted models. CONCLUSION Given that the aging population is increasing steadily, considering older adults' neighborhood amenities and lifestyle activities in their day-to-day lives can help clinicians to deliver more older adult-centered care. Incorporating the lifestyle activities and neighborhood amenities of older adults into care planning will lead to the design and development of integrated clinical and community screening programs.
Collapse
Affiliation(s)
- Osamu Katayama
- Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu City, 474-8511, Aichi, Japan.
- Japan Society for the Promotion of Science, Tokyo, Japan.
- Columbia University Irving Medical Center, New York, USA.
| | - Sangyoon Lee
- Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu City, 474-8511, Aichi, Japan
| | - Seongryu Bae
- Department of Health Care and Science, Dong-A University, Busan, Korea
| | - Keitaro Makino
- Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu City, 474-8511, Aichi, Japan
- Japan Society for the Promotion of Science, Tokyo, Japan
| | - Ippei Chiba
- Tohoku Medical Megabank Organization (ToMMo), Tohoku University, Sendai, Japan
| | - Kenji Harada
- Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu City, 474-8511, Aichi, Japan
| | - Yohei Shinkai
- Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu City, 474-8511, Aichi, Japan
| | - Hiroyuki Shimada
- Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu City, 474-8511, Aichi, Japan
| |
Collapse
|
14
|
Lusk JB, Blass B, Mahoney H, Hoffman MN, Clark AG, Bae J, Ashana DC, Cox CE, Hammill BG. Neighborhood socioeconomic deprivation, healthcare access, and 30-day mortality and readmission after sepsis or critical illness: findings from a nationwide study. Crit Care 2023; 27:287. [PMID: 37454127 PMCID: PMC10349422 DOI: 10.1186/s13054-023-04565-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND To determine if neighborhood socioeconomic deprivation independently predicts 30-day mortality and readmission for patients with sepsis or critical illness after adjusting for individual poverty, demographics, comorbidity burden, access to healthcare, and characteristics of treating healthcare facilities. METHODS We performed a nationwide study of United States Medicare beneficiaries from 2017 to 2019. We identified hospitalized patients with severe sepsis and patients requiring prolonged mechanical ventilation, tracheostomy, or extracorporeal membrane oxygenation (ECMO) through Diagnosis Related Groups (DRGs). We estimated the association between neighborhood socioeconomic deprivation, measured by the Area Deprivation Index (ADI), and 30-day mortality and unplanned readmission using logistic regression models with restricted cubic splines. We sequentially adjusted for demographics, individual poverty, and medical comorbidities, access to healthcare services; and characteristics of treating healthcare facilities. RESULTS A total of 1,526,405 admissions were included in the mortality analysis and 1,354,548 were included in the readmission analysis. After full adjustment, 30-day mortality for patients was higher for those from most-deprived neighborhoods (ADI 100) compared to least deprived neighborhoods (ADI 1) for patients with severe sepsis (OR 1.35 95% [CI 1.29-1.42]) or with prolonged mechanical ventilation with or without sepsis (OR 1.42 [95% CI 1.31, 1.54]). This association was linear and dose dependent. However, neighborhood socioeconomic deprivation was not associated with 30-day unplanned readmission for patients with severe sepsis and was inversely associated with readmission for patients requiring prolonged mechanical ventilation with or without sepsis. CONCLUSIONS A strong association between neighborhood socioeconomic deprivation and 30-day mortality for critically ill patients is not explained by differences in individual poverty, demographics, measured baseline medical risk, access to healthcare resources, or characteristics of treating hospitals.
Collapse
Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine, Durham, NC, USA
- Duke University Fuqua School of Business, Durham, NC, USA
| | - Beau Blass
- Duke University School of Medicine, Durham, NC, USA
| | - Hannah Mahoney
- Duke University Department of Population Health Sciences, 215 Morris St, Durham, NC, 27701, USA
| | - Molly N Hoffman
- Duke University Department of Population Health Sciences, 215 Morris St, Durham, NC, 27701, USA
| | - Amy G Clark
- Duke University Department of Population Health Sciences, 215 Morris St, Durham, NC, 27701, USA
| | - Jonathan Bae
- Duke University Health System, Durham, NC, USA
- Duke University Department of Medicine, Durham, NC, USA
| | | | | | - Bradley G Hammill
- Duke University School of Medicine, Durham, NC, USA.
- Duke University Department of Population Health Sciences, 215 Morris St, Durham, NC, 27701, USA.
| |
Collapse
|
15
|
Ying X, Pan Y, Rosenblatt R, Ng C, Sholle E, Fahoum K, Jesudian A, Fortune BE. Impact of Race and Neighborhood Socioeconomic Characteristics on Liver Cancer Diagnosis in Patients with Viral Hepatitis and Cirrhosis. J Clin Exp Hepatol 2023; 13:568-575. [PMID: 37440951 PMCID: PMC10333940 DOI: 10.1016/j.jceh.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/06/2023] [Indexed: 07/15/2023] Open
Abstract
Background Concerning data have revealed that viral hepatitis and hepatocellular carcinoma (HCC) disproportionally impact non-White patients and those from lower socioeconomic status. A recent study found that HCC clusters were more likely to be in high poverty areas in New York City. Aims We aim to investigate the impacts of neighborhood characteristics on those with viral hepatitis and cirrhosis, particularly with advanced HCC diagnosis. Methods Patients with cirrhosis and viral hepatitis admitted to a New York City health system between 2012 and 2019 were included. Those with prior liver transplants were excluded. Neighborhood characteristics were obtained from US Census. Our primary outcome was HCC and advanced HCC diagnosis. Results This study included 348 patients; 209 without history of HCC, 20 with early HCC, 98 with advanced HCC, and 21 patients with HCC but no staging information. Patients with advanced HCC were more likely to be older, male, Asian, history of HBV, and increased mortality. They were more likely to live in areas with more foreign-born, limited English speakers, and less than high school education. After adjusting for age, sex, and payor type, Asian race and low income were independent risk factors for advanced HCC. Neighborhood factors were not associated with mortality or readmissions. Conclusion We observed that in addition to age and sex, Asian race, lower household income, lower education, and lower English proficiency were associated with increased risk of advanced HCC. These disparities likely reflect suboptimal screening programs and linkage to care among vulnerable populations. Further efforts are crucial to validate and address these concerning disparities.
Collapse
Affiliation(s)
- Xiaohan Ying
- NewYork Presbyterian / Weill Cornell Medical College, New York, NY, USA
| | - Yushan Pan
- Massachusetts General Hospital, Boston, MA, USA
| | - Russell Rosenblatt
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, USA
| | - Catherine Ng
- NewYork Presbyterian / Weill Cornell Medical College, New York, NY, USA
| | - Evan Sholle
- NewYork Presbyterian / Weill Cornell Medical College, New York, NY, USA
| | | | - Arun Jesudian
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, USA
| | - Brett E. Fortune
- Montefiore-Albert Einstein College of Medicine, Division of Hepatology, Bronx, NY, USA
| |
Collapse
|
16
|
Diamond J, Ayodele I, Fonarow GC, Joynt-Maddox KE, Yeh RW, Hammond G, Allen LA, Greene SJ, Chiswell K, DeVore AD, Yancy C, Wadhera RK. Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:545-553. [PMID: 37074702 PMCID: PMC10116383 DOI: 10.1001/jamacardio.2023.0695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/26/2023] [Indexed: 04/20/2023]
Abstract
Importance Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown. Objective To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals. Design, Setting, and Participants Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022. Exposures Hospitals caring for high proportions of Black patients. Main Outcomes and Measures Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients. Results This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02). Conclusions and Relevance Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.
Collapse
Affiliation(s)
- Jamie Diamond
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
| | - Karen E. Joynt-Maddox
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Gmerice Hammond
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Larry A. Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Clyde Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
17
|
Eneanya ND, Adingwupu OM, Kostelanetz S, Norris KC, Greene T, Lewis JB, Beddhu S, Boucher R, Miao S, Chaudhari J, Levey AS, Inker LA. Social Determinants of Health and Their Impact on the Black Race Coefficient in Serum Creatinine-Based Estimation of GFR: Secondary Analysis of MDRD and CRIC Studies. Clin J Am Soc Nephrol 2023; 18:446-454. [PMID: 36723299 PMCID: PMC10103283 DOI: 10.2215/cjn.0000000000000109] [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] [Received: 09/28/2022] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND The cause for differences in serum creatinine between Black and non-Black individuals incorporated into prior GFR-estimating equations is not understood. We explored whether social determinants of health can account for this difference. METHODS We conducted a secondary analysis of baseline data of the Modification of Diet in Renal Disease and Chronic Renal Insufficiency Cohort studies ( N =1628 and 1423, respectively). Data in both study cohorts were stratified by race (Black versus non-Black). We first evaluated the extent to which the coefficient of Black race in estimating GFR from creatinine is explained by correlations of race with social determinants of health and non-GFR determinants of creatinine. Second, we evaluated whether the difference between race groups in adjusted mean creatinine can be explained by social determinants of health and non-GFR determinants of creatinine. RESULTS In models regressing measured GFR on creatinine, age, sex, and race, the coefficient for Black race was 21% (95% confidence interval, 0.176 to 0.245) in Modification of Diet in Renal Disease and 13% (95% confidence interval, 0.097 to 0.155) in the Chronic Renal Insufficiency Cohort and was not attenuated by the addition of social determinants of health, alone or in combination. In both studies, the coefficient for Black race was larger at lower versus higher income levels. In models, regressing creatinine on measured GFR, age, and sex, mean creatinine was higher in Black versus non-Black participants in both studies, with no effect of social determinants of health. CONCLUSIONS Adjustment for selected social determinants of health did not influence the relationship between Black race and creatinine-based estimated GFR.
Collapse
Affiliation(s)
- Nwamaka D. Eneanya
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ogechi M. Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Keith C. Norris
- Department of Medicine, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Julia B. Lewis
- Department of Medicine, Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Srinivasan Beddhu
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, Utah
| | - Robert Boucher
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, Utah
| | - Shiyuan Miao
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Juhi Chaudhari
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Andrew S. Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Lesley A. Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
18
|
Aggarwal R, Yeh RW, Joynt Maddox KE, Wadhera RK. Cardiovascular Risk Factor Prevalence, Treatment, and Control in US Adults Aged 20 to 44 Years, 2009 to March 2020. JAMA 2023; 329:899-909. [PMID: 36871237 PMCID: PMC9986841 DOI: 10.1001/jama.2023.2307] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023]
Abstract
Importance Declines in cardiovascular mortality have stagnated in the US over the past decade, in part related to worsening risk factor control in older adults. Little is known about how the prevalence, treatment, and control of cardiovascular risk factors have changed among young adults aged 20 to 44 years. Objective To determine if the prevalence of cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, obesity, and tobacco use), treatment rates, and control changed among adults aged 20 to 44 years from 2009 through March 2020, overall and by sex and race and ethnicity. Design, Setting, and Participants Serial cross-sectional analysis of adults aged 20 to 44 years in the US participating in the National Health and Nutrition Examination Survey (2009-2010 to 2017-March 2020). Main Outcomes and Measures National trends in the prevalence of hypertension, diabetes, hyperlipidemia, obesity, and smoking history; treatment rates for hypertension and diabetes; and blood pressure and glycemic control in those receiving treatment. Results Among 12 924 US adults aged 20 to 44 years (mean age, 31.8 years; 50.6% women), the prevalence of hypertension was 9.3% (95% CI, 8.1%-10.5%) in 2009-2010 and 11.5% (95% CI, 9.6%-13.4%) in 2017-2020. The prevalence of diabetes (from 3.0% [95% CI, 2.2%-3.7%] to 4.1% [95% CI, 3.5%-4.7%]) and obesity (from 32.7% [95% CI, 30.1%-35.3%] to 40.9% [95% CI, 37.5%-44.3%]) increased from 2009-2010 to 2017-2020, while the prevalence of hyperlipidemia decreased (from 40.5% [95% CI, 38.6%-42.3%] to 36.1% [95% CI, 33.5%-38.7%]). Black adults had high rates of hypertension across the study period (2009-2010: 16.2% [95% CI, 14.0%-18.4%]; 2017-2020: 20.1% [95% CI, 16.8%-23.3%]), and significant increases in hypertension were observed among Mexican American adults (from 6.5% [95% CI, 5.0%-8.0%] to 9.5% [95% CI, 7.3%-11.7%]) and other Hispanic adults (from 4.4% [95% CI, 2.1%-6.8%] to 10.5% [95% CI, 6.8%-14.3%]), while Mexican American adults had a significant rise in diabetes (from 4.3% [95% CI, 2.3%-6.2%] to 7.5% [95% CI, 5.4%-9.6%]). The percentage of young adults treated for hypertension who achieved blood pressure control did not significantly change (from 65.0% [95% CI, 55.8%-74.2%] in 2009-2010 to 74.8% [95% CI, 67.5%-82.1%] in 2017-2020], while glycemic control among young adults receiving treatment for diabetes remained suboptimal throughout the study period (2009-2010: 45.5% [95% CI, 27.7%-63.3%]) to 2017-2020: 56.6% [95% CI, 39.2%-73.9%]). Conclusions and Relevance In the US, diabetes and obesity increased among young adults from 2009 to March 2020, while hypertension did not change and hyperlipidemia declined. There was variation in trends by race and ethnicity.
Collapse
Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Heart and Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
- Associate Editor, JAMA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Chen A, Ghosh A, Gwynn KB, Newby C, Henry TL, Pearce J, Fleurant M, Schmidt S, Bracey J, Jacobs EA. Society of General Internal Medicine Position Statement on Social Risk and Equity in Medicare's Mandatory Value-Based Payment Programs. J Gen Intern Med 2022; 37:3178-3187. [PMID: 35768676 PMCID: PMC9485310 DOI: 10.1007/s11606-022-07698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022]
Abstract
The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations - a "Reverse Robin Hood" effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.
Collapse
Affiliation(s)
- Anders Chen
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Arnab Ghosh
- Department of Medicine, Weill Cornell Medical College of Columbia University, New York, NY, USA
| | - Kendrick B Gwynn
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Celeste Newby
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tracey L Henry
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jackson Pearce
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Stacie Schmidt
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer Bracey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | |
Collapse
|