The World Cities Project: rationale, organization, and design for comparison of megacity health systems

Access to outpatient care in Manhattan and Paris: A tale of real change in two world cities

France's system of universal health insurance (UHI) offers more equitable access to outpatient care than the patchwork system in the U.S., which does not have a UHI system. We investigate the degree to which the implementation of the Patient Protection and Affordable Care Act (ACA) has narrowed the gap in access to outpatient care between France and the U.S. To do so, we update a previous comparison of access to outpatient care in Manhattan and Paris as measured by age-adjusted rates of hospital discharge for avoidable hospital conditions (AHCs). We compare these rates immediately before and after the implementation of the ACA in 2014. We find that AHC rates in Manhattan declined by about 25% and are now lower than those in Paris. Despite evidence that access to outpatient care in Manhattan has improved, Manhattanites continue to experience greater residence-based neighborhood inequalities in AHC rates than Parisians. In Paris, there was a 3% increase in AHC rates and neighborhood-level inequalities increased significantly. Our analysis highlights the persistence of access barriers to outpatient care in Manhattan, particularly among racial and ethnic minorities, even following the expansion of health insurance coverage.

Public health in times of crisis: An overlooked variable in city management theories?

The volume of research that associates the theme of city management with crises resulting from emerging infectious disease is modest, even after the occurrences of Ebola and Severe Acute Respiratory Syndrome. Similarly, the Coronavirus disease (COVID-19) pandemic has thus far contributed only modestly to the expansion of attention to people's health, through city management, in times of crisis. This study, by means of a systematic literature review, analyzes the gap in research on urban theory on how epidemics are confronted. The term "cities" had 2,440,607 articles published and were identified 665 that presents the combination of the term "pandemic". After the development of content analysis were identified 11 articles prior to 2019 and 10 articles published between January and June 2020, adhering to the objective of this investigation. Prior to 2019 studies addressed topics related to the construction of an urban structure aimed at reducing people's vulnerability to infectious diseases, starting in 2020, the focus of researchers' attention is on the use of information and communication technologies used as tools for prevention and control. Theories of the management of cities indicate the need to extrapolate the urban perimeter, incorporating the relations of dependence in cities with the other actors within the surroundings, especially in times of crisis. Studies have emphasized that cities are not isolated islands; rather, they are parts of a complex system with multiple exchanges. This thematic field of study enhances research that presents urban planning solutions by using data-driven management to consider conduct, parameters, and protocols relating to public health in moments of crisis.

Inequalities in avoidable hospitalisation in large urban areas: retrospective observational study in the metropolitan area of Milan

OBJECTIVE

Significant inequalities in access to healthcare system exist between residents of world megacities, even if they have different healthcare systems. The aim of this study was to estimate avoidable hospitalisations in the metropolitan area of Milan (Italy) and explore inequalities in access to healthcare between patients and across their areas of residence.

DESIGN

Retrospective observational study.

SETTING

Public and accredited private hospitals in the metropolitan area of Milan. Data obtained from the hospital discharge database of the Italian Health Ministry.

PARTICIPANTS

472 579 patients hospitalised for ambulatory care sensitive conditions and resident in the metropolitan area of Milan from 2005 to 2016.

OUTCOME MEASURE

Age-adjusted rates of avoidable hospitalisations; OR for hospital admissions with ambulatory care sensitive conditions.

METHODS

Age-adjusted rates of avoidable hospitalisations in the metropolitan area of Milan were estimated from 2005 to 2016 using direct standardisation. For the hospitalised population, multilevel logistic regression model with patient random effects was used to identify patients, hospitals and municipalities' characteristics associated with risk of avoidable hospitalisation in the period 2012-2016.

RESULTS

The rate of avoidable hospitalisation in Milan fell steadily between 2005 and 2016 from 16.6 to 10.5 per 1000. Among the hospitalised population, the odds of being hospitalised with an ambulatory care sensitive condition was higher for male (OR 1.42, 95% CI 1.36 to 1.48), older (OR 1.012, 95% CI 1.01 to 1.014), low-educated (elementary school vs degree OR 4.23, 95% CI 3.72 to 4.81) and single (vs married OR 2.08, 95% CI 2.01 to 2.16) patients with comorbidities (OR 1.47, 95% CI 1.38 to 1.56); avoidable admissions were more frequent in public non-teaching hospitals while municipality's characteristics did not appear to be correlated with hospitalisation for ambulatory care sensitive conditions.

CONCLUSIONS

The health system in metropolitan Milan has experienced a reduction in avoidable hospitalisations between 2005 and 2016, quite homogeneously across its 134 municipalities. The study design allowed to explore inequalities among the hospitalised population for which we found specific sociodemographic disadvantages.

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

Neighborhood Environment and Disparities in Health Care Access Among Urban Medicare Beneficiaries With Diabetes: A Retrospective Cohort Study

Older adults' health is sensitive to variations in neighborhood environment, yet few studies have examined how neighborhood factors influence their health care access. This study examined whether neighborhood environmental factors help to explain racial and socioeconomic disparities in health care access and outcomes among urban older adults with diabetes. Data from 123 233 diabetic Medicare beneficiaries aged 65 years and older in New York City were geocoded to measures of neighborhood walkability, public transit access, and primary care supply. In 2008, 6.4% had no office-based "evaluation and management" (E&M) visits. Multilevel logistic regression indicated that this group had greater odds of preventable hospitalization in 2009 (odds ratio = 1.31; 95% confidence interval: 1.22-1.40). Nonwhites and low-income individuals had greater odds of a lapse in E&M visits and of preventable hospitalization. Neighborhood factors did not help to explain these disparities. Further research is needed on the mechanisms underlying these disparities and older adults' ability to navigate health care. Even in an insured population living in a provider-dense city, targeted interventions may be needed to overcome barriers to chronic illness care for older adults in the community.

Comparative analysis of health system performance in Montreal and New York: the importance of context for interpreting indicators

Although eliminating financial barriers to care is a necessary condition for improving access to health services, it is not sufficient. Given the contrasting health systems with regard to financing and organization of health insurance in the United States and Canada, there is a long history of comparing these countries. We extend the empirical studies on the Canadian and US health systems by comparing access to ambulatory care as measured by hospitalization rates for ambulatory care sensitive conditions (ACSC) in Montreal and New York City. We find that, in New York, ACSC rates were more than twice as high (12.6 per 1000 population) as in Montreal (4.8 per 1000 population). After controlling for age, sex, and number of diagnoses, significant differences in ACSC rates are present in both cities, but are more pronounced in New York. Our findings are consistent with the hypothesis that universal, first-dollar health insurance coverage has contributed to lower ACSC rates in Montreal than New York. However, Montreal's surprisingly low ACSC rate calls for further research.

Developing a European urban health indicator system: results of EURO-URHIS 1

Introduction

More than half of the world's population now live in cities, including over 70% in Europe. Cities bring opportunities but can be unhealthy places to live. The poorest urban dwellers live in the worst environments and are at the greatest risk of poor health outcomes. EURO-URHIS 1 set out to compile a cross-EU inventory of member states use of measures of urban health in order to support policymakers and improve public health policy. Following a literature review to define terms and find an appropriate model to guide urban health research, EURO-URHIS Urban Areas in all EU member states except Luxembourg, as well as Croatia, Turkey, Macedonia, Iceland and Norway, were defined and selected in collaboration with project partners. Following piloting of the survey tool, a the EURO-URHIS 45 data collection tool was sent out to contacts in all countries with identified EUA's, asking for data on 45 Urban Health Indicators (UHI) and 10 other indicators. 60 questionnaires were received from 30 countries, giving information on local health indicator availability, definitions and sources. Telephone interviews were also conducted with 14 respondents about their knowledge of sources of urban health data and barriers or problems experienced when collecting the data. Most participants had little problem identifying the sources of data, though some found that data was not always routinely recorded and was held by diverse sources or not at local level. Some participants found the data collection instrument to not be user-friendly and with UHI definitions that were sometimes unclear. However, the work has demonstrated that urban health and its measurement is of major relevance and importance for Public Health across Europe. The current study has constructed an initial system of European UHIs to meet the objectives of the project, but has also clearly demonstrated that further development work is required. The importance and value of examining UHIs has been confirmed, and the scene has been set for further studies on this topic.

Needed: Global Collaboration for Comparative Research on Cities and Health

Over half of the world's population lives in cities and United Nations (UN) demographers project an increase of 2.5 billion more urban dwellers by 2050. Yet there is too little systematic comparative research on the practice of urban health policy and management (HPAM), particularly in the megacities of middle-income and developing nations. We make a case for creating a global database on cities, population health and healthcare systems. The expenses involved in data collection would be difficult to justify without some review of previous work, some agreement on indicators worth measuring, conceptual and methodological considerations to guide the construction of the global database, and a set of research questions and hypotheses to test. We, therefore, address these issues in a manner that we hope will stimulate further discussion and collaboration.

General concepts of the relationship between urban areas and mental health

PURPOSE OF REVIEW

The worldwide explosion of urbanization has spurred recent research on the environmental, socioeconomic and cultural determinants of mental health.

RECENT FINDINGS

Recent efforts by a number of researchers have focused on conceptual models in urban and mental health, which in turn have influenced research-design changes in the field. The most contextually comprehensive conceptual framework is the integrated one. Examples of the application of such a framework are provided.

SUMMARY

Recent research is shedding light on the determinants of urban mental health. An integrated conceptual model can better address the multitude of context-dependent variables affecting mental health.

Intraurban influences on physician colorectal cancer screening practices

BACKGROUND

Community social and economic resources influence colorectal (CRC) screening decisions by physicians and patients. The aim of this study is to systematically assess the differences in screening recommendations of primary care physicians within two urban communities that are distinct in socioeconomic characteristics.

METHODS

Two-hundred-sixty-four primary care community (i.e., not hospital-based) physicians were stratified by community. Using self-report questionnaires, we examined primary care physicians' CRC screening practices, knowledge of risk factors and perceived physician and patient barriers to screening, Physicians practicing in upper-socioeconomic status (SES) communities were compared with those of participants practicing in lower SES communities.

RESULTS

Physicians practicing in low-SES urban communities were significantly more likely to screen with fecal occult blood test than were physicians in upper-SES areas. Alternatively, upper-SES physicians were significantly more likely to recommend screening colonoscopy than were lower-SES physicians. The number of physicians (N=11) who screened for CRC using the double-contrast barium enema were few.

CONCLUSIONS

Community-level SES influences physician cancer screening practices. Further understanding of these relationships may guide the development of interventions targeted to specific neighborhoods within urban areas.

Governing the Sick City: Urban Governance in the Age of Emerging Infectious Disease

  Based on a case study of the 2003 severe acute respiratory syndrome (SARS) outbreak in Toronto, Canada, this article suggests that we may have to rethink our common perception of what urban governance entails. Rather than operating solely in the conceptual proximity of social cohesion and economic competitiveness, urban governance may soon prove to be more centrally concerned with questions of widespread disease, life and death and the construction of new internal boundaries and regulations just at the time that globalization seems to suggest the breakdown of some traditional scalar incisions such as national boundaries in a post-Westphalian environment. We argue that urban governance must face the new (or reemerging) challenge of dealing with infectious disease in the context of the "new normal" and that global health governance may be better off by taking the possibilities that rest in metropolitan governance more seriously.

Rural and urban perspectives on growing old: developing a new research agenda

Urban and rural themes have played an important part in European gerontological research. This paper analyses current issues in the field of urban and rural studies as applied to understanding old age. Both dimensions are being affected by population movements of different kinds, driven to a significant degree by globalisation in its various forms. The paper summarises trends underpinning rural and urban living and evidence regarding the impact of change in these areas on daily life in old age. The article considers a number of research agendas which would advance rural and urban studies of ageing, these combining developments in geography and urban studies with those in critical gerontology. The paper argues that a revitalised rural and urban gerontology will bring forward major new themes and issues for social gerontology in the 21st century.

Cities and population health

A majority of the world's population will live in urban areas by 2007 and cities are exerting growing influence on the health of both urban and non-urban residents. Although there long has been substantial interest in the associations between city living and health, relatively little work has tried to understand how and why cities affect population health. This reflects both the number and complexity of determinants and of the absence of a unified framework that integrates the multiple factors that influence the health of urban populations. This paper presents a conceptual framework for studying how urban living affects population health. The framework rests on the assumption that urban populations are defined by size, density, diversity, and complexity, and that health in urban populations is a function of living conditions that are in turn shaped by municipal determinants and global and national trends. The framework builds on previous urban health research and incorporates multiple determinants at different levels. It is intended to serve as a model to guide public health research and intervention.

Infant mortality and income in 4 world cities: New York, London, Paris, and Tokyo

OBJECTIVES

We investigated the association between average income or deprivation and infant mortality rate across neighborhoods of 4 world cities.

METHODS

Using a maximum likelihood negative binomial regression model that controls for births, we analyzed data for 1988-1992 and 1993-1997.

RESULTS

In Manhattan, for both periods, we found an association (.05% significance level) between income and infant mortality. In Tokyo, for both periods, and in Paris and London for period 1, we found none (5% significance level). For period 2, the association just missed statistical significance for Paris, whereas for London it was significant (5% level).

CONCLUSIONS

In stark contrast to Tokyo, Paris, and London, the association of income and infant mortality rate was strongly evident in Manhattan.

Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon

BACKGROUND

Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

OBJECTIVE

This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

METHODS

This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values.

RESULTS

Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease.

CONCLUSIONS

A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

Sorting out the connections between the built environment and health: a conceptual framework for navigating pathways and planning healthy cities

The overarching goal of this article is to make explicit the multiple pathways through which the built environment may potentially affect health and well-being. The loss of close collaboration between urban planning and public health professionals that characterized the post-World War II era has limited the design and implementation of effective interventions and policies that might translate into improved health for urban populations. First, we present a conceptual model that developed out of previous research called Social Determinants of Health and Environmental Health Promotion. Second, we review empirical research from both the urban planning and public health literature regarding the health effects of housing and housing interventions. And third, we wrestle with key challenges in conducting sound scientific research on connections between the built environment and health, namely: (1) the necessity of dealing with the possible health consequences of myriad public and private sector activities; (2) the lack of valid and reliable indicators of the built environment to monitor the health effects of urban planning and policy decisions, especially with regard to land use mix; and (3) the growth of the "megalopolis" or "super urban region" that requires analysis of health effects across state lines and in circumscribed areas within multiple states. We contend that to plan for healthy cities, we need to reinvigorate the historic link between urban planning and public health, and thereby conduct informed science to better guide effective public policy.