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Watson RR, Niedziela CJ, Nuzzi LC, Netson RA, McNamara CT, Ayannusi AE, Flanagan S, Massey GG, Labow BI. Impact of Insurance Type on Access to Pediatric Surgical Care. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5831. [PMID: 38798939 PMCID: PMC11124593 DOI: 10.1097/gox.0000000000005831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/01/2024] [Indexed: 05/29/2024]
Abstract
Background This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance. Methods This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex. Results A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007). Conclusions No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.
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Affiliation(s)
- Rachel R. Watson
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Cassi J. Niedziela
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Laura C. Nuzzi
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Rebecca A. Netson
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Catherine T. McNamara
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Anuoluwa E. Ayannusi
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Sarah Flanagan
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Gabrielle G. Massey
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
| | - Brian I. Labow
- From the Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, Mass
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Ratnapradipa KL, Wang R, Kabayundo J, Marquez Lavenant W, Nelson E, Ahuja M, Zhang Y, Wang H. Cross-sectional analysis of primary care clinics' policies, practices, and availability of patient support services during the COVID-19 pandemic. BMC Health Serv Res 2024; 24:279. [PMID: 38443959 PMCID: PMC10916250 DOI: 10.1186/s12913-024-10660-6] [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: 10/31/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Healthcare accessibility and utilization are important social determinants of health. Lack of access to healthcare, including missed or no-show appointments, can have negative health effects and be costly to patients and providers. Various office-based approaches and community partnerships can address patient access barriers. OBJECTIVES (1) To understand provider perceptions of patient barriers; (2) to describe the policies and practices used to address late or missed appointments, and (3) to evaluate access to patient support services, both in-clinic and with community partners. METHODS Mailed cross-sectional survey with online response option, sent to all Nebraska primary care clinics (n = 577) conducted April 2020 and January through April 2021. Chi-square tests compared rural-urban differences; logistic regression of clinical factors associated with policies and support services computed odds ratios (OR) and 95% confidence intervals (CI). RESULTS Response rate was 20.3% (n = 117), with 49 returns in 2020. Perceived patient barriers included finances, higher among rural versus urban clinics (81.6% vs. 56.1%, p =.009), and time (overall 52.3%). Welcoming environment (95.5%), telephone appointment reminders (74.8%) and streamlined admissions (69.4%) were the top three clinic practices to reduce missed appointments. Telehealth was the most commonly available patient support service in rural (79.6%) and urban (81.8%, p =.90) clinics. Number of providers was positively associated with having a patient navigator/care coordinator (OR = 1.20, CI = 1.02-1.40). For each percent increase in the number of privately insured patients, the odds of providing legal aid decreased by 4% (OR = 0.96, CI = 0.92-1.00). Urban clinics were less likely than rural clinics to provide social work services (OR = 0.16, CI = 0.04-0.67) or assist with applications for government aid (OR = 0.22, CI = 0.06-0.90). CONCLUSIONS Practices to reduce missed appointments included a variety of reminders. Although finances and inability to take time off work were the most frequently reported perceived barriers for patients' access to timely healthcare, most clinics did not directly address them. Rural clinics appeared to have more community partnerships to address underlying social determinants of health, such as transportation and assistance applying for government aid. Taking such a wholistic partnership approach is an area for future study to improve patient access.
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Affiliation(s)
- Kendra L Ratnapradipa
- Department of Epidemiology, University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE, 68198-4395, USA.
| | - Runqiu Wang
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Josiane Kabayundo
- Department of Epidemiology, University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE, 68198-4395, USA
| | - Walter Marquez Lavenant
- Department of Epidemiology, University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE, 68198-4395, USA
| | - Eleanore Nelson
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Muskan Ahuja
- Department of Epidemiology, University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE, 68198-4395, USA
| | - Ying Zhang
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hongmei Wang
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha, NE, USA
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Smith CJ, Payne VM. Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors. Hum Exp Toxicol 2024; 43:9603271241236346. [PMID: 38394684 DOI: 10.1177/09603271241236346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
INTRODUCTION In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly. METHODS Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches. RESULTS Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty. CONCLUSIONS The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.
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Affiliation(s)
- Carr J Smith
- Department of Alzheimer's Section, Society for Brain Mapping and Therapeutics, Mobile, AL, USA
| | - Victoria M Payne
- Psychiatric Associates of North Carolina Professional Association, Raleigh, NC, USA
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Butts SA, Young B, Blackmon J, Doblecki-Lewis S. Addressing disparities in Pre-exposure Prophylaxis (PrEP) access: implementing a community-centered mobile PrEP program in South Florida. BMC Health Serv Res 2023; 23:1311. [PMID: 38012701 PMCID: PMC10683210 DOI: 10.1186/s12913-023-10277-1] [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: 04/10/2023] [Accepted: 11/04/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff. METHODS Forty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis. RESULTS Participant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants. CONCLUSIONS The Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention's components and evaluate implementation determinants in other highly impacted neighborhoods.
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Affiliation(s)
- Stefani A Butts
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, USA
| | - BreAnne Young
- Department of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Jakisha Blackmon
- Department of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Susanne Doblecki-Lewis
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, USA.
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Quimby AE, Venkatesh S, Corsten M, McDonald JT, Hwa TP, Bigelow DC, Ruckenstein MJ, Johnson-Obaseki S, Brant JA. Socioeconomic Status Among Cochlear Implant Candidates and Association With Surgical Pursuance. JAMA Otolaryngol Head Neck Surg 2023; 149:891-898. [PMID: 37615991 PMCID: PMC10450586 DOI: 10.1001/jamaoto.2023.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/27/2023] [Indexed: 08/25/2023]
Abstract
Importance Despite the sizeable global burden of hearing loss, cochlear implants have poor penetrance among eligible hearing-impaired individuals. Identifying populations who may benefit from a cochlear implant but among whom penetrance is poor is an important aim in reducing the health-related and economic effects of hearing loss on both individuals and society. Objectives To explore the association of socioeconomic status (SES) with cochlear implant candidacy and the decision to undergo cochlear implantation. Design, Setting, and Participants This retrospective cohort study was performed in a tertiary academic center. All adult patients evaluated for cochlear implant candidacy from January 1, 1999, through December 31, 2022, were included in the analysis. Exposures Household income quintile and rural or urban residence were used as proxies for SES based on zip code linkage to US Census and US Department of Agriculture data. Main Outcomes and Measures Odds of cochlear implant candidacy and surgery. Results A total of 754 individuals underwent candidacy evaluations and were included in the analysis (386 [51.2%] women; mean [SD] age, 64.0 [15.7] years). Of these, 693 (91.9%) were cochlear implant candidates, and 623 candidates (89.9%) underwent cochlear implantation. Multivariable analyses demonstrated that individuals in the highest income quintile had lower odds of cochlear implant candidacy compared with those in the lowest income quintile (odds ratio [OR], 0.26 [95% CI, 0.08-0.91]), and candidates in the highest income quintile had greater odds of undergoing cochlear implant surgery compared with those in the lowest quintile (OR, 2.59 [95% CI, 1.14-5.86]). Living in a small town or a micropolitan or rural area was associated with lower odds of undergoing cochlear implant surgery compared with living in a metropolitan core (OR, 0.18 [95% CI, 0.04-0.83]) after controlling for distance to the primary implant center. Conclusions and Relevance The findings of this cohort study suggest that individuals with higher SES are less likely to qualify for a cochlear implant; however, those who qualify are more likely to undergo surgery compared with those with lower SES. These findings highlight a hearing health care disparity that should be addressed through further studies to guide population-based initiatives.
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Affiliation(s)
- Alexandra E. Quimby
- Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Sanjena Venkatesh
- currently a medical student at Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Martin Corsten
- Department of Surgery, Division of Otolaryngology–Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - James Ted McDonald
- Department of Economics, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Tiffany P. Hwa
- Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania, Philadelphia
- Department of Otolaryngology–Head & Neck Surgery, Temple University, Philadelphia, Pennsylvania
| | - Douglas C. Bigelow
- Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Michael J. Ruckenstein
- Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | | | - Jason A. Brant
- Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Gurewich D, Linsky AM, Harvey KL, Li M, Griesemer I, MacLaren RZ, Ostrow R, Mohr D. Relationship Between Unmet Social Needs and Care Access in a Veteran Cohort. J Gen Intern Med 2023:10.1007/s11606-023-08117-3. [PMID: 37340267 DOI: 10.1007/s11606-023-08117-3] [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: 06/27/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The association between unmet social needs (e.g., food insecurity) and adverse health outcomes is well-established, especially for patients with and at risk for cardiovascular disease (CVD). This has motivated healthcare systems to focus on unmet social needs. Yet, little is known about the mechanisms by which unmet social needs impact health, which limits healthcare-based intervention design and evaluation. One conceptual framework posits that unmet social needs may impact health by limiting care access, but this remains understudied. OBJECTIVE Examine the relationship between unmet social needs and care access. DESIGN Cross-sectional study design using survey data on unmet needs merged with administrative data from the Veterans Health Administration (VA) Corporate Data Warehouse (September 2019-March 2021) and multivariable models to predict care access outcomes. Pooled and separate rural and urban logistic regression models were utilized with adjustments from sociodemographics, region, and comorbidity. SUBJECTS A national stratified random sample of VA-enrolled Veterans with and at risk for CVD who responded to the survey. MAIN MEASURES No-show appointments were defined dichotomously as patients with one or more missed outpatient visits. Medication non-adherence was measured as proportion of days covered and defined dichotomously as adherence less than 80%. KEY RESULTS Greater burden of unmet social needs was associated with significantly higher odds of no-show appointments (OR = 3.27, 95% CI = 2.43, 4.39) and medication non-adherence (OR = 1.59, 95% CI = 1.19, 2.13), with similar associations observed for rural and urban Veterans. Social disconnection and legal needs were especially strong predictors of care access measures. CONCLUSIONS Findings suggest that unmet social needs may adversely impact care access. Findings also point to specific unmet social needs that may be especially impactful and thus might be prioritized for interventions, in particular social disconnection and legal needs.
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Affiliation(s)
- Deborah Gurewich
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.
- Section of General Internal Medicine, Boston University School of Medicine (BUSM), Boston, MA, USA.
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine (BUSM), Boston, MA, USA
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Kimberly L Harvey
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Mingfei Li
- CHOIR, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Mathematical Sciences, Bentley University, Waltham, MA, USA
| | - Ida Griesemer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Risette Z MacLaren
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Rory Ostrow
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - David Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Butts S, Young B, Blackmon J, Doblecki-Lewis S. Addressing Disparities in Pre-Exposure Prophylaxis (PrEP) Access: Implementing a Community-Centered Mobile PrEP Program in South Florida. RESEARCH SQUARE 2023:rs.3.rs-2799359. [PMID: 37162949 PMCID: PMC10168452 DOI: 10.21203/rs.3.rs-2799359/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff. Methods Forty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis. Results Participant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants. Conclusions The Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention's components and evaluate implementation determinants in other highly impacted neighborhoods.
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8
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Roblin DW, Goodrich GK, Davis TL, Gander JC, McCracken CE, Weinfield NS, Ritzwoller DP. Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period? Med Care 2023; 61:S39-S46. [PMID: 36893417 PMCID: PMC9994577 DOI: 10.1097/mlr.0000000000001832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND/OBJECTIVE In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits. METHODS Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program. RESULTS For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02). CONCLUSIONS Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.
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Affiliation(s)
- Douglas W. Roblin
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | | | | | | | | | - Nancy S. Weinfield
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
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Graboyes EM, Chaiyachati KH, Sisto Gall J, Johnson W, Krishnan JA, McManus SS, Thompson L, Shulman LN, Yabroff KR. Addressing Transportation Insecurity Among Patients With Cancer. J Natl Cancer Inst 2022; 114:1593-1600. [PMID: 36130286 PMCID: PMC9745432 DOI: 10.1093/jnci/djac134] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 05/04/2022] [Indexed: 01/11/2023] Open
Abstract
Health-care-related transportation insecurity is common in the United States. Patients with cancer are especially vulnerable because cancer care is episodic in nature, occurs over a prolonged period, is marked by frequent clinical encounters, requires intense treatments, and results in substantial financial hardship. As a result of transportation insecurity, patients with cancer may forego, miss, delay, alter, and/or prematurely terminate necessary care. Limited data suggest that these alterations in care have the potential to increase the rates of cancer recurrence and mortality and exacerbate disparities in cancer incidence, severity, and outcomes. Transportation insecurity also negatively impacts at the informal caregiver, provider, health system, and societal levels. Recognizing that transportation is a critical determinant of outcomes for patients with cancer, there are ongoing efforts to develop evidence-based protocols to identify at-risk patients and address transportation insecurity at federal policy, health system, not-for-profit, and industry levels. In 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing key social determinants of health including food, housing, and transportation among patients with cancer. This commentary summarizes the formal presentations and discussions related to transportation insecurity and will 1) discuss the heterogeneous nature of transportation insecurity among patients with cancer; 2) characterize its prevalence along the cancer continuum; 3) examine its multilevel consequences; 4) discuss measurement and screening tools; 5) highlight ongoing efforts to address transportation insecurity; 6) suggest policy levers; and 7) outline a research agenda to address critical knowledge gaps.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Krisda H Chaiyachati
- Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Jerry A Krishnan
- Population Health Sciences Program, University of Illinois Chicago, Chicago, IL, USA
| | - Sapna S McManus
- Chief Diversity Office, Genentech Inc, San Francisco, CA, USA
| | | | - Lawrence N Shulman
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Kennesaw, GA, USA
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Anastos-Wallen RE, Mitra N, Coburn BW, Shultz K, Rhodes C, Snider C, Eberly L, Adusumalli S, Chaiyachati KH. Primary Care Appointment Completion Rates and Telemedicine Utilization Among Black and Non-Black Patients from 2019 to 2020. Telemed J E Health 2022; 28:1786-1795. [PMID: 35501950 PMCID: PMC9805847 DOI: 10.1089/tmj.2022.0104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 01/13/2023] Open
Abstract
Objective: To understand how differences in primary care appointment completion rates between Black and non-Black patients changed in 2020 within the context of the COVID-19 pandemic and when telemedicine utilization peaked. Materials and Methods: We conducted a retrospective cohort study using the electronic health record from January 1 to December 31, 2020, among all adults scheduled for a primary care appointment within a large academic medical center. We used mixed-effects logistic regression to estimate adjusted appointment completion rates for Black patients compared with those for non-Black patients in 2020 as compared with those in 2019 within four time periods: (1) prepandemic (January 1, 2020, to March 12, 2020), (2) shutdown (March 13, 2020, to June 3, 2020), (3) reopening (June 4, 2020, to September 30, 2020), and (4) second wave (October 1, 2020, to December 31, 2020). Results: Across 1,947,399 appointments, differences in appointment completion rates between Black and non-Black patients improved in all time periods: +1.4 percentage points prepandemic (95% confidence interval [CI]: +0.8 to +2.0), +11.7 percentage points during shutdown (95% CI: +11.0 to +12.3), +8.2 percentage points during reopening (95% CI: +7.8 to +8.7), and +7.1 percentage points during second wave (95% CI: +6.4 to +7.8) (all p-values <0.001). The types of conditions managed by primary care shifted during the shutdown period, but the remainder of 2020 mirrored those from 2019. Discussion: Racial differences in appointment completion rates narrowed significantly in 2020 even as the mix of disease conditions began to mirror patterns observed in 2019. Conclusions and Relevance: Telemedicine may be an important tool for improving access to primary care for Black patients. These findings should be key considerations as regulators and payors determine telemedicine's future.
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Affiliation(s)
- Rebecca E. Anastos-Wallen
- Department of Medicine and Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Oak Street Health, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brian W. Coburn
- Department of Medicine and Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kaitlyn Shultz
- Division of General Internal Medicine, Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Corinne Rhodes
- Department of Medicine and Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher Snider
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania, USA
| | - Lauren Eberly
- Department of Medicine and Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Cardiovascular Medicine, Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Srinath Adusumalli
- Department of Medicine and Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania, USA
- Division of Cardiovascular Medicine, Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Krisda H. Chaiyachati
- Department of Medicine and Epidemiology, and Informatics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania, USA
- Penn Medicine OnDemand, Philadelphia, Pennsylvania, USA
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11
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Renshaw S, Kenawy D, Azap R, Gupta A, Poulose B, Collins C. Impact of insurance type in postoperative emergency department utilization and clinical outcomes following ventral hernia repair (VHR). Surg Endosc 2022; 36:9416-9423. [PMID: 35585286 DOI: 10.1007/s00464-022-09287-7] [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: 09/13/2021] [Accepted: 04/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Access to care and barriers to achieving health equity remain persistent and prevailing issues in the USA, particularly for low socioeconomic (L-SES) populations. Previous studies have shown that public insurance (a surrogate marker for L-SES) is an independent predictor of emergent hernia repair. However, the impact of insurance type on postoperative healthcare utilization, including emergency department (ED) care, following ventral hernia repair (VHR) remains unknown. METHODS The 2013-2020 Abdominal Core Health Quality Collaborative (ACHQC) database was used to identify patients aged 18-64 undergoing ventral hernia repair (VHR) who had private or Medicaid insurance. Patients with no health insurance were also included. Using insurance type, the cohort was divided into three groups: private, public (Medicaid), and uninsured (self-pay). Multivariate logistic regression analyses were used to assess the impact of insurance type on emergency department (ED) utilization, postoperative complications, and readmission. RESULTS A total of 17,036 patients undergoing VHR were included in the study, out of which 13,980 (85.8%) had private insurance, 2,451 (8.4%) had public, and 605 (5.8%) were uninsured. Following adjustment for demographics (age, gender, race), comorbidities (hypertension, diabetes, smoking), and clinical characteristics (emergent procedure, ASA class, surgical approach), public insurance was associated with 1.7 times greater odds of returning to the emergency department (ED) within 30 days of surgery compared to private insurance (95% CI 1.4, 2.0; p = 0.01). Public insurance or being uninsured was also associated with increased odds of experiencing any postoperative complications compared to those who were privately insured (public: OR 1.3, p < 0.01; self-pay: OR 1.67, p < 0.01). CONCLUSION Our study demonstrates that public and self-pay insurance are associated with increased emergency department (ED) utilization and worse postoperative outcomes compared to those with private insurance. In an effort to promote health equity, healthcare providers need to assess how parameters beyond physical presentation may impact a patient's health.
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Affiliation(s)
- Savannah Renshaw
- Center for Abdominal Core Health, Department of Surgery, Ohio State University Wexner Medical Center, 181 Taylor Avenue, 11th Floor, Suite 1102A, Columbus, OH, 43203, USA
| | - Dahlia Kenawy
- Center for Abdominal Core Health, Department of Surgery, Ohio State University Wexner Medical Center, 181 Taylor Avenue, 11th Floor, Suite 1102A, Columbus, OH, 43203, USA
| | - Rosevine Azap
- College of Medicine, Ohio State University Wexner Medical Center, 181 Taylor Avenue, 11th Floor, Suite 1102A, Columbus, OH, 43203, USA
| | - Anand Gupta
- Center for Abdominal Core Health, Department of Surgery, Ohio State University Wexner Medical Center, 181 Taylor Avenue, 11th Floor, Suite 1102A, Columbus, OH, 43203, USA
| | - Benjamin Poulose
- Center for Abdominal Core Health, Department of Surgery, Ohio State University Wexner Medical Center, 181 Taylor Avenue, 11th Floor, Suite 1102A, Columbus, OH, 43203, USA
| | - Courtney Collins
- Center for Abdominal Core Health, Department of Surgery, Ohio State University Wexner Medical Center, 181 Taylor Avenue, 11th Floor, Suite 1102A, Columbus, OH, 43203, USA.
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12
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Telemedicine and Socioeconomics in Orthopaedic Trauma Patients: A Quasi-Experimental Study During the COVID-19 Pandemic. J Am Acad Orthop Surg 2022; 30:910-916. [PMID: 35834815 DOI: 10.5435/jaaos-d-21-01143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/20/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Socioeconomic factors may introduce barriers to telemedicine care access. This study examines changes in clinic absenteeism for orthopaedic trauma patients after the introduction of a telemedicine postoperative follow-up option during the COVID-19 pandemic with attention to patient socioeconomic status (SES). METHODS Patients (n = 1,060) undergoing surgical treatment of pelvic and extremity trauma were retrospectively assigned to preintervention and postintervention cohorts using a quasi-experimental design. The intervention is the April 2020 introduction of a telemedicine follow-up option for postoperative trauma care. The primary outcome was the missed visit rate (MVR) for postoperative appointments. We used Poisson regression models to estimate the relative change in MVR adjusting for patient age and sex. SES-based subgroup analysis was based on the Area Deprivation Index (ADI) according to home address. RESULTS The pre-telemedicine group included 635 patients; the post-telemedicine group included 425 patients. The median MVR in the pre-telemedicine group was 28% (95% confidence interval [CI], 10% to 45%) and 24% (95% CI, 6% to 43%) in the post-telemedicine group. Low SES was associated with a 40% relative increase in MVR (95% CI, 17% to 67%, P < 0.001) compared with patients with high SES. Relative MVR changes between pre-telemedicine and post-telemedicine groups did not reach statistical significance in any socioeconomic strata (low ADI, -6%; 95% CI, -25% to 17%; P = 0.56; medium ADI, -18%; 95% CI, -35% to 2%; P = 0.07; high ADI, -12%; 95% CI, -28% to 7%; P = 0.20). CONCLUSIONS Low SES was associated with a higher MVR both before and after the introduction of a telemedicine option. However, no evidence in this cohort demonstrated a change in absenteeism based on SES after the introduction of the telemedicine option. Clinicians should be reassured that there is no evidence that telemedicine introduces additional socioeconomic bias in postoperative orthopaedic trauma care. LEVEL OF EVIDENCE III.
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13
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Senteio C, Murdock PJ. The Efficacy of Health Information Technology in Supporting Health Equity for Black and Hispanic Patients With Chronic Diseases: Systematic Review. J Med Internet Res 2022; 24:e22124. [PMID: 35377331 PMCID: PMC9016513 DOI: 10.2196/22124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/25/2020] [Accepted: 01/23/2022] [Indexed: 12/26/2022] Open
Abstract
Background Racial inequity persists for chronic disease outcomes amid the proliferation of health information technology (HIT) designed to support patients in following recommended chronic disease self-management behaviors (ie, medication behavior, physical activity, and dietary behavior and attending follow-up appointments). Numerous interventions that use consumer-oriented HIT to support self-management have been evaluated, and some of the related literature has focused on racial minorities who experience disparate chronic disease outcomes. However, little is known about the efficacy of these interventions. Objective This study aims to conduct a systematic review of the literature that describes the efficacy of consumer-oriented HIT interventions designed to support self-management involving African American and Hispanic patients with chronic diseases. Methods We followed an a priori protocol using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-Equity 2012 Extension guidelines for systematic reviews that focus on health equity. Themes of interest included the inclusion and exclusion criteria. We identified 7 electronic databases, created search strings, and conducted the searches. We initially screened results based on titles and abstracts and then performed full-text screening. We then resolved conflicts and extracted relevant data from the included articles. Results In total, there were 27 included articles. The mean sample size was 640 (SD 209.5), and 52% (14/27) of the articles focused on African American participants, 15% (4/27) of the articles focused on Hispanic participants, and 33% (9/27) included both. Most articles addressed 3 of the 4 self-management behaviors: medication (17/27, 63%), physical activity (17/27, 63%), and diet (16/27, 59%). Only 15% (4/27) of the studies focused on follow-up appointment attendance. All the articles investigated HIT for use at home, whereas 7% (2/27) included use in the hospital. Conclusions This study addresses a key gap in research that has not sufficiently examined what technology designs and capabilities may be effective for underserved populations in promoting health behavior in concordance with recommendations.
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Affiliation(s)
- Charles Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, United States
| | - Paul Joseph Murdock
- Division of Health Sciences Informatics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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14
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Kallos A, Perez A, O'Neill MG, Holt NL, Bruce A, Childs M, Kane Poitras S, Kherani T, Ladha T, Majaesic C, Ball GDC. Recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling. Child Care Health Dev 2021; 47:834-843. [PMID: 34169559 DOI: 10.1111/cch.12891] [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: 07/02/2020] [Revised: 01/28/2021] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stakeholders can provide valuable input to improve scheduling paediatric ambulatory clinic appointments, a complex process that requires effective planning and communication between parents, administrative staff and clinicians. The purpose of our study was to characterize recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling. METHODS Conducted between February 2018 and January 2019, this qualitative study was guided by qualitative description. Data collection was completed using focus groups with three stakeholder groups: parents, administrative staff and clinicians. Participants provided recommendations to optimize paediatric ambulatory appointment scheduling at the Stollery Children's Hospital in Edmonton, Alberta, Canada. Focus group data were transcribed verbatim and analysed using manifest inductive content analysis. RESULTS Forty-six participants (mean age: 42.7; 87% female) participated in 12 focus groups. Parents (n = 11), administrative staff (n = 22) and clinicians (n = 13) made recommendations that were organized into two categories: appointment triaging and arranging. Triaging recommendations were related to appointment availability (e.g. providing alternatives to cancelling clinics with short notice) and waitlist management (e.g. developing clear and consistent policies regarding information flow and communication between clinics and administrative staff). Appointment arranging recommendations referred to booking (e.g. directly involving parents in the booking process), reminders (e.g. using text message reminders) and attendance (e.g. providing parents with a single point of contact who can provide the correct information about late and cancellation policies). Recommendations were similar across stakeholder groups. CONCLUSION Our findings showed congruent recommendations across stakeholder groups to address challenges with scheduling ambulatory appointments, many of which have the potential to be modified. Experimental research and quality improvement initiatives are needed to determine the feasibility, acceptability and effectiveness of stakeholder recommendations to improve triaging and scheduling paediatric ambulatory appointments.
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Affiliation(s)
- Alecia Kallos
- Three Hive Consulting, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Arnaldo Perez
- School of Dentistry, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marcus G O'Neill
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholas L Holt
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Aisha Bruce
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Childs
- Stollery Children's Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sarah Kane Poitras
- Stollery Children's Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | - Tamizan Kherani
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Tehseen Ladha
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carina Majaesic
- Stollery Children's Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | - Geoff D C Ball
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
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15
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Fiori KP, Heller CG, Rehm CD, Parsons A, Flattau A, Braganza S, Lue K, Lauria M, Racine A. Unmet Social Needs and No-Show Visits in Primary Care in a US Northeastern Urban Health System, 2018-2019. Am J Public Health 2020; 110:S242-S250. [PMID: 32663075 PMCID: PMC7362703 DOI: 10.2105/ajph.2020.305717] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objectives. To characterize the association between social needs prevalence and no-show proportion and variation in these associations among specific social needs.Methods. In this study, we used results from a 10-item social needs screener conducted across 19 primary care practices in a large urban health system in Bronx County, New York, between April 2018 and July 2019. We estimated the association between unmet needs and 2-year history of missed appointments from 41 637 patients by using negative binomial regression models.Results. The overall no-show appointment proportion was 26.6%. Adjusted models suggest that patients with 1 or more social needs had a significantly higher no-show proportion (31.5%) than those without any social needs (26.3%), representing an 19.8% increase (P < .001). We observed a positive trend (P < .001) between the number of reported social needs and the no-show proportion-26.3% for those with no needs, 30.0% for 1 need, 32.1% for 2 needs, and 33.8% for 3 or more needs. The strongest association was for those with health care transportation need as compared with those without (36.0% vs 26.9%).Conclusions. We found unmet social needs to have a significant association with missed primary care appointments with potential implications on cost, quality, and access for health systems.
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Affiliation(s)
- Kevin P Fiori
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Caroline G Heller
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Colin D Rehm
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Amanda Parsons
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Anna Flattau
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Sandra Braganza
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Kelly Lue
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Molly Lauria
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
| | - Andrew Racine
- Kevin P. Fiori, Anna Flattau, and Sandra Braganza are with the Department of Family and Social Medicine, Albert Einstein College of Medicine (AECOM), Bronx, NY. Andrew Racine is with Montefiore Medical Group, Bronx. Kelly Lue and Molly Lauria are affiliated with the Community Health Systems Lab, Integrate Health, New York, NY. Caroline G. Heller and Colin D. Rehm are with the Office of Community and Population Health at Montefiore Health System, Bronx. Amanda Parsons is with MetroPlus Health Plan, New York
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