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Drake C, Alfaro JM, Rader A, Maciejewski ML, Lee MS, Xu H, Wilson LE, Berkowitz SA, Eisenson H. Association of Patient-Reported Social Needs with Emergency Department Visits and Hospitalizations Among Federally Qualified Health Center Patients. J Gen Intern Med 2024; 39:2069-2078. [PMID: 38717665 PMCID: PMC11306909 DOI: 10.1007/s11606-024-08774-y] [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: 11/03/2023] [Accepted: 04/17/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Health care systems are increasingly screening for unmet social needs. The association between patient-reported social needs and health care utilization is not well understood. OBJECTIVE To investigate the association between patient-reported social needs, measured by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), and inpatient and emergency department (ED) utilization. DESIGN This cohort study analyzed merged 2017-2019 electronic health record (EHR) data across multiple health systems. PARTICIPANTS Adult patients from a federally qualified health center (FQHC) in central North Carolina who completed PRAPARE as part of a primary care visit with behavioral health services. MAIN MEASURES The count of up to 12 unmet social needs, aggregated as 0, 1, 2, or 3 + . Outcomes include the probability of an ED visit and hospitalization 12 months after PRAPARE assessment, modeled by logistic regressions controlling for age, sex, race, ethnicity, comorbidity burden, being uninsured, and prior utilization in the past 12 months. KEY RESULTS The study population consisted of 1924 adults (38.7% male, 50.1% Black, 36.3% Hispanic, 55.9% unemployed, 68.2% of patients reported 1 + needs). Those with more needs were younger, more likely to be unemployed, and experienced greater comorbidity burden. 35.3% of patients had ED visit(s) and 36.3% had hospitalization(s) 1 year after PRAPARE assessment. In adjusted analysis, having 3 + needs was associated with a percentage point increase in the predicted probability of hospitalization (average marginal effect 0.06, SE 0.03, p < 0.05) compared with having 0 needs. Similarly, having 2 needs (0.07, SE 0.03, p < 0.05) or 3 + needs (0.06, SE 0.03, p < 0.05) was associated with increased probability of ED visits compared to 0 needs. CONCLUSIONS Patient-reported social needs were common and associated with health care utilization patterns. Future research should identify interventions to address unmet social needs to improve health and avoid potentially preventable escalating medical intervention.
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Affiliation(s)
- Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - Jorge Morales Alfaro
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke University, Sanford School of Public Policy, Durham, NC, USA
- UC Berkeley School of Public Health, Berkeley, CA, USA
| | - Abigail Rader
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Michael S Lee
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hanzhang Xu
- Duke University School of Nursing, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Seth A Berkowitz
- Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Howard Eisenson
- Department of Family Medicine and Community Health, Duke University School of Medicine, DUMC Box 2914, Durham, NC, USA
- Lincoln Community Health Center, Durham, NC, USA
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Petts RA, Baskin T, Basiru T, Ippolito S, Rothwell-Termotto H, Shahidullah JD. Health-Related Social Needs Screening and Referral in Pediatric Primary Care: A Systematic Review. J Pediatr Health Care 2024:S0891-5245(24)00142-1. [PMID: 39023460 DOI: 10.1016/j.pedhc.2024.05.012] [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: 12/17/2023] [Revised: 05/30/2024] [Accepted: 05/30/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION This study aimed to review approaches to health-related social needs (HRSN) screening and referral in pediatric primary care. METHOD PsycINFO, PubMed, and Google Scholar databases were searched to include peer-reviewed studies conducted in the U.S. over the last 30 years that reported HRSN screening and/or referral outcomes in primary care up to age 18. Studies included multiple HRSN domains and a variety of study designs. Data were summarized descriptively. RESULTS 20 studies met inclusion criteria. A variety of screening targets and modalities were employed in addition to referral support methods. Positive screens among the domains reported varied depending on the screening process and sample. DISCUSSION This review highlights a range of patient-centered innovations for HRSN screening and referral that may be adaptable to a range of local needs and capacities. Ongoing rigorous evaluation of these models is needed.
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Jung D, Song S, Ma C. Where Patients Live Matter in Emergency Department Visits in Home Health Care: Rural/Urban Status and Neighborhood Socioeconomic Status. J Appl Gerontol 2024; 43:933-944. [PMID: 37991851 DOI: 10.1177/07334648231216644] [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: 11/24/2023] Open
Abstract
An increasing body of evidence highlights the importance of an individual's place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural-urban disparities and improving home health care.
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Affiliation(s)
- Daniel Jung
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Suhang Song
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Chenjuan Ma
- Rory Meyers College of Nursing, New York University, New York, NY, USA
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Schousboe JT, Langsetmo L, Kats AM, Taylor BC, Boyd C, Van Riper D, Kado DM, Duan-Porter W, Cawthon PM, Ensrud KE. Neighborhood Socioeconomic Deprivation and Health Care Costs in Older Community-Dwelling Adults: Importance of Functional Impairment and Frailty. J Gen Intern Med 2024:10.1007/s11606-024-08875-8. [PMID: 38937364 DOI: 10.1007/s11606-024-08875-8] [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: 01/24/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain. OBJECTIVES To estimate the association of neighborhood Area Deprivation Index (ADI) with total, inpatient, outpatient, skilled nursing facility (SNF), and home health care (HHC) costs among older community-dwelling Medicare beneficiaries, and determine whether these associations are explained by multimorbidity, phenotypic frailty, or functional impairments. DESIGN Four prospective cohort studies linked with each other and with Medicare claims. PARTICIPANTS In total, 8165 community-dwelling fee-for-service beneficiaries (mean age 79.2 years, 52.9% female). MAIN MEASURES ADI of participant residence census tract, Hierarchical Conditions Category multimorbidity score, self-reported functional impairments (difficulty performing four activities of daily living), and frailty phenotype. Total, inpatient, outpatient, post-acute SNF, and HHC costs (US 2020 dollars) for 36 months after the index examination. KEY RESULTS Mean incremental annualized total health care costs adjusted for age, race/ethnicity, and sex increased with ADI ($3317 [95% CI 1274 to 5360] for the most deprived vs least deprived ADI quintile, and overall p-value for ADI variable 0.009). The incremental cost for the most deprived vs least deprived ADI quintile was increasingly attenuated after separate adjustment for multimorbidity ($2407 [95% CI 416 to 4398], overall ADI p-value 0.066), frailty phenotype ($1962 [95% CI 11 to 3913], overall ADI p-value 0.22), or functional impairments ($1246 [95% CI -706 to 3198], overall ADI p-value 0.29). CONCLUSIONS Total health care costs are higher for older community-dwelling Medicare beneficiaries residing in the most socioeconomically deprived areas compared to the least deprived areas. This association was not significant after accounting for the higher prevalence of phenotypic frailty and functional impairments among residents of socioeconomically deprived neighborhoods.
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Affiliation(s)
- John T Schousboe
- HealthPartners Institute, Bloomington, MN, USA.
- Divison of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
| | - Lisa Langsetmo
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Allyson M Kats
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Brent C Taylor
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Cynthia Boyd
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - David Van Riper
- Minnesota Population Center, University of Minnesota, Minneapolis, MN, USA
| | - Deborah M Kado
- Department of Medicine, Stanford University, Palo Alto, CA, USA
- Geriatric Research Education and Clinical Center (GRECC), VA Health Care System, Palo Alto, CA, USA
| | - Wei Duan-Porter
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Peggy M Cawthon
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Kristine E Ensrud
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
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Morenz AM, Liao JM, Au DH, Hayes SA. Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review. JAMA Netw Open 2024; 7:e2356121. [PMID: 38358740 PMCID: PMC10870184 DOI: 10.1001/jamanetworkopen.2023.56121] [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: 10/19/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models. Objective To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost. Evidence Review A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023. Findings This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending. Conclusions and Relevance The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.
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Affiliation(s)
- Anna M. Morenz
- Department of Medicine, University of Washington, Seattle
- Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, Washington
| | - Joshua M. Liao
- Department of Medicine, University of Washington, Seattle
- Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, Washington
- Now with Department of Medicine, University of Texas Southwestern Medical Center, Dallas
- Now with Program on Policy Evaluation and Learning, Dallas, Texas
| | - David H. Au
- Department of Medicine, University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Sophia A. Hayes
- Department of Medicine, University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Rivier CA, Renedo D, Sunmonu A, de Havenon A, Sheth KN, Falcone GJ. Neighborhood Deprivation, Race, Ethnicity, and Undiagnosed Hypertension: Results From the All of Us Research Program. Hypertension 2024; 81:e10-e12. [PMID: 38232143 PMCID: PMC10962384 DOI: 10.1161/hypertensionaha.123.22055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Cyprien A. Rivier
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Daniela Renedo
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Abimbola Sunmonu
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Brain and Mind Health, New Haven, CT, USA
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Hogg-Graham R, Waters TM, Clear ER, Pearson K, Benitez JA, Mays GP. Longitudinal Trends in Insurer Participation in Multisector Population Health Activities. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241249092. [PMID: 38742676 PMCID: PMC11095183 DOI: 10.1177/00469580241249092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 04/01/2024] [Accepted: 04/05/2024] [Indexed: 05/16/2024]
Abstract
Healthcare organizations increasingly engage in activities to identify and address social determinants of health (SDOH) among their patients to improve health outcomes and reduce costs. While several studies to date have focused on the evolving role of hospitals and physicians in these types of population health activities, much less is known about the role health insurers may play. We used data from the National Longitudinal Survey of Public Health Systems for the period 2006 to 2018 to examine trends in health insurer participation in population health activities and in the multi-sector collaborative networks that support these activities. We also used a difference-in-differences approach to examine the impact of Medicaid expansion on insurer participation in population health networks. Insurer participation increased in our study period both in the delivery of population health activities and in the integration into collaborative networks that support these activities. Insurers were most likely to participate in activities focusing on community health assessment and policy development. Results from our adjusted difference-in-differences models showed variation in association between insurer participation in population health networks and Medicaid expansion (Table 2). Population health networks in expansion states experienced significant increases insurer participation in assessment (4.48 percentage points, P < .05) and policy and planning (7.66 percentage points, P < .05) activities. Encouraging insurance coverage gains through policy mechanisms like Medicaid expansion may not only improve access to healthcare services but can also act as a driver of insurer integration into population health networks.
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Affiliation(s)
| | - Teresa M. Waters
- Institute for Public and Preventive Health, Augusta University, Augusta, GA, United States
| | | | | | | | - Glen P. Mays
- University of Colorado Anschutz Campus, Aurora, CO, USA
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Zdrale G, Essary A, Bremer S, Peng W, Chen W, Kalpas E. Identifying High-Cost, High-Need Patients in a Network of Community Hospitals. J Prim Care Community Health 2024; 15:21501319241233410. [PMID: 38400584 PMCID: PMC10894528 DOI: 10.1177/21501319241233410] [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: 08/25/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
We examined healthcare costs at HonorHealth, a community-based academic health center comprised of 5 hospitals and numerous ambulatory care facilities. Patient encounters that resulted in admission in 2019 were included in the study. Mean costs in 2019 for high costs and high needs (HCHN) patients were compared with all remaining patients using a framework developed by the National Academy of Medicine. HCHN patients were older (71 vs 52 years), with a lower percentage of females (41.7% vs 59.8%), more frequently White (90.1% vs 87.5%), less frequently married (52.4% vs 54.5%), with a longer length of stay (6.5 vs 3.0 days) and higher mean charges ($134 743 vs $16 414). The mean cost per patient in the HCHN group decreased by age group ($192, 963, $165 200, $144 584, $134 795, and $108 356) for 0 to 18, 19 to 44, 45 to 64, 65 to 84, and 85+ years, respectively. HCHN patients were more publicly insured (49% vs 38%). Targeted interventions to treat HCHN may lead to lower healthcare costs and improved health outcomes within this system.
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Affiliation(s)
- Gabriel Zdrale
- Arizona State University, Tempe, AZ, USA
- HonorHealth, Scottsdale, AZ, USA
| | - Alison Essary
- HonorHealth, Scottsdale, AZ, USA
- Northern Arizona University, Phoenix, AZ, USA
| | | | | | - Weiqi Chen
- Arizona State University, Tempe, AZ, USA
| | - Edward Kalpas
- Arizona State University, Tempe, AZ, USA
- HonorHealth, Scottsdale, AZ, USA
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Soleimanvandiazar N, Mohaqeqi Kamal SH, Basakha M, Karim S, Ahmadi S, Ghaedamini Harouni G, Sajjadi H, Setareh Forouzan A. Decomposition of Healthcare Utilization Inequality in Iran: The Prominent Role of Health Literacy and Neighborhood Characteristics. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241229622. [PMID: 38339828 PMCID: PMC10859068 DOI: 10.1177/00469580241229622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/27/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024]
Abstract
Unequal utilization in healthcare can potentially affect the right to health. Access to healthcare services and achieving positive health outcomes and health equity are essential principles in promoting human rights. This study aims to assess and analyze socioeconomic-related inequalities in outpatient health services utilization (OHSU) among various socio-demographic subgroups to inform policies that foster health equity. Data were collected through a cross-sectional survey of 1200 households in Tehran, Iran. Inequality in OHSU among the socio-demographic subgroups was calculated by concentration, Wagstaff, and Erigers indices. Decomposition was used to identify the factors contributing to inequality in OHSU. Marginal effect and elasticity were used to calculate the relative absolute shares of socio-demographic variables in the inequality. The rate of OHSU was 63.61% (CI: 60-66.80) which concentrated among households with better socioeconomic status. Based on the results, living in an affluent neighborhood (Relative share (RS): 85.48) and having a disabled member in the household (RS: 6.58) were the most important factors in the concentration of OHSU in favor of the privileged groups. In contrast, very low levels of health knowledge (RS: -83.79) and having basic insurance coverage (RS: -3.92) concentrated OHSU in favor of the lower socioeconomic households. The study was conducted based on survey data, and this may lead to some limitations. Given that this study was a cross-sectional study, we were unable to establish causal relationships between explanatory variables and outpatient health service utilization and its relevant predictors. Households with disabled member(s), as well as a member(s) with chronic diseases, may experience severe inequalities in access to healthcare services. Policies that facilitate access to health services for these households can play a significant role in improving health equity.
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Affiliation(s)
| | | | - Mehdi Basakha
- University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | | | - Sina Ahmadi
- Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Homeira Sajjadi
- University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Gillespie C, Wilhite JA, Hanley K, Hardowar K, Altshuler L, Fisher H, Porter B, Wallach A, Zabar S. Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs. BMJ Qual Saf 2023; 32:632-643. [PMID: 35623722 DOI: 10.1136/bmjqs-2021-013904] [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: 07/02/2021] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs. METHODS Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams. RESULTS 108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%-60%; p=0.045) and declined for the proxy comparison (61%-42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams. CONCLUSIONS Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.
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Affiliation(s)
- Colleen Gillespie
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Institute for Innovations in Medical Education, NYU Grossman School of Medicine, New York, New York, USA
| | - Jeffrey A Wilhite
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Kathleen Hanley
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
| | - Khemraj Hardowar
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Lisa Altshuler
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Harriet Fisher
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Barbara Porter
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Andrew Wallach
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
| | - Sondra Zabar
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
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Khatana SAM, Yang L, Eberly LA, Nathan AS, Gupta R, Lorch SA, Groeneveld PW. Medicaid Expansion And Outpatient Cardiovascular Care Use Among Low-Income Nonelderly Adults, 2012-15. Health Aff (Millwood) 2023; 42:1586-1594. [PMID: 37931196 PMCID: PMC10923246 DOI: 10.1377/hlthaff.2023.00512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Adults with lower socioeconomic status have a disproportionately higher burden of cardiovascular disease. Medicaid expansion under the Affordable Care Act, which went into effect January 1, 2014, in adopting states, led to an expansion of health insurance coverage for low-income adults. To understand whether Medicaid expansion was associated with increased access to outpatient cardiovascular care in expansion states, we examined Medicaid Analytic eXtract administrative claims data for nonelderly adult beneficiaries from the period 2012-15 for two states that expanded Medicaid eligibility (New Jersey and Minnesota) and two states that did not (Georgia and Tennessee) and calculated population-level rates of cardiovascular care use. There was a 38.1 percent greater increase in expansion states in the rate of beneficiaries with outpatient visits for cardiovascular disease management associated with Medicaid expansion relative to nonexpansion states. This was accompanied by a 42.9 percent greater increase in the prescription rate for cardiovascular disease management agents. These results suggest that expansion of Medicaid eligibility was associated with an increase in cardiovascular care use among low-income nonelderly adults in expansion states.
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Affiliation(s)
- Sameed Ahmed M Khatana
- Sameed Ahmed M. Khatana , University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Lin Yang
- Lin Yang, University of Pennsylvania
| | | | | | - Ravi Gupta
- Ravi Gupta, Johns Hopkins University, Baltimore, Maryland
| | - Scott A Lorch
- Scott A. Lorch, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Peter W. Groeneveld, University of Pennsylvania and Corporal Michael J. Crescenz VA Medical Center
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12
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Mota L, Marcaccio CL, Zhu M, Moreira CC, Rowe VL, Hughes K, Liang P, Schermerhorn ML. Impact of neighborhood social disadvantage on the presentation and management of peripheral artery disease. J Vasc Surg 2023; 77:1477-1485. [PMID: 36626955 PMCID: PMC10122713 DOI: 10.1016/j.jvs.2022.12.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Studies examining the relationship between socioeconomic disparities and peripheral artery disease (PAD) often focus on individual social health determinants and fail to account for the complex interplay between factors that ultimately impact disease severity and outcomes. Area deprivation index (ADI), a validated measure of neighborhood adversity, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on PAD severity and its management. METHODS We identified all patients who underwent infrainguinal revascularization (open or endovascular) or amputation for symptomatic PAD in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing adversity. Patients were categorized by ADI quintiles (Q1-Q5). The outcomes of interest included indication for procedure (claudication, rest pain, or tissue loss) and rates of revascularization (vs primary amputation). Multinomial logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes. RESULTS Among the 79,973 patients identified, 9604 (12%) were in the lowest ADI quintile (Q1), 14,961 (18.7%) in Q2, 19,800 (24.8%) in Q3, 21,735 (27.2%) in Q4, and 13,873 (17.4%) in Q5. There were significant trends toward lower rates of claudication (Q1: 39% vs Q5: 34%, P < .001), higher rates of rest pain (Q1: 12.4% vs Q5: 17.8%, P < .001) as the indication for intervention, and lower rates of revascularization (Q1: 80% vs Q5: 69%, P < .001) with increasing ADI quintiles. In adjusted analyses, there was a progressively higher likelihood of presenting with rest pain vs claudication, with patients in Q5 having the highest probability when compared with those in Q1 (relative risk: 2.0; 95% confidence interval: 1.8-2.2; P < .001). Patients in Q5, when compared with those in Q1, also had a higher likelihood of presenting with tissue loss vs claudication (relative risk: 1.4; 95% confidence interval: 1.3-1.6; P < .001). Compared with patients in Q1, patients in Q2-Q5 had a lower likelihood of undergoing any revascularization procedure. CONCLUSIONS Among patients who underwent infrainguinal revascularization or amputation in the Vascular Quality Initiative, those with higher neighborhood adversity had more advanced disease at presentation and lower rates of revascularization. Further work is needed to better understand neighborhood factors that are contributing to these disparities in order to identify community-level targets for improvement.
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Affiliation(s)
- Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Max Zhu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Carla C Moreira
- Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Vincent L Rowe
- Division of Vascular Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Kakra Hughes
- Division of Vascular Surgery, Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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13
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Mota L, Marcaccio CL, Patel PB, Soden PA, Moreira CC, Stangenberg L, Hughes K, Schermerhorn ML. The impact of neighborhood social disadvantage on abdominal aortic aneurysm severity and management. J Vasc Surg 2023; 77:1077-1086.e2. [PMID: 36347436 PMCID: PMC10038823 DOI: 10.1016/j.jvs.2022.10.048] [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: 07/05/2022] [Revised: 09/22/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent studies have highlighted socioeconomic disparities in the severity and management of abdominal aortic aneurysm (AAA) disease. However, these studies focus on individual measures of social disadvantage such as income and insurance status. The area deprivation index (ADI), a validated measure of neighborhood deprivation, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on AAA severity and its management. METHODS We identified all patients who underwent endovascular or open repair of an AAA in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing deprivation. Patients were categorized by ADI quintiles. Outcomes of interest included rates of ruptured AAA (rAAA) repair versus an intact AAA repair and rates of endovascular repair (EVAR) versus the open approach. Logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes. RESULTS Among 55,931 patients who underwent AAA repair, 6649 (12%) were in the lowest ADI quintile, 11,692 (21%) in the second, 15,958 (29%) in the third, 15,035 (27%) in the fourth, and 6597 (12%) in the highest ADI quintile. Patients in the two highest ADI quintiles had a higher proportion of rAAA repair (vs intact repair) compared with those in the lowest ADI quintile (8.8% and 9.1% vs 6.2%; P < .001). They were also less likely to undergo EVAR (vs open approach) when compared with the lowest ADI quintile (81% and 81% vs 88%; P < .001). There was an overall trend toward increasing rAAA and decreasing EVAR rates with increasing ADI quintiles (P < .001). In adjusted analyses, when compared with patients in the lowest ADI quintile, patients in the highest ADI quintile had higher odds of rAAA repair (odds ratio, 1.4; 95% confidence interval, 1.2-1.8; P < .001) and lower odds of undergoing EVAR (odds ratio, 0.54; 95% confidence interval, 0.45-0.65; P < .001). CONCLUSIONS Among patients who underwent AAA repair in the Vascular Quality Initiative, those with higher neighborhood deprivation had significantly higher rates of rAAA repair (vs intact repair) and lower rates of EVAR (vs open approach). Further work is needed to better understand neighborhood factors that are contributing to these disparities to identify community-level targets for improvement.
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Affiliation(s)
- Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Peter A Soden
- Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Carla C Moreira
- Division of Vascular Surgery, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kakra Hughes
- Division of Vascular Surgery, Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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14
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Impact of neighborhood social disadvantage on carotid artery disease presentation, management, and discharge outcomes. J Vasc Surg 2023; 77:1700-1709.e2. [PMID: 36787807 DOI: 10.1016/j.jvs.2023.01.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Recent studies have highlighted that race and socioeconomic status serve as important determinants of disease presentation and perioperative outcomes in carotid artery disease. However, these investigations only focus on individual factors of social disadvantage, and fail to account for community factors that may drive disparities. Area Deprivation Index (ADI) is a validated measure of neighborhood adversity that offers a more comprehensive assessment of social disadvantage. We examined the impact of ADI ranking on carotid artery disease severity, management, and postoperative outcomes. METHODS We identified patients who underwent carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR) in the Vascular Quality Initiative registry between 2016 and 2020. Patients were assigned ADI scores of 1 to 100 based on zip codes and grouped into quintiles, with higher quintiles reflecting increasing adversity. Outcomes assessed included disease presentation, intervention type, and discharge patterns. Logistic regression was used to evaluate independent associations between ADI quintiles and these outcomes. RESULTS Among 91,904 patients undergoing carotid revascularization, 9811 (10.7%) were in the lowest ADI quintile (Q1), 18,905 (20.6%) in Q2, 25,442 (27.7%) in Q3, 26,099 (28.4%) in Q4, and 11,647 (12.7%) in Q5. With increasing ADI quintiles, patients were more likely to present with symptomatic disease (Q5, 52.1% vs Q1, 46.6%; P < .001), and stroke vs transient ischemic attack (Q5, 63.1% vs Q1, 53.5%; P < .001); they also more frequently underwent CAS vs CEA (Q5, 46.4% vs Q1, 33.9%; P < .001), and specifically tfCAS vs TCAR (Q5, 54.2% vs Q1, 33.9%; P < .001). In adjusted analyses, higher ADI quintiles remained as independent risk factors for presenting with symptomatic disease and stroke and undergoing CAS and tfCAS. Across ADI quintiles, patients were more likely to experience death (Q5, 0.8% vs Q1, 0.4%; P < .001), stroke/death (Q5, 2.1% vs Q1, 1.6%; P = .001), failure to discharge home (Q5, 11.5% vs Q1, 8.0%; P < .001) and length of stay >2 days (Q5, 33.3% vs Q1, 26.3%; P < .001) following revascularization. CONCLUSIONS Among carotid revascularization patients, those with greater neighborhood social disadvantage had greater disease severity and more frequently underwent tfCAS. These patients also had higher rates of death and stroke/death, were less frequently discharged home, and had prolonged hospital stays. Greater efforts are needed to ensure that patients in higher ADI quintiles undergo better carotid surveillance and are treated appropriately for their carotid artery disease.
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Grembowski D, Leibbrand C. A conceptual model of health insurance stability in the United States health care system. Health Serv Manage Res 2022:9514848221146677. [DOI: 10.1177/09514848221146677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.
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Affiliation(s)
- David Grembowski
- Health Systems and Population Health, University of Washington, Seattle, WA, USA
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16
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Wood SM, Yue M, Kotsis SV, Seyferth AV, Wang L, Chung KC. Preventable Hospitalization Trends Before and After the Affordable Care Act. AJPM FOCUS 2022; 1:100027. [PMID: 37791234 PMCID: PMC10546541 DOI: 10.1016/j.focus.2022.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction The Patient Protection and Affordable Care Act aimed to increase the number of individuals with health insurance, which may lead to adequate primary care management and reduced rates of preventable hospitalizations. To investigate the rates of preventable hospitalization after the passing of the Affordable Care Act in 2010 and Medicaid expansion in 2014 across 26 states, a population-based study was conducted using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2005-2017. Methods A logistic regression and trend analysis was performed to assess the changes in preventable hospitalization rates over time and the impact of policy changes on the rate of preventable hospitalization. Individuals were included if they were aged between 18 and 64 years and had a preventable quality indicator International Classification of Diseases, Ninth or Tenth Revision code as determined by the Agency for Healthcare Research and Quality. Results More than 45 million preventable-hospitalization admissions were reported between 2005 and 2017. There was a significant decrease in preventable hospitalization rates after the passing of the Affordable Care Act from 12.0% to 10.8% (p<0.01) and from 11.5% to 10.6% (p<0.01) after Medicaid expansion. Bacterial pneumonia declined from 1.5% to 0.6% (p<0.01), along with chronic obstructive pulmonary disease and asthma in older adults from 1.9% to 1.7% (p=0.01) after the expansion. Conclusions States that have not implemented Medicaid expansion should make it a priority because it may lead to a reduction in preventable hospitalization rates. Furthermore, preventable hospitalization rates may be considered a quality measure to examine the accessibility and effectiveness of primary care intervention.
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Affiliation(s)
- Shannon M. Wood
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Molin Yue
- University of Pittsburg, Pittsburg, Pennsylvania
| | - Sandra V. Kotsis
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Anne V. Seyferth
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lu Wang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, Michigan
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Zhang Y, Flory JH, Bao Y. Chronic Medication Nonadherence and Potentially Preventable Healthcare Utilization and Spending Among Medicare Patients. J Gen Intern Med 2022; 37:3645-3652. [PMID: 35018567 PMCID: PMC9585123 DOI: 10.1007/s11606-021-07334-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/14/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The association between nonadherence to chronic medications and potentially preventable healthcare utilization and spending is largely unknown. OBJECTIVES To examine the associations of chronic medication nonadherence with potentially preventable utilization and spending among patients who were prescribed diabetic medications, renin-angiotensin system antagonists (RASA) for hypertension, or statins for high cholesterol, and compare the associations by patient race/ethnicity and socioeconomic status. DESIGN Retrospective cohort study. Medicare fee-for-service claims data from 2013 to 2016 for 177,881 patients. MEASURES Medication nonadherence was defined as having a below 80% proportion of days covered in each 6-month interval after the index prescription. Potentially preventable utilization was measured by preventable emergency department visits and preventable hospitalizations. Potentially preventable spending was calculated as the geographically adjusted spending associated with preventable encounters. RESULTS After adjustment for other patient characteristics, medication nonadherence was associated with a 1.7-percentage-point increase (95% confidence interval [CI]: 1.4 to 2.0 percentage points, p < 0.001) in the probability of preventable utilization among the diabetic medication cohort, a 1.7-percentage-point increase (95% CI: 1.5 to 1.9 percentage points, p < 0.001) among the RASA cohort, and a 1.0-percentage-point increase (95% CI: 0.8 to 1.1 percentage points, p < 0.001) among the statin cohort. Among patients with at least one preventable encounter, medication nonadherence was associated with $679-$898 increased preventable spending. The incremental probability of preventable utilization and incremental spending associated with nonadherence were higher among racial/ethnic minority and low socioeconomic groups. CONCLUSIONS Improving medication adherence is a potential avenue to reducing preventable utilization and spending. Interventions are needed to address racial/ethnic and socioeconomic disparities.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA.
| | - James H Flory
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
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Preussler JM, Meyer CL, Sees Coles JA, Yoo D, Mau LW, Garrett ND, Auletta JJ. Enhancing Administrative Claims Data: Feasibility, Validation and Application of Linking Medicare Claims Data and National Marrow Donor Program Search Data. JCO Clin Cancer Inform 2022; 6:e2200069. [PMID: 36228178 PMCID: PMC9848571 DOI: 10.1200/cci.22.00069] [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: 05/05/2022] [Revised: 06/22/2022] [Accepted: 08/26/2022] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Administrative claims data provide real-world service utilization of acute myeloid leukemia (AML) treatment, but lacks insight into treatment delays or barriers. The National Marrow Donor Program (NMDP)/Be The Match Search (Search) data contains information on donor search, but lacks information on treatment received if allogeneic hematopoietic cell transplant (HCT) is not performed. We hypothesized that linking these two data sets would create a rich resource to define factors associated with receiving HCT that could not be evaluated with either data set alone. METHODS A subset of 2010-2016 Medicare administrative claims data was linked with Search data. A total of 5,351 patients with AML age 65-74 years (HCT = 607, no HCT = 4,744) were identified using Medicare. These patients were then linked to 93,800 records with a donor search between 2009 and 2016. Patient date of birth, sex, disease, ZIP code, transplant center/hospital, and diagnosis date were used for matching. Exploratory analysis was conducted to identify predictors associated with receiving HCT for patients with AML who received a search. RESULTS The data sets were successfully linked, showing high sensitivity and specificity. The final cohort included 5,085 patients with AML (HCT = 533, no HCT = 4,552). Of 97 patients who received HCT without a matched search, more than 85% received a related donor HCT. Of those not receiving HCT, 609 had a matched NMDP search and 3,943 did not have a matched NMDP search. Multivariate analysis showed time to search, age, diagnosis year, race/ethnicity, and neighborhood education status associated with receiving HCT. CONCLUSION Methods herein demonstrate the feasibility of linking Search and Medicare data. Similar methods may be applied to answer critical questions regarding barriers to HCT, thereby identifying areas to improve access to care.
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Affiliation(s)
- Jaime M. Preussler
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Christa L. Meyer
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Jennifer A. Sees Coles
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Dana Yoo
- National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Lih-Wen Mau
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | | | - Jeffery J. Auletta
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
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Hollin IL, Bonilla B, Bagley A, Tucker CA. Social and environmental determinants of health among children with long-term movement impairment. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:831070. [PMID: 36188898 PMCID: PMC9397841 DOI: 10.3389/fresc.2022.831070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/13/2022] [Indexed: 11/13/2022]
Abstract
The healthcare research community increasingly recognizes the need to address social (SDOH) and environmental determinants of health (EDOH) to optimize health and healthcare. This is particularly relevant to disability and functioning and to those with child onset conditions that impair mobility and impact functioning and participation. Using the World Health Organization (WHO)'s International Classification of Functioning, Disability, and Health (ICF) as a comprehensive framework, this paper aims to discuss our understanding of the relationships between social and EDOH and outcomes among people with impaired mobility that impacts functioning. This paper offers suggestions for future developments and guidance to use SDOH and EDOH in research and clinical practice.
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Affiliation(s)
- Ilene L. Hollin
- Department of Health Services Administration and Policy, Temple University College of Public Health, Philadelphia, PA, United States
- *Correspondence: Ilene L. Hollin
| | - Bethney Bonilla
- Center for Healthcare Policy and Research, University of California, Davis, Davis, CA, United States
- Bethney Bonilla
| | - Anita Bagley
- Clinical Research, Shriners Hospitals for Children, Northern California, Sacramento, CA, United States
| | - Carole A. Tucker
- Department of Nutrition, Metabolic and Rehabilitation Sciences, University of Texas Medical Branch, School of Health Professions, Galveston, TX, United States
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Miller-Rosales C, McCloskey J, Uratsu CS, Ralston JD, Bayliss EA, Grant RW. Associations Between Different Self-reported Social Risks and Neighborhood-level Resources in Medicaid Patients. Med Care 2022; 60:563-569. [PMID: 35640038 PMCID: PMC9262842 DOI: 10.1097/mlr.0000000000001735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adverse social conditions are a key contributor to health disparities. Improved understanding of how social risk factors interact with each other and with neighborhood characteristics may inform efforts to reduce health disparities. DATA A questionnaire of 29,281 patients was collected through the enrollment of Medicaid beneficiaries in a large Northern California integrated health care delivery system between May 2016 and February 2020. EXPOSURES Living in the least resourced quartile of neighborhoods as measured by a census-tract level Neighborhood Deprivation Index score. MAIN OUTCOMES Five self-reported social risk factors: financial need, food insecurity, housing barriers, transportation barriers, and functional limitations. RESULTS Nearly half (42.0%) of patients reported at least 1 social risk factor; 22.4% reported 2 or more. Mean correlation coefficient between social risk factors was ρ=0.30. Multivariable logistic models controlling for age, race/ethnicity, sex, count of chronic conditions, and insurance source estimated that living in the least resourced neighborhoods was associated with greater odds of food insecurity (adjusted odds ratio=1.07, 95% confidence interval: 1.00-1.13) and transportation barriers (adjusted odds ratio=1.20, 95% confidence interval: 1.11-1.30), but not financial stress, housing barriers, or functional limitations. CONCLUSIONS AND RELEVANCE We found that among 5 commonly associated social risk factors, Medicaid patients in a large Northern California health system typically reported only a single factor and that these factors did not correlate strongly with each other. We found only modestly greater social risk reported by patients in the least resourced neighborhoods. These results suggest that individual-level interventions should be targeted to specific needs whereas community-level interventions may be similarly important across diverse neighborhoods.
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Affiliation(s)
| | - Jodi McCloskey
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Connie S. Uratsu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - James D. Ralston
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle WA
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Min JY, Williams N, Simmons W, Banerjee S, Wang F, Zhang Y, Reese AB, Mushlin AI, Flory JH. Baseline haemoglobin A1c and the risk of COVID-19 hospitalization among patients with diabetes in the INSIGHT Clinical Research Network. Diabet Med 2022; 39:e14815. [PMID: 35179807 PMCID: PMC9111874 DOI: 10.1111/dme.14815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/06/2022] [Accepted: 02/16/2022] [Indexed: 11/26/2022]
Abstract
AIMS To examine the association between baseline glucose control and risk of COVID-19 hospitalization and in-hospital death among patients with diabetes. METHODS We performed a retrospective cohort study of adult patients in the INSIGHT Clinical Research Network with a diabetes diagnosis and haemoglobin A1c (HbA1c) measurement in the year prior to an index date of March 15, 2020. Patients were divided into four exposure groups based on their most recent HbA1c measurement (in mmol/mol): 39-46 (5.7%-6.4%), 48-57 (6.5%-7.4%), 58-85 (7.5%-9.9%), and ≥86 (10%). Time to COVID-19 hospitalization was compared in the four groups in a propensity score-weighted Cox proportional hazards model adjusting for potential confounders. Patients were followed until June 15, 2020. In-hospital death was examined as a secondary outcome. RESULTS Of 168,803 patients who met inclusion criteria; 50,016 patients had baseline HbA1c 39-46 (5.7%-6.4%); 54,729 had HbA1c 48-57 (6.5-7.4%); 47,640 had HbA1c 58-85 (7.5^%-9.9%) and 16,418 had HbA1c ≥86 (10%). Compared with patients with HbA1c 48-57 (6.5%-7.4%), the risk of hospitalization was incrementally greater for those with HbA1c 58-85 (7.5%-9.9%) (adjusted hazard ratio [aHR] 1.19, 95% confidence interval [CI] 1.06-1.34) and HbA1c ≥86 (10%) (aHR 1.40, 95% CI 1.19-1.64). The risk of COVID-19 in-hospital death was increased only in patients with HbA1c 58-85 (7.5%-9.9%) (aHR 1.29, 95% CI 1.06, 1.61). CONCLUSIONS Diabetes patients with high baseline HbA1c had a greater risk of COVID-19 hospitalization, although association between HbA1c and in-hospital death was less consistent. Preventive efforts for COVID-19 should be focused on diabetes patients with poor glucose control.
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Affiliation(s)
- Jea Young Min
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Nicholas Williams
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Will Simmons
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Samprit Banerjee
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Fei Wang
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Yongkang Zhang
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | | | - Alvin I. Mushlin
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - James H. Flory
- Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNew YorkUSA
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Shin DY, Chang J, Ramamonjiarivelo ZH, Medina M. Does Geographic Location Affect the Quality of Care? The Difference in Readmission Rates Between the Border and Non-Border Hospitals in Texas. Risk Manag Healthc Policy 2022; 15:1011-1023. [PMID: 35585871 PMCID: PMC9109891 DOI: 10.2147/rmhp.s356827] [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: 01/14/2022] [Accepted: 04/24/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Materials and Methods Results Conclusion
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Affiliation(s)
- Dong Yeong Shin
- Department of Public Health Sciences, New Mexico State University, Las Cruces, NM, USA
| | - Jongwha Chang
- Department of Healthcare Administration, College of Business, Texas Woman’s University, Denton, TX, USA
- Correspondence: Jongwha Chang, Healthcare Administration, College of Business, Texas Woman’s University, 304 Administration Dr., Denton, TX, 76204, USA, Email
| | | | - Mar Medina
- School of Pharmacy, University of Texas at El Paso, El Paso, TX, USA
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23
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Sparling A, Walls M, Mayfield CA, Priem JS, Durham J, Hetherington T, Taylor YJ. Racial/Ethnic Disparities in Health Care Setting Choice for Adults Seeking Severe Acute Respiratory Syndrome Coronavirus 2 Testing. Med Care 2022; 60:3-12. [PMID: 34739414 PMCID: PMC8662947 DOI: 10.1097/mlr.0000000000001654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Equitable access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing is important for reducing disparities. We sought to examine differences in the health care setting choice for SARS-CoV-2 testing by race/ethnicity and insurance. Options included traditional health care settings and mobile testing units (MTUs) targeting communities experiencing disproportionately high coronavirus disease 2019 (COVID-19) rates. METHODS We conducted a retrospective, observational study among patients in a large health system in the Southeastern US. Descriptive statistics and multinomial logistic regression analyses were employed to evaluate associations between patient characteristics and health care setting choice for SARS-CoV-2 testing, defined as: (1) outpatient (OP) care; (2) emergency department (ED); (3) urgent care (UC); and (4) MTUs. Patient characteristics included race/ethnicity, insurance, and the existence of an established relationship with the health care system. RESULTS Our analytic sample included 105,386 adult patients tested for SARS-CoV-2. Overall, 55% of patients sought care at OP, 24% at ED, 12% at UC, and 9% at MTU. The sample was 58% White, 24% Black, 11% Hispanic, and 8% other race/ethnicity. Black patients had a higher likelihood of getting tested through the ED compared with White patients. Hispanic patients had the highest likelihood of testing at MTUs. Patients without a primary care provider had a higher relative risk of being tested through the ED and MTUs versus OP. CONCLUSIONS Disparities by race/ethnicity were present in health care setting choice for SARS-CoV-2 testing. Health care systems may consider implementing mobile care delivery models to reach vulnerable populations. Our findings support the need for systemic change to increase primary care and health care access beyond short-term pandemic solutions.
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Affiliation(s)
| | - Morgan Walls
- Division of Academic General Pediatrics, Deparment of Pediatrics
| | | | | | - Jason Durham
- Information and Analytic Services, Atrium Health, Charlotte, NC
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24
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Prescription smoking-cessation medication pharmacy claims after stroke and transient ischemic attack. Prev Med Rep 2021; 25:101682. [PMID: 35127360 PMCID: PMC8800020 DOI: 10.1016/j.pmedr.2021.101682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/07/2021] [Accepted: 12/25/2021] [Indexed: 11/27/2022] Open
Abstract
Smoking cessation is critical in secondary prevention after stroke and transient ischemic attack. Data regarding use of smoking-cessation interventions after stroke and transient ischemic attack are sparse. We examined the use of prescription smoking-cessation medications in these patients. This is a retrospective cohort study using 2013-2016 data from the INSIGHT Clinical Research Network, comprised of Medicare prescription claims data merged with electronic health record data for patients receiving care across five New York City health care institutions. Active smoking was ascertained based on a validated ICD-9-CM diagnosis code or the presence of an electronic health record active smoking indicator, reflecting clinician-entered data in the health record. The primary outcome was a claim for any prescription smoking-cessation medication (varenicline or bupropion) within 12 months of hospital discharge. We evaluated claims for any statin medication as a comparator because statins are a standard component of stroke secondary prevention. We identified 3,153 patients with stroke or transient ischemic attack who were active smokers at the time of their event. Among these patients, 3.1% (95% CI, 2.5-3.9) had a pharmacy claim for a prescription smoking-cessation medication at 6 months, and 4.7% (95% CI, 3.9-5.6) did at 12 months hospital discharge. In contrast, cumulative statin medication claims rates were 67.5% (95% CI, 65.5-69.5%) at 6 months and 74.6% (95% CI, 72.7-76.6%) at 12 months. Prescription smoking-cessation medications were infrequently used after stroke and transient ischemic attack.
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25
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Attiq A, Yao LJ, Afzal S, Khan MA. The triumvirate of NF-κB, inflammation and cytokine storm in COVID-19. Int Immunopharmacol 2021; 101:108255. [PMID: 34688149 PMCID: PMC8516728 DOI: 10.1016/j.intimp.2021.108255] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 01/08/2023]
Abstract
The coronavirus disease (COVID-19) has once again reminded us of the significance of host immune response and consequential havocs of the immune dysregulation. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) inflicts severe complications to the infected host, including cough, dyspnoea, fever, septic shock, acute respiratory distress syndrome (ARDs), and multiple organ failure. These manifestations are the consequence of the dysregulated immune system, which gives rise to excessive and unattended production of pro-inflammatory mediators. Elevated circulatory cytokine and chemokine levels are accompanied by spontaneous haemorrhage, thrombocytopenia and systemic inflammation, which are the cardinal features of life-threatening cytokine storm syndrome in advanced COVID-19 diseases. Coronavirus hijacked NF-kappa B (NF-κB) is responsible for upregulating the expressions of inflammatory cytokine, chemokine, alarmins and inducible enzymes, which paves the pathway for cytokine storm. Given the scenario, the systemic approach of simultaneous inhibition of NF-κB offers an attractive therapeutic intervention. Targeted therapies with proteasome inhibitor (VL-01, bortezomib, carfilzomib and ixazomib), bruton tyrosine kinase inhibitor (acalabrutinib), nucleotide analogue (remdesivir), TNF-α monoclonal antibodies (infliximab and adalimumab), N-acetylcysteine and corticosteroids (dexamethasone), focusing the NF-κB inhibition have demonstrated effectiveness in terms of the significant decrease in morbidity and mortality in severe COVID-19 patients. Hence, this review highlights the activation, signal transduction and cross-talk of NF-κB with regard to cytokine storm in COVID-19. Moreover, the development of therapeutic strategies based on NF-κB inhibition are also discussed herein.
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Affiliation(s)
- Ali Attiq
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, MAHSA University, Bandar Saujana Putra, 42610 Jenjarom, Selangor, Malaysia.
| | - Lui Jin Yao
- Kuala Balah Health Clinic (Klinik Kesihatan Kuala Balah), Kuala Balah, 17600 Jeli, Kelantan, Malaysia
| | - Sheryar Afzal
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, MAHSA University, Bandar Saujana Putra, 42610 Jenjarom, Selangor, Malaysia
| | - Mansoor Ali Khan
- COVID-19 Vaccination Centres, University College London Hospitals, National Health Service, N10QH London, England
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26
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Garg R, Steensma JT, Luke AA, Huang K, Golla B, Greer R, Joynt Maddox KE. Helpline Calls Associated With Preventable Emergency Department Utilization. Am J Prev Med 2021; 61:729-732. [PMID: 34210582 DOI: 10.1016/j.amepre.2021.04.022] [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: 02/12/2021] [Revised: 03/29/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Unmet social needs are linked with greater healthcare utilization, but most studies lack timely and granular data on these needs. The 2-1-1 helpline is a telephone helpline focused on social needs. The objective of the study is to determine whether the number of 2-1-1 requests per 1,000 people is associated with preventable emergency department visits and compare the strength of the association with another commonly used predictor, Area Deprivation Index. METHODS This cross-sectional study linked 2-1-1 requests to emergency department visits from uninsured and Medicaid-insured patients by ZIP code for a large urban hospital system from January 1, 2016 to August 31, 2019. Negative binomial regression analysis was used to estimate the association of 2-1-1 service requests and Area Deprivation Index with preventable emergency department visits. RESULTS A total of 233,146 preventable emergency department visits and 520,308 2-1-1 requests were analyzed. For every 1-SD increase in 2-1-1 requests per 1,000 population, preventable emergency department visits increased by a factor of 3.05, even after controlling for local area deprivation and other population characteristics (p<0.001). CONCLUSIONS Requests to 2-1-1 helplines are strongly associated with preventable emergency department visits. This information may help hospital leaders and policymakers target social needs interventions to the neighborhoods with the greatest need.
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Affiliation(s)
- Rachel Garg
- Health Communication Research Laboratory, Brown School, Washington University in St. Louis, St. Louis, Missouri.
| | - Joseph T Steensma
- Health Communication Research Laboratory, Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Alina A Luke
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, School of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Kristine Huang
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, School of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Balaji Golla
- Health Communication Research Laboratory, Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Regina Greer
- United Way 2-1-1, United Way of Greater St. Louis, St. Louis, Missouri
| | - Karen E Joynt Maddox
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, School of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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27
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Drake C, Batchelder H, Lian T, Cannady M, Weinberger M, Eisenson H, Esmaili E, Lewinski A, Zullig LL, Haley A, Edelman D, Shea CM. Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework. BMC Health Serv Res 2021; 21:975. [PMID: 34530826 PMCID: PMC8445654 DOI: 10.1186/s12913-021-06991-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients' health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response. METHODS Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis. RESULTS Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach. CONCLUSION Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.
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Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Center for Personalized Health Care, Duke University School of Medicine, Durham, NC, USA.
| | - Heather Batchelder
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC, USA
| | - Tyler Lian
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Meagan Cannady
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Emily Esmaili
- Lincoln Community Health Center, Durham, NC, USA.,Global Health Institute, Duke University, Durham, NC, USA
| | - Allison Lewinski
- Duke University School of Nursing, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, USA
| | - Amber Haley
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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28
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Sherry MK, Bishai DM, Padula WV, Weiner JP, Szanton SL, Wolff JL. Impact of Neighborhood Social and Environmental Resources on Medicaid Spending. Am J Prev Med 2021; 61:e93-e101. [PMID: 34039496 DOI: 10.1016/j.amepre.2021.02.019] [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: 10/28/2020] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. Research linking medical spending to variation in neighborhood resources is critical to building the case for increased funding for social conditions. However, few studies link neighborhood factors to medical spending. This study assesses the relationship between neighborhood social and environmental resources and medical spending across the spending distribution. METHODS Individual-level health outcomes were drawn from a sample of Medicaid enrollees living in Baltimore, Maryland during 2016. A multidimensional index of neighborhood social and environmental resources was created and stratified by tertile (high, medium, and low). Differences were examined in individual-level medical spending associated with living in high-, medium-, or low-resource neighborhoods in unadjusted and adjusted 2-part models and quantile regression models. Analyses were conducted in 2019. RESULTS Enrollees who live in neighborhoods with low social and environmental resources incur significantly higher spending at the mean and across the distribution of medical spending even after controlling for age, race, sex, and morbidity than those who live in neighborhoods with high social and environmental resources. On average, this spending difference between individuals in low- and those in high-resource neighborhoods is estimated to be $523.60 per person per year. CONCLUSIONS Living in neighborhoods with low (versus those with high) resources is associated with higher individual-level medical spending across the distribution of medical spending. Findings suggest potential benefits from efforts to address the social and environmental context of neighborhoods in addition to the traditional orientation to addressing individual behavior and risk.
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Affiliation(s)
- Melissa K Sherry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - David M Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - William V Padula
- Department of Pharmaceutical and Health Economics, USC School of Pharmacy, University of Southern California, Los Angeles, California; Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Jonathan P Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins Center for Population Health Information Technology (CPHIT), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah L Szanton
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Center on Innovative Care in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; The Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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29
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Zhang Y, Khullar D, Wang F, Steel P, Wu Y, Orlander D, Weiner M, Kaushal R. Socioeconomic variation in characteristics, outcomes, and healthcare utilization of COVID-19 patients in New York City. PLoS One 2021; 16:e0255171. [PMID: 34324574 PMCID: PMC8321227 DOI: 10.1371/journal.pone.0255171] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/10/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES There is limited evidence on how clinical outcomes differ by socioeconomic conditions among patients with coronavirus disease 2019 (COVID-19). Most studies focused on COVID-19 patients from a single hospital. Results based on patients from multiple health systems have not been reported. The objective of this study is to examine variation in patient characteristics, outcomes, and healthcare utilization by neighborhood social conditions among COVID-19 patients. METHODS We extracted electronic health record data for 23,300 community dwelling COVID-19 patients in New York City between March 1st and June 11th, 2020 from all care settings, including hospitalized patients, patients who presented to the emergency department without hospitalization, and patients with ambulatory visits only. Zip Code Tabulation Area-level social conditions were measured by the Social Deprivation Index (SDI). Using logistic regressions and Cox proportional-hazards models, we examined the association between SDI quintiles and hospitalization and death, controlling for race, ethnicity, and other patient characteristics. RESULTS Among 23,300 community dwelling COVID-19 patients, 60.7% were from neighborhoods with disadvantaged social conditions (top SDI quintile), although these neighborhoods only account for 34% of overall population. Compared to socially advantaged patients (bottom SDI quintile), socially disadvantaged patients (top SDI quintile) were older (median age 55 vs. 53, P<0.001), more likely to be black (23.1% vs. 6.4%, P<0.001) or Hispanic (25.4% vs. 8.5%, P<0.001), and more likely to have chronic conditions (e.g., diabetes: 21.9% vs. 10.5%, P<0.001). Logistic and Cox regressions showed that patients with disadvantaged social conditions had higher risk for hospitalization (odds ratio: 1.68; 95% confidence interval [CI]: [1.46, 1.94]; P<0.001) and mortality (hazard ratio: 1.91; 95% CI: [1.35, 2.70]; P<0.001), adjusting for other patient characteristics. CONCLUSION Substantial socioeconomic disparities in health outcomes exist among COVID-19 patients in NYC. Disadvantaged neighborhood social conditions were associated with higher risk for hospitalization, severity of disease, and death.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
| | - Dhruv Khullar
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
- NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Fei Wang
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
| | - Peter Steel
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, United States of America
| | - Yiyuan Wu
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
| | - Duncan Orlander
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
| | - Mark Weiner
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
| | - Rainu Kaushal
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States of America
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
- NewYork-Presbyterian Hospital, New York, NY, United States of America
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, United States of America
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30
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Zhang Y, Li J, Yu J, Braun RT, Casalino LP. Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending. JAMA Netw Open 2021; 4:e2113212. [PMID: 34110394 PMCID: PMC8193453 DOI: 10.1001/jamanetworkopen.2021.13212] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation. OBJECTIVE To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH. MAIN OUTCOMES AND MEASURES 2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context. RESULTS Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P < .001). The total contribution (including through both direct and indirect pathways) of SDoH was 37.7% ($1428 of $3785) of this variation, compared with 59.8% ($2265 of $3785) by patient clinical risk, 14.5% ($549 of $3785) by supply of health care resources, and 19.8% ($751 of $3785) by patient demographic characteristics. When all factors were included within the same model, the direct contribution of SDoH was associated with 5.8% of the variation, compared with 4.6% by supply, 4.7% by patient demographic characteristics, and 62.0% by patient clinical risk. CONCLUSIONS AND RELEVANCE These findings suggest social determinants of health are associated with considerable proportions of geographic variation in Medicare spending. Policies addressing SDoH for disadvantaged patients in certain regions have the potential to contain health care spending and improve the value of health care; patient SDoH may need to be accounted for in publicly reported physician performance, and in value-based purchasing incentive programs for health care professionals.
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Affiliation(s)
- Yongkang Zhang
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Jing Li
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Jiani Yu
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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31
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Benitez J, Courtemanche C, Yelowitz A. Racial and Ethnic Disparities in COVID-19: Evidence from Six Large Cities. JOURNAL OF ECONOMICS, RACE, AND POLICY 2020; 3:243-261. [PMID: 35300199 PMCID: PMC7584480 DOI: 10.1007/s41996-020-00068-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/07/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
As of June 2020, the coronavirus pandemic has led to more than 2.3 million confirmed infections and 121 thousand fatalities in the USA, with starkly different incidence by race and ethnicity. Our study examines racial and ethnic disparities in confirmed COVID-19 cases across six diverse cities-Atlanta, Baltimore, Chicago, New York City, San Diego, and St. Louis-at the ZIP code level (covering 436 "neighborhoods" with a population of 17.7 million). Our analysis links these outcomes to six separate data sources to control for demographics; housing; socioeconomic status; occupation; transportation modes; health care access; long-run opportunity, as measured by income mobility and incarceration rates; human mobility; and underlying population health. We find that the proportions of Black and Hispanic residents in a ZIP code are both positively and statistically significantly associated with COVID-19 cases per capita. The magnitudes are sizeable for both Black and Hispanic, but even larger for Hispanic. Although some of these disparities can be explained by differences in long-run opportunity, human mobility, and demographics, most of the disparities remain unexplained even after including an extensive list of covariates related to possible mechanisms. For two cities-Chicago and New York-we also examine COVID-19 fatalities, finding that differences in confirmed COVID-19 cases explain the majority of the observed disparities in fatalities. In other words, the higher death toll of COVID-19 in predominantly Black and Hispanic communities mostly reflects higher case rates, rather than higher fatality rates for confirmed cases.
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Affiliation(s)
- Joseph Benitez
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY 40536 USA
| | - Charles Courtemanche
- Department of Economics, Gatton Business & Economics Building, University of Kentucky, Lexington, KY 40506-0034 USA
| | - Aaron Yelowitz
- Department of Economics, Gatton Business & Economics Building, University of Kentucky, Lexington, KY 40506-0034 USA
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