Socioeconomic status and utilization of health care services in Canada and the United States: findings from a binational health survey

Income inequality and deaths of despair risk in Canada, identifying possible mechanisms

BACKGROUND

Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services).

METHODS

We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion, and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death.

RESULTS

Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HRadj. = 1.28; 95 CI = 1.05, 1.55), suicide (HRadj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HRadj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HRadj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes.

CONCLUSION

Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada.

Factors associated with adherence to recommendations for medical visits following annual health checkups among Japanese employees: A prospective cohort study

There are growing concerns in Japanese workplaces that many employees do not follow recommendations to visit medical institutions for further examinations following annual health checkups. Although previous studies have shown that job- and health-related factors affect adherence to such recommendations, these longitudinal associations are unknown. We examined the longitudinal associations between job- and health-related factors and visiting medical institutions after annual health checkups among Japanese employees. We conducted a prospective cohort study in a food-related company in fiscal year 2019. Participants completed a self-administered questionnaire to assess job- and health-related factors. Of 2914 employees who completed the questionnaire, 615 received recommendations to visit medical institutions following annual health checkups in fiscal year 2020; these employees comprised our sample. We used logistic regression analysis to examine the associations between each factor and medical institution visits. Of participants, 474 (77.1 %) were men, 432 (70.2 %) were aged over 40 years, and 293 (47.6 %) visited a medical institution. Logistic regression analysis showed that participants with a primary doctor and those with obesity were more likely to visit medical institutions. In Japanese workplaces, having a primary doctor may be important in increasing adherence to medical visit recommendations following annual health checkups. However, more focus is also needed on employees without obesity who may be more confident about their health and so less likely to follow recommendations. Further intervention studies focusing on these factors are needed to identify effective interventions to improve adherence to medical recommendations.

Association between socioeconomic status and treatment in patients with low back or neck pain: a population-based cross-sectional study in South Korea

INTRODUCTION

Socioeconomic status affects the treatment of patients with low back pain and/or neck pain. We examined the relationship between socioeconomic status (occupation and household income level) and treatments such as chronic opioid use and interventional procedures among these patients.

METHODS

Data from the National Health Insurance Service database in South Korea were used in this population-based cross-sectional study. Approximately 2.5% of adult patients diagnosed with low back pain and/or neck pain between 2010 and 2019 were selected using a stratified random sampling technique and included in the analysis.

RESULTS

We analyzed the data of 5,861,007 patients with low back pain and/or neck pain in total. Among them, 4.9% were chronic opioid users and 17.7% underwent interventional procedures. Healthcare workers and unemployed individuals had 18% lower and 6% higher likelihood of chronic opioid use compared with office workers, respectively. Those with a very low household income had 18% higher likelihood of chronic opioid use than those with a poor household income. Other workers and unemployed individuals had 4% and 8% higher likelihood of undergoing interventional procedures than office workers, respectively. Healthcare workers had 5% lower likelihood of undergoing interventional procedures than office workers. Patients with middle, high, and very poor household incomes had a higher likelihood of undergoing interventional procedures, while those in the very high household income group had a lower likelihood of undergoing interventional procedures than those with poor household incomes.

CONCLUSIONS

Socioeconomic status factors are associated with treatment in patients with low back pain and/or neck pain.

Association of frailty with health service use among older Chinese adults: analysis of population-based panel data

Background

Frailty is a common syndrome characterized by rapid growth in the aging population that has an impact on healthcare systems. This study aimed to investigate the impact of frailty on health service use and whether this effect varies with chronic diseases and socioeconomic status among older individuals in China.

Methods

A balanced panel data analysis was conducted on 3,306 older individuals who completed follow-ups for the three waves of the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, and 2015. The Physical Frailty Phenotype (PFP) Scale was used to assess frailty status. Negative binomial regression was used to test the associations between frailty status, outpatient visits in the past 4 weeks, and annual inpatient hospital days.

Results

Compared with robust individuals, individuals with pre-frail or frail status were likely to report a higher number of outpatient visits [pre-frail: incidence rate ratio (IRR) = 1.28, 95% CI = 1.16-1.41; frail: IRR = 1.45, 95% CI = 1.23-1.71], and inpatient hospital days (pre-frail: IRR = 1.40, 95% CI = 1.24-1.58; frail: IRR = 2.17, 95% CI = 1.81-2.60) after controlling for all covariates. All five frailty components (weight loss, exhaustion, low physical activity, slowness, and weakness) were associated with a higher number of inpatient hospital days, and two components (weight loss and exhaustion) were associated with a higher number of outpatient visits. The effect of frailty on inpatient hospital stays persisted in different socioeconomic groups, across all health insurance programmes and physical comorbidities.

Conclusion

Frailty is associated with greater health service use among older individuals. Effective screening, prevention, intervention, and management of frailty may be important to reduce health service use.

Factors Contributing to Stroke Clinic Follow-Up “No Show”: A Quality Improvement Project

Objective Controlling modifiable risk factors provides a strong impact on secondary stroke prevention. Stroke outpatient follow-up (OPFU) provides a significant role in assuring these goals are met. However, in our institute in 2018, one out of four patients was not seen in the stroke clinic after their stroke. To increase this ratio, we instituted a performance improvement project (PIP) to determine factors that contribute to OPFU and offered rescheduling after their missed appointment. Methods The nurse scheduler called patients labeled as "no-show," asked for reasons for the missed appointment, and offered rescheduling accordingly. Other data were collected retrospectively. Results Of the 53 "no show" patients, most were females, single, Black, uninsured, and had a Modified Rankin Scale (MRS) of 0. Of the 30 patients who participated in the phone interview, a most common reason for "no show" was transportation. Fifteen out of 27 patients kept their rescheduled appointment, increasing patients seen in the clinic by 6.7%. Conclusion This PIP determined contributing factors on health care seeking practices of our stroke clinic patients allowing necessary improvements in our institute. Rescheduling increased the number of stroke patients seen in the stroke clinic. Our general neurology ambulatory department consequently adopted this process as well.

Impact of Telehealth and Process Virtualization on Healthcare Utilization

Telehealth has emerged as a tool to improve patient access by virtualizing healthcare services, particularly during the COVID-19 pandemic. However, concerns have been raised that telehealth may actually increase healthcare spending by leading to new types of utilization. Our research provides empirical evidence that this concern is unfounded based on a state-wide study of patient visit-level data of telehealth use in 58 hospitals in Maryland from 2012 to 2021. On average, telehealth use can reduce future outpatient visits by 13.6% within 30 days after a telehealth visit, leading to a cost reduction of $239. The benefits of telehealth are most apparent for diseases with high potential for process virtualization, such as mental health, skin disorders, metabolic, and musculoskeletal diseases. Although telehealth has a substitution effect on future healthcare utilization, this effect is not observed among rural patients who use telehealth as a gateway to utilize more primary care and specialist services. Our findings suggest that policymakers should promote the use of telehealth in a value-based healthcare environment by providing monetary incentives to expand telehealth use among patients and providers, and expand the scope of telehealth services to include consultation with specialists especially among rural patients.

Similarities in COVID-19 Mortality Between Canadian Provinces and American States Before Vaccines Were Available

Canada and the USA are often compared for their markedly different approaches to health care despite cultural similarities and sharing the world's longest international boundary. The period between the onset of the COVID-19 pandemic in January 2020 and the availability of a vaccine in December 2020 offers an ideal opportunity to compare subnational Canadian and American pandemic mortality. Preventing the spread of COVID-19 was through compliance with health orders and best practices; treatment was only available to those admitted to hospitals and whose lives were at risk. Using publicly available data from the Johns Hopkins University 2019 Novel Coronavirus Visual Dashboard, we seek to uncover if there were any similarities in Canadian provinces' and American states' monthly COVID-19 mortality per 100,000 people, building on a broader scientific push towards understanding the successes and failures of different health systems in the pandemic. The similar province and state cumulative COVID-19 mortality rate trajectories identified in our analyses do not amount to intuitive comparative jurisdictions which suggests the importance of identifying localized pandemic responses.

Characterisation of medical conditions of children with sickle cell disease in the USA: findings from the 2007-2018 National Health Interview Survey (NHIS)

OBJECTIVES

We used the National Health Interview Survey (NHIS) data set to examine the prevalence of comorbid medical conditions; explore barriers to accessing healthcare and special educational services; and assess the associations between sickle cell disease (SCD) status and demographics/socioeconomic status (SES), and social determinants of health (SDoH) on comorbidities among children in the USA.

DESIGN

Cross-sectional.

SETTING

NHIS Sample Child Core questionnaire 2007-2018 data set.

PARTICIPANTS

133 481 children; presence of SCD was determined by an affirmative response from the adult or guardian of the child.

MAIN OUTCOME MEASURES

Multivariate logistic regression was used to compare the associations between SCD status, SES and SDoH for various medical conditions for all races and separately for black children at p<0.05.

RESULTS

133 481 children (mean age 8.5 years, SD: 0.02), 215 had SCD and ~82% (weighted) of the children with SCD are black. Children with SCD were more likely to suffer from comorbid conditions, that is, anaemia (adjusted OR: 27.1, p<0.001). Furthermore, children with SCD had at least two or more emergency room (ER) visits (p<0.001) and were more likely to have seen a doctor 1-15 times per year (p<0.05) compared with children without SCD. Household income (p<0.001) and maternal education were lower for children with SCD compared with children without SCD (52.4% vs 63.5% (p<0.05)). SCD children with a maternal parent who has < / > High School degree were less likely to have no ER visits or 4-5 ER visits, and more likely to have 2-3 ER visits within 12 months.

CONCLUSION

Children with SCD experienced significant comorbid conditions and have high healthcare usage, with black children being disproportionately affected. Moreover, maternal education status and poverty level illustrates how impactful SES can be on healthcare seeking behaviour for the SCD population. SDoH have significant implications for managing paediatric patients with SCD in clinical settings.

Coronavirus Disease Pandemic Effect on Medical-Seeking Behaviors Even in One Resource-Competent Community: A Case Controlled Study

(1) Background: The coronavirus disease 2019 (COVID-19) pandemic had overwhelming impacts on medical services. During its initial surge, Taiwan was unique in maintaining its medical services without imposing travel restrictions, which provided an ideal environment in which to test if the fear of becoming infected with COVID-19 interfered with health-seeking behavior (HSB). We tested this hypothesis among adults with acute complicated appendicitis (ACA). (2) Methods: Adults with acute appendicitis were enrolled between 1 January and 30 June 2020 (COVID-19 period). The first two quarters of the preceding 3 years were defined as a historical control group. Outcome measures included the rate of ACA and the number of hospital stays. (3) Results: The COVID-19 era included 145 patients with acute appendicitis. Compared to the historical control (320 patients), the COVID-19 era was significantly associated with a higher length of symptom duration until presentation to the emergency room within >48 h (17.2% vs. 9.1%, p = 0.011), a higher incidence of ACA (29.7% vs. 19.4%, p = 0.014), and a longer length of hospital stays (5.0 days vs. 4.0 days, p = 0.043). The adjusted models showed that the COVID-19 period had a significant relationship with a higher rate of ACA (odds ratio (OR) = 1.87; 95% confidence interval (CI): 1.23-2.52; p = 0.008) and longer length of hospital stays (OR= 2.10; 95% CI: 0.92 to 3.31; p < 0.001). (4) Conclusions: The fear of COVID-19 may prohibit patients from seeking medical help, worsening their clinical outcomes. The surgical community should take action to provide scientific information to relive mental stress.

The potential risk of using historic claims to set bundled payment prices: the case of physical therapy after lower extremity joint replacement

Background

One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.

Methods

This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015–2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.

Results

The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β = 7.46, SE = 0.498, p-value< 0.001; THA: β = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.

Conclusions

This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.

A systematic review of sociodemographic reporting and representation in eating disorder psychotherapy treatment trials in the United States

OBJECTIVE

Eating disorders (EDs) were once conceptualized as primarily affecting affluent, White women, a misconception that informed research and practice for many years. Abundant evidence now discredits this stereotype, but it is unclear if prevailing "evidence-based" treatments have been evaluated in samples representative of the diversity of individuals affected by EDs. Our goal was to evaluate the reporting, inclusion, and analysis of sociodemographic variables in ED psychotherapeutic treatment randomized controlled trials (RCTs) in the US through 2020.

METHODS

We conducted a systematic review of ED psychotherapeutic treatment RCTs in the US and examined the reporting and inclusion of gender identity, age, race/ethnicity, sexual orientation, and socioeconomic status (SES) of enrolled participants, as well as recruitment methods, power analyses, and discussion of limitations and generalizability.

RESULTS

Our search yielded 58 studies meeting inclusion criteria dating back to 1985. Reporting was at times incomplete, absent, or centered on the racial/gender majority group. No studies reported gender diverse participants, and men and people of color were underrepresented generally, with differences noted across diagnoses. A minority of papers considered sociodemographic variables in analyses or acknowledged limitations related to sample characteristics. Some progress was made across the decades, with studies increasingly providing full racial and ethnic data, and more men included over time. Although racial and ethnic diversity improved somewhat, progress appeared to stall in the last decade.

DISCUSSION

We summarize findings, consider context and challenges for RCT researchers, and offer suggestions for researchers, journal editors, and reviewers on improving representation, reporting, and analytic practices.

PUBLIC SIGNIFICANCE

Randomized controlled trials of eating disorder psychotherapeutic treatment in the US are increasingly reporting full race/ethnicity data, but information on SES is inconsistent and sexual orientation absent. White women still comprise the overwhelming majority of participants, with few men and people of color, and no gender-diverse individuals. Findings underscore the need to improve reporting and increase representation to ensure evidence-based treatments are effective across and within diverse groups.

Provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians

BACKGROUND

Despite spending 11.0% of the total gross domestic product, the quality of healthcare services in Canada has received mixed reviews. We first separately examined provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. Second, we evaluated provincial variations in the impact of not having a regular medical doctor on having unmet healthcare needs among Canadians.

METHODS

We applied logistic regressions using data from the 2014 and 2017-2018 Canadian Community Health Surveys (CCHS). The total sample size for this study was 120,345 individuals aged 12 years and older: 61,240 from the 2014 CCHS and 59,105 from the 2017-2018 CCHS.

RESULTS

We found significant provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. People in Quebec and the Territories were more likely not to have a regular medical doctor than their peers in Alberta. People in Quebec and the Territories were also more likely to have unmet healthcare needs than their counterparts in Alberta. Not having a regular medical doctor impacted whether Canadians reported having unmet healthcare needs to varying degrees across provinces.

CONCLUSION

Findings from this study may contribute to designing province-specific policy interventions and inform efforts that seek to address barriers to having a regular medical doctor and reducing unmet healthcare needs among Canadians.

Association of functional disability with mental health services use and perceived unmet needs for mental health care among adults with serious mental illness

BACKGROUND

Approximately 13.1 million U.S. adults experienced serious mental illness (SMI) in 2019. Persons with disability (PWD) have higher risks of SMI. Ensuring adequate access to mental health (MH) services for PWD is imperative to ameliorate this burden.

METHODS

Using the 2015-2019 National Survey on Drug Use and Health, we obtained study variables for U.S. adults with SMI in the past year and used multivariable logistic regression models to examine the association of disability with MH services and perceived unmet needs.

RESULTS

The sample comprised 12,532 respondents, representing 11,143,650 U.S. adults with SMI. Overall, PWD had higher proportions of using prescription medications (64.7% vs. 46.2%), outpatient treatment (48.4% vs. 36.5%) and inpatient treatment (8.6% vs. 4.7%) compared to persons without disability; however, the prevalence of perceived unmet MH service needs was also higher (46.3% vs. 39.4%) among PWD. Multivariable logistic regression models showed presence of any disability, cognitive and ≥2 limitations were significantly associated with MH services use (all p<0.01). However, PWD were significantly more likely to report perceived unmet MH service needs (p<0.01 for any disability as well as cognitive, complex activity, and ≥2 limitations).

LIMITATIONS

Due to data limitations, disability status and SMI may be misclassified for some respondents, and the results may not be generalized to all individuals with SMI.

CONCLUSION

While PWD were more likely to use MH services, they also had higher odds of unmet MH needs. These results call for more effective and tailored mental health services for PWD.

Incidence, Demographic, and Seasonal Risk Factors of Infections Caused by Five Major Enteric Pathogens, Ontario, Canada, 2010-2017

In Canada, enteric infections cause significant health and economic burden. We evaluated the individual characteristics of laboratory-confirmed cases of Campylobacter spp. (n = 28,728), non-typhoidal Salmonella spp. (n = 22,640), Yersinia spp. (n = 1674), Verotoxin-producing Escherichia coli (VTEC; n = 1340), and Listeria monocytogenes (n = 471), reported between 2010 and 2017 inclusive, in Ontario, Canada (population ∼13,500,000). We calculated overall and pathogen-specific annual and mean incidence rates (IRs) for Ontario. We used multivariable Poisson and negative binomial regression models to estimate incidence rate ratios (IRRs) for years, seasons, age groups, and sexes, and we included two-way age and sex interaction terms in the models. Campylobacter and Salmonella infections had the highest IRs whereas Listeria infections had the lowest IRs. None of the infections showed long-term trends over the 8-year study period; however, rates of all five infections were elevated in the summer. More Salmonella, VTEC, and Listeria infections were linked to disease outbreaks than were Campylobacter and Yersinia infections. Overall, mean IRs of Campylobacter, Salmonella, Yersinia, and VTEC infections were highest in children 0-4 years old, whereas Listeria IRs peaked in adults 60 years and older. Higher mean IRs of Campylobacter were observed in males. No other differences by sex were statistically significant. The same mean rate was observed in both sexes for Listeria. Adjusting for all other factors, significant age- and sex-specific differences in IRs were observed in Campylobacter, Salmonella, and VTEC infection rates. No significant interactions of age and sex were found for Yersinia and Listeria infections. Future research should focus on the pathogen-specific socioeconomic, environmental, or agricultural risk factors that might be responsible for these infections.

Unmet Healthcare Need Due to Cost Concerns among U.S. Transgender and Gender-Expansive Adults: Results from a National Survey

This study examines past-year unmet healthcare need due to cost experienced by transgender and gender-expansive (TGE) adults in the United States in the context of the Patient Protection and Affordable Care Act (ACA). It also aims to estimate the importance of having health insurance among TGE Americans (transgender men, transgender women, nonbinary/genderqueer people, and cross-dressers). Data were from the 2015 U.S. Transgender Survey (N = 19,157 adults, aged 25 to 64 years). Multivariable logistic regression models were used to determine the adjusted odds ratios (AOR) and 95 percent confidence intervals (CI) of TGE individuals' past-year unmet healthcare need due to cost. Although the majority (86.8 percent) reported seeing a doctor or healthcare provider in the past year, 32.1 percent reported past-year unmet healthcare need due to cost. One in six respondents (17.1 percent) was uninsured and almost one-third (29.8 percent) were at/near poverty. The prevalence of unmet healthcare need was greater among the uninsured (65.1 percent) than among the insured (25.2 percent). Compared with transgender women, nonbinary/genderqueer people (AOR = 1.31, 95% CI [1.18, 1.46]) and transgender men (AOR = 1.30, 95% CI [1.18, 1.42]) had greater odds of unmet healthcare need due to cost. Social workers can lobby to fully enact the ACA by underscoring affordability and availability as important dimensions of healthcare access for TGE populations.

The Impact of Language on Emergency Department Visits, Hospitalizations, and Length of Stay Among Home Care Recipients

BACKGROUND

Research considering the impact of language on health care utilization is limited. We conducted a population-based study to: (1) investigate the association between residents' preferred language and hospital-based health care utilization; and (2) determine whether this association is modified by dementia, a condition which can exacerbate communication barriers.

METHODS

We used administrative databases to establish a retrospective cohort study of home care recipients (2015-2017) in Ontario, Canada, where the predominant language is English. Residents' preferred language (obtained from in-person home care assessments) was coded as English (Anglophones), French (Francophones), or other (Allophones). Diagnoses of dementia were ascertained with a previously validated algorithm. We identified all emergency department (ED) visits and hospitalizations within 1 year.

RESULTS

Compared with Anglophones, Allophones had lower annual rates of ED visits (1.3 vs. 1.8; P<0.01) and hospitalizations (0.6 vs. 0.7; P<0.01), while Francophones had longer hospital stays (9.1 vs. 7.6 d per admission; P<0.01). After adjusting for potential confounders, Francophones and Allophones were less likely to visit the ED or be hospitalized than Anglophones. We found evidence of synergism between language and dementia; the average length of stay for Francophones with dementia was 25% (95% confidence interval: 1.10-1.39) longer when compared with Anglophones without dementia.

CONCLUSIONS

Residents whose preferred language was not English were less frequent users of hospital-based health care services, a finding that is likely attributable to cultural factors. Francophones with dementia experienced the longest stays in hospital. This may be related to the geographic distribution of Francophones (predominantly in rural areas) or to suboptimal patient-provider communication.

Two aspects of health literacy and their importance for the use of health-promotion measures by teachers in the school setting

Purpose

Teachers are exposed to many stressors. Compared to other occupational groups, they are more frequently affected by psychosomatic complaints. In recent decades, numerous prevention and intervention measures for promoting health have been developed and implemented for this target group. However, it remains unclear how the uptake of health-promotion measures (HPMs) by teachers can be increased in order to prevent stress-related disorders. This paper examines two facets of health literacy—health awareness and health value—in terms of their importance in both the take-up and intended take-up of HPMs.

Design/methodology/approach

In the 2017/2018 school year, data were collected by paper and pencil from a representative sample of 830 teachers across all school types in the German State of Brandenburg.

Findings

Teachers who place great value on their own health show significantly higher levels of take-up and intended take-up of HPMs. The findings regarding health awareness are more heterogeneous. Further associations were found with age and psychosocial stress.

Originality/value

While there has been growing academic interest in developing HPMs for teachers, there has been relatively little focus on the factors that may influence the implementation and uptake of these measures. The paper contributes to addressing this gap by shedding light on the relevance of two facets of health literacy. Strengthening the perceived importance of health could be a starting point for increasing the use of HPMs by teachers and thus improving their health.

Health-Related Quality of Life (HRQoL) Outcomes Following Injury in Childhood and Adolescence Using EuroQol (EQ-5D) Responses with Pooled Longitudinal Data

BACKGROUND

Injury is a leading contributor to the global disease burden in children, affecting their health-related quality of life (HRQoL)-yet valid estimates of burden are absent.

METHODS

This study pooled longitudinal data from five cohort studies of pediatric injury survivors (5-17 years) at baseline, 1-, 4-, 6-, 12-, and 24- months (n = 2334). HRQoL post-injury was measured using the 3-level EQ-5D utility score (EQ-5D) and five health states (mobility, self-care, activity, pain, anxiety and depression (anxiety)).

RESULTS

Mean EQ-5D post-injury did not return to baseline level (0.95) by 24 months (0.88) and was lower for females over time (-0.04, 95%CI -0.05, -0.02). A decreased adjusted risk ratio over time (ARR) was observed for intentional injuries (pain: 0.85, 95%CI 0.73,0.98; anxiety: 0.62, 95%CI 0.49,0.78); spinal cord injuries (mobility: 0.61, 95%CI 0.45,0.83), self-care: 0.76, 95%CI 0.63,0.91, activity: 0.64, 95%CI 0.47,0.88); moderate/severe traumatic brain injury (activity: 0.83, 95%CI 0.71,0.96). ARRs were also low for certain fractures, with various health states affected.

CONCLUSIONS

HRQoL outcomes over time for children and adolescents post-injury differed across key demographic and injury related attributes. HRQoL did not reach levels consistent with full health by 24 months with recovery plateauing from 6 to 24 months. Tailored interventions are required to respond to the varying post-injury recovery trajectories in this population.

Emergency department use in people who experience imprisonment in Ontario, Canada

OBJECTIVES

The aims of this study were to describe emergency department (ED) utilization by people in provincial prison and on release, and to compare with ED utilization for the general population.

METHODS

We linked correctional and health administrative data for people released from provincial prison in Ontario in 2010. We matched each person by age and sex with four people in the general population. We compared ED utilization rates using generalized estimating equations, by sex and for high urgency and ambulatory care sensitive conditions.

RESULTS

People who experienced imprisonment (N = 48,861) had higher ED utilization rates compared with the general population (N = 195,444), with rate ratios of 3.2 (95% CI 3.0-4.4) for men and 6.5 (95% CI 5.6-7.5) for women in prison and a range of rate ratios between 3.1 and 7.7 for men and 4.2 and 8.8 for women over the 2 years after release. Most ED visits were high urgency, and between 1.0% and 5.1% of visits were for ambulatory care sensitive conditions. ED utilization rates increased on release from prison.

CONCLUSIONS

People experiencing imprisonment in Ontario have higher ED utilization compared with matched people in the general population, primarily for urgent issues, and particularly in women and in the week after release. Providing high-quality ED care and implementing prison- and ED-based interventions could improve health for this population and prevent the need for ED use.

How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study

BACKGROUND

The retirement of a family physician can represent a challenge in accessibility and continuity of care for patients. In this population-based, longitudinal cohort study, we assess whether and how long it takes for patients to find a new majority source of primary care (MSOC) when theirs retires, and we investigate the effect of demographic and clinical characteristics on this process.

METHODS

We used provincial health insurance records to identify the complete cohort of patients whose majority source of care left clinical practice in either 2007/2008 or 2008/2009 and then calculated the number of days between their last visit with their original MSOC and their first visit with their new one. We compared the clinical and sociodemographic characteristics of patients who did and did not find a new MSOC in the three years following their original physician's retirement using Chi-square and Fisher's exact test. We also used Cox proportional hazards models to determine the adjusted association between patient age, sex, socioeconomic status, location and morbidity level (measured using Johns Hopkins' Aggregated Diagnostic Groupings), and time to finding a new primary care physician. We produce survival curves stratified by patient age, sex, income and morbidity.

RESULTS

Fifty-four percent of patients found a new MSOC within the first 12 months following their physician's retirement. Six percent of patients still had not found a new physician after 36 months. Patients who were older and had higher levels of morbidity were more likely to find a new MSOC and found one faster than younger, healthier patients. Patients located in more urban regional health authorities also took longer to find a new MSOC compared to those in rural areas.

CONCLUSIONS

Primary care physician retirements represent a potential threat to accessibility; patients followed in this study took more than a year on average to find a new MSOC after their physician retired. Providing programmatic support to retiring physicians and their patients, as well as addressing shortages of longitudinal primary care more broadly could help to ensure smoother retirement transitions.

A review of appropriate indicators for need-based financial resource allocation in health systems

BACKGROUND

Optimal, need-based, and equitable allocation of financial resources is one of the most important concerns of health systems worldwide. Fulfilling this goal requires considering various criteria when allocating resources. The present study was conducted to identify the need indicators used to allocate health resources in different countries worldwide.

METHODS

A systematic review conducted on all published articles and reports on the need-based allocation of health financial resources in the English language from 1990 to 2020 in databases, including PubMed, Cochrane, and Scopus as well as those in Persian language databases, including magiran, SID, and Google and Google scholar search engines. After performing different stages of screening, appropriate studies were identified and their information were extracted independently by two people, which were then controlled by a third person. The extracted data were finally analyzed by content analysis method using MAXQDA 10 software.

RESULT

This search yielded 823 studies, of which 29 were included for the final review. The findings indicated that many need-based resource allocation formulas attempt to deal with health care needs using some weighting methods for individuals. In this regard, the most commonly used indicators were found as follows: age, gender, socio-economic status or deprivation, ethnicity, standardized mortality ratio (SMR), the modified health indicators (disease consequences, self-assessed health, and disability), geographical area / place of residence (geographical) (rural versus urban), cross-boundary flows, cost of services, and donations.

CONCLUSION

The indicators used in allocating the health systems' financial resources in each country should be designed in order to be simple and transparent and in accordance with the moral norms of that society. Moreover, these should be a good representative of the health needs of people in different geographical areas of that country. In addition, their related data should be available to an acceptable extent.

Multi-State Analysis of the Impact of Childhood Starvation on the Healthy Life Expectancy of the Elderly in China

Background: Child malnutrition is not only common in developing countries but also an important issue faced by developed countries. This study aimed to explore the influence and degree of childhood starvation on the health of the elderly, which provides a reference for formulating health-related policies under the concept of full lifecycle health. Methods: Based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2008, 2011, and 2014, this study took a total of 13,185 elderly people aged 65-99 years as the target population. By IMaCH software, with gender and income level as the control variables, the average life expectancy and healthy life expectancy of the elderly were measured. The x2test was used to explore the differences in the socioeconomic status of elderly people with or without starvation in childhood. Statistical differences between average life expectancy and healthy life expectancy were analyzed by rank tests. Results: (1) The results showed that there was a statistically significant difference in age, gender, residency, education level, and income level between the groups with or without starvation (P < 0.05). (2) Transition probabilities in health-disability, health-death, and disability-death all showed an upward trend with age (P < 0.05), where the elderly who experienced starvation in childhood were higher than those without such an experience (P < 0.05). However, the probability of disability-health recovery showed a downward trend with age (P < 0.05), in which the elderly who experienced starvation in childhood were lower than those without starvation (P < 0.05). (3) For the elderly who experienced starvation in childhood, the health indicators of the average life expectancy, healthy life expectancy, and healthy life expectancy proportion accounted for the remaining life were lower than those of the elderly without childhood starvation (P < 0.05). Conclusions: The average life expectancy and healthy life expectancy of the elderly with childhood starvation are lower than those without childhood starvation. It shows that the negative impact of childhood starvation on health through the life course till old age has a persistent negative cumulative effect on the quantity and quality of life. Therefore, it is important to pay attention to the nutritional status of children in poor families from the perspective of social policymaking.

Factors Influencing the Vietnamese Older Persons in Choosing Healthcare Facilities

BACKGROUND

The rapidly growing aging population poses major challenges for health systems in Vietnam. This study was therefore aimed to examine factors influencing the choices of healthcare facilities among older patients in Vietnam, using a national survey on older people.

METHODS

We applied multinomial logistic regression models based on Andersen's Behavioral Model with various predisposing factors, enabling factors and healthcare-needs factors associated with different types of healthcare facilities where older patients utilized services.

DATA

We used data from the Vietnam Aging Survey (VNAS) in 2011. This was the first-ever nationally representative survey on older persons in Vietnam.

RESULTS

Among those who used healthcare services, 15.1% visited central hospitals; 23.6% visited provincial hospitals; 28.0% visited district hospitals; 8.8% visited commune heath centres; 18.3% visited private hospitals/clinics; and 6.2% visited other facilities. The results showed that "having to pay cost" and "having sufficient income" were strong predictors for using commune health centres, district hospitals, and private facilities, while "having health insurance" was not a significant predictor for using these facilities. Also, we showed that apart from enabling factors (such as age, gender, educational levels, employment status, living regionand place of residence), predisposing factor (such as health insurance, perceived sufficient income, household wealth and having to pay medical cost) as well as need factors (such as self-rated health and chronic disease) were also associated with the choice of healthcare facilities.

CONCLUSIONS

Based on the findings, we discussed the implications of the results for organizing healthcare finance and delivery to achieve efficiency and equity for older people in Vietnam.

The Impact of the Upgrading of the Industrial Structure on the Urban Employee Basic Medical Insurance Fund: An Empirical Study in China

BACKGROUND

During the transformation of economy to a high-quality level in China, industrial restructuring and upgrading have played an important role. The upgrading of the industrial structure has affected not only the development in society and economy but also other fields, thereby having great impact on social security. In recent years, with the aging of the population and economic development, the social medical insurance fund is undertaking more payment pressure. However, the existing research rarely focuses on the impact of industrial structure upgrading on medical insurance.

OBJECTIVE

The main aim of this study was to analyze the impact of the upgrading of industrial structure on the income and expenditure of the urban employee basic medical insurance fund.

METHODS

China's provincial panel data from 2007 to 2018, collected by the National Bureau of Statistics of China, were used to establish a panel regression model in order to investigate the impact of the upgrading of the industrial structure on the income and expenditure of the urban employee basic medical insurance fund.

RESULTS

The research showed that the upgrading of the industrial structure, in combination with the internal upgrading in the tertiary industry, had a positive impact on the income and expenditure of the urban employee basic medical insurance fund and that there were regional differences. The simple upgrading of the three major industries had no effect on the income or expenditure of the urban employee basic medical insurance fund. In addition to the upgrading of industrial structure, other factors such as the average salary of employed persons in urban units, the proportion of retirees among all insured persons in urban employee basic medical insurance and the expenditure of urban employee basic medical insurance were also found to have impact on the income of urban employee basic medical insurance. Moreover, the expenditure of urban employee basic medical insurance was associated with the proportion of retirees among all insured persons in urban employee basic medical insurance, GDP and an aging population.

CONCLUSION

In the context of the upgrading of the industrial structure, measures such as strengthening employment and income security, delaying retirement, adjusting birth policy, strengthening the scientific management of personal accounts and accurately positioning the regional industrial structure were suggested to be adopted in order to minimize the payment pressures on the urban employee basic medical insurance fund.

Difficult binds: A systematic review of facilitators and barriers to treatment among mothers with substance use disorders

BACKGROUND

The United States and Canada have observed sharp increases in substance use disorder among women of child-bearing or child-rearing age. Substance use disorder can have deleterious effects on children, families, and communities. Many evidence-based treatments exist, but engaging mothers in treatment is difficult. No recent review is available to help systems and providers understand the facilitators of and barriers to treatment for mothers.

OBJECTIVE

To systematically identify facilitators and barriers to substance use and mental health treatment for mothers with substance use disorder who are pregnant or parenting young children in the United States and Canada.

METHODS

We systematically searched the literature using five online databases and performed a gray literature search. We included studies published in the past two decades focused on parent or provider perspectives.

RESULTS

Our search identified 23 high-quality papers. The majority of papers qualitatively examined the perspectives of treatment-seeking pregnant women and mothers diverse in race/ethnicity, region, and treatment settings. Our synthesis of findings revealed the compelling and complex centrality of motherhood, which served as both a facilitator and barrier. Motherhood often interacted with relational (e.g., perceiving stigma vs. support from providers, family, friends, partners) and structural (e.g., time commitments, childcare) factors to both hinder and help engagement in treatment.

CONCLUSIONS

Our findings can help policy-makers and practitioners make tangible improvements to the financing and delivery of substance use treatment for mothers. Our review points to specific areas for future research, including an examination of the relationships between various structural factors and treatment outcomes.

Policy Literacy, Barriers, and Gender Impact on Accessibility to Healthcare Services under Compulsory Migrant Health Insurance among Myanmar Migrant Workers in Thailand

Accessibility to health service and experience of healthcare are important factors for public health policymaking. The current study aimed to describe the status of accessibility and barriers to getting care as well as policy literacy among Myanmar migrant workers and ultimately to identify the predictors of accessibility to healthcare services among this population through Thailand's Compulsory Migrant Health Insurance (CMHI). A cross-sectional survey was used to collect data from 240 Myanmar migrant workers who were 18 years or older, resided in Songkhla Province, and had Compulsory Migrant Health Insurance. The instrument was a set of questionnaires consisting of a Personal Data Form, Policy Literacy Questionnaire, Barriers to Get Care Questionnaire, and Accessibility to Healthcare Services Questionnaire. Descriptive statistics, correlation analysis, and multiple regression analysis were used to analyze data. The majority of participants had a high level of policy literacy (36.3%), barriers to get care (34.2%), and accessibility to health care services (35.8%). Policy literacy (β = 0.35, p < 0.001), barriers to get care (β = -0.32, p < 0.001), and gender (p < 0.001) were significant predictors of accessibility to healthcare services and could explain 43.2% of the total variance. To increase the accessibility to healthcare services among migrant workers with Compulsory Migrant Health Insurance, public health policymakers are recommended to cooperate more with healthcare staff and the workers' employers to enhance the distribution of information about the health insurance to decrease barriers to get care.

Disparities in use of telehealth at the onset of the COVID-19 public health emergency

Introduction

The coronavirus disease 2019 (COVID-19) pandemic resulted in an unprecedented expansion in telehealth, but little is known about differential use of telehealth according to demographics, rurality, or insurance status.

Methods

We performed a cross-sectional analysis of 7742 family medicine encounters at a single USA institution in the initial month of the COVID-19 public health emergency (PHE). We compared the demographics of those using telehealth during the PHE to those with face-to-face visits during the same time period; we also compared the demographics of those using full audio-video to those using audio-only.

Results

The likelihood of any telehealth visit in the first 30 days of telehealth expansion was higher for women, those age 65 years and older, self-pay patients, and those with Medicaid and Medicare as primary payers. The likelihood of a telehealth visit was reduced for rural residence and Black or other races. Among all telehealth visits, the likelihood of a full audio-video telehealth visit was reduced for patients who were older, Black, from urban areas, or who were self-pay, Medicaid, or Medicare payer status.

Discussion

Significant disparities exist in telehealth use during the COVID-19 PHE by age, race, residence and payer.

Correlates of hospitalization among the oldest old: results of the AgeCoDe-AgeQualiDe prospective cohort study

BACKGROUND

Hospitalization is a key driver of health care costs. Thus far, there are only a few longitudinal studies investigating whether changes in explanatory variables lead to hospitalization. Moreover, these longitudinal studies did not focus on individuals in highest age.

AIM

The purpose of the current study was to examine the correlates of hospitalization among the oldest old in Germany longitudinally.

METHODS

A multicenter prospective cohort study ["Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)", AgeQualiDe]. Primary care patients ≥ 85 years took part [n = 861 at follow-up (FU) 7, average age of 89.0 years; 85-100 years]. Two waves were used. Hospitalization in the last 6 months was used as outcome measure. Well-established scales were used to quantify the independent variables such as Instrumental Activities of Daily Living Scale, Global Deterioration Scale or Geriatric Depression Scale.

RESULTS

Logistic random effects regressions showed that the probability of hospitalization in the preceding 6 months significantly increased with increases in the social network, more depressive symptoms, functional decline, and increase in chronic conditions, whereas it was not significantly associated with age, sex, marital status, education, and cognitive impairment. Social networks moderate the relationship between functional decline and hospitalization.

DISCUSSION

The results of the present longitudinal study emphasize the association of depressive symptoms, functional decline, more social networks, and chronic conditions with hospitalization among the oldest old.

CONCLUSIONS

Treatments with the aim to reduce or postpone these factors might also help to reduce hospitalization.

Duration of opioid use and association with socioeconomic status, daily dose and formulation: a two-decade population study in Queensland, Australia

Background There is an association between the duration of prescription opioids use and an increased risk of serious harm, often unintentional. Objective (1) Describe the trends in duration of prescription opioids dispensing and, (2) determine the risk of long-term use (≥4 months) based on patients' socioeconomic status, daily dose in oral daily morphine milligram equivalent, and opioid formulation. Setting Residents of Queensland (2,827,727), Australia from the age 18 years and who were dispensed pharmaceutical opioids from 1 January 1997 to 31 December 2018. Method Retrospective, longitudinal population-based analysis using data obtained from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health. Main outcome measure Contribution of socioeconomic status, and daily dose and opioid formulation (modified-release or immediate-release) to the risk of long-term opioid use. Results There was little difference between the number of patients dispensed opioids for ≥4 months and ≤3 months between 1997 and 2011. Thereafter, the number for those using opioids long-term increased. The highest risk of having opioids dispensed for ≥4 months were for patients in the lowest level of socioeconomic status (adjusted odds ratio 1.36; 95% CI, 1.34, 1.38), compared to people in the highest socioeconomic status areas, followed by the low-socioeconomic status areas, mid-socioeconomic status areas, and high-socioeconomic status areas respectively. The risk of being dispensed prescription opioids for ≥4 months significantly increased as the dose increased: adjusted odds ratio 1.73; 95% CI, 1.71, 1.75, adjusted odds ratio 1.89; 95% CI, 1.87, 1.92, and adjusted odds ratio 3.63; 95% CI, 3.58, 3.69 for the ≥20 to <50 oral daily morphine milligram equivalent, ≥50 to <100 oral daily morphine milligram equivalent and ≥100 oral daily morphine milligram equivalent dose categories, respectively. Conclusion Higher doses and living in a low socioeconomic status areas were associated with increased risk of long-term dispensing of opioid prescriptions.

Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments

Transgender people encounter interpersonal and structural barriers to healthcare access that contribute to their postponement or avoidance of healthcare, which can lead to poor physical and mental health outcomes. Using the 2015 U.S. Transgender Survey, this study examined avoidance of healthcare due to anticipated discrimination among transgender adults aged 25 to 64 (N = 19,157). Multivariable logistic regression analysis was conducted to test whether gender identity/expression, socio-demographic, and transgender-specific factors were associated with healthcare avoidance. Almost one-quarter of the sample (22.8%) avoided healthcare due to anticipated discrimination. Transgender men had increased odds of healthcare avoidance (AOR = 1.32, 95% CI = 1.21–1.45) relative to transgender women. Living in poverty (AOR = 1.52, 95% CI = 1.40–1.65) and visual non-conformity (AOR = 1.48, 95% CI = 1.33–1.66) were significant risk factors. Having health insurance (AOR = 0.87, 95% CI = 0.79–0.96) and disclosure of transgender identity (AOR = 0.77, 95% CI = 0.68–0.87) were protective against healthcare avoidance. A significant interaction of gender identity/expression with health insurance was found; having health insurance moderated the association between gender identity/expression and healthcare avoidance. Providers should consider gender differences, socio-demographic, and transgender-specific factors to improve accessibility of services to transgender communities. A multi-level and multi-faceted approach should be used to create safe, trans-affirmative environments in health systems.

•

Transgender people encounter barriers to healthcare access.

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Providers should consider transgender-specific factors to improve healthcare access.

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A multi-faceted approach should be used to create trans-affirmative health settings.

Depressive Symptoms and Father Involvement in Canada: Evidence from a National Study

Paternal involvement in instrumental and emotional parenting behaviours benefits families and children. While fathers have become more involved in childrearing over the past several decades, significant variability in paternal involvement with children remains. Yet, little work has focused on the facilitators and barriers to involved fathering and work in the Canadian context is particularly sparse. This study focuses on one potentially important factor, depressive symptoms, and its relationship with multiple dimensions of father involvement among Canadian men. Using national quantitative data from the Survey of Canadian Fathers-Enquête des Pères Canadiens (n = 2,099) and ordinary least squares regression models, we focus on the relationship between depressive symptoms and six measures of fathering behavior. Results indicate that depression is significantly associated with most behaviours, but these results diverge from studies in other countries and contexts. Overall, our findings underscore the importance of context-specific studies on parenting and the need for additional work on fathering and mental health in Canada.

Effect of income on length of stay in a hospital or long-term care facility among older adults with dementia in Japan

OBJECTIVE

We aimed to ascertain the degree of influence of income disparity among older people with newly developed dementia on the probability and duration of stay in a hospital or long-term care facility and the degree of influence on medical expenses for hospitalization and care costs.

METHODS

This was a retrospective cohort study. Study participants included 12 829 individuals aged 75 years or older not diagnosed with dementia between April 2012 and March 2013 but newly diagnosed with dementia between April 2013 and March 2014. Participants were categorized according to income. We evaluated the associations of income with the probability and duration of stay in a hospital or long-term care facility and the costs for hospitalization and care.

RESULTS

In the adjusted analyses, high-income individuals had a lower probability of admission to a hospital or long-term care facility than middle- and high-income individuals. In all hospitals, low-income individuals had the longest duration of stay, but in long-term care facilities, income categories varied by facility type. Medical expenses for hospitalization and care costs were highest in the low-income group.

CONCLUSION

Income category affects the probability and duration of stay in the hospital or a long-term care facility, as well as expenses for hospitalization and care. It is necessary to consider a policy to enable low-income older patients with dementia to continue living at home.

Patient social risk factors and continuity of care for Medicare beneficiaries

OBJECTIVE

To identify patient social risk factors associated with Continuity of Care (COC) index.

DATA SOURCES/STUDY SETTING

Medicare Current Beneficiary Survey (MCBS), the Dartmouth Institute, and Area Resource File for 2006-2013.

STUDY DESIGN

We use regression methods to assess the effect of patient social risk factors on COC after adjusting for medical complexity. In secondary analyses, we assess the effect of social risk factors on annual utilization of physicians and specialists for evaluation and management (E&M).

DATA COLLECTION/EXTRACTION METHODS

We retrospectively identified 59 499 patient years for Medicare beneficiaries with one year of enrollment and three or more E&M visits.

PRINCIPAL FINDINGS

After adjustment for medical complexity, individual-level social risk factors such as lack of education, low income, and living alone are all associated with better patient COC (P < .05). Similarly, area-level social risk factors such as living in areas that are nonurban or high poverty, as well as in areas with low specialist or high primary care physician supply, are all associated with better patient COC (P < .05). We found the opposite pattern of associations between these same risk factors and annual patient utilization of physicians and specialists (P < .05).

CONCLUSIONS

Medicare patients with multiple social risk factors have consistently better COC; these same social risk factors are associated with reduced patient-realized access to specialist physician care.

The Intersection of HIV, Diabetes, and Race: Exploring Disparities in Diabetes Care among People Living with HIV

In a setting of universal health care access, we compared diabetes control between Caucasians and African Americans (AA) living with HIV. This was a cross-sectional analysis of data from a cohort study among military members living with HIV and diabetes. Using adjusted logistic regression models, we compared proportions of Caucasians and AA meeting the following diabetes treatment goals: hemoglobin A1c <7.0%, blood pressure (BP) <140/90 mm Hg, low density lipoprotein cholesterol <100 mg/dL, and not smoking. We included 107 Caucasian (mean age 37 years) and 126 AA (mean age 33 years) participants. A similar proportion of Caucasians and AA were prescribed diabetes (∼60%) and BP (∼80%) medications. Yet, more Caucasians met the BP treatment goal (77% [54%, 90%]) than AA (61% [36%, 82%]). Thus, more Caucasians met the combined A1c, BP, and cholesterol goals for diabetes control (25% [10%, 49%]) than AA (13% [5%, 31%]). Despite having equal access to health care, AA in this study have poorer diabetes control than Caucasians.

Utilization of LGBT-Specific clinics and providers across three cohorts of lesbian, gay, and bisexual people in the United States

Lesbian, gay, and bisexual (LGB) people navigate issues of stigma, discrimination, structural barriers, and a history of medical mistrust when seeking healthcare services. Lesbian, gay, bisexual, and transgender (LGBT)-specific clinics and providers offer alternative spaces where these issues may be avoided, but limited research is available on how LGB people utilize these resources. The current study analyzes data from a nationally-representative survey of 1534 LGB people across three age cohorts. Gender, sexual identity, income, proximity to LGBT community health centers, perceived health status, and the total number of lifetime diagnoses are each associated with past utilization of LGBT-specific clinics and providers; interest in future utilization is associated with sexual identity, race/ethnicity, several psychosocial factors, income, a usual source of care, and mental distress. We conclude that LGBT-specific clinics and providers represent an important piece of the healthcare landscape for LGB people but access remains an important barrier to utilization.

Medical and socio-demographic characteristics associated with patient-perceived continuity of primary care: A cross-sectional survey in Hangzhou, China

BACKGROUND

This study measured the perceived continuity of general practitioner (GP) care from the patient's perspective and identified the associated factors.

METHODS

A cross-sectional survey was carried out on 624 patients in community health care centres in Hangzhou, China. A self-designed Likert scale was used to measure patients' perceptions on informational, managerial, and relational continuity of GP care. An average score for three types of continuity ranging from 0 to 100 was calculated. Linear regression models were developed to determine the factors influencing continuity.

RESULTS

Average rating scores of 57.73 (±15.31), 50.74 (±17.18), 61.61 (±18.07), and 63.57 (±17.40) were found for total, informational, managerial, and relational continuity of care, respectively. Older patients reported a more positive rating on all types of continuity. Income was negatively associated with managerial continuity. The factors affecting informational, relational, and total continuities included chronic diseases, walking distance to nearest community health centres, signing a contract with a GP, and knowing the names of contracted GPs.

CONCLUSION

Patients' perception of continuity of GP care remains at a low level, especially for informational continuity. The varied association between continuity of care and identified factors suggests that targeted actions should be considered for improving the quality of GP services.

Factors Affecting the Choice of National and Public Hospitals Among Outpatient Service Users in South Korea

The present study analyzed factors underlying outpatient service users' choice of national and public (rather than private) hospitals. Based on Andersen's Behavioral Model, we developed a framework that covered needs, enabling, and personal factors. Data of outpatient service usage were obtained from the Korean medical panel survey during 2008 to 2013. Logistic regression analyses were conducted, and results revealed that the rate of national and public hospital use was very low (5.57%), and our model adequately explained variance in service use. Specifically, several demographic factors-older age, low income, national merit and medical care, being chronically ill, and having a disability-were predictive of whether an individual is likely to choose national and public hospitals. We discuss the need to strengthen national and public hospitals' medical services in order to better manage care for low-income vulnerable groups.

Here comes the SUN: Self-assessed unmet need, worsening health outcomes, and health care inequity

Utilization-based approaches have predominated the measurement of socioeconomic-related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access-self-reported unmet need (SUN)-which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self-reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization-based approaches.

General practice for the poor and specialist services for the rich: inequality evidence from a cross-sectional survey on Hangzhou residents, China

Background

Inequalities in health care services are becoming an increasing concern in the world including in China. This study measured the income-related inequalities of residents in Hangzhou of China in access to general practice and specialist care and identified socioeconomic factors associated with such inequalities.

Methods

A cross-sectional questionnaire survey was conducted on 1048 residents in ten urban communities in Hangzhou, China. The percentage and frequency of respondents visiting general practice (GP) and hospital specialist clinics over the past four weeks prior to the survey were estimated. Income-related inequalities in access to these services were measured by the concentration index. Logistic regression and Poisson regression models were established to decompose the contributions of socioeconomic factors (residency, income, education, marital status, and social health insurance) to the inequalities in the probability and frequency of accessing these services, respectively, after adjustment for the needs factors (age, sex and illness conditions).

Results

The GP services were in favor of the poor, with a concentration index of − 0.0464 and − 0.1346 for the probability and frequency of GP visits, respectively. In contrast, the specialist services were in favor of the rich, with a concentration index of 0.1258 and 0.1279 for the probability and frequency of specialist visits, respectively. Income is the biggest contributor to the inequalities, except for the frequency of visits to specialists in which education played the greatest role.

Conclusions

Income-related inequalities in GP and specialist care are evident in China. Policy interventions should pay increasing attention to the emergence of a two-tier system, potentially enlarging socioeconomic disparities in health care services.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0966-6) contains supplementary material, which is available to authorized users.

Factors affecting access and use of preventive and weight management care: A public health lens

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

Access to Health Services Among Young Adult Gay Men in New York City

This research is a cross-sectional study of young adult gay men (YAGM), ages 18 to 29, that aims to understand their health-care access including: having a primary care provider (PCP), frequency of health-care visits, and instances of foregone health care. Surveys were conducted with a modified time-space sample of 800 YAGM in New York City (NYC). Surveys were conducted between November 2015 and June 2016. This study examined associations between sociodemographic characteristics and health-care access using multivariable logistic regression models. In multivariable logistic regression models, there were higher odds of having a PCP among participants enrolled in school (Adjusted Odds Ratio [AOR] = 1.85, 95% CI [1.18, 2.91], p < .01) and covered by insurance (AOR = 21.29, 95% CI [11.77, 38.53], p < .001). Modeling indicated higher odds of more than one health visit in the past 12 months for non-White participants (AOR = 2.27, 95% CI [1.43, 3.63], p < .001), those covered by insurance (AOR = 3.10, 95% CI [1.06, 9.04], p < .05), and those who disclosed their sexual orientation to their PCP (AOR = 2.99, 95% CI [1.58, 5.69], p < .001). Participants with insurance were less likely to report instances of foregone care (AOR = 0.21, 95% CI [0.21, 0.13], p < .001). Understanding the facilitators and barriers to health-care access among YAGM populations is of critical importance, as many YAGM between the ages of 18 and 29 are establishing their access to health care without parental guidance. Health-care access, including the decision to forego care, can represent a missed opportunity for primary prevention and early diagnosis of health issues, as well as more effective, less invasive, and less costly treatments.

The Institutional Determinants of Health Insurance: Moving Away from Labor Market, Marriage, and Family Attachments under the ACA

For more than a century, the American welfare state required working-age adults to obtain social welfare benefits through their linkages to employers, spouses, or children. Recent changes to U.S. healthcare policy prompted by the Patient Protection and Affordable Care Act (ACA), however, provide adults with new pathways for accessing a key form of social welfare-health insurance-decoupled from employers, spouses, and children. Taking advantage of this fundamental shift in the country's system of social welfare provision, I use data from the National Survey on Drug Use and Health (NSDUH) to explore patterns of health insurance coverage from before and after the ACA became active in 2014. The results show that the salience of labor market, marriage, and family attachments as pathways to coverage significantly declined in the first three years following passage of the ACA. By providing adults with a new route to coverage decoupled from their institutional attachments, the ACA helped narrow health insurance inequalities across gender, race and ethnicity, and education. Given the strong association between health insurance and health outcomes, the results from this study raise important questions about the centrality of institutional attachments for our knowledge of health inequalities.

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Background

Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population.

Methods

We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method.

Results

Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care.

Conclusions

Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3660-2) contains supplementary material, which is available to authorized users.

Gaps in health insurance coverage and emergency department use among children with asthma

Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children's Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR = 2.5; 95% CI: 1.3, 4.7, p = 0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.

Household Income Relationship With Health Services Utilization and Healthcare Expenditures in People Aged 75 Years or Older in Japan: A Population-Based Study Using Medical and Long-term Care Insurance Claims Data

Background

This study aimed to determine whether there are disparities in healthcare services utilization according to household income among people aged 75 years or older in Japan.

Methods

We used data on medical and long-term care (LTC) insurance claims and on LTC insurance premiums and needs levels for people aged 75 years or older in a suburban city. Data on people receiving public welfare were not available. Participants were categorized according to household income level using LTC insurance premiums data. The associations of low income with physician visit frequency, length of hospital stay (LOS), and medical and LTC expenditures were evaluated and adjusted for 5-year age groups and LTC needs level.

Results

The study analyzed 12,852 men and 18,020 women, among which 13.3% and 41.5%, respectively, were categorized as low income. Participants with low income for both genders were more likely to be functionally dependent. In the adjusted analyses, lower income was associated with fewer physician visits (incidence rate ratio [IRR] 0.90; 95% confidence interval [CI], 0.87–0.92 for men and IRR 0.97; 95% CI, 0.95–0.99 for women), longer LOS (IRR 1.98; 95% CI, 1.54–2.56 and IRR 1.42; 95% CI, 1.20–1.67, respectively), and higher total expenditures (exp(β) 1.09; 95% CI, 1.01–1.18 and exp(β) 1.09; 95% CI, 1.05–1.14, respectively).

Conclusions

This study suggests that older people with lower income had fewer consultations with physicians but an increased use of inpatient services. The income categorization used in this study may be an appropriate proxy of socioeconomic status.

Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain

BACKGROUND

The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders.

METHODS

A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables.

RESULTS

The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70).

CONCLUSION

Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience

This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.

Asthma health services utilisation before, during and after pregnancy: a population-based cohort study

During pregnancy, females with asthma may be at higher risk of exacerbation. The objective of this study was to determine whether females with asthma in Ontario, Canada have increased health services utilisation (HSU) during pregnancy.Rates of asthma-specific, asthma-related and non-pregnancy-related HSU were calculated in a population-based cohort of pregnant females with asthma. Poisson regression with repeated measures was used to determine adjusted rate ratios and 95% confidence intervals of HSU during and 1 year after pregnancy, compared to the year before pregnancy.The cohort consisted of 103 976 pregnant females with asthma. Compared to the year prior to pregnancy, hospitalisation rates per 100 person-months during pregnancy increased 30% for asthma (from 0.016 to 0.020), 24% for asthma-related conditions (from 0.012 to 0.015) and decreased 37% for non-pregnancy-related conditions (from 0.24 to 0.15). Emergency department visits for asthma and asthma-related conditions did not increase significantly during pregnancy. During pregnancy, physician office visits decreased 19% for asthma (from 2.20 to 1.79), 10% for asthma-related conditions (from 9.44 to 8.47) and increased 74% for non-pregnancy-related conditions (from 56.4 to 98.2).Hospitalisations for asthma and asthma-related conditions increased during pregnancy, demonstrating that the overall increase in non-pregnancy-related physician office visits may not meet the primary care needs of pregnant females with asthma.

Depressed Women of Low Socioeconomic Status Have High Numbers of Physician Visits in the Year Before Pregnancy: Implications for Care

Background

There is a higher prevalence of depression in women of low socioeconomic status (SES) than other women. Further, previous depression is the best predictor of future depression. Therefore, due to the negative effects of maternal depression on the fetus and subsequent child, particularly in combination with low SES, depression is ideally treated before pregnancy. During the year before pregnancy and by SES, we aimed to assess the odds of a physician visit associated with maternal depression and the mean number of physician visits in women by depressive status.

Methods

We used population-based registry data of 243,933 women with 348,273 singleton live births in British Columbia from 1999 - 2009 and estimated family SES decile using tax-file data. Mixed effects logistic regression, adjusting for maternal age and parity, was used to calculate odds ratios and a two-sided, two-sample test was used to compare proportions. STATA 14 was used for analyses.

Results

Compared to women of middle SES (Decile-6), women of low SES (from Decile-1, Decile-2) had higher odds of more than 20 physician visits whether depressed (aOR = 1.46 (95% CI: (1.15, 1.86); aOR = 1.26 (95% CI: (0.98, 1.61)) or non-depressed (aOR = 1.26 (95% CI: (1.13, 1.41); aOR = 1.24 (95% CI: (1.11, 1.38)) during the year before pregnancy. During pre-pregnancy, depressed women had more than three times the mean number of physician visits than non-depressed women: (8.56 (8.38, 8.73) versus (2.59 (2.57, 2.61), P < 0.00005.

Conclusions

Physicians have ample opportunities to assess women of child-bearing age for depression and to refer for appropriate treatment. It is particularly important that physicians pay extra attention to identify depression in those of lower SES who are likely to become pregnant. Further, identifying depression and providing appropriate referral for treatment in all women who are likely to become pregnant, are already pregnant or are caring for children is important. In such a way, the possible negative effects of prenatal and post-partum depression, along with the interactive effects of low SES on the child, might be reduced.