The relationship between living arrangements and higher use of hospital care at middle and older ages: to what extent do observed and unobserved individual characteristics explain this association?

Unmet needs for hypertension diagnosis among older adults in Myanmar: secondary analysis of a multistage sampling study

Background

Hypertension is a major cause of morbidity among older adults. We investigated older adults’ access to health services in Myanmar by focusing on unmet needs in diagnosing hypertension. This study aims to identify factors associated with the unmet needs for hypertension diagnosis in the study areas of Myanmar.

Methods

This is a secondary data analysis of the survey which is a cross-sectional study conducted with older adults (aged ≥ 60 years) in the Yangon and Bago regions of Myanmar. Objective indicators of health were collected, including blood pressure, height and weight. The diagnosis of hypertension was considered an unmet need when a participant’s blood pressure measurement met the diagnostic criteria for hypertension but the disease had not yet been diagnosed. Bivariate and multivariate analyses using logistic regression were performed to identify factors associated with the unmet need for hypertension diagnosis. Factors related to lifestyle habits and medical-seeking behaviour were selected and put into the multivariate model.

Results

Data from 1200 people, 600 from each of the two regions, were analysed. Altogether 483 (40.3%) participants were male, 530 (44.2%) were aged ≥ 70 years, and 857 were diagnosed with hypertension based on their measured blood pressure or diagnostic history, or both, which is a 71.4% prevalence of hypertension. Moreover, 240 (20.0%) participants had never been diagnosed with hypertension. In the multivariate analysis, these unmet needs for hypertension diagnosis were significantly associated with male sex (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.05–2.05), residence in the Bago region (OR 1.64, 95% CI 1.09–2.45) and better self-rated health (OR 1.70, 95% CI 1.24–2.33), but not with education, category on the wealth index or living arrangement.

Conclusions

There are barriers to accessing health services for hypertension diagnosis, as evidenced by the regional disparities found in this study, and charitable clinics may decrease the financial barrier to this diagnosis.

Social disparities in unplanned 30-day readmission rates after hospital discharge in patients with chronic health conditions: A retrospective cohort study using patient level hospital administrative data linked to the population census in Switzerland

Unplanned readmissions shortly after discharge from hospital are common in chronic diseases. The risk of readmission has been shown to be related both to hospital care, e.g., medical complications, and to patients’ resources and abilities to manage the chronic disease at home and to make appropriate use of outpatient medical care. Despite a growing body of evidence on social determinants of health and health behaviour, little is known about the impact of social and contextual factors on readmission rates. The objective of this study was to analyse possible effects of educational, financial and social resources of patients with different chronic health conditions on unplanned 30 day-readmission risks. The study made use of nationwide inpatient hospital data that was linked with Swiss census data. The sample included n = 62,109 patients aged 25 and older, hospitalized between 2012 and 2016 for one of 12 selected chronic conditions. Multivariate logistic regressions analysis was performed. Our results point to a significant association between social factors and readmission rates for patients with chronic conditions. Patients with upper secondary education (OR = 1.26, 95% CI: 1.11, 1.44) and compulsory education (OR = 1.51, 95% CI: 1.31, 1.74) had higher readmission rates than those with tertiary education when taking into account demographic, social and health status factors. Having private or semi-private hospital insurance was associated with a lower risk for 30-day readmission compared to patients with mandatory insurance (OR = 0.81, 95% CI: 0.73, 0.90). We did not find a general effect of social resources, measured by living with others in a household, on readmission rates. The risk of readmission for patients with chronic conditions was also strongly predicted by type of chronic condition and by factors related to health status, such as previous hospitalizations before the index hospitalization (+77%), number of comorbidities (+15% higher probability per additional comorbidity) as well as particularly long hospitalizations (+64%). Stratified analysis by type of chronic condition revealed differential effects of social factors on readmissions risks. Compulsory education was most strongly associated with higher odds for readmission among patients with lung cancer (+142%), congestive heart failure (+63%) and back problems (+53%). We assume that low socioeconomic status among patients with chronic conditions increases the risk of unplanned 30-day readmission after hospitalisation due to factors related to their social situation (e.g., low health literacy, material deprivation, high social burden), which may negatively affect cooperation with care providers and adherence to recommended therapies as well as hamper active participation in the medical process and the development of a shared understanding of the disease and its cure. Higher levels of comorbidity in socially disadvantaged patients can also make appropriate self-management and use of outpatient care more difficult. Our findings suggest a need for increased preventive measures for disadvantaged populations groups to promote early detection of diseases and to remove financial or knowledge-based barriers to medical care. Socially disadvantaged patients should also be strengthened more in their individual and social resources for coping with illness.

Social inequalities, length of hospital stay for chronic conditions and the mediating role of comorbidity and discharge destination: A multilevel analysis of hospital administrative data linked to the population census in Switzerland

Social factors are recognized determinants of morbidity and mortality and also have an impact on use of medical services. The objective of this study was to assess the associations of educational attainment, social and financial resources, and migration factors with length of hospital stays for chronic conditions. In addition, the study investigated the role of comorbidity and discharge destination in mediating these associations. The study made use of nationwide inpatient data that was linked with Swiss census data. The study sample included n = 141,307 records of n = 92,623 inpatients aged 25 to 84 years, hospitalized between 2010 and 2016 for a chronic condition. Cross-classified multilevel models and mediation analysis were performed. Patients with upper secondary and compulsory education stayed longer in hospital compared to those with tertiary education (β 0.24 days, 95% CI 0.14–0.33; β 0.37, 95% CI 0.27–0.47, respectively) when taking into account demographic factors, main diagnosis and clustering on patient and hospital level. However, these effects were almost fully mediated by burden of comorbidity. The effect of living alone on length of stay (β 0.60 days, 95% CI 0.50–0.70) was partially mediated by both burden of comorbidities (33%) and discharge destination (30.4%). (Semi-) private insurance was associated with prolonged stays, but an inverse effect was observed for colon and breast cancer. Allophone patients had also prolonged hospital stays (β 0.34, 95% CI 0.13–0.55). Hospital stays could be a window of opportunity to discern patients who need additional time and support to better cope with everyday life after discharge, reducing the risks of future hospital stays. However, inpatient care in Switzerland seems to take into account rather obvious individual needs due to lack of immediate support at home, but not necessarily more hidden needs of patients with low health literacy and less resources to assert their interests within the health system.

Medical Complexity Mediates Healthcare Resource Use in the Socially Vulnerable

GOAL

The objective of this retrospective, observational study was to assess the mediating effect of medical complexity on the relationship between social vulnerability and four acute care resource use outcomes-number of hospitalizations, emergency department (ED) visits, observation stays, and total visits. Such information may help healthcare managers better anticipate the effects of interventions targeted to the socially vulnerable in their patient population.

METHODS

Electronic health records of 147,496 adults served by 27 primary care practices in one large health system from 2015 to 2017 were used. Descriptive statistics were applied to characterize patients and the primary care practices included in the study. Causal mediation analyses using a modified Baron and Kenny approach were performed.

PRINCIPAL FINDINGS

Causal mediation analyses demonstrated that increased social vulnerability was associated with increased medical complexity (incidence rate ratio [IRR] = 1.57) and increased numbers of hospitalizations (IRR = 1.63), ED visits (IRR = 2.14), observation stays (IRR = 1.94), and total visits (IRR = 2.04). Effects remained significant, though attenuated, after adjusting for medical complexity (mediator), demographics, and medications (hospitalizations IRR = 1.44, ED visits IRR = 2.02, observation stays IRR = 1.74, total visits IRR = 1.86). Social vulnerability, given medical complexity, explained between 8% (ED visits) and 26% (hospitalizations) of the variation in outcomes.

PRACTICAL APPLICATIONS

These findings reinforce the need to modify interventions for medically complex adults to address their social needs and, consequently, reduce costly health services. Health systems seeking to reduce costly care can use these results to estimate savings in the treatment of patients with high social vulnerability-before they get chronic conditions and later as they seek care.

Four-year trajectories of episodic memory decline in mid-late life by living arrangements: a cross-national comparison between China and England

BACKGROUND

There is mixed evidence on the association between living arrangements and mid-late life cognition, which may be due to distinct familial arrangements and preferences between populations. To address such heterogeneity, we assessed these associations in China and England.

METHODS

Four-year trajectories of episodic memory scores (0-20, word recall test) by living arrangements (living with partner only, living with partner and children/grandchildren, living with no partner but with children/grandchildren, and living alone) were estimated using latent growth curve modelling for men and women aged 50+ from China (n=12 801) and England (n=10 964).

RESULTS

After adjusting for baseline socioeconomic, health behaviours and health covariates, worse baseline memory was found in Chinese adults living with no partner but with children/grandchildren and in Chinese women living with partner and children/grandchildren, compared with those living with partner only. Better baseline memory was associated with living alone in English women. A faster memory decline was found in Chinese men living with no partner but with children/grandchildren (-0.122 word/year, 95% CI -0.213 to -0.031), as well as in English women living with children/grandchildren with (-0.114, 95% CI -0.180 to -0.049) or without (-0.118, 95% CI -0.209 to -0.026) a partner, and those living alone (-0.075, 95% CI -0.127 to -0.024). No differences at baseline nor over follow-up were found between English men in different living arrangements.

CONCLUSION

Overall, our findings did not confirm the protective effects of co-residence with children/grandchildren, nor the detrimental effects of living alone on mid-late life cognition in China and England.

Do multigenerational living arrangements influence depressive symptoms in mid-late life? Cross-national findings from China and England

BACKGROUND

While living alone predicts depression in diverse ageing populations, the impact of multigenerational living is unclear. This study compared mid-late life depressive symptoms by living arrangements between societies with distinct kinship ties.

METHODS

Repeated data on depressive symptoms and living arrangements over 4 years from 16,229 Chinese (age≥45) and 10,403 English adults (age≥50) were analyzed using multilevel mixed-effects logistic regression. Elevated depressive symptoms were identified using the Center for Epidemiological Depression Scale criteria in each study.

RESULTS

Higher odds ratios (ORs) of elevated depressive symptoms were found in both Chinese and English adults aged<60 living with no partner but with children/grandchildren, compared to those living with a partner only. These ORs were greater for men (Chinese men: 3.09, 95% confidence interval: 2.00-4.78; English men: 3.44, 1.36-8.72) than for women (Chinese women: 1.77, 1.23-2.56; English women: 2.88, 1.41-3.67), after controlling for socioeconomic position, health behaviors, and health status. This male disadvantage was also observed for English, but not for Chinese, adults aged<60 living alone. For adults aged 60+, the increased odds among those living with no partner but with children/grandchildren and those living alone were smaller in both countries.

LIMITATIONS

Bias may exist because depressed participants are more likely to experience divorce or separation prior to baseline.

CONCLUSIONS

The relationship between living arrangements and depressive symptoms appears robust and consistent across social contexts, although the mechanisms differ. The protective role of partners in both China and England supports targeting those who do not live with partners to reduce depression.

Age-Related Changes in the Association Between Traumatic Brain Injury and Dementia in Older Men and Women

OBJECTIVE

To investigate age-related changes in the association between traumatic brain injury (TBI) and dementia in older men and women separately.

SETTING

A total of 243 general practices in the UK.

PARTICIPANTS

This study included 4760 patients who received a first TBI diagnosis between 1995 and 2010 (index date), and 4760 patients without TBI who were matched to those with TBI by age, sex, index year, Charlson Comorbidity Index, alcohol dependence, and physician (index date: a randomly selected visit date).

DESIGN

Retrospective cohort study.

MAIN MEASURES

Incidence of dementia in the decade following index date.

RESULTS

Within 10 years of index date, 8.8% of men with TBI and 4.8% of those without TBI were diagnosed with dementia, while the respective figures were 9.0% and 6.7% in women (P values < .01). There was a significant association between TBI and dementia in men (hazard ratio [HR] = 2.29, 95% confidence interval [CI]: 1.64-3.19) and in women (HR = 1.33, 95% CI: 1.07-1.64). Furthermore, the association between TBI and dementia was significant in men aged 60 to 70 (HR = 2.51, 95% CI: 1.27-4.96) and 71 to 80 years (HR = 3.00, 95% CI: 1.82-4.93), whereas the relationship was only significant and potentially unreliable in women aged 81 to 90 years (HR = 1.49, 95% CI: 1.03-2.14).

CONCLUSIONS

The age-related relationship between TBI and dementia differed between men and women. More research of a prospective nature and including behavioral data is needed to better understand these differences.

Factors associated with low contraceptive use amongst vulnerable mothers in South West State, Nigeria

Background

Young mothers tend to be more prone to high maternal and perinatal risks and are thus deemed vulnerable to adverse sexual and reproductive health rights (SRHR) in terms of their right to choose contraceptives of their choice to enhance their maternal well-being and childbirth spacing should be well discussed. Achieving sufficient SRHR may be averted if the use of family planning by disadvantaged groups is not given required attention.

Aim

This study aimed to identify and analyse the factors associated with the low use of contraceptives amongst vulnerable women in the South West region in Nigeria.

Setting

The study area was purposively chosen to capture contraceptive use amongst vulnerable women in Osun State, Nigeria.

Methods

A primary data collection was done in three senatorial districts of Osun State, Nigeria, with 140 respondents each to give a total of 420 respondents. Collected data were analysed using univariate, bivariate and multivariate measures.

Results

The result showed a magnitude of association and relationship at both levels of analyses. Living arrangements and family types were 89% and 88.3%, respectively, associated with family planning use. In the same vein, living arrangement and family types were also statistically significant at p < 0.05with an odds ratio of 0.23 (95% CI: 0.1184–0.4583) and an odds ratio of 0.35 (95% CI: 0.1756–0.6970) with family planning use, respectively.

Conclusion

We concluded that policies and interventions to accelerate and encourage contraceptives use amongst vulnerable mothers in South West, Nigeria should be targeted at those whose husbands lived elsewhere and those whose husbands have more than one wife.