Innovative health care mobility services in the US

Extra/ordinary medicine: Toward an anthropology of primary care

Primary care is at the forefront of healthcare delivery. It is the site of disease prevention and health management and serves as the bridge between communities and the health care system As ethnographers of primary care, in this article we discuss what is gained by situating anthropological inquiry within primary care. We articulate how anthropologists can contribute to a better understanding of the issues that emerge in primary care. We provide a review of anthropological work in primary care and offer empirical data from two ethnographic case studies based in the United States, one focused on social risk screening in primary care and the other examining the diagnosis and care of people with dementia in primary care. Through these cases, we demonstrate how research of and within primary care can open important avenues for the study of the multidimensionality of primary care. This multidimensionality is apparent in the ways the medical field addresses the social and structural experiences of patients, scope of practice and disciplinary boundaries, and the intersection of ordinary and extraordinary medicine that emerge in the care of patients in primary care.

The Complex Patchwork of Transportation for In-Center Hemodialysis

Reliable transportation is an important determinant of access to health care and health outcomes that carries particular significance for people with ESKD. In the United States, there are almost half a million patients receiving treatment with in-center dialysis, translating into more than 70 million roundtrips to dialysis centers annually. Difficulty with transportation can interfere with patients' quality of life and contribute to missed or shortened dialysis treatments, increasing their risk for hospitalization. Medicare, the principal payer for dialysis in this country, has not traditionally provided coverage for nonemergency medical transportation, placing the burden of traveling to and from the dialysis center on patients and families and a range of other private and public entities that were not designed and are poorly equipped for this purpose. Here, we review the relationship between access to reliable transportation and health outcomes such as missed and shortened dialysis treatments, hospitalizations, and quality of life. We also describe current approaches to the delivery of transportation for patients receiving in-center hemodialysis, highlighting potential opportunities for improvement.

Screening for Health-Related Social Needs and Collaboration With External Partners Among US Hospitals

Importance

In recent years, hospitals and health systems have reported increasing rates of screening for patients' individual and community social needs, but few studies have explored the national landscape of screening and interventions directed at addressing health-related social needs (HRSNs) and social determinants of health (SDOH).

Objective

To evaluate the associations of hospital characteristics and area-level socioeconomic indicators to quantify the presence and intensity of hospitals' screening practices, interventions, and collaborative external partnerships that seek to measure and ameliorate patients' HRSNs and SDOH.

Design, Setting, and Participants

This cross-sectional study used national data from the American Hospital Association Annual Survey Database for fiscal year 2020. General-service, acute-care, nonfederal hospitals were included in the study's final sample, representing nationally diverse hospital settings. Data were analyzed from July 2022 to February 2023.

Exposures

Organizational characteristics and area-level socioeconomic indicators.

Main Outcomes and Measures

The outcomes of interest were hospital-reported patient screening of and strategies to address 8 HRSNs and 14 external partnership types to address SDOH. Composite scores for screening practices and external partnership types were calculated, and ordinary least-square regression analyses tested associations of organizational characteristics with outcome measures.

Results

Of 2858 US hospital respondents (response rate, 67.0%), most hospitals (79.2%; 95% CI, 77.7%-80.7%) reported screening patients for at least 1 HRSN, with food insecurity or hunger needs (66.1%; 95% CI, 64.3%-67.8%) and interpersonal violence (66.4%; 95% CI, 64.7%-68.1%) being the most commonly screened social needs. Most hospitals (79.4%; 95% CI, 66.3%-69.7%) reported having strategies and programs to address patients' HRSNs; notably, most hospitals (52.8%; 95% CI, 51.0%-54.5%) had interventions for transportation barriers. Hospitals reported a mean of 4.03 (95% CI, 3.85-4.20) external partnership types to address SDOH and 5.69 (5.50-5.88) partnership types to address HRSNs, with local or state public health departments and health care practitioners outside of the health system being the most common. Hospitals with accountable care contracts (ACCs) and bundled payment programs (BPPs) reported higher screening practices (ACC: β = 1.03; SE = 0.13; BPP: β = 0.72; SE = 0.14), interventions (ACC: β = 1.45; SE = 0.12; BPP: β = 0.61; SE = 0.13), and external partnership types to address HRSNs (ACC: β = 2.07; SE = 0.23; BPP: β = 1.47; SE = 0.24) and SDOH (ACC: β = 2.64; SE = 0.20; BPP: β = 1.57; SE = 0.21). Compared with nonteaching, government-owned, and for-profit hospitals, teaching and nonprofit hospitals were also more likely to report more HRSN-directed activities. Patterns based on geographic and area-level socioeconomic indicators did not emerge.

Conclusions and Relevance

This cross-sectional study found that most US hospitals were screening patients for multiple HRSNs. Active participation in value-based care, teaching hospital status, and nonprofit status were the characteristics most consistently associated with greater overall screening activities and number of related partnership types. These results support previously posited associations about which types of hospitals were leading screening uptake and reinforce understanding of the role of hospital incentives in supporting health equity efforts.

Transportation Planning for Older Americans: Challenges, Federal Policies, and Next Steps

With the rapidly increasing number of older people, vehicle dependence in countries like the U.S. poses many challenges for transportation planning. Vehicle dependence among most Americans has substantial environmental, safety, and equity implications, and it excludes those with limited ability to drive from participating in many everyday social activities. Also, an age-based digital divide weakens the potential role of transportation technologies and information and communication technologies in reducing travel difficulties for older people. Nevertheless, current federal policies do not sufficiently address the transportation challenges facing an aging population. This paper provides an agenda for sustainable and equitable transportation in an aging society through various modes of transportation and enhanced interagency coordination and collaboration.

A scoping review of patients' barriers to eye care for glaucoma and keratitis

In this scoping review, we examine underlying causes of loss to follow-up for chronic (glaucoma) and acute (corneal ulcers) eye conditions using the Penchansky and Thomas access to care framework. We explore barriers by World Health Organization income levels and by studying geographical location. We identified 6,363 abstracts, with 75 articles retrieved and 16 meeting inclusion criteria. One article discussed barriers to follow-up care for people with corneal ulcers, and the other 15 were for people with glaucoma. The most frequent barriers to care were affordability, awareness, and accessibility. The international studies had a greater percentage of studies report acceptability as a barrier to loss to follow-up. Countries with universal healthcare included affordability as a loss to follow-up barrier, emphasizing that cost goes beyond the ability to pay for direct treatment costs. Understanding and addressing barriers to follow-up care can aid the goal of continued care and decrease the risk of poor outcomes and vision loss.

Transport, Mobility and the Wellbeing of Older Adults: An Exploration of Private Chauffeuring and Companionship Services in Malaysia

As physical abilities and health decline with age, older adults tend to lose their driving abilities, which affects their mobility. As mobility is important to older adults' wellbeing, there is a need to explore alternative modes of transportation to increase their ability to actively participate in society. Hence, this paper aims to understand the characteristics of private chauffeuring and companionship services for older adults, and to assess their possible effects on older adults' wellbeing. We gathered the views of transport operators, government agencies, and city councils that offer private chauffeuring and companionship services for older adults. We frame the model of private chauffeuring and companionship services as alternative mobility for older adults and outline a conceptual framework for its possible effects on their wellbeing. The underlying mobility characteristics were availability, accessibility, safety, and affordability-all of which influence wellbeing. The study found that the private chauffeuring and companionship model for older adults includes an additional model of government-to-consumer services in addition to the existing peer-to-peer and business-to-consumer services. While the services are available, the services provided are not standardized, with different operators offering different services and prices, and limiting certain geographical areas. Transport operators perceived that the services they offer promote older adults' physical and mental health, improve their social participation in the community, and empower them in making their travel decisions. The findings of the paper provide insights for policy makers for future planning of alternative transportation for older adults to enhance their mobility.

Transportation barriers to care among frequent health care users during the COVID pandemic

BACKGROUND

Transportation problems are known barriers to health care and can result in late arrivals and delayed or missed care. Groups already prone to greater social and economic disadvantage, including low-income individuals and people with chronic conditions, encounter more transportation barriers and experience greater negative health care consequences. Addressing transportation barriers is important not only for mitigating adverse health care outcomes among patients, but also for avoiding additional costs to the health care system. In this study, we investigate transportation barriers to accessing health care services during the COVID-19 pandemic among high-frequency health care users.

METHODS

A web-based survey was administered to North Carolina residents aged 18 and older in the UNC Health system who were enrolled in Medicaid or Medicare and had at least six outpatient medical appointments in the past year. 323 complete responses were analyzed to investigate the prevalence of reporting transportation barriers that resulted in having arrived late to, delayed, or missed care, as well as relationships between demographic and other independent variables and transportation barriers. Qualitative analyses were performed on text response data to explain transportation barriers.

RESULTS

Approximately 1 in 3 respondents experienced transportation barriers to health care between June 2020 and June 2021. Multivariate logistic regressions indicate individuals aged 18-64, people with disabilities, and people without a household vehicle were significantly more likely to encounter transportation barriers. Costs of traveling for medical appointments and a lack of driver or car availability emerged as major transportation barriers; however, respondents explained that barriers were often complex, involving circumstantial problems related to one's ability to access and pay for transportation as well as to personal health.

CONCLUSIONS

To address transportation barriers, we recommend more coordination between transportation and health professionals and the implementation of programs that expand access to and improve patient awareness of health care mobility services. We also recommend transportation and health entities direct resources to address transportation barriers equitably, as barriers disproportionately burden younger adults under age 65 enrolled in public insurance programs.

The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population

Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.

Lack of Health Insurance Coverage and Emergency Medical Service Transport for Pediatric Trauma Patients

INTRODUCTION

Pediatric trauma patients who lack insurance coverage may have less access to transport other than emergency medical services (EMS) or face financial barriers that prevent utilization of these services. We analyzed the association between health insurance coverage and EMS transport while controlling for injury and patient characteristics.

MATERIALS AND METHODS

De-identified Trauma Quality Programs registry data were queried for pediatric trauma patients age <18 y. The primary outcome was arrival by EMS (excluding interfacility transfer) versus private transport or walk-in, and the primary exposure was insurance coverage (any versus none). After exact matching on injury and facility characteristics, propensity matching was used to balance demographic covariates and comorbidities between insured and uninsured patients.

RESULTS

Of the 130,246 patients analyzed, 9501 (7%) did not have insurance coverage. After matching 9494 uninsured cases to 9494 insured controls, fixed-effects logistic regression found that uninsured patients had 18% greater odds of using EMS transport, compared to insured patients (odds ratio: 1.18; 95% confidence interval: 1.11, 1.26; P < 0.001). Results were similar when comparing uninsured patients to privately insured or publicly insured patients only.

CONCLUSIONS

Uninsured pediatric trauma patients have a higher likelihood of using EMS transport compared to insured patients with similar demographic and clinical characteristics, including the exact same score of injury severity. Lack of access to private transport may drive higher EMS utilization in uninsured patients with minor injuries and contribute to higher costs of pediatric trauma care borne by institutions and families.

Geographical Access to Child and Family Healthcare Services and Hospitals for Africa-Born Migrants and Refugees in NSW, Australia; A Spatial Study

Background: African-born migrants and refugees arriving from fragile states and countries with political and economic challenges have unique health needs requiring tailored healthcare services and support. However, there is little investigation into the distribution of this population and their spatial access to healthcare in Australia. This paper reports on research that aimed to map the spatial distribution of Africa-born migrants from low and lower-middle-income countries (LLMICs) and refugees in New South Wales (NSW) and access to universal child and family health (CFH) services and hospitals. Methods: We analysed the Australian Bureau of Statistics 2016 Census data and Department of Social Services 2018 Settlement data. Using a Geographic Information System mapping software (Caliper Corporation. Newton, MA, USA), we applied data visualisation techniques to map the distribution of Africa-born migrants and refugees relative to CFH services and their travel distance to the nearest service. Results: Results indicate a spatial distribution of 51,709 migrants from LLMICs in Africa and 13,661 refugees from Africa live in NSW, with more than 70% of the total population residing in Sydney. The Africa-born migrant and refugee population in Sydney appear to be well served by CFH services and hospitals. However, there is a marked disparity between local government areas. For example, the local government areas of Blacktown and Canterbury-Bankstown, where the largest number of Africa-born migrants and refugees reside, have more uneven and widely dispersed services than those in Sydney’s inner suburbs. Conclusion: The place of residence and travel distance to services may present barriers to access to essential CFH services and hospitals for Africa-born refugees and migrants. Future analysis into spatial-access disadvantages is needed to identify how access to health services can be improved for refugees and migrants.

An Analysis of Individual and Contextual-Level Disparities in Screening, Treatment, and Outcomes for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and affects patients of all genders, races, ethnicities, and socioeconomic status. While the causes of HCC are numerous, the primary etiology is cirrhosis from alcohol and non-alcoholic fatty liver disease in the United States and from infectious agents such as Hepatitis B and Hepatitis C in the developing world. In patients at-risk for developing HCC, screening is recommended with ultrasound imaging and alpha fetoprotein laboratory tests. In socioeconomically vulnerable patients, however, individual-level barriers (eg, insurance status) and contextual-level disparities (eg, health facilities) may not be readily available, thus limiting screening. Additional challenges faced by racial/ethnic minorities can further challenge the spectrum of HCC care and lead to inadequate screening, delayed diagnosis, and unequal access to treatment. Efforts to improve these multilevel factors that lead to screening and treatment disparities are critical to overcoming challenges. Providing health insurance to those without access, improving societal challenges that confine patients to a lower socioeconomic status, and reducing challenges to seeking healthcare can decrease the morbidity and mortality of these patients. Additionally, engaging with communities and allowing them to collaborate in their own healthcare can also help to attenuate these inequities. Through collaborative multidisciplinary change, we can make progress in tackling disparities in vulnerable populations to achieve health equity

Barriers and facilitators of older adults' use of ride share services

Introduction

Safe, affordable, and convenient transportation may help older adults (age 65 and older) stay independent, access healthcare services, and maintain their quality of life. While older adults in the United States primarily rely on private automobiles, those who reduce or cease driving may require alternative forms of transportation. Ride share services show promise as an alternative mode of transportation for older adults, particularly for those who no longer drive.

Methods

We employed a qualitative research design to explore barriers and facilitators of older adults' use of ride share services and compare findings to younger adults (age 18 to 64). We conducted 96 telephone interviews (68 older adults and 28 younger adults), and 10 in-person focus groups (56 older adults and 17 younger adults), including individuals who used a ride share service and those who never used a ride share service. We conducted qualitative data analysis to identify key themes and developed a conceptual framework to organize and describe findings.

Results

The qualitative analysis revealed the most important facilitator of older adults' use of ride share services was the desire to remain independent, particularly among those with health conditions and special needs that prevented them from using other transportation. Other facilitators included driver assistance (door-to-door service), a polite and courteous driver, a clean vehicle, and prompt and dependable service. Barriers among older adults included safety concerns, affordability, technology, and a lack of ride share services in the community. Among younger adults, technology was a facilitator of use.

Conclusion

Ride share services are a promising transportation option. Findings highlight a need to tailor these services to older adults' needs. Ride share services that are safe, reliable, and offer driver assistance and telephone scheduling have the potential to support older adults' health, mobility, and independence.

How is the COVID-19 pandemic shaping transportation access to health care?

The Coronavirus disease 19 (COVID-19) pandemic has disrupted both transportation and health systems. While about 40% of Americans have delayed seeking medical care during the pandemic, it remains unclear to what extent transportation is contributing to missed care. To understand the relationship between transportation and unmet health care needs during the pandemic, this paper synthesizes existing knowledge on transportation patterns and barriers across five types of health care needs. While the literature is limited by the absence of detailed data for trips to health care, key themes emerged across populations and settings. We find that some patients, many of whom already experience transportation disadvantage, likely need extra support during the pandemic to overcome new travel barriers related to changes in public transit or the inability to rely on others for rides. Telemedicine is working as a partial substitute for some visits but cannot fulfill all health care needs, especially for vulnerable groups. Structural inequality during the pandemic has likely compounded health care access barriers for low-income individuals and people of color, who face not only disproportionate health risks, but also greater difficulty in transportation access and heightened economic hardship due to COVID-19. Partnerships between health and transportation systems hold promise for jointly addressing disparities in health- and transportation-related challenges but are largely limited to Medicaid-enrolled patients. Our findings suggest that transportation and health care providers should look for additional strategies to ensure that transportation access is not a reason for delayed medical care during and after the COVID-19 pandemic.

Associating ridesourcing with road safety outcomes: Insights from Austin, Texas

Improving road safety and setting targets for reducing traffic-related crashes and deaths are highlighted as part of the United Nations sustainable development goals and worldwide vision zero efforts. The advent of transportation network companies and ridesourcing expands mobility options in cities and may impact road safety outcomes. We analyze the effects of ridesourcing use on road crashes, injuries, fatalities, and driving while intoxicated (DWI) offenses in Travis County, Texas. Our approach leverages real-time ridesourcing volume to explain variation in road safety outcomes. Spatial panel data models with fixed-effects are deployed to examine whether the use of ridesourcing is significantly associated with road crashes and other safety metrics. Our results suggest that for a 10% increase in ridesourcing trips, we expect a 0.12% decrease in road crashes, a 0.25% decrease in road injuries, and a 0.36% decrease in DWI offenses in Travis County. On the other hand, ridesourcing use is not significantly associated with road fatalities. This study augments existing work because it moves beyond binary indicators of ridesourcing availability and analyzes crash and ridesourcing trips patterns within an urbanized area rather than their metropolitan-level variation. Contributions include developing a data-rich approach for assessing the impacts of ridesourcing use on the transportation system's safety, which may serve as a template for future analyses for other cities. Our findings provide feedback to policymakers by clarifying associations between ridesourcing use and traffic safety and uncover the potential to achieve safer mobility systems with transportation network companies.