1
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Celis K, Zaman A, Adams LD, Gardner O, Farid R, Starks TD, Lacroix FC, Hamilton-Nelson K, Mena P, Tejada S, Laux R, Song YE, Caban-Holt A, Feliciano-Astacio B, Vance JM, Haines JL, Byrd GS, Beecham GW, Pericak-Vance MA, Cuccaro ML. Neuropsychiatric features in a multi-ethnic population with Alzheimer disease and mild cognitive impairment. Int J Geriatr Psychiatry 2023; 38:e5992. [PMID: 37655494 PMCID: PMC10518518 DOI: 10.1002/gps.5992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 08/12/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Alzheimer disease (AD) is more prevalent in African American (AA) and Hispanic White (HIW) compared to Non-Hispanic White (NHW) individuals. Similarly, neuropsychiatric symptoms (NPS) vary by population in AD. This is likely the result of both sociocultural and genetic ancestral differences. However, the impact of these NPS on AD in different groups is not well understood. METHODS Self-declared AA, HIW, and NHW individuals were ascertained as part of ongoing AD genetics studies. Participants who scored higher than 0.5 on the Clinical Dementia Rating (CDR) Scale (CDR) were included. Group similarities and differences on Neuropsychiatric Inventory Questionnaire (NPI-Q) outcomes (NPI-Q total score, NPI-Q items) were evaluated using univariate ANOVAs and post hoc comparisons after controlling for sex and CDR stage. RESULTS Our sample consisted of 498 participants (26% AA; 30% HIW; 44% NHW). Overall, NPI-Q total scores differed significantly between our groups, with HIW having the highest NPI-Q total scores, and by AD stage as measured by CDR. We found no significant difference in NPI-Q total score by sex. There were six NPI-Q items with comparable prevalence in all groups and six items that significantly differed between the groups (Anxiety, Apathy, Depression, Disinhibition, Elation, and Irritability). Further, within the HIW group, differences were found between Puerto Rican and Cuban American Hispanics across several NPI-Q items. Finally, Six NPI-Q items were more prevalent in the later stages of AD including Agitation, Appetite, Hallucinations, Irritability, Motor Disturbance, and Nighttime Behavior. CONCLUSIONS We identified differences in NPS among HIW, AA, and NHW individuals. Most striking was the high burden of NPS in HIW, particularly for mood and anxiety symptoms. We suggest that NPS differences may represent the impact of sociocultural influences on symptom presentation as well as potential genetic factors rooted in ancestral background. Given the complex relationship between AD and NPS it is crucial to discern the presence of NPS to ensure appropriate interventions.
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Affiliation(s)
- Katrina Celis
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Andrew Zaman
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Larry Deon Adams
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Olivia Gardner
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rajabli Farid
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Takiyah D Starks
- Maya Angelou Center for Health Equity, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Faina C Lacroix
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kara Hamilton-Nelson
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pedro Mena
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sergio Tejada
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Renee Laux
- Department of Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Yeunjoo E Song
- Department of Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Allison Caban-Holt
- Maya Angelou Center for Health Equity, Wake Forest University, Winston-Salem, North Carolina, USA
| | | | - Jeffery M Vance
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
- Dr. John T Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan L Haines
- Department of Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
- Cleveland Institute for Computational Biology, Cleveland, Ohio, USA
| | - Goldie S Byrd
- Maya Angelou Center for Health Equity, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Gary W Beecham
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
- Dr. John T Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Margaret A Pericak-Vance
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
- Dr. John T Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael L Cuccaro
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida, USA
- Dr. John T Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida, USA
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Figueroa JF, Burke LG, Horneffer KE, Zheng J, John Orav E, Jha AK. Avoidable Hospitalizations And Observation Stays: Shifts In Racial Disparities. Health Aff (Millwood) 2021; 39:1065-1071. [PMID: 32479235 DOI: 10.1377/hlthaff.2019.01019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa is an assistant professor of health policy and management in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an associate physician and assistant professor of medicine in the Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, both in Boston, Massachusetts
| | - Laura G Burke
- Laura G. Burke is an assistant professor of emergency medicine in the Department of Emergency Medicine, Harvard Medical School
| | - Kathryn E Horneffer
- Kathryn E. Horneffer is a research assistant in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston
| | - Jie Zheng
- Jie Zheng is associate director of analytics at the Harvard Global Health Institute, in Cambridge, Massachusetts
| | - E John Orav
- E. John Orav is an associate professor of biostatistics in the Department of Medicine, Brigham and Women's Hospital
| | - Ashish K Jha
- Ashish K. Jha is the director of the Harvard Global Health Institute and is dean of global strategy and the K. T. Li Professor of Global Health, Harvard T. H. Chan School of Public Health
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3
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Yerramilli P, May FP, Kerry VB. Reducing Health Disparities Requires Financing People-Centered Primary Care. JAMA HEALTH FORUM 2021; 2:e201573. [DOI: 10.1001/jamahealthforum.2020.1573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pooja Yerramilli
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Folasade P. May
- Vatche and Tamar Manoukian Division of Digestive Diseases and Jonsson Comprehensive Cancer Center, David Geffen School of Medicine, University of California, Los Angeles
- Seed Global Health, Boston, Massachusetts
| | - Vanessa Bradford Kerry
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
- Seed Global Health, Boston, Massachusetts
- Department of Global Health and Social Medicine, Harvard Medical School, Boston Massachusetts
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4
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Confronting the Post-ACA American Health Crisis: Designing Health Care for Value and Equity. J Ambul Care Manage 2020; 42:202-210. [PMID: 31136391 DOI: 10.1097/jac.0000000000000278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The United States is in the midst of a health crisis marked by unprecedented 3-year declines in life expectancy. Addressing this national crisis requires alignment of public policies, public health policies, and health care policies, with the overarching aim of improving national health and health equity. Aligning national polices to support human needs provides a foundation for implementing post-Affordable Care Act national health care reform. Reform should start with the twin goals of improving health care value and equity. A focus on value, that is, outcomes and processes desired by patients, is critical to ensuring that resources are judiciously deployed to optimize individual and population health. A focus on health care equity ensures that the health care system is intentionally designed to minimize inequities in health care processes and outcomes, particularly for member of socially disadvantaged groups. All sectors related to the health care system-from policies and payment mechanisms to delivery design, measurement, patient engagement/democratization, training, and research-should be tightly aligned with improving health care value and equity during this next era of health care reform.
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5
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Changes in Insurance Coverage and Healthcare Use Among Immigrants and US-Born Adults Following the Affordable Care Act. J Racial Ethn Health Disparities 2020; 8:363-374. [DOI: 10.1007/s40615-020-00790-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 12/29/2022]
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Haley SJ, Moscou S, Murray S, Rieckmann T, Wells KL. The availability of alcohol, tobacco and other drug services for adults in New York State Community Health Centers. JOURNAL OF SUBSTANCE USE 2019. [DOI: 10.1080/14659891.2018.1562577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sean J. Haley
- Department of Health Policy and Management, CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | | | - Sharifa Murray
- Ross University School of Medicine, Roseau, Commonwealth of Dominica, West Indies
| | - Traci Rieckmann
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kameron L. Wells
- Department of Clinical Affairs, Community Health Care Association of New York State, New York, NY, USA
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7
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Ford-Gilboe M, Wathen CN, Varcoe C, Herbert C, Jackson BE, Lavoie JG, Pauly BB, Perrin NA, Smye V, Wallace B, Wong ST, Browne For The Equip Research Program AJ. How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy. Milbank Q 2018; 96:635-671. [PMID: 30350420 PMCID: PMC6287068 DOI: 10.1111/1468-0009.12349] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Policy Points A consensus regarding the need to orient health systems to address inequities is emerging, with much of this discussion targeting population health interventions and indicators. We know less about applying these approaches to primary health care. This study empirically demonstrates that providing more equity‐oriented health care (EOHC) in primary health care, including trauma‐ and violence‐informed, culturally safe, and contextually tailored care, predicts improved health outcomes across time for people living in marginalizing conditions. This is achieved by enhancing patients’ comfort and confidence in their care and their own confidence in preventing and managing health problems. This promising new evidence suggests that equity‐oriented interventions at the point of care can begin to shift inequities in health outcomes for those with the greatest need.
Context Significant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary health care context. Although the provision of equity‐oriented health care (EOHC) is widely assumed to lead to improvements in patients’ health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship. Methods Our analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self‐report measures and survey questions over a 2‐year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients’ perceptions of EOHC led to improvements in self‐reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress [PTSD] and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination). Findings Over a 24‐month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes. Conclusions This study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity‐focused organizational and provider‐level processes in primary health care as a means of improving patients’ health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and across a broader range of health care contexts requires further study.
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Affiliation(s)
| | - C Nadine Wathen
- Arthur Labatt Family School of Nursing, University of Western Ontario.,Centre for Research and Education on Violence Against Women and Children, University of Western Ontario
| | | | - Carol Herbert
- Schulich School of Medicine and Dentistry, University of Western Ontario
| | - Beth E Jackson
- Centre for Chronic Disease and Health Equity, Public Health Agency of Canada.,Carleton University, Canada
| | - Josée G Lavoie
- Ongomiizwin-Research, Indigenous Institute of Health and Healing, Rady Faculty of Health Sciences, University of Manitoba
| | | | | | - Victoria Smye
- Arthur Labatt Family School of Nursing, University of Western Ontario
| | - Bruce Wallace
- School of Social Work, University of Victoria, Canada
| | - Sabrina T Wong
- School of Nursing, University of British Columbia.,Centre for Health Services and Policy Research, University of British Columbia
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8
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Corscadden L, Levesque JF, Lewis V, Breton M, Sutherland K, Weenink JW, Haggerty J, Russell G. Barriers to accessing primary health care: comparing Australian experiences internationally. Aust J Prim Health 2017; 23:223-228. [PMID: 27927280 DOI: 10.1071/py16093] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/07/2016] [Indexed: 11/23/2022]
Abstract
Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain.
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Affiliation(s)
- Lisa Corscadden
- Bureau of Health Information, Level 11, 67 Albert Avenue, Chatswood, NSW 2067, Australia
| | - Jean-Frederic Levesque
- Bureau of Health Information, Level 11, 67 Albert Avenue, Chatswood, NSW 2067, Australia
| | - Virginia Lewis
- Australian Institute for Primary Care & Ageing, LaTrobe University, Melbourne, Vic. 3068, Australia
| | - Mylaine Breton
- Community Health Sciences Department, Université de Sherbrooke, Longueuil, QC, J4K 0A8, Canada
| | - Kim Sutherland
- Bureau of Health Information, Level 11, 67 Albert Avenue, Chatswood, NSW 2067, Australia
| | - Jan-Willem Weenink
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center PO Box 9101, NL-6500 HB Nijmegen, Netherlands
| | - Jeannie Haggerty
- Faculty of Medicine, McGill University, Montreal, QC, H3A 0G4, Canada
| | - Grant Russell
- Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Clayton, Vic. 3800, Australia
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9
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Grogan CM. How the ACA Addressed Health Equity and What Repeal Would Mean. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2017; 42:985-993. [PMID: 28663184 DOI: 10.1215/03616878-3940508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This commentary reviews the many different ways the Affordable Care Act (ACA) explicitly and implicitly attempted to improve health equity, and then assesses how the Republican proposal to repeal and replace the ACA (the proposed American Health Care Act) would impact efforts to improve health equity. Although the American health care system still had a long way to go to achieve health equity, it may be argued that the ACA was a major step forward in creating new programs and regulations that had the potential to improve health equity. In stark contrast, Trumpcare makes no mention of health equity as a goal and-if passed-would result in an increase in health inequity. It would shamefully represent the first time in modern US history that a major federal health reform bill would actually move us further away from creating more equal access to health care coverage and toward reduced health equity.
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10
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Interventions that Reach into Communities--Promising Directions for Reducing Racial and Ethnic Disparities in Healthcare. J Racial Ethn Health Disparities 2016; 2:336-40. [PMID: 26413456 DOI: 10.1007/s40615-014-0078-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Racial/ethnic disparities in healthcare are widespread in the United States and are prevalent across healthcare organizations, including the "equal access" Veterans' Affairs (VA) integrated healthcare system. Despite substantial attention to these disparities over the last decade, there has been limited progress in reducing them. Based on a review of evidence commissioned by the VA to guide its efforts to address racial and ethnic disparities, the conceptual framework describes the root causes of disparities in healthcare quality and outcomes, demonstrating why improvements in the quality of medical care have had limited influence over healthcare disparities that depend largely on social determinants of health. The recommended interventions-including care coordination, culturally-tailored health education, and community health workers-extend the reach of health systems beyond clinics and hospitals and into the communities and social and cultural contexts in which patients live, and in which most health promotion activities occur. To make inroads into addressing disparities, healthcare systems will need to move beyond conceptualizing care delivery as constrained to the clinical encounter and instead, incorporate an understanding of the social determinants of health.
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11
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Purnell TS, Calhoun EA, Golden SH, Halladay JR, Krok-Schoen JL, Appelhans BM, Cooper LA. Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research. Health Aff (Millwood) 2016; 35:1410-5. [DOI: 10.1377/hlthaff.2016.0158] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Tanjala S. Purnell
- Tanjala S. Purnell is an assistant professor in the Department of Surgery and training director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, both at the Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Elizabeth A. Calhoun
- Elizabeth A. Calhoun is a professor in the Department of Public Health Policy and Management at the University of Arizona, in Tucson. At the time this research was conducted, she was codirector of the Center for Population Health and Health Disparities at the University of Illinois at Chicago
| | - Sherita H. Golden
- Sherita H. Golden is the Hugh P. McCormick Family Professor in the Department of Medicine at the Johns Hopkins University School of Medicine and a core faculty member in the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities
| | - Jacqueline R. Halladay
- Jacqueline R. Halladay is an associate professor in the Department of Family Medicine and the Center to Reduce Cardiovascular Disparities, School of Medicine, at the University of North Carolina at Chapel Hill
| | - Jessica L. Krok-Schoen
- Jessica L. Krok-Schoen is a research specialist in the Comprehensive Cancer Center and the Center for Population Health and Health Disparities at the Ohio State University, in Columbus
| | - Bradley M. Appelhans
- Bradley M. Appelhans is an associate professor in the Department of Preventive Medicine and the Center for Urban Health Equity at Rush University, in Chicago
| | - Lisa A. Cooper
- Lisa A. Cooper (
) is the James F. Fries Professor in the Department of Medicine and director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, both at the Johns Hopkins University School of Medicine
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12
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Tarraf W, Mahmoudi E, Dillaway HE, González HM. Health spending among working-age immigrants with disabilities compared to those born in the US. Disabil Health J 2016; 9:479-90. [PMID: 26917103 PMCID: PMC5072124 DOI: 10.1016/j.dhjo.2016.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Revised: 11/03/2015] [Accepted: 01/15/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Immigrants have disparate access to health care. Disabilities can amplify their health care burdens. OBJECTIVE/HYPOTHESIS Examine how US- and foreign-born working-age adults with disabilities differ in their health care spending patterns. METHODS Medical Expenditures Panel Survey yearly-consolidated files (2000-2010) on working-age adults (18-64 years) with disabilities. We used three operational definitions of disability: physical, cognitive, and sensory. We examined annual total, outpatient/office-based, prescription medication, inpatient, and emergency department (ED) health expenditures. We tested bivariate logistic and linear regression models to, respectively, assess unadjusted group differences in the propensity to spend and average expenditures. Second, we used multivariable two-part models to estimate and test per-capita expenditures adjusted for predisposing, enabling, health need and behavior indicators. RESULTS Adjusted for age and sex differences, US-born respondents with physical, cognitive, sensory spent on average $2977, $3312, and $2355 more in total compared to their foreign-born counterparts (P < 0.01). US-born spending was also higher across the four types of health care expenditures considered. Adjusting for the behavioral model factors, especially predisposing and enabling indicators, substantially reduced nativity differences in overall, outpatient/office-based and medication spending but not in inpatient and ED expenditures. CONCLUSIONS Working-age immigrants with disabilities have lower levels of health care use and expenditures compared to their US-born counterparts. Affordable Care Act provisions aimed at increasing access to insurance and primary care can potentially align the consumption patterns of US- and foreign-born disabled working-age adults. More work is needed to understand the pathways leading to differences in hospital and prescription medication care.
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Affiliation(s)
- Wassim Tarraf
- Wayne State University, Institute of Gerontology, 87 East Ferry Street, Knapp Bldg, Room 240, USA.
| | | | | | - Hector M González
- Michigan State University, Department of Epidemiology and Biostatistics, USA
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13
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Dowrick C, Bower P, Chew-Graham C, Lovell K, Edwards S, Lamb J, Bristow K, Gabbay M, Burroughs H, Beatty S, Waheed W, Hann M, Gask L. Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study. BMC Health Serv Res 2016; 16:58. [PMID: 26883118 PMCID: PMC4756439 DOI: 10.1186/s12913-016-1298-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 02/09/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions. METHODS We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data. RESULTS Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement. CONCLUSIONS We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model. TRIAL REGISTRATION Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.
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Affiliation(s)
- Christopher Dowrick
- />Institute of Psychology, Health and Society, Waterhouse Building, University of Liverpool, Liverpool, L69 3GL UK
| | - Peter Bower
- />NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
| | - Carolyn Chew-Graham
- />Primary Care and Health Sciences Research Institute, Keele University, Keele, Staffordshire ST5 5BG UK
- />West Midlands Collaboration for Leadership in Applied Health Research & Care, Birmingham, UK
| | - Karina Lovell
- />School of Nursing, Midwifery and Social Work, Jean MacFarlane Building, University of Manchester, Manchester, M13 9PL UK
| | - Suzanne Edwards
- />College of Medicine, Grove Building, Swansea University, Swansea, SA2 8PP UK
| | - Jonathan Lamb
- />NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
| | - Katie Bristow
- />Institute of Psychology, Health and Society, Waterhouse Building, University of Liverpool, Liverpool, L69 3GL UK
| | - Mark Gabbay
- />Institute of Psychology, Health and Society, Waterhouse Building, University of Liverpool, Liverpool, L69 3GL UK
| | - Heather Burroughs
- />Primary Care and Health Sciences Research Institute, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Susan Beatty
- />School of Nursing, Midwifery and Social Work, Jean MacFarlane Building, University of Manchester, Manchester, M13 9PL UK
| | - Waquas Waheed
- />NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
| | - Mark Hann
- />NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
| | - Linda Gask
- />NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
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14
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Abstract
The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.
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Affiliation(s)
- Kevin Fiscella
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
| | - Mechelle R Sanders
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
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DeVoe JE, Tillotson CJ, Angier H, Wallace LS. Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role. Matern Child Health J 2015; 19:889-96. [PMID: 25070735 DOI: 10.1007/s10995-014-1590-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To identify predictors of coverage continuity for United States children and assess how they have changed in the first 12 years since implementation of the Children's Health Insurance Program in 1997. Using data from the nationally-representative Medical Expenditure Panel Survey, we used logistic regression to identify predictors of discontinuity in 1998 and 2009 and compared differences between the 2 years. Having parents without continuous coverage was the greatest predictor of a child's coverage gap in both 1998 and 2009. Compared to children with at least one parent continuously covered, children whose parents did not have continuous coverage had a significantly higher relative risk (RR) of a coverage gap [RR 17.96, 95 % confidence interval (CI) 14.48-22.29 in 1998; RR 12.88, 95 % CI 10.41-15.93 in 2009]. In adjusted models, parental continuous coverage was the only significant predictor of discontinuous coverage for children (with one exception in 2009). The magnitude of the pattern was higher for privately-insured children [adjusted relative risk (aRR) 29.17, 95 % CI 20.99-40.53 in 1998; aRR 25.54, 95 % CI 19.41-33.61 in 2009] than publicly-insured children (aRR 5.72, 95 % CI 4.06-8.06 in 1998; aRR 4.53, 95 % CI 3.40-6.04 in 2009). Parental coverage continuity has a major influence on children's coverage continuity; this association remained even after public health insurance expansions for children. The Affordable Care Act will increase coverage for many adults; however, 'churning' on and off programs due to income fluctuations could result in coverage discontinuities for parents. If parental coverage instability persists, these discontinuities may continue to have a negative impact on children's coverage stability as well.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode FM, Portland, OR, 97239, USA,
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Sealy-Jefferson S, Vickers J, Elam A, Wilson MR. Racial and Ethnic Health Disparities and the Affordable Care Act: a Status Update. J Racial Ethn Health Disparities 2015; 2:583-8. [PMID: 26668787 PMCID: PMC4676760 DOI: 10.1007/s40615-015-0113-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Persistent racial and ethnic health disparities exist in the USA, despite decades of research and public health initiatives. Several factors contribute to health disparities, including (but not limited to) implicit provider bias, access to health care, social determinants, and biological factors. Disparities in health by race/ethnicity are unacceptable and correctable. The Patient Protection and Affordable Care Act is a comprehensive legislation that is focused on improving health care access, quality, and cost control. This health care reform includes specific provisions which focus on preventive care, the standardized collection of data on race, ethnicity, primary language and disability status, and health information technology. Although some provisions of the Patient Protection and Affordable Care Act have not been implemented, such as funding for the U.S. Public Health Sciences track, which would have addressed the shortage of medical professionals in the USA who are trained to use patient-centered, interdisciplinary, and care coordination approaches, this legislation is still poised to make great strides toward eliminating health disparities. The purpose of this manuscript is to highlight the unprecedented opportunities that exist for the Patient Protection and Affordable Care Act to reduce racial and ethnic disparities in health in the USA.
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Affiliation(s)
- Shawnita Sealy-Jefferson
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Avenue, Detroit, MI 48201, USA
| | - Jasmine Vickers
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Avenue, Detroit, MI 48201, USA
| | - Angela Elam
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - M. Roy Wilson
- Office of the President, Wayne State University, 656 W. Kirby, 4200 Faculty/Administration Building, Detroit, MI 48202, USA
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Perzynski A, Blixen C, Cage J, Colón-Zimmermann K, Sajatovic M. Informing Policy for Reducing Stroke Health Disparities from the Experience of African-American Male Stroke Survivors. J Racial Ethn Health Disparities 2015; 3:527-36. [PMID: 27294742 DOI: 10.1007/s40615-015-0171-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/01/2015] [Accepted: 09/20/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND The burden of stroke is severe among African-Americans. Despite overall declines in the rate of stroke since 2000, outcomes are largely unimproved or have worsened for African-American men. Adverse psychosocial challenges may hinder adherence to a regimen of risk factor reduction. METHODS AND RESULTS Focus group analysis was combined with a review of current published guidelines and epidemiologic evidence on risk factors to better understand stroke health disparities and potential policy solutions. Transcripts from three focus groups with ten African-American male stroke survivors under age 65 and their care partners (N = 7) were analyzed and compared with existing published data on (a) the burden of stroke (b) trends in clinical risk factors, and (c) trends in behavioral risk factors. Participants described myriad psychosocial barriers that impede reduction of risk indicators, including low trust in providers, poor social support, access difficulties, depression, and distress. CONCLUSIONS In order to be effective, policies and programs must target mechanisms consistent with the challenges faced by African-American men. Infrastructure is needed to better identify and share practices effective for improving cardiovascular outcomes within specific racial and ethnic groups.
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Affiliation(s)
- Adam Perzynski
- Case Western Reserve University, Cleveland, OH, USA. .,Center for Health Care Research and Policy, The MetroHealth System, 2500 MetroHealth Dr. R225A, Cleveland, OH, 44109, USA.
| | - Carol Blixen
- Case Western Reserve University, Cleveland, OH, USA.,Center for Health Care Research and Policy, The MetroHealth System, 2500 MetroHealth Dr. R225A, Cleveland, OH, 44109, USA
| | - Jamie Cage
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Martha Sajatovic
- Case Western Reserve University, Cleveland, OH, USA.,University Hospitals, Cleveland, OH, USA
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Goeddel LA, Porterfield JR, Hall JD, Vetter TR. Ethical Opportunities with the Perioperative Surgical Home. Anesth Analg 2015; 120:1158-1162. [DOI: 10.1213/ane.0000000000000700] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Loignon C, Fortin M, Bedos C, Barbeau D, Boudreault-Fournier A, Gottin T, Goulet É, Laprise E, Haggerty JL. Providing care to vulnerable populations: a qualitative study among GPs working in deprived areas in Montreal, Canada. Fam Pract 2015; 32:232-6. [PMID: 25670205 PMCID: PMC4371892 DOI: 10.1093/fampra/cmu094] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Communication barriers between persons living in poverty and healthcare professionals reduce care effectiveness. Little is known about the strategies general practitioners (GPs) use to enhance the effectiveness of care for their patients living in poverty. OBJECTIVE The aim of this study was to identify strategies adopted by GPs to deliver appropriate care to patients living in poverty. METHODS We conducted in-depth semi-structured interviews with 35 GPs practising in Montreal, Canada, who regularly provide care to underprivileged patients in primary care clinics located in deprived urban areas. Analysis consisted of interview debriefing, transcript coding, thematic analysis and data interpretation. RESULTS GPs develop specific skills for caring for these patients that are responsive to their complex medical needs and challenging social context. Our respondents used three main strategies in working with their patients: building a personal connection to overcome social distance, aligning medical expectations with patients' social vulnerability and working collaboratively to empower patients. With these strategies, the physicians were able to enhance the patient-physician relationship and to take into account the impact of poverty on illness self-management. CONCLUSIONS Our results may help GPs improve the health and care experience of their vulnerable patients by adopting these strategies. The strategies' impacts on patients' experience of care and health outcomes should be evaluated as a prelude to integrating them into primary care practice and the training of future physicians.
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Affiliation(s)
| | - Martin Fortin
- Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Quebec
| | | | - David Barbeau
- Faculty of Medicine, University of Montreal, Montreal, Quebec
| | | | - Thomas Gottin
- Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Quebec
| | - Émilie Goulet
- Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Quebec
| | - Elisha Laprise
- Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Quebec
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Haley SJ, Kreek MJ. A window of opportunity: maximizing the effectiveness of new HCV regimens in the United States with the expansion of the Affordable Care Act. Am J Public Health 2015; 105:457-63. [PMID: 25602859 PMCID: PMC4330831 DOI: 10.2105/ajph.2014.302327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2014] [Indexed: 12/18/2022]
Abstract
Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management. New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.
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Affiliation(s)
- Sean J Haley
- Sean J. Haley is with the Department of Health and Nutrition Sciences, Brooklyn College and the City University of New York, School of Public Health, New York. Mary Jeanne Kreek is with the Laboratory of the Biology of Addictive Diseases, The Rockefeller University, New York
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21
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Beck AF, Huang B, Simmons JM, Moncrief T, Sauers HS, Chen C, Ryan PH, Newman NC, Kahn RS. Role of financial and social hardships in asthma racial disparities. Pediatrics 2014; 133:431-9. [PMID: 24488745 PMCID: PMC3934338 DOI: 10.1542/peds.2013-2437] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Health care reform offers a new opportunity to address child health disparities. This study sought to characterize racial differences in pediatric asthma readmissions with a focus on the potential explanatory role of hardships that might be addressed in future patient care models. METHODS We enrolled 774 children, aged 1 to 16 years, admitted for asthma or bronchodilator-responsive wheezing in a population-based prospective observational cohort. The outcome was time to readmission. Child race, socioeconomic status (measured by lower income and caregiver educational attainment), and hardship (caregivers looking for work, having no one to borrow money from, not owning a car or home, and being single/never married) were recorded. Analyses used Cox proportional hazards. RESULTS The cohort was 57% African American, 33% white, and 10% multiracial/other; 19% were readmitted within 12 months. After adjustment for asthma severity classification, African Americans were twice as likely to be readmitted as whites (hazard ratio: 1.98; 95% confidence interval: 1.42 to 2.77). Compared with whites, African American caregivers were significantly more likely to report lower income and educational attainment, difficulty finding work, having no one to borrow money from, not owning a car or home, and being single/never married (all P ≤ .01). Hardships explained 41% of the observed racial disparity in readmission; jointly, socioeconomic status and hardship explained 49%. CONCLUSIONS African American children were twice as likely to be readmitted as white children; hardships explained >40% of this disparity. Additional factors (eg, pollution, tobacco exposure, housing quality) may explain residual disparities. Targeted interventions could help achieve greater child health equity.
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Affiliation(s)
- Andrew F. Beck
- Divisions of General and Community Pediatrics,,Hospital Medicine, and
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Hadley S. Sauers
- Divisions of General and Community Pediatrics,,Hospital Medicine, and
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick H. Ryan
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Turner SJ, Brown J, Paladino JA. Protease inhibitors for hepatitis C: economic implications. PHARMACOECONOMICS 2013; 31:739-751. [PMID: 23839698 DOI: 10.1007/s40273-013-0073-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Chronic hepatitis C virus (HCV) infection, a blood-borne virus, is the leading cause of chronic liver disease and liver transplantation worldwide. Chronic HCV infection is usually asymptomatic in the early stages of the disease, making an estimation of the total population affected difficult to elicit. The gold standard treatment option to date has been a combination of pegylated interferon and ribavirin. Recent developments have led to the introduction of two protease inhibitors for use in chronic HCV-boceprevir and telaprevir. Phase III studies have shown both agents have the potential to significantly increase the probability of attaining a sustained virologic response (the primary outcome of interest in chronic HCV) in genotype 1 infections. However, the added cost of these agents also presents the need for decision makers to determine their place on drug formularies. The protease inhibitors are to be administered as triple therapy with the existing gold standard. However, significant variation exists as to the proposed duration of triple therapy, use of lead-in pegylated interferon and ribavirin and subsequent pegylated interferon therapy after finishing the course of triple therapy. Treatment algorithms also exist for the use of stopping rules in the case of early non-responders.The aim of this review is to highlight the current understanding of the economic impact protease inhibitors may have on health care systems and considerations required in the treatment of HCV. Economic and health-related quality of life issues are addressed from multiple viewpoints. The major aspects of the economic evaluations, to date, that included triple therapy as an alternative in the treatment of chronic HCV are brought to light. Future economic evaluations in alternative settings would be useful. The review also emphasizes the challenges for future research. This includes the potential for new therapies to no longer require inclusion of pegylated interferon and/or ribavirin, as well as the use of protease inhibitors in non-genotype 1 patients or those with significant co-morbidities such as HIV/AIDS.
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Affiliation(s)
- Stuart J Turner
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 205 Kapoor Hall, Buffalo, NY 14214, USA
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Zhang S, Dorn B. A Community-Based Participatory Research Model and Web Application for Studying Health Professional Shortage Areas in the United States. INTERNATIONAL JOURNAL OF HEALTHCARE INFORMATION SYSTEMS AND INFORMATICS 2013. [DOI: 10.4018/jhisi.2013070102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Health Professional Shortage Areas (HPSA) are still associated with “worse general health status and poor physical health” (Jiexin, 2007) in the United States today. Meanwhile, limitations still exist in HPSA studies for multiple reasons, including limited data resources and availability, lack of efficient way to share and collaborate, and lack of community participation and public awareness. To overcome these limitations, we proposed a Community-Based Participatory Research (CBPR) approach for HPSA studies that allows researchers to share and collaborate on HPSA related data, and allows the general public to learn about HPSA and participate in survey and discussions that help supplement researchers’ data. Through CBPR, effective and location-appropriate research, planning, and awareness can be achieved (O'Fallon & Dearry, 2002). We then described a Web application, which was designed based on our CBPR model, through the use of Google Fusion Table and Geocoding.
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Affiliation(s)
- Sonya Zhang
- Department of Computer Information Systems, Cal Poly Pomona, Pomona, CA, USA
| | - Bradley Dorn
- California State University, Fresno, Fresno, CA, USA
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24
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[Clinical bioethics for primary health care]. Semergen 2013; 39:445-9. [PMID: 23608158 DOI: 10.1016/j.semerg.2013.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 02/04/2013] [Accepted: 02/06/2013] [Indexed: 11/23/2022]
Abstract
The clinical decision making process with ethical implications in the area of primary healthcare differs from other healthcare areas. From the ethical perspective it is important to include these issues in the decision making model. This dissertation explains the need for a process of bioethical deliberation for Primary Healthcare, as well as proposing a method for doing so. The decision process method, adapted to this healthcare area, is flexible and requires a more participative Healthcare System. This proposal involves professionals and the patient population equally, is intended to facilitate the acquisition of responsibility for personal and community health.
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25
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Kousoulis AA, Angelopoulou KE, Lionis C. Exploring health care reform in a changing Europe: lessons from Greece. Eur J Gen Pract 2013; 19:194-9. [PMID: 23581404 DOI: 10.3109/13814788.2013.779663] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The economic crisis is the major theme in the Eurozone and its impact on public health and outcomes is largely discussed. Under this pressure, concerns of further inequalities exist that may have an impact on the burden of several diseases in certain European countries. In this context, Greece is currently an issue of top interest in any international economic discussion. Although the background of the recession has been largely discussed as a political crisis, its health effects on the population, as well as the key role of primary care and general practice/family medicine in health care reform remain to be explored. Serving both the worldwide trend of orienting health care systems towards strengthened primary care and the inner need for minimizing the demand and lessening the burden from the dysfunctional and costly hospital-care system, the economic crisis sets the perfect timing for prioritizing primary health care. In this article a unique window of opportunity for health care reform in Greece is examined, attempting to establish the axes of an example of how health care system can be reshaped amidst the economic crisis. Equity, quality, value framework, medical professionalism, information technology and decentralization emerge as topics of central interest. There is no doubt that Europe is transitioning under challenging social, economic and public health perspectives. However, taking Greece as an example, the current economic situation sets a good timing for health care reform and the key messages of this paper could be used by other countries facing similar problems.
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Hunt LM, Kreiner MJ. Pharmacogenetics in primary care: the promise of personalized medicine and the reality of racial profiling. Cult Med Psychiatry 2013; 37:226-35. [PMID: 23264029 PMCID: PMC3593998 DOI: 10.1007/s11013-012-9303-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Many anticipate that expanding knowledge of genetic variations associated with disease risk and medication response will revolutionize clinical medicine, making possible genetically based Personalized Medicine where health care can be tailored to individuals, based on their genome scans. Pharmacogenetics has received especially strong interest, with many pharmaceutical developers avidly working to identify genetic variations associated with individual differences in drug response. While clinical applications of emerging genetic knowledge are becoming increasingly available, genetic tests for drug selection are not as yet widely accessible, and many primary care clinicians are unprepared to interpret genetic information. We conducted interviews with 58 primary care clinicians, exploring how they integrate emerging pharmacogenetic concepts into their practices. We found that in their current practices, pharmacogenetic innovations have not led to individually tailored treatment, but instead have encouraged use of essentialized racial/ethnic identity as a proxy for genetic heritage. Current manifestations of Personalized Medicine appear to be reinforcing entrenched notions of inherent biological differences between racial groups, and promoting the belief that racial profiling in health care is supported by cutting-edge scientific authority. Our findings raise concern for how pharmacogenetic innovations will actually affect diverse populations, and how unbiased treatment can be assured.
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Affiliation(s)
- Linda M Hunt
- Department of Anthropology, Michigan State University, 338 Baker Hall, East Lansing, MI 48824, USA.
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Colais P, Agabiti N, Fusco D, Pinnarelli L, Sorge C, Perucci CA, Davoli M. Inequality in 30-day mortality and the wait for surgery after hip fracture: the impact of the regional health care evaluation program in Lazio (Italy). Int J Qual Health Care 2013; 25:239-47. [PMID: 23335054 DOI: 10.1093/intqhc/mzs082] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE INTERVENTIONS that address inequalities in health care are a priority for public health research. We evaluated the impact of the Regional Health Care Evaluation Program in the Lazio region, which systematically calculates and publicly releases hospital performance data, on socioeconomic differences in the quality of healthcare for hip fracture. DESIGN Retrospective cohort study. SETTING and participants We identified, in the hospital information system, elderly patients hospitalized for hip fracture between 01 January 2006 and 31 December 2007 (period 1) and between 01 January 2009 and 30 November 2010 (period 2). MAIN OUTCOME MEASURES We used multivariate regression models to test the association between socioeconomic position index (SEP, level I well-off to level III disadvantaged) and outcomes: mortality within 30 days of hospital arrival, median waiting time for surgery and proportion of interventions within 48 h. RESULTS We studied 11 581 admissions. Lower SEP was associated with a higher risk of 30-day mortality in period 1 (relative risk (RR) = 1.42, P = 0.027), but not in period 2. Disadvantaged people were less likely to undergo intervention within 48 h than well-off persons in period 1 (level II: RR = 0.72, P < 0.001; level III: RR = 0.46, P < 0.001) and period 2 (level II: RR = 0.88, P = 0.037; level III: RR = 0.63, P < 0.001). We observed a higher probability of undergoing intervention within 48 h in period 2 compared with the period 1 for each socioeconomic level. CONCLUSION This study suggests that a systematic evaluation of health outcome approach, including public disclosure of results, could reduce socioeconomic differences in healthcare through a general improvement in the quality of care.
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Affiliation(s)
- P Colais
- Department of Epidemiology, Regional Health Service, Lazio Region Via Santa Costanza 53, 00198 Rome, Italy.
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McLeod L, Kingston-Riechers J, Jonsson E. A conceptual framework identifying sources of risk to patient safety in primary care. Aust J Prim Health 2012; 18:185-9. [DOI: 10.1071/py11062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 10/26/2011] [Indexed: 11/23/2022]
Abstract
The potential risks to patient safety in a primary care setting are different than the risks to patient safety in an acute care setting. The main differences arise from the organisational structures of primary care delivery and the greater involvement of patients in their care. To account for these differences, we present the Patient Safety in Primary Care Framework to conceptualise the sources of risk to patient safety.
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Jean-Jacques M, Persell SD, Thompson JA, Hasnain-Wynia R, Baker DW. Changes in disparities following the implementation of a health information technology-supported quality improvement initiative. J Gen Intern Med 2012; 27:71-7. [PMID: 21892661 PMCID: PMC3250541 DOI: 10.1007/s11606-011-1842-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 07/01/2011] [Accepted: 08/05/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Health information technology (HIT)-supported quality improvement initiatives have been shown to increase ambulatory care quality for several chronic conditions and preventive services, but it is not known whether these types of initiatives reduce disparities. OBJECTIVES To examine the effects of a multifaceted, HIT-supported quality improvement initiative on disparities in ambulatory care. DESIGN Time series models were used to assess changes in racial disparities in performance between white and black patients for 17 measures of chronic disease and preventive care from February 2008 through February 2010, the first 2 years after implementation of a HIT-supported, provider-directed quality improvement initiative. PATIENTS Black and white adults receiving care in an academic general internal medicine practice in Chicago. INTERVENTIONS The quality improvement initiative used provider-directed point-of-care clinical decision support tools and quality feedback to target improvement in process of care and intermediate outcome measures for coronary heart disease, heart failure, hypertension, and diabetes as well as receipt of several preventive services. MAIN MEASURES Modeled rate of change in performance, stratified by race and modeled rate of change in disparities for 17 ambulatory care quality measures KEY RESULTS Quality of care improved for 14 of 17 measures among white patients and 10 of 17 measures among black patients. Quality improved for both white and black patients for five of eight process of care measures, four of five preventive services, but none of the four intermediate outcome measures. Of the seven measures with racial disparities at baseline, disparities declined for two, remained stable for four, and increased for one measure after implementation of the quality improvement initiative. CONCLUSIONS Generalized and provider-directed quality improvement initiatives can decrease racial disparities for some chronic disease and preventive care measures, but achieving equity in areas with persistent disparities will require more targeted, patient-directed, and systems-oriented strategies.
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Affiliation(s)
- Muriel Jean-Jacques
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Thorlby R, Jorgensen S, Siegel B, Ayanian JZ. How health care organizations are using data on patients' race and ethnicity to improve quality of care. Milbank Q 2011; 89:226-55. [PMID: 21676022 PMCID: PMC3142338 DOI: 10.1111/j.1468-0009.2011.00627.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
CONTEXT Racial and ethnic disparities in the quality of health care are well documented in the U.S. health care system. Reducing these disparities requires action by health care organizations. Collecting accurate data from patients about their race and ethnicity is an essential first step for health care organizations to take such action, but these data are not systematically collected and used for quality improvement purposes in the United States. This study explores the challenges encountered by health care organizations that attempted to collect and use these data to reduce disparities. METHODS Purposive sampling was used to identify eight health care organizations that collected race and ethnicity data to measure and reduce disparities in the quality and outcomes of health care. Staff, including senior managers and data analysts, were interviewed at each site, using a semi-structured interview format about the following themes: the challenges of collecting and collating accurate data from patients, how organizations defined a disparity and analyzed data, and the impact and uses of their findings. FINDINGS To collect accurate self-reported data on race and ethnicity from patients, most organizations had upgraded or modified their IT systems to capture data and trained staff to collect and input these data from patients. By stratifying nationally validated indicators of quality for hospitals and ambulatory care by race and ethnicity, most organizations had then used these data to identify disparities in the quality of care. In this process, organizations were taking different approaches to defining and measuring disparities. Through these various methods, all organizations had found some disparities, and some had invested in interventions designed to address them, such as extra staff, extended hours, or services in new locations. CONCLUSION If policymakers wish to hold health care organizations accountable for disparities in the quality of the care they deliver, common standards will be needed for organizations' data measurement, analysis, and use to guide systematic analysis and robust investment in potential solutions to reduce and eliminate disparities.
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Affiliation(s)
- Ruth Thorlby
- Nuffield Trust, 59 New Cavendish Street, London W1G 0AN, UK.
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