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Vining R, Finn M. Why and how is photovoice used as a decolonising method for health research with Indigenous communities in the United States and Canada? A scoping review. Nurs Inq 2024; 31:e12605. [PMID: 37805822 DOI: 10.1111/nin.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 10/09/2023]
Abstract
Globally, including in North America, Indigenous populations have poorer health than non-Indigenous populations. This health disparity results from inequality and marginalisation associated with colonialism. Photovoice is a community-based participatory research method that amplifies the voices of research participants. Why and how photovoice has been used as a decolonising method for addressing Indigenous health inequalities has not been mapped. A scoping review of the literature on photovoice for Indigenous health research in the United States and Canada was carried out. Five electronic databases and the grey literature were searched, with no time limit. A total of 215 titles and abstracts and 97 full texts were screened resulting in 57 included articles. Analysis incorporated Lalita Bharadwaj's Framework For Building Research Partnerships with First Nations Communities. Photovoice was selected to improve knowledge mobilisation and participant empowerment and engagement. Studies incorporated relationship building, meaningful data collection, and public dissemination but had a lesser focus on the inclusion of Indigenous peer researchers or participant involvement in analysis. For photovoice to truly realise its decolonising potential, it must be incorporated into a broader participatory and decolonising research paradigm. In addition, more resources are required to support the involvement of Indigenous people in the research process.
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Affiliation(s)
- Rebecca Vining
- Centre for Global Health, Trinity College Dublin, Dublin, Ireland
- Department of Geography, Maynooth University, Kildare, Ireland
| | - Mairéad Finn
- Centre for Global Health, Trinity College Dublin, Dublin, Ireland
- Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Ireland
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Landon BE, Hatfield LA, Bakx P, Banerjee A, Chen YC, Fu C, Gordon M, Heine R, Huang N, Ko DT, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, Uyl-de Groot C, Yan L, Weinreb G, Cram P. Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries. JAMA 2023; 329:1088-1097. [PMID: 37014339 PMCID: PMC10074220 DOI: 10.1001/jama.2023.1699] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/01/2023] [Indexed: 04/05/2023]
Abstract
Importance Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.
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Affiliation(s)
- Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Laura A. Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Pieter Bakx
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, England
- Department of Cardiology, University College London Hospitals, London, England
| | - Yu-Chin Chen
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Michal Gordon
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Renaud Heine
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Dennis T. Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa M. Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Victor Novack
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Laura Pasea
- Institute of Health Informatics, University College London, London, England
| | - Feng Qiu
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Therese A. Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Carin Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
| | - Lin Yan
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Peter Cram
- ICES, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Texas Medical Branch, Galveston
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Shah T, Milosavljevic S, Bath B. Geographic availability to optometry services across Canada: mapping distribution, need and self-reported use. BMC Health Serv Res 2020; 20:639. [PMID: 32650762 PMCID: PMC7350740 DOI: 10.1186/s12913-020-05499-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 07/02/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This research investigates the distribution of optometrists in Canada relative to population health needs and self-reported use of vision services. METHODS Optometrist locations were gathered from provincial regulatory bodies. Optometrist-to-population ratios (i.e. the number of providers per 10,000 people at the health region level) were then calculated. Utilization of vision care services was extracted from the Canadian Community Health Survey (CCHS) 2013-2014 question regarding self-reported contacts with optometrists or ophthalmologists. Data from the 2016 Statistics Canada census were used to create three population 'need' subgroups (65 years and over; low-income; and people aged 15 and over with less than a high school diploma). Cross-classification mapping compared optometrist distribution to self-reported use of vision care services in relation to need. Each variable was converted into three classes (i.e., low, moderate, and high) using a standard deviation (SD) classification scheme where ±0.5SD from the mean was considered as a cut-off. Three classes: low (< - 0.5SD), moderate (- 0.5 to 0.5SD), and high (> 0.5SD) were used for demonstrating distribution of each variable across health regions. RESULTS A total of 5959 optometrists across ten Canadian provinces were included in this analysis. The nationwide distribution of optometrists is variable across Canada; they are predominantly concentrated in urban areas. The national mean ratio of optometrists was 1.70 optometrists per 10,000 people (range = 0.13 to 2.92). Out of 109 health regions (HRs), 26 were classified as low ratios, 51 HRs were classified as moderate ratios, and 32 HRs were high ratios. Thirty-five HRs were classified as low utilization, 39 HRs were classified as moderate, and 32 HRs as high utilization. HRs with a low optometrist ratio relative to eye care utilization and a high proportion of key sociodemographic characteristics (e.g. older age, low income) are located throughout Canada and identified with maps indicating areas of likely greater need for optometry services. CONCLUSION This research provides a nationwide overview of vision care provided by optometrists identifying gaps in geographic availability relative to "supply" and "need" factors. This examination of variation in accessibility to optometric services will be useful to inform workforce planning and policies.
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Affiliation(s)
- Tayyab Shah
- School of Rehabilitation Science, University of Saskatchewan, Suite 3400, 3rd Floor, 104 Clinic Pl, Saskatoon, Saskatchewan S7N 2Z4 Canada
- School of Geography, Earth Science, and Environment, University of the South Pacific, Suva, Fiji
| | - Stephan Milosavljevic
- School of Rehabilitation Science, University of Saskatchewan, Rm 3410, Health Sciences Building, 104 Clinic Place PO Box 23, Saskatoon, Saskatchewan S7N 2Z4 Canada
| | - Brenna Bath
- School of Rehabilitation Science and Canadian Centre for Health and Safety in Agriculture (CCHSA), University of Saskatchewan, Rm 1340 - E wing - Health Sciences Building, 104 Clinic Place PO Box 23, Saskatoon, Saskatchewan S7N 2Z4 Canada
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Lowry CA, Jin AY. Improving the Social Relevance of Experimental Stroke Models: Social Isolation, Social Defeat Stress and Stroke Outcome in Animals and Humans. Front Neurol 2020; 11:427. [PMID: 32477259 PMCID: PMC7240068 DOI: 10.3389/fneur.2020.00427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/22/2020] [Indexed: 01/05/2023] Open
Abstract
The outcome of ischemic stroke varies across socioeconomic strata, even among countries with universal health care. Emerging evidence suggests that psychosocial aspects of low socioeconomic status such as social isolation and social defeat stress interact with, and contribute to, stroke pathophysiology. However, experimental investigations of stroke rarely account for such socioeconomic influences. Social isolation in stroke survivors is associated with increased infarction volume, increased risk of post-stroke depression, and worse long-term functional outcome. Social defeat is thought to contribute significantly to chronic stress in low socioeconomic status groups and is associated with poor health outcomes. Chronic stress is also associated with worse post-stroke functional outcome and greater disability even after accounting for stroke severity, vascular risk factors, and access to acute stroke care. Experimental stroke studies which incorporate social isolation or social defeat stress have shown that both tissue and functional stroke outcome is affected by the increased expression of TNF-α and IL-6, increased glucocorticoid production, and suppression of the protooncogene bcl-2. This review explores the consequences of social isolation and social defeat stress on stroke, preclinical stroke models that have been used to investigate these factors, and possible molecular mechanisms underlying the influence of socioeconomic disparities on stroke outcome.
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Affiliation(s)
- Chloe A Lowry
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Albert Y Jin
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Medicine, Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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Revon-Rivière G, Pauly V, Baumstarck K, Bernard C, André N, Gentet JC, Seyler C, Fond G, Orleans V, Michel G, Auquier P, Boyer L. High-intensity end-of-life care among children, adolescents, and young adults with cancer who die in the hospital: A population-based study from the French national hospital database. Cancer 2019; 125:2300-2308. [PMID: 30913309 DOI: 10.1002/cncr.32035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/17/2018] [Accepted: 01/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Efforts to improve the quality of end-of-life (EOL) care depend on better knowledge of the care that children, adolescents, and young adults with cancer receive, including high-intensity EOL (HI-EOL) care. The objective was to assess the rates of HI-EOL care in this population and to determine patient- and hospital-related predictors of HI-EOL from the French national hospital database. METHODS This was a population-based, retrospective study of a cohort of patients aged 0 to 25 years at the time of death who died at hospital as a result of cancer in France between 2014 and 2016. The primary outcome was HI-EOL care, defined as the occurrence of ≥1 chemotherapy session <14 days from death, receiving care in an intensive care unit ≥1 time, >1 emergency room admission, and >1 hospitalization in an acute care unit in the last 30 days of life. RESULTS The study included 1899 individuals from 345 hospitals; 61.4% experienced HI-EOL care. HI-EOL was increased with social disadvantage (adjusted odds ratio [AOR], 1.30; 95% confidence interval [CI], 1.03-1.65; P = .028), hematological malignancies (AOR, 2.09; 95% CI, 1.57-2.77; P < .001), complex chronic conditions (AOR, 1.60; 95% CI, 1.23-2.09; P = .001) and care delivered in a specialty center (AOR, 1.70; 95% CI, 1.22-2.36; P = .001). HI-EOL was reduced in cases of palliative care (AOR, 0.31; 95% CI, 0.24-0.41; P < .001). CONCLUSION A majority of children, adolescents, and young adults experience HI-EOL care. Several features (eg, social disadvantage, cancer diagnosis, complex chronic conditions, and specialty center care) were associated with HI-EOL care. These findings should now be discussed with patients, families, and professionals to define the optimal EOL.
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Affiliation(s)
- Gabriel Revon-Rivière
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
- Fédération des Équipes Ressources Régionales de Soins Palliatifs Pédiatriques
| | - Vanessa Pauly
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- Department of Medical Information, APHM, Marseille, France
| | - Karine Baumstarck
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Cecile Bernard
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Nicolas André
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
| | - Jean-Claude Gentet
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
| | | | - Guillaume Fond
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- Department of Medical Information, APHM, Marseille, France
| | | | - Gérard Michel
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Pascal Auquier
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Laurent Boyer
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- Department of Medical Information, APHM, Marseille, France
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6
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Abstract
Pharmaceutical industry representatives and public drug plan managers hold competing visions of drug access, ones I theorize as "fast" and "slow" care paces. The relationship between free market imaginaries and population-based biopolitics is negotiated through these paces from within the flexible political category of rare disease. In this article, I explore expensive rare disease drug access in Canada's universal health system through a temporal lens. I show how two families navigate these powerful negotiations, asserting themselves as deserving of resources while finding ways to consider life and death outside of this clash between health system pragmatics and pharmaceutical promise.
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Affiliation(s)
- Marlee McGuire
- Department of Anthropology, University of British Columbia, Vancouver, Canada
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Gilliland JA, Shah TI, Clark A, Sibbald S, Seabrook JA. A geospatial approach to understanding inequalities in accessibility to primary care among vulnerable populations. PLoS One 2019; 14:e0210113. [PMID: 30615678 PMCID: PMC6322734 DOI: 10.1371/journal.pone.0210113] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 12/16/2018] [Indexed: 11/18/2022] Open
Abstract
Many Canadians experience unequal access to primary care services, despite living in a country with a universal health care system. Health inequalities affect all Canadians but have a much stronger impact on the health of vulnerable populations. Health inequalities are preventable differences in the health status or distribution of health resources as experienced by vulnerable populations. A geospatial approach was applied to examine how closely the distribution of primary care providers (PCPs) in London, Ontario meet the needs of vulnerable populations, including people with low income status, seniors, lone parents, and linguistic minorities. Using enhanced two step floating catchment area (E2SFCA) method, an index of geographic access scores for all PCPs and PCPs speaking French, Arabic, and Spanish were separately developed at the dissemination area (DA) level. To analyze how PCPs are distributed, comparative analyses were performed in association with specific vulnerable groups. Geographical accessibility to all PCPs, and PCPs who speak specific minority languages vary considerably across the city of London. Access scores for French- and Arabic-speaking PCPs are found comparatively high (mean = 2.85 and 1.01 respectively) as compared to Spanish-speaking PCPs (mean = 0.47). Additionally, many areas with high proportions of vulnerable populations experience low accessibility. Despite its exploratory nature, this study offers insight into intra-urban distributions of geographical accessibility to primary care resources for vulnerable groups. These findings can facilitate health researchers and policymakers in the development of recommendations to increase levels of accessibility of specific population groups in underserved areas.
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Affiliation(s)
- Jason A. Gilliland
- Department of Geography, Western University, London, ON, Canada
- Human Environments Analysis Laboratory, Western University, London, ON, Canada
- School of Health Studies, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Paediatrics, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Children’s Health Research Institute, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Tayyab I. Shah
- Department of Geography, Western University, London, ON, Canada
- Human Environments Analysis Laboratory, Western University, London, ON, Canada
| | - Andrew Clark
- Department of Geography, Western University, London, ON, Canada
- Human Environments Analysis Laboratory, Western University, London, ON, Canada
| | - Shannon Sibbald
- School of Health Studies, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Family Medicine, Western University, London, ON, Canada
| | - Jamie A. Seabrook
- Human Environments Analysis Laboratory, Western University, London, ON, Canada
- Department of Paediatrics, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Children’s Health Research Institute, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- School of Food and Nutritional Sciences, Brescia University College, London, ON, Canada
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Wu CC, Lin CH, Chiang HS, Tang MJ. A population-based study of the influence of socioeconomic status on prostate cancer diagnosis in Taiwan. Int J Equity Health 2018; 17:79. [PMID: 29903010 PMCID: PMC6003124 DOI: 10.1186/s12939-018-0792-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 05/31/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Disparities in prostate cancer (PCa) outcomes and their links to socioeconomic status (SES) have been intensively studied. A relatively low incidence rate and a high proportion of late-stage diagnosis have been documented in studies of Asian populations. For the past 20 years, the trend in the growth of PCa cases in Taiwan was opposite to that of Western countries. However, there is a striking paucity of local studies on these important issues. To mitigate this gap in knowledge, we exploited two population databases to investigate the impact of SES on PCa incidence rate and stage at diagnosis. Particularly, we sought to explore the discriminating capabilities of various indexes of SES on two diagnostic outcome indicators. METHOD We conducted a population-based, follow-up, observational study. Data of study populations and newly diagnosed PCa cases between 2011 and 2013 were collected from the National Health Insurance Research Database and the Taiwan Cancer Registry. We retrieved 50-79 old male subjects who were classified as government employee, enterprise employee, or labor class. People with a diagnosis of any type of cancer before January 1, 2011, were excluded. The influences of four independent variables, i.e., age, beneficiary's insurance status, occupation and income, were analyzed. We used Cox proportional hazard models to calculate the hazard ratios of PCa and used logistic regression models to analyze the odds ratios (ORs) of late-stage PCa diagnosis. RESULTS The low crude PCa incidence rate (112 per 100,000 person-years) and the high percentage of late-stage presentation (44%) were similar to those found in previous studies of old Asian men. Unsurprisingly, age was consistently revealed to be the most determinant factor in PCa diagnosis, while the insurance status of the beneficiaries showed no significant difference. Significant socioeconomic disparities in PCa diagnosis were demonstrated by occupation and income indexes, individually or in combination. However, occupation and income showed varied capabilities in discriminating disparities between different outcome indicators. CONCLUSION Our study supported the findings of extant works showing that advantaged populations have a higher PCa incidence rate and a lower percentage of late-stage diagnosis. The discriminating capabilities of health disparity by occupation and/or income were contingent on the choice of health outcome indicators. The relatively high percentage of late-stage presentation is a critical public health challenge, and a tailored coping strategy is urgently needed. For more effective health policy-making, local socioeconomic effects on the other outcome indicators of PCa, such as incidence to mortality ratio, warrant further investigation.
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Affiliation(s)
- Chi-Chen Wu
- Graduate Institute of International Business, College of Management, National Taiwan University, No.1, Sec. 4, Roosevelt Rd, Taipei City, 106, Taiwan, Republic of China.,Fu Jen Catholic University, No. 510 Zhongzheng Rd., Xinzhuang Dist, New Taipei City, 24205, Taiwan, Republic of China.,Urological Department, Fu Jen Catholic University Hospital, No. 69, Guizi Rd., Taishan Dist, New Taipei City, 24352, Taiwan, Republic of China
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung, 40705, Taiwan, Republic of China. .,Department of Public Health, College of Medicine, Fu Jen Catholic University, No. 510 Zhongzheng Rd., Xinzhuang Dist, New Taipei City, 24205, Taiwan, Republic of China. .,Department of Health Care Management, National Taipei University of Nursing and Health Sciences, No. 365, Ming-te Road, Peitou District, Taipei, 11219, Taiwan, Republic of China.
| | - Han-Sun Chiang
- Fu Jen Catholic University, No. 510 Zhongzheng Rd., Xinzhuang Dist, New Taipei City, 24205, Taiwan, Republic of China.,Urological Department, Fu Jen Catholic University Hospital, No. 69, Guizi Rd., Taishan Dist, New Taipei City, 24352, Taiwan, Republic of China
| | - Ming-Je Tang
- Graduate Institute of International Business, College of Management, National Taiwan University, No.1, Sec. 4, Roosevelt Rd, Taipei City, 106, Taiwan, Republic of China
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9
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Variations in diagnostic testing utilization in Italy: Secondary analysis of a national survey. PLoS One 2018; 13:e0196673. [PMID: 29894473 PMCID: PMC5997319 DOI: 10.1371/journal.pone.0196673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/17/2018] [Indexed: 11/19/2022] Open
Abstract
Background According to the principle of horizontal equity, individuals with similar need may have the same possibility of access to health services. The aim of this study is to identify patterns of diagnostic services utilization, in people with, and without chronic disease in Italy. Methods Secondary analysis of data from the national survey on Health and use of health care in Italy, carried out in 2013, including 99,497 participants. Multilevel analysis has been used to study the variables associated to diagnostic services utilization. Results 13.78% of participants have had one diagnostic testing in the four weeks before the interview. In healthy people, utilization of diagnostic testing is reduced in people with low educational level (OR 0.75; 95%CI 0.67–0.84), in housewives (OR 0.66; 95%CI 0.51–0.87), or in those unable to work (OR 0.48; 95%CI 0.26–0.87), while increased in those perceiving a worse health status (up to OR 4.00, 95%CI 2.00–8.01 in very bad health). In people afflicted with chronic disease, access to diagnostic assessment is impaired by educational level (OR 0.69; 95%CI 0.61–0.78) and low household income (OR 0.75; 95%CI 0.58–0.97), while it is increased in the presence of a ticket exemption (OR 1.55, 95%CI 1.42–1.68), and fixed-term occupation (OR2.28, 95%CI 1.31–3.95). Being former-smokers in associated to an increased utilization of services in both groups. Conclusions Despite a universal and theoretically egalitarian, public, health care system, variations in diagnostic services utilization are still registered in Italy, both in healthy people and those afflicted by chronic diseases, on socio-economic/occupational basis, and self-perceived health status. Moreover, this significant effect of occupation on healthcare utilization, suggests the need for a comprehensive evaluation of economics in occupational health.
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10
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Martin D, Miller AP, Quesnel-Vallée A, Caron NR, Vissandjée B, Marchildon GP. Canada's universal health-care system: achieving its potential. Lancet 2018; 391:1718-1735. [PMID: 29483027 PMCID: PMC7138369 DOI: 10.1016/s0140-6736(18)30181-8] [Citation(s) in RCA: 240] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 01/05/2023]
Abstract
Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.
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Affiliation(s)
- Danielle Martin
- Women's College Hospital and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Ashley P Miller
- Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Amélie Quesnel-Vallée
- McGill Observatory on Health and Social Services Reforms, Department of Epidemiology, Biostatistics and Occupational Health, and Department of Sociology, McGill University, Montréal, QC, Canada
| | - Nadine R Caron
- Department of Surgery, Northern Medical Program and Centre for Excellence in Indigenous Health, University of British Columbia, Prince George, BC, Canada
| | - Bilkis Vissandjée
- School of Nursing and Public Health Research Institute, Université de Montréal, SHERPA Research Centre, Montréal, QC, Canada
| | - Gregory P Marchildon
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Johnson-Shoyama Graduate School of Public Policy, University of Regina, Regina, SK, Canada
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Alter DA, Yu B, Bajaj RR, Oh PI. Relationship Between Cardiac Rehabilitation Participation and Health Service Expenditures Within a Universal Health Care System. Mayo Clin Proc 2017; 92:S0025-6196(17)30075-7. [PMID: 28365098 DOI: 10.1016/j.mayocp.2016.12.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/06/2016] [Accepted: 12/28/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To examine the relationship between cardiac rehabilitation participation and health service expenditures in Ontario, Canada. PATIENTS AND METHODS A total of 6284 patients referred to cardiac rehabilitation between April 1, 2003, and December 31, 2010, were linked to 6284 matched cardiac rehabilitation eligible nonreferred controls and followed over a 3-year period across multiple linked administrative databases to identify health service utilization expenditures and mortality. All patients had previous cardiac hospitalizations within the preceding year. Four cardiac rehabilitation eligible groups of patients were balanced using propensity score weights: (1) no referral; (2) no participation; (3) low participation levels (ie, attending <67% of prescheduled classes); and (4) high participation levels (ie, attending ≥67% prescheduled classes). Each group of patients was balanced in age, sex, geography, socioeconomic status, previous hospitalizations, ambulatory care conditions, cardiovascular risk factors, comorbidities, and previous health care expenditures. Generalized linear models were used to examine differences in health service expenditures (from all sources including hospitalizations, physician visits, diagnostic tests, and drugs for those older than 65 years) per "eligible day alive" over the 3-year period. RESULTS Compared with the nonreferred population, health service expenditures followed a dose-response relationship and were lowest in patients who had the highest cardiac rehabilitation programmatic participation levels (P<.001). Cost differences across groups separated early, remained divergent, and applied to all components of health care expenditures (P<.001). Sensitivity analyses confirmed that the findings were not secondary to reverse causality. CONCLUSION Participation in cardiac rehabilitation is associated with lower long-term health service utilization expenditures within a publicly funded health care system.
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Affiliation(s)
- David A Alter
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Bing Yu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ravi R Bajaj
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Paul I Oh
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Chen BK, Yang YT, Yang CY. Trends in amenable deaths based on township income quartiles in Taiwan, 1971-2008: did universal health insurance close the gap? J Public Health (Oxf) 2016; 38:e524-e536. [PMID: 28158683 DOI: 10.1093/pubmed/fdv156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brian K Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC 29208, USA
| | - Y Tony Yang
- College of Health and Human Services, George Mason University, 4400 University Dr, Fairfax, VA 22030-4444, USA
| | - Chun-Yuh Yang
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan
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Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients? J Trauma Acute Care Surg 2016; 80:764-75; discussion 775-7. [PMID: 26958790 DOI: 10.1097/ta.0000000000001004] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Abstract
The current U.S. health care system, with both rising costs and demands, is unsustainable. The combination of a sense of individual entitlement to health care and limited acceptance of individual responsibility with respect to personal health has contributed to a system which overspends and underperforms. This sense of entitlement has its roots in a perceived right to health care. Beginning with the so-called moral right to health care (all life is sacred), the issue of who provides health care has evolved as individual rights have trumped societal rights. The concept of government providing some level of health care ranges from limited government intervention, a 'negative right to health care' (e.g., prevention of a socially-caused, preventable health hazard), to various forms of a 'positive right to health care'. The latter ranges from a decent minimum level of care to the best possible health care with access for all. We clarify the concept of legal rights as an entitlement to health care and present distributive and social justice counter arguments to present health care as a privilege that can be provided/earned/altered/revoked by governments. We propose that unlike a 'right', which is unconditional, a 'privilege' has limitations. Going forward, expectations about what will be made available should be lowered while taking personal responsibility for one's health must for elevated. To have access to health care in the future will mean some loss of personal rights (e.g., unhealthy behaviors) and an increase in personal responsibility for gaining or maintaining one's health.
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Affiliation(s)
- Shelley Morrisette
- Department of Management and Marketing, Shippensburg University, 1871 Old Main Drive, Grove Hall, Shippensburg, PA, 17257-2299, USA,
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Kuluski K, Gandhi S, Diong C, Steele Gray C, Bronskill SE. Patterns of community follow-up, subsequent health service use and survival among young and mid-life adults discharged from chronic care hospitals: a retrospective cohort study. BMC Health Serv Res 2016; 16:382. [PMID: 27522347 PMCID: PMC4983410 DOI: 10.1186/s12913-016-1631-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/04/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the demand for rehabilitation and chronic care services across the life course, policy and care strategies tend to focus on older adults and overlook medically complex younger adult populations. This study examined young and mid-life adults discharged from tertiary chronic care hospitals in order to describe their health service use and to examine the association between patterns of timely community follow-up, and subsequent health outcomes. METHODS This population-based retrospective cohort study used linked administrative data to identify 1,906 individuals aged 18-64 years and discharged alive from tertiary chronic care hospitals in Ontario, Canada between April 1, 2005 and March 31, 2006. Multivariate Cox proportional hazard models were used to examine the effect of community follow-up within 7 days of discharge (home care and/or a primary care physician visit or neither) on time to first hospitalization and emergency department (ED) visit. Five-year survival was examined using Kaplan-Meier survival curves. RESULTS The cohort had a high prevalence of multi-morbidity and use of hospital, emergency services and physician services was high in the year following discharge. Most individuals received follow-up care from a primary care physician and/or home care within 7 days of discharge while 30 % received neither. Within 1 year of discharge, 18 % of individuals died. Among those who survived, time to acute care hospitalization in the year following discharge was significantly longer among those who received both a home care and a physician follow-up visit compared to those who received neither. No significant associations were found between community follow-up and ED visits within 1 year. CONCLUSIONS Immediate community follow-up may reduce subsequent use of acute care services. Future research should determine why some individuals, who would likely benefit from services, are not receiving them including barriers to access.
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Affiliation(s)
- Kerry Kuluski
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System (Bridgepoint Hospital Site), 1 Bridgepoint Drive, Toronto, ON M4M 2B5 Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3 M6 Canada
| | - Sima Gandhi
- Institute for Clinical Evaluative Sciences, G123, 2075 Bayview Avenue, Toronto, ON M4N 3 M5 Canada
| | - Christina Diong
- Institute for Clinical Evaluative Sciences, G123, 2075 Bayview Avenue, Toronto, ON M4N 3 M5 Canada
| | - Carolyn Steele Gray
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System (Bridgepoint Hospital Site), 1 Bridgepoint Drive, Toronto, ON M4M 2B5 Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3 M6 Canada
| | - Susan E. Bronskill
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3 M6 Canada
- Institute for Clinical Evaluative Sciences, G123, 2075 Bayview Avenue, Toronto, ON M4N 3 M5 Canada
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Fralick M, Thiruchelvam D, Tien HC, Redelmeier DA. Risk of suicide after a concussion. CMAJ 2016; 188:497-504. [PMID: 26858348 DOI: 10.1503/cmaj.150790] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community. METHODS We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion. RESULTS We identified 235,110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14-1.64). The increased risk applied regardless of patients' demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life. INTERPRETATION Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.
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Affiliation(s)
- Michael Fralick
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Deva Thiruchelvam
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Homer C Tien
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Donald A Redelmeier
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont.
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Wayne N, Perez DF, Kaplan DM, Ritvo P. Health Coaching Reduces HbA1c in Type 2 Diabetic Patients From a Lower-Socioeconomic Status Community: A Randomized Controlled Trial. J Med Internet Res 2015; 17:e224. [PMID: 26441467 PMCID: PMC4642794 DOI: 10.2196/jmir.4871] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/06/2015] [Accepted: 08/12/2015] [Indexed: 01/16/2023] Open
Abstract
Background Adoptions of health behaviors are crucial for maintaining good health after type 2 diabetes mellitus (T2DM) diagnoses. However, adherence to glucoregulating behaviors like regular exercise and balanced diet can be challenging, especially for people living in lower-socioeconomic status (SES) communities. Providing cost-effective interventions that improve self-management is important for improving quality of life and the sustainability of health care systems. Objective To evaluate a health coach intervention with and without the use of mobile phones to support health behavior change in patients with type 2 diabetes. Methods In this noninferiority, pragmatic randomized controlled trial (RCT), patients from two primary care health centers in Toronto, Canada, with type 2 diabetes and a glycated hemoglobin/hemoglobin A1c (HbA1c) level of ≥7.3% (56.3 mmol/mol) were randomized to receive 6 months of health coaching with or without mobile phone monitoring support. We hypothesized that both approaches would result in significant HbA1c reductions, although health coaching with mobile phone monitoring would result in significantly larger effects. Participants were evaluated at baseline, 3 months, and 6 months. The primary outcome was the change in HbA1c from baseline to 6 months (difference between and within groups). Other outcomes included weight, waist circumference, body mass index (BMI), satisfaction with life, depression and anxiety (Hospital Anxiety and Depression Scale [HADS]), positive and negative affect (Positive and Negative Affect Schedule [PANAS]), and quality of life (Short Form Health Survey-12 [SF-12]). Results A total of 138 patients were randomized and 7 were excluded for a substudy; of the remaining 131, 67 were allocated to the intervention group and 64 to the control group. Primary outcome data were available for 97 participants (74.0%). While both groups reduced their HbA1c levels, there were no significant between-group differences in change of HbA1c at 6 months using intention-to-treat (last observation carried forward [LOCF]) (P=.48) or per-protocol (P=.83) principles. However, the intervention group did achieve an accelerated HbA1c reduction, leading to a significant between-group difference at 3 months (P=.03). This difference was reduced at the 6-month follow-up as the control group continued to improve, achieving a reduction of 0.81% (8.9 mmol/mol) (P=.001) compared with a reduction of 0.84% (9.2 mmol/mol)(P=.001) in the intervention group. Intervention group participants also had significant decreases in weight (P=.006) and waist circumference (P=.01) while controls did not. Both groups reported improvements in mood, satisfaction with life, and quality of life. Conclusions Health coaching with and without access to mobile technology appeared to improve glucoregulation and mental health in a lower-SES, T2DM population. The accelerated improvement in the mobile phone group suggests the connectivity provided may more quickly improve adoption and adherence to health behaviors within a clinical diabetes management program. Overall, health coaching in primary care appears to lead to significant benefits for patients from lower-SES communities with poorly controlled type 2 diabetes. Trial Registration ClinicalTrials.gov NCT02036892; http://clinicaltrials.gov/ct2/show/NCT02036892 (Archived by WebCite at http://www.webcitation.org/6b3cJYJOD)
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Affiliation(s)
- Noah Wayne
- School of Kinesiology & Health Science, Faculty of Health, York University, Toronto, ON, Canada
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Nayyar D, Hwang SW. Cardiovascular Health Issues in Inner City Populations. Can J Cardiol 2015; 31:1130-8. [DOI: 10.1016/j.cjca.2015.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 11/28/2022] Open
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Brittin J, Elijah-Barnwell S, Nam Y, Araz O, Friedow B, Jameton A, Drummond W, Huang TTK. Community-Engaged Public Health Research to Inform Hospital Campus Planning in a Low Socioeconomic Status Urban Neighborhood. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2015; 8:12-24. [DOI: 10.1177/1937586715575908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To compare sociodemographic and motivational factors for healthcare use and identify desirable health-promoting resources among groups in a low socioeconomic status (SES) community in Chicago, IL. Background: Disparities in health services and outcomes are well established in low SES urban neighborhoods in the United States and many factors beyond service availability and quality impact community health. Yet there is no clear process for engaging communities in building resources to improve population-level health in such locales. Methods: A hospital building project led to a partnership of public health researchers, architects, and planners who conducted community-engaged research. We collected resident data and compared factors for healthcare use and choice and likelihood of engaging new health-promoting services. Results: Neighborhood areas were strongly associated with ethnic groupings, and there were differences between groups in healthcare choice and service needs, such as, proximity to home was more important to Latinos than African Americans in choice of healthcare facility ( padj = .001). Latinos expressed higher likelihood to use a fitness facility ( padj = .001). Despite differences in vehicle ownership, >75% of all respondents indicated that nearby public transportation was important in choosing healthcare. Conclusion: Knowledge of community needs and heterogeneity is essential to decision makers of facility and community development plans. Partnerships between public health, urban planning, architecture, and local constituents should be cultivated toward focus on reducing health disparities. Further work to integrate community perspectives through the planning and design process and to evaluate the long-term impact of such efforts is needed.
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Affiliation(s)
- Jeri Brittin
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
- HDR Architecture, Omaha, NE, USA
| | | | - Yunwoo Nam
- Community and Regional Planning, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Ozgur Araz
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
| | | | - Andrew Jameton
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
| | - Wayne Drummond
- College of Architecture, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Terry T.-K. Huang
- Department of Health Promotion, Social & Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE, USA
- School of Public Health, City University of New York, New York, NY, USA
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Bélanger D, Gosselin P, Valois P, Abdous B. Neighbourhood and dwelling characteristics associated with the self-reported adverse health effects of heat in most deprived urban areas: A cross-sectional study in 9 cities. Health Place 2015; 32:8-18. [DOI: 10.1016/j.healthplace.2014.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/16/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
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Yom Din G, Zugman Z, Khashper A. The impact of preventive health behaviour and social factors on visits to the doctor. Isr J Health Policy Res 2014; 3:41. [PMID: 25584186 PMCID: PMC4290136 DOI: 10.1186/2045-4015-3-41] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 12/02/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The aim of this study is to examine the joint impact of preventive health behavior (PHB) and social and demographic factors on the utilization of primary and secondary medical care under a universal health care system, as measured by visits to the doctor, who were categorized as either a General Practitioner (GP) or Specialist Doctor (SD). METHODS An ordered probit model was utilized to analyze data obtained from the 2009 Israeli National Health Survey. The problem of endogeneity between PHB factors and visits to GP was approached using the two-stage residuals inclusion and instrumental variables method. RESULTS We found a positive effect of PHB on visits to the doctor while the addition of the PHB factors to the independent variables resulted in important changes in explaining visits to GP (in values of the estimates, in their sign, and in their statistical significance), and only in slight changes for visits to SD. A 1% increase in PHB factors results in increasing the probability to visit General Practitioner in the last year in 0.6%. The following variables were identified as significant in explaining frequency of visits to the doctor: PHB, socio-economic status (pro-poor for visits to GP, pro-rich for visits to SD), location (for visits to SD), gender, age (age 60 or greater being a negative factor for visits to GP and a positive factor for visits to SD), chronic diseases, and marital status (being married was a negative factor for visits to GP and a positive factor for visits to SD). CONCLUSIONS There is a need for allowing for endogeneity in examining the impact of PHB, social and demographic factors on visits to GP in a population under universal health insurance. For disadvantaged populations with low SES and those living in peripheral districts, the value of IndPrev is lower than for populations with high SES and living in the center of the country. Examining the impact of these factors, significant differences in the importance and sometimes even in the sign of their influence on visits to different categories of doctors - GP and SD, are found.
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Affiliation(s)
- Gregory Yom Din
- />The Open University of Israel, Raanana, Israel, Faculty of Exact Sciences, Tel-Aviv University, Tel-Aviv, Israel
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Alter DA, Zagorski B, Marzolini S, Forhan M, Oh PI. On-site programmatic attendance to cardiac rehabilitation and the healthy-adherer effect. Eur J Prev Cardiol 2014; 22:1232-46. [DOI: 10.1177/2047487314544084] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/30/2014] [Indexed: 11/17/2022]
Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
- Department of Medicine, University of Toronto, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Brandon Zagorski
- Department of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Susan Marzolini
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
| | - Mary Forhan
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Canada
| | - Paul I Oh
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
- Department of Medicine, University of Toronto, Canada
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Din GY, Zugman Z, Khashper A. Utilization of primary and secondary medical care among disadvantaged populations: a log-linear model analysis. Glob J Health Sci 2014; 6:9-21. [PMID: 25168981 PMCID: PMC4825475 DOI: 10.5539/gjhs.v6n5p9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 03/14/2014] [Indexed: 11/12/2022] Open
Abstract
AIM We examined how, where an overall population is covered by universal health insurance, characteristics of disadvantaged populations interact to influence inequality in primary and secondary medical care utilization. SUBJECTS & METHODS Disadvantaged populations, the focus of the study, were defined as populations who have lower socio-economic status (SES), who are elderly and/or reside in a peripheral area. Data from the 2009 Israeli National Health Survey were analysed using log-linear models to estimate utilization of medical care. RESULTS The main findings were: a) pro-poor utilization of primary medical care among elderly populations, with higher odds ratios for low SES populations in the periphery; (b) lack of interaction between SES and primary medical care utilization among younger populations, between SES and secondary medical care utilization among the elderly and pro-rich utilization of secondary medical care among younger populations who did not regularly visit general practitioners (GP); (c) the odds ratios of secondary medical care utilization increased as SES decreased for both elderly and younger populations who also regularly visited a GP. CONCLUSION Potential policy implications for disadvantaged populations, regarding possible inequality in primary and secondary medical care utilization, can be drawn using log-linear model analysis of interactions among characteristics (SES, age, location) of disadvantaged populations.
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Affiliation(s)
- Gregory Yom Din
- The Open University of Israel, Raanana, Israel; Faculty of Exact Sciences, Tel-Aviv University, Tel-Aviv, Israel.
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Wijeysundera HC, Bennell MC, Alter DA. Patients, providers, and systems: the complex and unfinished tale of socioeconomic status and health. Can J Cardiol 2013; 29:1577-8. [PMID: 24041995 DOI: 10.1016/j.cjca.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 08/02/2013] [Accepted: 08/02/2013] [Indexed: 11/29/2022] Open
Affiliation(s)
- Harindra C Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
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Cohen D, Manuel DG, Tugwell P, Ramsay T, Sanmartin C. Inequity in primary and secondary preventive care for acute myocardial infarction? Use by socioeconomic status across middle-aged and older patients. Can J Cardiol 2013; 29:1579-85. [PMID: 23948088 DOI: 10.1016/j.cjca.2013.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 06/05/2013] [Accepted: 06/10/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There has been limited research exploring socioeconomic inequity in targeted preventive care for acute myocardial infarction (AMI). The objective of this study was to examine socioeconomic disparities in the use of primary and secondary preventive services relevant to the identification and management of heart disease in a cohort of patients with AMI. METHODS Preventive services used before the AMI event were examined in a cohort of 30,491 patients with first-time AMI in Ontario, Canada from 2010 to 2012. Using logistic regression, socioeconomic differences in lipid testing, glucose testing, stress testing, electrocardiography (ECG), and echocardiography in middle-aged and older patients were examined. RESULTS For many of the services, there were no differences in the use of primary and secondary preventive services between patients according to socioeconomic status; however, a number of exceptions were found. Controlling for other factors, we found that for primary preventive services, low-income middle-aged patients had 13% (95% confidence interval [CI], 0.790-0.967) and 10% (95% CI, 0.812-0.997) lower odds of receiving lipid and glucose testing, respectively, when compared with high-income middle-aged patients. Controlling for other factors, we found that for secondary preventive services, low-income middle-aged and older patients had 24% (95% CI, 1.087-1.415) and 10% (95% CI, 1.012-1.202) higher odds of receiving echocardiography when compared with their high-income counterparts. CONCLUSIONS Socioeconomic disparities in primary and secondary preventive services for patients with AMI could not be demonstrated in many instances. However, inequities in primary preventive care were found in middle-aged patients receiving lipid and glucose testing, which may have implications for Canadian health policy to ensure healthy aging across the age spectrum.
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Affiliation(s)
- Deborah Cohen
- Department of Population Health, University of Ottawa, Ontario, Canada.
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Alter DA, Franklin B, Ko DT, Austin PC, Lee DS, Oh PI, Stukel TA, Tu JV. Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One 2013; 8:e65130. [PMID: 23755180 PMCID: PMC3670842 DOI: 10.1371/journal.pone.0065130] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI). Background The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear. Methods We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity. Results As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87–0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70–1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation. Conclusions Functional recovery may play an important role in explaining SES-mortality gradients following AMI.
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Affiliation(s)
- David A Alter
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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[Factors associated with dental consultation in children in Talca (Chile) and in Chilean immigrants in Montreal (Canada)]. GACETA SANITARIA 2013; 27:344-9. [PMID: 23578526 DOI: 10.1016/j.gaceta.2013.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 02/09/2013] [Accepted: 02/12/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify the factors that influence the use of dental services in 4-7-year-olds and in 10-13-year-olds resident in the cities of Talca (Chile) and Montreal (Canada). METHODS A nonprobabilistic cross-sectional study was carried out in 147 boys and girls in Talca and in 94 boys and girls in Montreal between 2009 and 2011. Sociodemographic variables were recorded in parents and children, including age and sex. Data were also gathered on parental education, family composition, and proximity to health centers within neighborhoods. The data were analyzed with Fisher's exact test and the robust Cox regression model (with constant time) with a significance level of 0,05. RESULTS In Talca, parental education was significantly associated with dental care visits at least twice a year. The children of parents with university education were 2.20 times more likely to consult a dentist (95% CI: 1.30-3.73). Children whose parents perceived their children's health positively were 53% (OR = 0,47; 95% CI: 0,28-0,77) less likely to consult a dentist. In Montreal, the children of parents with university education were 2.10 times more likely to consult a dentist (95%CI: 1.17-3.76), while older children (10-13 years) were 2.11 (95% CI: 1.15-3.88) times more likely to consult a dentist. CONCLUSIONS In both cities, parental education level was associated with the use of dental services.
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Abstract
Background and Purpose—
Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income.
Methods—
We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions.
Results—
Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications.
Conclusions—
Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.
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Affiliation(s)
- Kun Huang
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Nadia Khan
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Allison Kwan
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Jiming Fang
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Lingsong Yun
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
| | - Moira K. Kapral
- From the Department of Medicine, University of Toronto, Toronto, Ontario, Canada (K.H., A.K., M.K.K.); Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada (N.K.); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.F., L.Y., M.K.K.); and Division of General Internal Medicine and Toronto General Research Institute,
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Abstract
Geographic variation has been of interest to both health planners and social epidemiologists. However, while the major focus of interest of planners has been on variation in health care spending, social epidemiologists have focused on health; and while social epidemiologists have observed strong associations between poor health and poverty, planners have concluded that income is not an important determinant of variation in spending. These different conclusions stem, at least in part, from differences in approach. Health planners have generally studied variation among large regions, such as states, counties, or hospital referral regions (HRRs), while epidemiologists have tended to study local areas, such as ZIP codes and census tracts. To better understand the basis for geographic variation in hospital utilization, we drew upon both approaches. Counties and HRRs were disaggregated into their constituent ZIP codes and census tracts and examined the interrelationships between income, disability, and hospital utilization that were examined at both the regional and local levels, using statistical and geomapping tools. Our studies centered on the Milwaukee and Los Angeles HRRs, where per capita health care utilization has been greater than elsewhere in their states. We compared Milwaukee to other HRRs in Wisconsin and Los Angeles to the other populous counties of California and to a region in California of comparable size and diversity, stretching from San Francisco to Sacramento (termed "San-Framento"). When studied at the ZIP code level, we found steep, curvilinear relationships between lower income and both increased hospital utilization and increasing percentages of individuals reporting disabilities. These associations were also evident on geomaps. They were strongest among populations of working-age adults but weaker among seniors, for whom income proved to be a poor proxy for poverty and whose residential locations deviated from the major underlying income patterns. Among working-age adults, virtually all of the excess utilization in Milwaukee was attributable to very high utilization in Milwaukee's segregated "poverty corridor." Similarly, the greater rate of hospital use in Los Angeles than in San-Framento could be explained by proportionately more low-income ZIP codes in Los Angeles and fewer in San-Framento. Indeed, when only high-income ZIP codes were assessed, there was little variation in hospital utilization among California's 18 most populous counties. We estimated that had utilization within each region been at the rate of its high-income ZIP codes, overall utilization would have been 35 % less among working-age adults and 20 % less among seniors. These studies reveal the importance of disaggregating large geographic units into their constituent ZIP codes in order to understand variation in health care utilization among them. They demonstrate the strong association between low ZIP code income and both higher percentages of disability and greater hospital utilization. And they suggest that, given the large contribution of the poorest neighborhoods to aggregate utilization, it will be difficult to curb the growth of health care spending without addressing the underlying social determinants of health.
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Affiliation(s)
- Richard A Cooper
- Department of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Alter DA, Wijeysundera HC, Franklin B, Austin PC, Chong A, Oh PI, Tu JV, Stukel TA. Obesity, lifestyle risk-factors, and health service outcomes among healthy middle-aged adults in Canada. BMC Health Serv Res 2012; 12:238. [PMID: 22863333 PMCID: PMC3439326 DOI: 10.1186/1472-6963-12-238] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 07/19/2012] [Indexed: 12/31/2022] Open
Abstract
Background The extent to which uncomplicated obesity among an otherwise healthy middle-aged population is associated with higher longitudinal health-care expenditures remains unclear. Methods To examine the incremental long-term health service expenditures and outcomes associated with uncomplicated obesity, 9398 participants of the 1994–1996 National Population Health Survey were linked to administrative data and followed longitudinally forward for 11.5 years to track health service utilization costs and death. Patients with pre-existing heart disease, those who were 65 years of age and older, and those with self-reported body mass indexes of <18.5 kg/m2 at inception were excluded. Propensity-matching was used to compare obesity (+/− other baseline risk-factors and lifestyle behaviours) with normal-weight healthy controls. Cost-analyses were conducted from the perspective of Ontario’s publicly-funded health care system. Results Obesity as an isolated risk-factor was not associated with significantly higher health-care costs as compared with normal weight matched controls (Canadian $8,294.67 vs. Canadian $7,323.59, P = 0.27). However, obesity in combination with other lifestyle factors was associated with significantly higher cumulative expenditures as compared with normal-weight healthy matched controls (CAD$14,186.81 for those with obesity + 3 additional risk-factors vs. CAD$7,029.87 for those with normal BMI and no other risk-factors, P < 0.001). The likelihood that obese individuals developed future diabetes and hypertension also rose markedly when other lifestyle factors, such as smoking, physical inactivity and/or psychosocial distress were present at baseline. Conclusions The incremental health-care costs associated with obesity was modest in isolation, but increased significantly when combined with other lifestyle risk-factors. Such findings have relevance to the selection, prioritization, and cost-effective targeting of therapeutic lifestyle interventions.
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Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, Canada.
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Lowcock EC, Rosella LC, Foisy J, McGeer A, Crowcroft N. The social determinants of health and pandemic H1N1 2009 influenza severity. Am J Public Health 2012; 102:e51-8. [PMID: 22698024 PMCID: PMC3464856 DOI: 10.2105/ajph.2012.300814] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2012] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We explored the effects of social determinants of health on pandemic H1N1 2009 influenza severity and the role of clinical risk factors in mediating such associations. METHODS We used multivariate logistic regression with generalized estimating equations to examine the associations between individual- and ecological-level social determinants of health and hospitalization for pandemic H1N1 2009 illness in a case-control study in Ontario, Canada. RESULTS During the first pandemic phase (April 23-July 20, 2009), hospitalization was associated with having a high school education or less and living in a neighborhood with high material or total deprivation. We also observed the association with education in the second phase (August 1-November 6, 2009). Clinical risk factors for severe pandemic H1N1 2009 illness mediated approximately 39% of the observed association. CONCLUSIONS The main clinical risk factors for severe pandemic H1N1 2009 illness explain only a portion of the associations observed between social determinants of health and hospitalization, suggesting that the means by which the social determinants of health affect pandemic H1N1 2009 outcomes extend beyond clinically recognized risk factors.
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Affiliation(s)
- Elizabeth C Lowcock
- Department of Surveillance and Epidemiology, Public Health Ontario, Toronto, Ontario, Canada
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Bonnar KK, McCarthy M. Health related quality of life in a rural area with low racial/ethnic density. J Community Health 2012; 37:96-104. [PMID: 21656020 DOI: 10.1007/s10900-011-9422-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to compare the self-reported quality of life of racial/ethnic minorities and Caucasians living in a rural, northern New York county, where 94% of the population is Caucasian. Participants completed a 79-item survey online and in-person assessing health status, health-related quality of life, perceptions of health information, and health care access/use. Frequencies, Chi-Square, and ANOVA were used to analyze the results. A total of 1,039 surveys were completed. Racial/ethnic minorities earned significantly less income, F (1, 1031) = 29.306, P = .000, relied more on public health insurance, X ( 2 )(7, 1033) = 47.827, P = .000, were significantly less likely to see a doctor because of the cost, F(1,990) = 17.042, P = .000, and reported using health-related services significantly less often when compared to Caucasians, F(1, 1032) = 17.051, P = .000. In terms of quality of life, while there were no significant differences in self-reported physical health, racial/ethnic minorities were more likely to feel sad/blue/depressed, F(1, 1031) = 7.193, P = .011 and worried/tense/anxious, F(1, 1031) = 5.550, P = .040. Findings from this study offer some initial evidence that, while perceived health status is generally good, rural racial/ethnic minorities residing in predominantly Caucasian rural areas may experience more mental health problems that are risk factors for chronic diseases. This coupled with lower use of health care services increases the need for culturally competent health programs and services for this population.
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Affiliation(s)
- Kelly K Bonnar
- School of Education and Professional Studies, Department of Community Health, State University of New York at Potsdam, Potsdam, NY, USA.
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Keratoplasty for corneal endothelial disease, 2001-2009. Ophthalmology 2012; 119:1303-10. [PMID: 22512985 DOI: 10.1016/j.ophtha.2012.01.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 12/12/2011] [Accepted: 01/12/2012] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To determine the rates of keratoplasty for corneal endothelial disease (CED) from 2001 to 2009 in a large managed care network in the United States, factors that affect which patients undergo this procedure and surgical outcomes. DESIGN A retrospective review of data from a longitudinal cohort study. PARTICIPANTS Beneficiaries with CED aged ≥ 40 years who were receiving eye care during 2001 to 2009. METHODS Rates of keratoplasty for CED were determined at 6-month intervals from January 2001 to December 2009. The mean number of postoperative visits and rates of severe adverse events in the year after keratoplasty surgery were monitored over the course of the decade. Univariable and multivariable logistic regression were performed to identify sociodemographic and other factors associated with undergoing keratoplasty for CED. MAIN OUTCOME MEASURES Odds of undergoing keratoplasty with 95% confidence intervals, changes in the number of postoperative visits, and rates of adverse events in the year after keratoplasty. RESULTS Of the 38 648 enrollees who met the inclusion criteria, 2187 underwent ≥ 1 keratoplasty surgeries from January 2001 to December 2009. After adjustment for confounding factors, individuals with CED had 47% increased odds of undergoing keratoplasty during 2007-2009 relative to 2001-2006. The mean number of postoperative visits to eyecare providers in the year after keratoplasty declined from 12.6 in 2001-2006 to 10.5 in 2007-2008. There was no difference in the proportion of enrollees who developed adverse events after keratoplasty over time. CONCLUSIONS In this analysis of claims data, from 2001 to 2009, a period during which there was an increase in the rate of endothelial keratoplasty, we observed a trend of greater rates of keratoplasty in patients with CED and fewer visits for postoperative care in the later years of the decade compared with the earlier years, along with no change in rates of severe adverse events.
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Abstract
Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
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Affiliation(s)
- B Starfield
- Department of Health Policy and Management, Johns Hopkins University, USA
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Grace SL, Leung YW, Reid R, Oh P, Wu G, Alter DA, CRCARE Investigators. The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization. J Cardiopulm Rehabil Prev 2012; 32:41-7. [PMID: 22193933 PMCID: PMC4508132 DOI: 10.1097/hcr.0b013e31823be13b] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral. METHODS Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using χ. RESULTS When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy. CONCLUSION Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.
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Affiliation(s)
- Sherry L Grace
- Kinesiology and Health Science, 368 Bethune College, York University, Toronto, Ontario, Canada.
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Perception of Neighborhood Disorder and Health Service Usage in a Canadian Sample. Ann Behav Med 2011; 43:162-72. [DOI: 10.1007/s12160-011-9310-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Suurvali H, Hodgins DC, Toneatto T, Cunningham JA. Motivators for Seeking Gambling-Related Treatment Among Ontario Problem Gamblers. J Gambl Stud 2011; 28:273-96. [DOI: 10.1007/s10899-011-9268-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Price JH, Braun RE. Uninsured African American Youths— The Need for Targeted Interventions. J Natl Med Assoc 2011; 103:979-82. [DOI: 10.1016/s0027-9684(15)30455-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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