Delays and unmet need for health care among adult primary care patients in a restructured urban public health system

Increasing Access to Medical Care for Hispanic Women Without Insurance: A Mobile Clinic Approach

The purpose of this study was to describe the health status and barriers of people who sought care on a free mobile health clinic for women without insurance in California. Participants were 221 women who attended the Salud para Mujeres (Women's Health) mobile medical clinic between 2019 and 2021. Medical chart abstractions provided data on sociodemographic factors, medical history, barriers to care, depressive symptoms, and dietary factors. Anthropometric measure, blood pressure, and biomarkers of cardiometabolic disease risk were also abstracted. Participants were young adult (29.1 [SD 9.3] years), Hispanic (97.6%), farm-working (62.2%) women from Mexico (87.0%). Prevalent barriers to accessing (non-mobile) medical care included high cost (74.5%), language (47.6%), hours of operation (36.2%), and transportation (31.4%). The majority (89.5%) of patients had overweight (34.0%) or obesity (55.5%), and 27% had hypertension. Among those (n = 127) receiving a lipid panel, 60.3% had higher than recommended levels of low-density lipoprotein and 89% had lower than recommended levels of high-density lipoprotein. Point-of-care HbA1c tests (n = 133) indicated that 9.0% had diabetes and 24.8% had prediabetes. Over half (53.1%) of patients reported prevalent occupational exposure to pesticides and 19% had moderate to severe depressive symptoms. Weekly or more frequent consumption of sugar sweetened beverages (70.9%) and fast food (43.5%) were also prevalent. Mobile health units have potential for reaching women who face several barriers to care and experience major risk factors for cardometabolic disease. Findings suggest a compelling need to assure that Hispanic and Indigenous women and farmworkers have access to healthcare.

Association Between Objective Social Isolation and Unmet Medical Needs: A Nationwide Cross-sectional Study in Korea

OBJECTIVES

The aim of this study was to analyze the relationship between objective social isolation (SI) and unmet medical needs (UMN) in adults aged 19 and older.

METHODS

A cross-sectional analysis was conducted of 208 619 adults aged 19 and older, excluding missing data, using the 2019 Korea Community Health Survey. To analyze the association between objective SI and UMN, the chi-square test and logistic regression analysis were performed.

RESULTS

The prevalence of UMN was 1.14 times higher (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.06 to 1.23) among those with SI than among those without SI, and the OR for groups with 5 SI types was 2.77 (95% CI, 1.86 to 4.12) compared to those with no SI types. In addition, a stratified analysis by age group showed that the association between SI and UMN existed even in groups under 64 years old. However, among those aged 65 and older, SI was associated with an OR of 1.53 (95% CI, 1.37 to 1.71) for UMN compared to non-SI. As the number of SI types increased, the prevalence of UMN also increased, indicating a strong association between SI and UMN in older adults.

CONCLUSIONS

This study found that individuals with SI experienced UMN due to fear and anxiety about interpersonal relationships. Therefore, based on the results of this cross-sectional study, it is necessary to investigate the causal relationship between SI and UMN through future longitudinal data.

Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care

Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.

Delays in Care by Race, Ethnicity, and Gender Before and During the COVID-19 Pandemic Using Cross-Sectional Data From National Institutes of Health's All of Us Research Program

PURPOSE

Delays in receiving medical care are an urgent problem. This study aims to determine whether the odds of, and reasons for, experiencing care delays differ by gender, race-ethnicity, and survey completion before versus during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of survey data from participants age ≥18 in the National Institutes of Health's All of Us Research Program collected from May 6, 2018, to January 1, 2022. Logistic regressions were performed to assess the association of gender, race-ethnicity, and survey completion date with any of nine reasons for delaying care in the past 12 months.

RESULTS

Of 119,983 participants, 37.8% reported delaying care in the past 12 months. After adjusting for employment status, education, income, marital status, health insurance, and age, women of every race-ethnicity and Black and other race-ethnicity men were more likely than white men to report delays in care: Asian women (odds ratio [OR] 1.23; 95% confidence interval [CI] [1.13, 1.34]), Black men (OR 1.15; 95% CI [1.05, 1.25]) and women (OR 1.46; 95% CI [1.38, 1.54]), Hispanic women (OR 1.36; 95% CI [1.28, 1.44]), white women (OR 1.55; 95% CI [1.50, 1.60]), and other race-ethnicity men (OR 1.15; 95% CI [1.05, 1.27]) and women (OR 1.79; 95% CI [1.67, 1.91]). A small but statistically significant difference was seen in reports of care delays for non-pandemic-related reasons during versus before the COVID-19 pandemic (OR 0.88; 95% CI [0.83, 0.93]).

CONCLUSIONS

In this study of diverse U.S. participants, women and Black and other race-ethnicity men were more likely than white men to report delays in care, both before and during COVID-19. Addressing care delays may be necessary to ameliorate health disparities by race-ethnicity and gender.

Nativity differences in socioeconomic barriers and healthcare delays among cancer survivors in the All of Us cohort

PURPOSE

We aimed to assess whether nativity differences in socioeconomic (SES) barriers and health literacy were associated with healthcare delays among US cancer survivors.

METHODS

"All of Us" survey data were analyzed among adult participants ever diagnosed with cancer. A binary measure of healthcare delay (1+ delays versus no delays) was created. Health literacy was assessed using the Brief Health Literacy Screen. A composite measure of SES barriers (education, employment, housing, income, and insurance statuses) was created as 0, 1, 2, or 3+. Multivariable logistic regression model tested the associations of (1) SES barriers and health literacy with healthcare delays, and (2) whether nativity modified this relationship.

RESULTS

Median participant age was 64 years (n = 10,020), with 8% foreign-born and 18% ethnic minorities. Compared to survivors with no SES barriers, those with 3+ had higher likelihood of experiencing healthcare delays (OR 2.18, 95% CI 1.84, 2.58). For every additional barrier, the odds of healthcare delays were greater among foreign-born (1.72, 1.43, 2.08) than US-born (1.27, 1.21, 1.34). For every 1-unit increase in health literacy among US-born, the odds of healthcare delay decreased by 9% (0.91, 0.89, 0.94).

CONCLUSION

We found that SES barriers to healthcare delays have a greater impact among foreign-born than US-born cancer survivors. Higher health literacy may mitigate healthcare delays among US cancer survivors. Healthcare providers, systems and policymakers should assess and address social determinants of health and promote health literacy as a way to minimize healthcare delays among both foreign- and US-born cancer survivors.

The impact of the pandemic on the presentation and treatment of head and neck squamous cell carcinoma at a county hospital

INTRODUCTION

In March 2020, the World Health Organization declared COVID-19 a pandemic, initiating stay-at-home orders which delayed cancer care and screening. The impact on head and neck cancer care in populations at risk has yet to be elucidated. The objective of this investigation is to evaluate how the presentation, diagnosis, and treatment of head and neck squamous cell carcinoma cancer patients at a county hospital were affected by the pandemic.

METHODS

A retrospective review of patients with head and neck squamous cell carcinoma that were diagnosed at a county hospital 365 days before and after stay-at-home orders were initiated. The primary outcomes were duration between diagnosis from imaging and initiation of treatment. Secondary outcomes included mortality, stage, nodal status, and distant metastasis at presentation.

RESULTS

There was a total of 105 diagnoses. Sixty-five (62 %) head and neck squamous cell carcinoma diagnoses were diagnosed before the stay-at-home orders were initiated, and 40 (38 %) after. Eighty percent (32/40) of diagnoses presenting after had stage IV disease compared to 58 % (38/65) in those before (p < 0.05). A higher percentage of patients who presented later had a >30-day delay to biopsy (43 % v. 20 %, OR: 3.0, p < 0.05). This difference was exacerbated by those with laryngeal, oral cavity, or oropharyngeal cancer (45 % v. 15 %, OR: 4.5, p < 0.05). There was a larger delay from diagnosis to treatment after the orders were initiated (68 v. 53, p < 0.05) however there was no difference in one-year mortality (25 % v. 23 %, p > 0.05). This investigation found a 14 % loss to follow-up.

CONCLUSIONS AND RELEVANCE

In this cohort of head and neck squamous cell carcinoma diagnoses at a county hospital, those diagnosed after the stay-at-home orders were initiated presented with more advanced disease. They also had more delays in diagnosis and initiation of treatment. There was no difference in one-year mortality rates between the two groups however there was a significant loss to follow-up, limiting prognostication. These findings serve to better prepare healthcare providers to implement optimized care during future shutdowns related to public health crises.

LEVEL OF EVIDENCE

III.

Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults

Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.

Factors affecting unmet medical needs of patients with diabetes: A population-based study

AIMS

The purpose of this study was to identify unmet medical needs and related factors in patients with diabetes.

DESIGN

A cross-sectional study.

METHODS

Participants included 2269 diabetes patients aged >19 years by using data from the National Health and Nutrition Examination Surveys. A complex sample design multiple logistic regression analysis was performed.

RESULTS

The study found that 8.7% of diabetes patients experienced unmet medical needs, and it was found to be higher for those who thought their self-assessed health status was unhealthy and often felt stressed in their daily life. Gender and education level had a moderating effect on income level on unmet medical needs experience.

CONCLUSION

These findings have important implications for nursing practice in the management of diabetes. Nurses can develop targeted interventions that address the specific needs of patients who are at risk for unmet medical needs, particularly those from low-income backgrounds. By considering the factors that contribute to unmet medical needs and the moderating effect of income level, nurses can improve patient outcomes and reduce the burden of diabetes.

"Advocating for what we need": A CBPR approach to advance care planning in the Latinx older adult community

BACKGROUND

Advance care planning (ACP) is low among Latinx older adults. We used community-based participatory research (CBPR) to identify ACP barriers/facilitators and design community-based ACP events.

METHODS

In partnership with community-based organizations, clinicians, and local government, we formed a Latinx Community Committee (n = 13 community members). We then conducted 6 focus groups with Latinx-identifying, English or Spanish-speaking older adults (age ≥ 55), caregivers, and community leaders to assess ACP barriers/facilitators. We analyzed transcripts using thematic analysis and, based on these learnings, designed and implemented community-based ACP events. Using a validated survey, we assessed acceptability and pre-to-post-event ACP readiness (4-point scale; 4 = most ready; 0.2 change considered meaningful) with Wilcoxon signed-rank tests.

RESULTS

Focus groups included 10 Spanish-speaking older adults, 8 caregivers, and 10 community leaders. Themes highlighted the importance of ACP (e.g., means of advocacy), barriers (e.g., how to start conversations), and facilitators (e.g., trusted community spaces) in the Latinx community. Ninety-seven people attended 5 events targeting 3 Latinx populations (LGBTQI+, intergenerational, and older adults broadly). Overall pre-to-post-event ACP readiness increased (2.62 (SD 0.97) to 2.95 (SD 0.93); p = 0.05). Readiness to document wishes increased significantly (2.44 (SD 1.0) to 2.98 (SD 0.95); p = 0.003). Most reported being comfortable attending events (85%) and would recommend them to others (90%).

CONCLUSIONS

This study describes a feasible, acceptable, and effective CBPR ACP intervention. Co-developed community events represent a promising approach to reducing disparities in ACP among the Latinx population.

Factors affecting unmet healthcare needs in female baby boomers: Andersen model application in Korea

This study aimed to measure unmet healthcare needs and investigate the factors affecting them in female baby boomers (individuals born between 1955 and 1963) using the Korea Health Panel Data 2017 from February to June 2017 by the Korea Institute for Health and Social Affairs and the National Health Insurance Corporation. The data were analyzed using descriptive statistics, chi-square test, t-test, and multiple logistic regression using SPSS WIN 25.0 program. The results showed that the proportion of unmet healthcare needs was 11.1%, and the primary reason for unmet healthcare needs was the lack of visitation time. Female baby boomers experienced more unmet healthcare needs when they had no spouse (1.63 times), eating problems (2.33 times), and stress (1.31 times). This study is significant because it measured the unmet healthcare needs of women in the baby boomer generation and identified the factors influencing unmet healthcare needs. The study's results can help provide essential data to decrease the unmet healthcare needs of female baby boomers.

The impact of entering poverty on the unmet medical needs of Korean adults: a 5-year cohort study

Background

Studies on the effects of poverty on unmet medical needs are limited. Therefore, this study aimed to identify the impact of entering poverty on the unmet medical needs of South Korean adults.

Methods

This study used data from the Korea Health Panel Survey (2014–2018) and included 10,644 adults. Logistic regression was used to examine the impact of entering poverty on unmet medical needs (poverty status: no → no, yes → no, no → yes, yes → yes; unmet medical needs: no, yes). Poverty line was considered to be below 50% of the median income.

Results

When entering poverty, the proportion of unmet medical needs was 22.8% (adjusted odds ratio [AOR] 1.17, 95% confidence interval [CI] 1.01–1.36). Men (AOR 1.29, 95% CI 1.02–1.64), rural dwellers (AOR 1.24, 95% CI 1.01–1.50), and national health insurance (NHI) beneficiaries (AOR 1.21, 95% CI 1.04–1.42) were susceptible to unmet medical needs and entering poverty. Poverty line with below-median 40% had an AOR of 1.48 (95% CI 1.28–1.71). For the cause of unmet medical needs, the AORs were 1.50 for poverty (95% CI 1.16–1.94) and 1.08 for low accessibility to health care and information (95% CI 0.79–1.48).

Conclusions

Entering poverty had the potential to adversely affect unmet medical needs. Men, rural dwellers, and NHI beneficiaries were vulnerable to unmet medical needs after entering poverty. Rigid definitions of poverty and inaccessibility to health care and information increase the likelihood of unmet medical needs and poverty. Society must alleviate unmet medical needs due to the increase in the population entering poverty.

Frequency and factors associated with foregone and delayed medical care due to COVID-19 among nonelderly US adults from August to December 2020

OBJECTIVES

To estimate the frequency and factors associated with foregone and delayed medical care attributed to the COVID-19 pandemic among nonelderly adults from August to December 2020 in the United States.

METHODS

We used three survey waves from the Urban Institute's Household Pulse Survey (HPS) collected between August 19-31, October 14-26 and December 9-21. The final sample included 155,825 nonelderly (18-64) respondents representing 135,835,598 million individuals in the United States. We used two multivariable logistic regressions to estimate the association between respondents' characteristics and foregone and delayed care.

RESULTS

The frequency of foregone and delayed medical care was 26.9% and 35.9%, respectively. Around 60% of respondents reported difficulties in paying for usual household expenses in the last 7 days. More than half reported several days of mental health issues. The regression results indicated that foregone or delayed care were significantly associated with difficulties in paying usual household expenses (p < 0.001), worse self-reported health status (p < 0.001), increased mental health problems (p < 0.001), Veterans Affairs (p <0.001) or Medicaid (p = 0.003) coverage compared to private healthcare coverage, and older age groups. Individuals who participated in the latter two waves of the survey (October, December) were less likely to report foregone and delayed care compared to those who participated in Wave 1 (August).

CONCLUSION

Overall, the frequency of foregone and delayed medical care remained high from August to December 2020 among nonelderly US adults. Our findings highlight that pandemic-induced access barriers are major drivers of reduced healthcare provision during the second half of the pandemic and highlight the need for policies to support patients in seeking timely care.

Unmet healthcare needs among middle-aged and older adults in China

BACKGROUND

Unmet healthcare needs have increasingly been recognised as an indicator of equity of healthcare access and utilisation, having the potential to capture frailty of health and social protection systems.

OBJECTIVES

This study aimed to estimate the prevalence of unmet healthcare needs and its correlates among middle-aged and older adults in China.

METHODS

This study is based on analyses of the China Health and Retirement Longitudinal Study carried out in 2011 among Chinese adults aged 45 years and above. Multivariable logistic regression models were conducted to examine associated factors, stratified by rural or urban residence. Reasons for having unmet needs for inpatient and outpatient services were also analysed.

RESULTS

Among 14,774 participants, the prevalence of unmet healthcare needs was 13.0% (95% confidence interval 12.3-13.8%) and was higher in rural areas. The most prevalent reasons for unmet need for inpatient and outpatient care were 'not enough money' and 'illness is not serious, don't need treatment', respectively. The respondents who were unmarried, employed, had poor self-reported health, needed help with activities of daily living, reported lower life satisfaction, multiple chronic conditions and depressive symptoms had increased odds of unmet healthcare needs.

CONCLUSION

This study suggests that unmet healthcare needs are more concentrated among people living with multiple health conditions and mental health problems in China. If universal health coverage goals and sustainable development goal 3 are to be met, it is essential that effective mechanisms for addressing unmet healthcare needs are identified.

Prevalence and correlates of forgone care among adult Israeli Jews: A survey conducted during the COVID-19 outbreak

Efforts to control the spread of the novel Coronavirus (COVID-19) pandemic include drastic measures such as isolation, social distancing, and lockdown. These restrictions are accompanied by serious adverse consequences such as forgoing of healthcare. The study aimed to assess the prevalence and correlates of forgone care for a variety of healthcare services during a two-month COVID-19 lockdown, using Andersen's Behavioral Model of Healthcare Utilization. A cross-sectional study using computerized phone interviews was conducted with 302 Israeli Jewish participants aged 40 and above. Almost half of the participants (49%) reported a delay in seeking help for at least one needed healthcare service during the COVID-19 lockdown period. Among the predisposing factors, we found that participants aged 60+, being more religious, and reporting higher levels of COVID-19 fear were more likely to report forgone care than younger, less religious and less concerned participants. Among need factors, a statistically significant association was found with a reported diagnosis of diabetes, with participants with the disease having a considerably higher likelihood of forgone care. The findings stress the importance of developing interventions aimed at mitigating the phenomenon of forgoing care while creating nonconventional ways of consuming healthcare services. In the short term, healthcare services need to adapt to the social distancing and isolation measures required to stanch the epidemic. In the long term, policymakers should consider alternative ways of delivering healthcare services to the public regularly and during crisis without losing sight of their budgetary consequences. They must recognize the possibility of having to align medical staff to the changing demand for healthcare services under conditions of health uncertainty.

Health and Health Care of Sexual and Gender Minorities

Research on the social dimensions of health and health care among sexual and gender minorities (SGMs) has grown rapidly in the last two decades. However, a comprehensive review of the extant interdisciplinary scholarship on SGM health has yet to be written. In response, we offer a synthesis of recent scholarship. We discuss major empirical findings and theoretical implications of health care utilization, barriers to care, health behaviors, and health outcomes, which demonstrate how SGMs continue to experience structural- and interactional-level inequalities across health and medicine. Within this synthesis, we also consider the conceptual and methodological limitations that continue to beleaguer the field and offer suggestions for several promising directions for future research and theory building. SGM health bridges the scholarly interests in social and health sciences and contributes to broader sociological concerns regarding the persistence of sexuality- and gender-based inequalities.

Impact of Long Working Hours and Shift Work on Unmet Health Care Need Among Korean Workers

Background

This study aimed to identify work-related risk factors, including long working hours and night/shift work, for unmet health care need using data of a representative panel of Korean adults.

Methods

Associations between work-related factors and unmet health care need were analyzed using data of 3,440 participants (10,320 observations) from the 2011-2013 Korean Health Panel Study. A generalized estimating equation was used for the analysis of repeated measures.

Results

The prevalence of unmet health care was 16.6%. After adjusting sex, age, socioeconomic status, work characteristics, and working more than 60 hours per week (odds ratio [OR]: 1.43, 95% confidence interval [CI]: 1.23–1.65) or 50–59 hours per week (OR: 1.26, 95% CI: 1.08–1.46) instead of 40–49 hours per week and night/shift work (OR: 1.27, 95% CI: 1.06–1.51) were associated with unmet health care need.

Conclusion

Long working hours and night/shift work are risk factors for unmet health care need among the Korean working population.

Forgoing Care in Southernmost Texas: Compounding Hardship and Health Among Latinx Immigrant Border Residents

This study examines how material hardship and perceived discrimination are associated with health care access and self-rated health among lower Rio Grande Valley residents. Of respondents to surveys administered at 2 clinic systems (N = 546), approximately 67% reported forgoing medical care in the past 12 months. Regression results suggested that perceived discrimination (odds ratio [OR] = 1.05, P < .05) and material hardship (OR = 1.63, P < .001) increased the odds of forgoing care. Also, discrimination (OR = 1.04, P < .01) and material hardship (OR = 1.24, P < .001) were independently associated with worse self-rated health. Service providers should consider screening for hardship experiences to target resources to address these stressors on patient health.

Factors affecting unmet healthcare needs of low-income overweight and obese women in Korea: analysis of the Korean National Health and Nutrition Examination Survey 2017

PURPOSE

The purpose of this study was to explore unmet healthcare needs among low-income overweight and obese women and to identify the factors affecting unmet healthcare needs.

METHODS

The study was a secondary analysis of data from the 2017 Korea National Health and Nutrition Examination Survey. A final sample of 388 out of 8,127 participants was analyzed using complex descriptive statistics, the chi-square test, the independent t-test, and logistic regression.

RESULTS

The mean age of the participants was 66.51±1.05 years. Unmet healthcare needs were experienced by 19.4% of low-income overweight and obese women. Women with depression, stress, and poor self-reported health status were significantly more likely than their counterparts to experience unmet healthcare needs. Poor self-reported health status was confirmed to be related to unmet health needs in low-income overweight and obese women (odds ratio, 2.65; p=.011).

CONCLUSION

The study provides the novel insight that the unmet healthcare needs of low-income overweight and obese women were influenced by self-reported health status. Healthcare providers should make efforts to develop strategies to reduce unmet healthcare needs among low-income overweight and obese women, who constitute a vulnerable population.

Unmet need for primary healthcare and associated individual and household-level factors in Kenya: results from a national survey

OBJECTIVE

To determine the prevalence of unmet need for primary healthcare and associated individual and household-level factors in Kenya.

DESIGN

The data for this study are drawn from the 2016 Kenya Integrated Household Budget Survey (KIHBS). A multistage sampling technique involving a systematic selection of clusters at the national level and final selection of households was used.

SETTING

This study was conducted in Kenya. The KIHBS is a nationally representative survey on a wide range of indicators to assess the progress made in improving the living standards of the population at the national level.

PARTICIPANTS

A total of 9447 households comprising 15 539 household members who reported a sickness or injury over the 4 weeks preceding this survey were included in this study. The study respondents comprised of the household heads.

PRIMARY OUTCOME MEASURE

The primary outcome of this study is unmet need for primary healthcare defined as an unexpressed demand for primary healthcare following a reported sickness or injury over the 4 weeks preceding this survey.

RESULTS

About one in every five study participants experienced an unexpressed demand for primary care. The odds of having unmet need for primary healthcare were 68% higher among participants without health insurance coverage compared with those with health insurance (adjusted OR 1.68; p<0.001; 95% CI 1.34 to 2.09) and 45% higher among households headed by single or unmarried persons compared with the those who were in a marital union (adjusted OR 1.45; p<0.05; 95% CI 1.06 to 1.98).

CONCLUSIONS

Our findings show that there is still a considerable unexpressed demand for primary care services despite widespread implementation of Universal Health Coverage (UHC) in Kenya, with households without a health insurance cover bearing the highest burden. Therefore, the design of UHC reforms in Kenya should focus on embedding social health protection to escalate the demand for primary healthcare services.

Subjective Well-Being, Depression, and Delays in Care Among Older Adults: Dual-Eligible Versus Medicare-Only Beneficiaries

We aimed to (a) determine the role of subjective well-being and depression in care delays among Medicare beneficiaries and (b) examine whether subjective well-being and depression play a differential role among Medicare-only and dual-eligible beneficiaries. A nationally representative sample of 1,696 older adults participated in the study. Roughly, 22% of participants reported often or sometimes experiencing care delays, with more delays among dual eligibles. We found that higher levels of subjective well-being were significantly related to less frequent care delays. In contrast, higher levels of depression were significantly related to more frequent care delays. Moreover, as depression increased, the predicted probability of delays increased to a greater extent among dual eligibles than Medicare-only beneficiaries. These findings signify the importance of identifying and implementing strategies to enhance subjective well-being and reduce depression in older adults, particularly dual eligibles, to improve access to timely care.

Evaluation of Neighborhood Socioeconomic Characteristics and Advance Care Planning Among Older Adults

IMPORTANCE

Advance care planning (ACP) is low among older adults with socioeconomic disadvantage. There is a need for tailored community-based approaches to increase ACP, but community patterns of ACP are poorly understood.

OBJECTIVE

To examine the association between neighborhood socioeconomic status (nSES) and ACP and to identify communities with both low nSES and low rates of ACP.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study examined University of California San Francisco electronic health record (EHR) data and place-based data from 9 San Francisco Bay Area counties. Participants were primary care patients aged 65 years or older and living in the San Francisco Bay Area in July 2017. Statistical analysis was performed from May to June 2020.

EXPOSURES

Patients' home addresses were geocoded and assigned to US Census tracts. The primary factor, nSES, an index combining area-level measures of income, education, poverty, employment, occupation, and housing or rent values, was divided into quintiles scaled to the distribution of all US Census tracts in the Bay Area (Q1 = lowest nSES). Covariates were from the EHR and included health care use (primary care, outpatient specialty, emergency department, and inpatient encounters in the prior year).

MAIN OUTCOMES AND MEASURES

ACP was defined as a scanned document (eg, advance directive), ACP Current Procedural Terminology code, or ACP note type in the EHR.

RESULTS

There were 13 104 patients included in the cohort-mean (SD) age was 75 (8) years, with 7622 female patients (58.2%), 897 patients (6.8%) identified as Black, 913 (7.0%) as Latinx, 3788 (28.9%) as Asian/Pacific Islander, and 748 (5.7%) as other minority race/ethnicity, and 2393 (18.3%) self-reported that they preferred to speak a non-English language. Of these, 3827 patients (29.2%) had documented ACP. The cohort was distributed across all 5 quintiles of nSES (Q1: 1426 patients [10.9%]; Q2: 1792 patients [13.7%]; Q3: 2408 patients [18.4%]; Q4: 3330 patients [25.4%]; Q5: 4148 patients [31.7%]). Compared with Q5 and after adjusting for health care use, all lower nSES quintiles showed a lower odds of ACP in a graded fashion (Q1: adjusted odds ratio [aOR] = 0.71 [95% CI, 0.61-0.84], Q2: aOR = 0.74 [95% CI, 0.64-0.86], Q3: aOR = 0.81 [95% CI, 0.71-0.93], Q4: aOR = 0.82 [95% CI, 0.72-0.93]. A bivariable map of ACP by nSES allowed identification of 5 neighborhoods with both low nSES and ACP.

CONCLUSIONS AND RELEVANCE

In this study, lower nSES was associated with lower ACP documentation after adjusting for health care use. Using EHR and place-based data, communities of older adults with both low nSES and low ACP were identified. This is a first step in partnering with communities to develop targeted, community-based interventions to meaningfully increase ACP.

Unmet Healthcare Needs of Children in Vulnerable Families in South Korea: Finding from the Community Child Center Child Panel Survey

Presented in this paper is a study that examined the status of unmet healthcare needs of children in vulnerable families and identified factors affecting such unmet needs. The Community Child Center (CCC) Child Panel Survey data in Korea were used. A multiple stepwise logistic regression analysis was performed to examine factors influencing unmet healthcare needs of children. Influencing factors comprised predisposing, enabling, and need factors based on the Andersen Behavioral Model of Health Services Utilization. A total of 340 sixth-graders from vulnerable families participated, and 96 (28.2%) children had unmet healthcare needs. Factors included absence of an after-school caregiver (OR = 1.95, 95% CI [1.16, 3.27]), perceived physical symptoms (OR = 1.33, 95% CI [1.02, 1.73]), parental indifference (OR = 1.33, 95% CI [1.002, 1.77]), duration of daily stay at CCCs (OR = 1.32, 95% CI [1.01, 1.71]), and satisfaction with CCC teachers (OR = 0.65, 95% CI [0.49, 0.85]). The relationship with parents and CCC teachers had the strongest influence on unmet healthcare needs of children. In order to reduce the unmet healthcare needs of children in vulnerable families, existing support structures should be expanded to offer financial and administrative support for children’s parents and CCC teachers.

Unmet Healthcare Needs, Catastrophic Health Expenditure, and Health in South Korea's Universal Healthcare System: Progression Towards Improving Equity by NHI Type and Income Level

This study examined the effects of healthcare inequality on personal health. It aimed to determine how health insurance type and income level influence catastrophic health expenditure and unmet healthcare needs among South Koreans. Unbalanced Korean Health Panel data from 2011 to 2015, including 33,374 adults, were used. A time-trend and panel regression analysis were performed. The first to identify changes in the main variables and, the second, mediating effects of unmet healthcare needs and catastrophic health expenditure on the relationship between health insurance type, income level, and health status. The independent variables were: high-, middle-, low-income employee insured, high-, middle-, low-income self-employed insured, and medical aid. The dependent variable was health status, and the mediators were unmet needs and catastrophic health expenditure. The medical aid beneficiaries and low-income self-employed insured groups demonstrated a higher probability of reporting poor health status than the high-income, insured group (15.6%, 2.2%, and 2.3%, respectively). Participants who experienced unmet healthcare needs or catastrophic health expenditure were 10.7% and 5.6% higher probability of reporting poor health, respectively (Sobel test: p < 0.001). National policy reforms could improve healthcare equality by integrating insurance premiums based on income among private-sector employees and self-employed individuals within the health insurance network.

A Toolkit for Community-Based, Medicaid-Funded Case Managers to Introduce Advance Care Planning to Frail, Older Adults: A Pilot Study

Background: Advance care planning (ACP) among frail, older adults receiving in-home care is low. Leveraging case managers to introduce ACP may increase engagement. Objective: Pilot an ACP-Toolkit for case managers and their clients. Design: Feasibility pilot of an ACP-Toolkit for case managers to introduce ACP and the PREPAREforYourCare.org website and advance directives. Setting/Subjects: Case managers from four local aging service organizations who referred English-speaking clients ≥55 years old. Measurements: Using validated surveys (five-point Likert scales), we assessed changes in case managers' attitudes, confidence, and readiness to facilitate ACP and clients' readiness to engage in ACP from baseline to follow-up (one-week) using Wilcoxon signed-rank tests. Results: We enrolled 9 case managers and 12 clients (median age 69 [standard deviation 8], 75% minority race/ethnicity). At follow-up, case managers' confidence increased (3.2 [0.7] to 4.2 [0.7]; p = 0.02), and clients' readiness increased (2.8 [1.5] to 3.4 [1.4]; p = 0.06). All case managers agreed the Toolkit was easy to use, helped start ACP conversations, and would recommend it to others. All clients found the Toolkit easy to understand and were comfortable with case managers using it. Nearly all clients (92%) would recommend it to others. Suggestions for improvement included offering the Toolkit in other languages and disseminating it in clinical and community settings. Conclusions: The ACP-Toolkit resulted in higher case manager confidence in facilitating ACP and client readiness to engage in ACP, and usability was high. A brief ACP-Toolkit may be a feasible solution to increase ACP engagement among frail, older adults receiving in-home care.

Waiting for care: Chronic illness and health system uncertainties in the United States

Structures of power and inequality shape day-to-day life for individuals who are poor, imposing waiting in multiple forms and for a variety of services, including for healthcare (Andaya, 2018a; Auyero, 2012; Strathmann and Hay, 2009). Constraints, such as the age requirements for Medicare, losing employer-provided health insurance, or the bureaucracy involved in filing for disability often require people to wait to follow recommendations for medical treatments. In 2016–2017, we conducted 52 narrative interviews in St. Louis, a city with significant racial and economic health inequities and without Medicaid expansion. We interviewed people with one or more chronic illnesses for which they were prescribed medication and who identified as having difficulties affording their prescriptions. Throughout the interviews, participants frequently recounted 1) experiences of waiting for care, along with other services, and 2) the range of strategies they utilized to manage the waiting. In this article, we develop the concept of active waiting to describe both the lived experiences of waiting for care and the responses that people devise to navigate, shorten, or otherwise endure waiting. Waiting is structured into healthcare and other social services at various scales in ways that reinforce feelings of marginalization, and also that require work on the part of those who wait. While much medical and public health research focuses on issues of diagnostic or treatment delay, we conclude that this conceptualization of active waiting provides a far more productive frame for accurately understanding the emotional and physical experiences of individuals who are disproportionately poor and made to wait for their care. Only with such understanding can we hope to build more just and compassionate social systems.

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Poor and chronically ill people wait to receive medical care and social services.

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People wait actively, making decisions to manage the repercussions of waiting.

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The idea of delaying care is inadequate to explain realities of illness and poverty.

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Waiting broadens and deepens structural vulnerability for marginalized people.

Annual Disease Experience by Type and Correlations with Unmet Healthcare Needs among ROK Military Personnel

Introduction

The National Statistical Yearbook of Defense 2018 issued by the Republic of Korea (ROK) Ministry of National Defense reported that the number of patients using military hospitals steadily increased from 2008 to 2017. However, in the outpatient clinic statistics for years 2015–2017 from the ROK Armed Forces Medical Command, the amount of medical care received from some medical departments, such as the infection medicine, surgery, and anesthesiology departments, decreased. Therefore, the purpose of this study was to observe the differences in incidence of military personnel’s unmet healthcare needs according to number of diseases by type.

Materials and Methods

The study used data from the Military Health Survey, which was conducted from 2014 to 2015 and included 5162 responses from ROK military personnel. The number of diseases by type and unmet healthcare needs were self-reported. A multiple logistic regression analysis was used to examine the validity of the annual disease experience by type and correlations with unmet healthcare needs.

Results

Of the 5162 military personnel, 25.2% experienced unmet healthcare needs, and the more people with the number of disease by type, the more likely they were to experience unmet healthcare needs (1: 13.4%, 2: 22.9%, 3: 29.2%, 4: 34.5%, 5: 41.4%). The logistic regression analysis also revealed significant differences (1 = REF, 2 odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.50–2.24; 3 OR = 2.53, 95% CI: 2.05–3.11, 4 OR = 3.10, 95% CI = 2.49–3.85; ≥5 OR = 3.85, 95% CI = 3.08–4.81). In addition, subgroup analysis showed that female military personnel are more likely to experience unmet healthcare needs than are male military personnel. We have also confirmed that working areas and private insurance can affect unmet healthcare needs.

Conclusion

This study suggests that unmet healthcare needs are influenced by the number of disease by the type of ROK military personnel. It is therefore necessary to strive to reduce the number of military personnel who experience unmet healthcare needs through this data.

Outpatient Visits among Older Adults Living Alone in China: Does Health Insurance and City of Residence Matter?

This study aimed to examine the association between health insurance, city of residence, and outpatient visits among older adults living alone in China. A sample of 3173 individuals was derived from “Survey on Older Adults Aged 70 and Above Living Alone in Urban China” in five different cities. Logistic regression models indicated that older adults living alone who had urban employee basic medical insurance, urban resident basic medical insurance, and public medical insurance were more likely to have outpatient visits than those without any health insurance. After controlling the number of chronic diseases, only those with public medical insurance were more likely to have outpatient visits than uninsured older adults. Additionally, older adults who resided in Shanghai and Guangzhou were more likely to have outpatient visits than those in Chengdu, whereas older adults who were in Dalian and Hohhot were less likely to have outpatient visits. To improve the equity of outpatient visits among older adults living alone in China, policy efforts should be made to reduce fragmentation of different health insurance plans, expand the health insurance coverage for older adults, provide programs that consider the needs of this special group of older adults, and reduce the inequality in health resources and health insurance policies across cities.

The Role of Social Determinants of Health in Self-Reported Access to Health Care Among Women Undergoing Screening Mammography

Background: Social determinants of health (SDOH) contribute to health care disparities, with social and economic barriers often leading to difficulties in obtaining necessary care. We evaluated barriers to receiving health care, focusing on caretaker responsibilities, health insurance and cost, and transportation. Materials and Methods: We included women ages ≥40 years receiving screening mammography across three Breast Cancer Surveillance Consortium registries from 2012 to 2017. Women self-reported social and financial barriers to receiving health care in the 12 months before their screening mammogram. We evaluated woman- and census-based community-level factors associated with reporting a barrier using multivariate logistic regression. We assessed interaction with urban versus nonurban residence using Wald tests. Results: Among 393,430 women, 3.6% reported a barrier with a higher proportion in urban versus nonurban settings (3.9% [n = 11,977] vs. 2.2% [n = 1,655], respectively; p < 0.001). Among women reporting a barrier, health care cost and/or no insurance was the most common (49.3%), and no transportation was the least common (7.8%). Compared with white women, odds of reporting barriers were higher among black (adjusted odds ratio [aOR] = 1.30, 95% confidence interval [CI]: 1.16-1.44), Hispanic (aOR = 1.66, 95% CI: 1.53-1.80), and other race (aOR = 1.84, 95% CI: 1.65-2.04) women. Barriers were less likely in women with higher median household income (aOR = 0.69, 95% CI: 0.61-0.79) or higher average health insurance costs (aOR = 0.85, 95% CI: 0.74-0.98), but were more likely in high diversity index areas (aOR = 1.28, 95% CI: 1.11-1.48). Conclusions: Social and financial barriers exist based on race/ethnicity and SDOH related to income, insurance costs, and place of residence among women undergoing screening mammography. Breast imaging facilities could utilize information on these barriers to improve biennial screening adherence or ensure that women with abnormal findings obtain appropriate follow-up care through targeted interventions.

Insurance impacts survival for children, adolescents, and young adults with bone and soft tissue sarcomas

Background

While racial/ethnic survival disparities have been described in pediatric oncology, the impact of income has not been extensively explored. We analyzed how public insurance influences 5‐year overall survival (OS) in young patients with sarcomas.

Methods

The University of California San Francisco Cancer Registry was used to identify patients aged 0‐39 diagnosed with bone or soft tissue sarcomas between 2000 and 2015. Low‐income patients were defined as those with no insurance or Medicaid, a means‐tested form of public insurance. Survival curves were computed using the Kaplan‐Meier method and compared using log‐rank tests and Cox models. Causal mediation was used to assess whether the association between public insurance and mortality is mediated by metastatic disease.

Results

Of 1106 patients, 39% patients were classified as low‐income. Low‐income patients were more likely to be racial/ethnic minorities and to present with metastatic disease (OR 1.96, 95% CI 1.35‐2.86). Low‐income patients had significantly worse OS (61% vs 71%). Age at diagnosis and extent of disease at diagnosis were also independent predictors of OS. When stratified by extent of disease, low‐income patients consistently had significantly worse OS (localized: 78% vs 84%, regional: 64% vs 73%, metastatic: 23% vs 30%, respectively). Mediation analysis indicated that metastatic disease at diagnosis mediated 15% of the effect of public insurance on OS.

Conclusions

Low‐income patients with bone and soft tissue sarcomas had decreased OS regardless of disease stage at presentation. The mechanism by which insurance status impacts survival requires additional investigation, but may be through reduced access to care.

Neighborhood Deprivation and Unmet Health Care Needs: A Multilevel Analysis of Older Individuals in South Korea

Objectives

In this study the relationship between neighborhood deprivation and the unmet health care needs of elderly individuals (≥ 65 years) was examined. Some previous studies suggested that neighborhood characteristics affect access to health care, yet research on the unmet needs of older individuals is limited.

Methods

Multilevel logistic regression analysis was used to assess the relationship of neighborhood-level factors with unmet health care needs due to costs, adjusting for individual-level factors, in individuals ≥ 65 years in the 2017 Korean Community Health Survey (n = 63,388).

Results

There were 2.6% of elderly individuals who experienced unmet health care needs due to costs. Following adjustment for individual and neighborhood characteristics, the neighborhood deprivation in urban areas was found to have an inverse association with unmet needs (odds ratio = 0.50; 95% confidence interval = 0.24-1.06) for the most deprived quartile versus the least deprived quartile). However, in rural areas neighborhood deprivation was not a significant variable. Among the individual-level variables, household income was one of the strongest correlates with unmet needs in both urban and rural areas.

Conclusion

The present findings suggest that targeted policy interventions reflecting both neighborhood and individual characteristics, should be implemented to reduce the unmet health care needs of elderly individuals.

Leveraging In-Home Supportive Services Programs to Engage People in Advance Care Planning: Input from Staff, Providers, and Client Stakeholders

Background: In-Home Supportive Services (IHSS) cares for millions of Medicaid-eligible older adults who are often homebound and socially isolated. Advance care planning (ACP) can be challenging for this population, and IHSS programs may play an important role. Objective: To explore the feasibility of an IHSS ACP program for frail older adults. Design: Semistructured focus groups. Setting/Subjects: Fifty IHSS stakeholders (20 administrators, 9 case managers, 13 in-home caregivers, and 8 clients) participated in 10 focus groups in San Francisco. Measurements: Qualitative thematic content analysis by two independent coders. Results: Four main themes emerged: (1) Unmet needs: patients' wishes unknown during a medical crisis, lack of education/training for clients and staff; (2) Barriers: conflict of interest and potential medical overreach of IHSS caregivers, lack of billing avenues, time limitations, and cultural, literacy, and language barriers; (3) Facilitators: leveraging established workflows, available technology, and training programs; and (4) Implementation: use a tailored, optional approach based on clients' readiness, focus on case managers not caregivers to prevent conflict of interest; use established intake, follow-up, and training procedures; consider cultural and literacy-appropriate messaging; and standardize easy-to-use procedures, simple scripts, and educational guides, within established workflow to support case managers. Conclusions: An IHSS ACP program is important and feasible for Medicaid-eligible, frail older adults. Implementation suggestions for success by IHSS stakeholders include focusing on case managers rather than in-home caregivers to prevent conflict of interest; tailoring programs to clients' readiness, literacy, and language; creating educational programs for IHSS staff, clients, and community; and standardizing easy-to-use guides and procedures into IHSS workflows.

The relationship between employment and health and health care among working-age adults with and without disabilities in the United States

Purpose: To better understand the relationship between employment and health and health care for people with disabilities in the United States (US). Methods: We pooled US Medical Expenditure Panel Survey (2004-2010) data to examine health status, and access to health care among working-age adults, comparing people with physical disabilities or multiple disabilities to people without disabilities, based on their employment status. Logistic regression and least squares regression were conducted, controlling for sociodemographics, health insurance (when not the outcome), multiple chronic conditions, and need for assistance. Results: Employment was inversely related to access to care, insurance, and obesity. Yet, people with disabilities employed in the past year reported better general and mental health than their peers with the same disabilities who were not employed. Those who were employed were more likely to have delayed/forgone necessary care, across disability groups. Part-time employment, especially for people with multiple limitations, was associated with better health and health care outcomes than full-time employment. Conclusion: Findings highlight the importance of addressing employment-related causes of delayed or foregone receipt of necessary care (e.g., flex-time for attending appointments) that exist for all workers, especially those with physical or multiple disabilities. Implications for rehabilitation These findings demonstrate that rehabilitation professionals who are seeking to support employment for persons with physical limitations need to ensure that overall health concerns are adequately addressed, both for those seeking employment and for those who are currently employed. Assisting clients in prioritizing health equally with employment can ensure that both areas receive sufficient attention. Engaging with employers to develop innovative practices to improve health, health behaviors and access to care for employees with disabilities can decrease turnover, increase productivity, and ensure longer job tenure.

Unmet healthcare needs of elderly people in Korea

BACKGROUND

Elderly people often have more complicated healthcare needs than younger adults due to additional functional decline, physical illness, and psychosocial needs. Unmet healthcare needs increase illness severity, complications, and mortality. Despite this, research on the unmet healthcare needs of elderly people is limited in Korea. This study analysed the effect of functional deterioration related to aging on unmet healthcare needs based on the Korea Health Panel Study.

METHODS

This cross-sectional study used data from the 2011-2013 survey of 8666 baseline participants aged 65 years and older. Unmet healthcare needs were calculated using a complex weighted sample design. Group differences in categorical variables were analysed using the Rao-Scott Chi-square test. Using logistic regression analysis, the association between unmet healthcare needs and aging factors was analysed.

RESULTS

The prevalence of unmet healthcare needs in Korean elderly was 17.4%. Among them, the leading reason was economic hardship (9.2%). Adjusting for sex, age, socioeconomic characteristics, and health-related characteristics, the group with depression syndrome was 1.45 times more likely to have unmet healthcare needs than that without depression syndrome (95% CI = 1.13-1.88). The group with visual impairment was 1.48 times more likely to have unmet healthcare needs than that without it (95% CI = 1.22-1.79). The group with hearing impairment was 1.40 times more likely to have unmet healthcare needs than that without it (95% CI = 1.15-1.72). The group with memory impairment was 1.74 times more likely to have unmet healthcare needs than that without it (95% CI = 1.28-2.36).

CONCLUSIONS

The unmet medical needs of the elderly are more diverse than those of younger adults. This is because not only socioeconomic and health-related factors but also aging factors that are important to the health of the elderly are included. All factors were linked organically; therefore, integrated care is needed to improve healthcare among the elderly. To resolve these unmet healthcare needs, it is necessary to reorganize the healthcare system in Korea to include preventive and rehabilitative services that address chronic diseases in an aged society and promote life-long health promotion.

Patients' experience with nonsurgical treatment for lumbar spinal stenosis: a qualitative study

BACKGROUND CONTEXT

Lumbar spinal stenosis (LSS) is a highly prevalent disease in older adults that causes significant limitations in walking and other daily activities. Research into optimal nonsurgical treatment approaches for LSS is lacking.

PURPOSE

The purpose of this qualitative study is to assess the opinions of participants in a randomized clinical trial of nonsurgical LSS treatments regarding the interventions they received, factors contributing to adherence to the interventions, and methods of outcomes assessment.

STUDY DESIGN/SETTING

This study used a qualitative focus group design conducted at an academic research center.

PATIENT SAMPLE

Individuals participating in a randomized clinical trial (RCT) for non-surgical LSS treatment were invited to discuss their study treatments and general experiences with LSS. The three treatment arms in the study were medical care, community-based group exercise, and clinic-based manual therapy and individual exercise.

OUTCOME MEASURES

Following coding of qualitative data, kappa statistic was used to calculate agreement between observers. Themes were identified and agreed upon by both coders.

METHODS

This study was funded by the Patient-Centered Outcomes Research Institute (PCORI). Fifty individuals (28 women, mean age 73±7.7 years) participated in a focus group. Two focus groups based on modified grounded theory were held for participants of each of the three treatment arms, for a total of six focus groups. Discussion topics included perceived effectiveness of the assigned treatment, suggestions for improvement, barriers and facilitators to completing treatment, and opinions of research outcome measures.

RESULTS

Several themes were evident across all treatment groups. First, patients prefer individualized treatment that is tailored to their specific impairments and functional limitations. They also want to learn self-management strategies to rely less upon formal health care providers. Participants consistently stated that exercise improved their pain levels and physical function. However, they noted that these effects are temporary, so commitment to exercising long-term is important. Common barriers to completing the assigned LSS treatment included transportation issues and other comorbid health conditions. All three treatment groups cited perceived treatment benefit as a strong facilitator to continuing treatment. In addition, the ability of the health care provider to relate to the patient and listen to the patient's concerns was a common facilitator. Within the community-based group exercise treatment arm, most individuals continued group exercise after study completion, and social support was often mentioned as a facilitator to continuing treatment. Medical care was most often associated with minimal to no effect of treatment.

CONCLUSIONS

Many individuals with LSS report barriers to accessing non-surgical treatment, but may also be willing to commit to a long-term treatment strategy that includes exercise. Social support from others with LSS and from health care providers with good communication skills may facilitate compliance with treatment recommendations.

Providing no-cost transport to patients in an underserved area: Impact on access to physical therapy

Background: Barriers to accessing outpatient health care services are common and contribute to poor health outcomes. We describe the efforts of a private practice physical therapy (PT) clinic to reduce these barriers by offering a door-to-door van service at no cost to patients. Methods: Clinic records and national census databases were retrospectively reviewed to explore the impact of offering no-cost van rides to patients attending outpatient PT appointments. We used descriptive statistics and linear regression to describe volume of utilization of the van service over a 40-month period. Paired t-tests compared PT clinic attendance rates (percentage of scheduled visits that were attended) before and after implementation of the van service. Results: Use of the van service increased significantly over time, from a mean of 83 riders per month in 2010 to 205 riders per month in 2013 (p < 0.001). Overall clinic attendance rate increased from 80.1% to 84.1% after implementation of the service (p = 0.002). Following introduction of the van service, 48% of patients using the van, compared to 25% of clinic patients overall, were uninsured or insured by Medicaid. Conclusion: Use of the van service increased over time, and availability of no-cost van transportation was associated with increased visit attendance for patients at an outpatient PT clinic.

Access to Care and Satisfaction Among Health Center Patients With Chronic Conditions

This study examined access to care and satisfaction among health center patients with chronic conditions. Data for this study were obtained from the 2009 Health Center Patient Survey. Dependent variables of interest included 5 measures of access to and satisfaction with care, whereas the main independent variable was number of chronic conditions. Results of bivariate analysis and multiple logistic regressions showed that patients with chronic conditions had significantly higher odds of reporting access barriers than those without chronic conditions. Our results suggested that additional efforts and resources are necessary to address the needs of health center patients with chronic conditions.

Subjective perceptions of unmet need for health care in Europe among social groups: Findings from the European social survey (2014) special module on the social determinants of health

Background

Unmet need can be defined as the individually perceived subjective differences between services judged necessary to deal with health problems and the services actually received. This study examines what factors are associated with unmet need, as well as how reasons for unmet need are distributed across socioeconomic and demographic groups in Europe.

Methods

Multilevel logistic regression models were employed using data from the 7th round of the European Social Survey, on people aged 25–75. Self-reported unmet need measured whether respondents had been unable to get medical consultation or treatment in the last 12 months. Reasons for unmet need were grouped into three categories: availability, accessibility and acceptability. Health status was measured by self-reported health, non-communicable diseases and depressive symptoms.

Results

Two-thirds of all unmet need were due waiting lists and appointment availability. Females and young age groups reported more unmet need. We found no educational inequalities, while financial strain was found to be an important factor for all types of unmet need for health care in Europe. All types of health care use and poor health were associated with unmet need. Low physician density and high out-of-pocket payments were found to be associated with unmet need due to availability.

Conclusion

Even though health care coverage is universal in many European welfare states, financial strain appeared as a major determinant for European citizens’ access to health care. This may suggest that higher income groups are able to bypass waiting lists. European welfare states should, therefore, intensify their efforts in reducing barriers for receiving care.

Rural-Urban Differences in Access to Preventive Health Care Among Publicly Insured Minnesotans

PURPOSE

Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota.

METHODS

This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities.

RESULTS

Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees.

CONCLUSIONS

Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence.

Measuring Nutrition-Related Unmet Needs in Recently Hospital-Discharged Homebound Older Adults

Functional limitations in homebound older adults may cause difficulties with obtaining and preparing adequate healthy food. Services exist to help with these difficulties, however, not all individuals who could benefit receive them. This secondary analysis of observational data, obtained via questionnaires from homebound, recently hospital discharged older adults (n = 566), aimed to identify the prevalence and correlates of unmet need for such services, and to examine the disagreement between self-reported need for a service and functional limitation that could be addressed by that service. One-fifth of respondents reported unmet need for vision services and oral health services, and one-tenth reported unmet need for transportation services and physical therapy. There was a significant association between reported need and functional limitation (p < 0.001) for all services, except mental health and grocery delivery. However, for each service there were participants who under-reported need, compared with functional ability indicators. More research is required to determine the best methods for measuring these needs to ensure that nutritional vulnerability is detected and addressed in those returning from hospital.

Microinterventions produce immediate but not lasting benefits in mood and distress

Untreated depression remains one of the largest public health concerns. However, barriers such as unavailability of mental health providers and high cost of services limit the number of people able to benefit from traditional treatments. Though unsupported Internet interventions have proven effective at bypassing many of these barriers given their reach and scalability, attrition from interventions has been an ongoing concern. Microinterventions, or ultra-brief online tools meant to produce a rapid improvement in mood, may offer a way to provide the benefits of unsupported Internet interventions quickly, before attrition might occur. This study examined the immediate and lasting effects of three microinterventions (Breathing Exercises, Thought Records, and a Pleasant Activities Selector) on mood and distress. Participants (N=122) were randomized into three groups, each group completing two of the three microinterventions. Participants were asked to rate their mood and level of distress before and after completing the microintervention. Depression and perceived stress were assessed at baseline and at four weekly follow-ups. Although lasting effects were not found, a significant within-group reduction in distress and improvement in mood were observed immediately following the completion of the microintervention. This study demonstrates the potential benefits of microinterventions to individuals for their immediate needs vis-à-vis mood and distress.

Regional Disparity and Factors Influencing Unmet Medical Needs: A Study Based on the Sixth Korea National Health and Nutrition Examination Survey (2015)

Objectives

This study aimed to determine regional differences and the factors that affect unmet medical needs.

Methods

Data from the 6th Korea National Health and Nutrition Examination Survey (2015) were used, and 4,946 health survey participants who provided responses on medical utilization and health behavior were included in the study.

Results

A statistically significant difference was observed in the incidence rate of unmet medical needs in terms of region. The independent variables that affected unmet medical needs were sex, age, education, region, household income, insurance type, smoking status, self-reported health status, and stress awareness. Gender (female), lower education level, rural residents, lowest household income, poor self-reported health status, and stress awareness increased the probability of unmet medical needs.

Conclusion

Our findings suggested that different policies and approaches should be considered for each population that is at risk to address the primary cause of the unmet medical needs. Further studies that include medical expenses and the relevant variables of an area should be conducted in the future.

Comparing Health Care Financial Burden With an Alternative Measure of Unaffordability

Health insurance plans with high deductibles increase exposure to health care costs, raising concerns about how the growth in these plans may be impacting both the financial burden of health care expenditures on families and their access to health care. We find that foregoing medical care is common among low-income, privately insured families, occurring at a greater rate than those with higher incomes or Medicare coverage. To better understand the relationship between out-of-pocket (OOP) spending and access, we used the 2011-2014 Medical Expenditure Panel Survey (MEPS) data and a logistic model to analyze the likelihood of avoiding or delaying needed medical care based on health insurance design and other individual and family characteristics. We find that avoiding or delaying medical care is strongly correlated with coverage under a high-deductible health plan, and with depression, poor perceived health, or poverty. However, it is relatively independent of the percent of income spent on OOP costs, making the percent of income spent on OOP costs by itself a poor measure of health care unaffordability. Individuals who spend a small percentage of their income on health care costs may still be extremely burdened by their health plan when financial concerns prevent access to health care. This work emphasizes the importance of insurance design as a predictor of access and the need to expand the definition of financial barriers to care beyond expenditures, particularly for the low-income, privately insured population.

Out-of-Pocket Payments and Subjective Unmet Need of Healthcare

We present a critical review of the literature that discusses the link between the level of out-of-pocket payments in developed countries and the share of people in these countries reporting that they postpone or forgo healthcare for financial reasons. We discuss the pros and cons of measuring access problems with this subjective variable. Whereas the quantitative findings in terms of numbers of people postponing care must be interpreted with utmost caution, the picture for the vulnerable groups in society is reasonably robust and unsurprising: people with low incomes and high morbidity and incomplete (or non-existent) insurance coverage are most likely to postpone or forgo healthcare for financial reasons. It is more surprising that people with high incomes and generous insurance coverage also report that they postpone care. We focus on some policy-relevant issues that call for further research: the subtle interactions between financial and non-financial factors, the possibility of differentiation of out-of-pocket payments between patients and between healthcare services, and the normative debate around accessibility and affordability.

Transportation Barriers and Use of Dental Services among Medicaid-Insured Adults

This study explores how travel distance and other transportation barriers are associated with dental utilization in a Medicaid expansion population. We analyzed data from the Iowa Dental Wellness Plan (DWP), which provides comprehensive dental benefits for low-income adults aged 19 to 64 y as part of Iowa’s Medicaid expansion. Transportation and geographical characteristics were evaluated as enabling factors within the framework of Andersen’s behavioral model of health services use. In March 2015, a random sample of DWP members ( n = 4,800) was surveyed; adjusted survey response rate was 30% ( n = 1,258).The questionnaire was based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Dental Plan Survey and assessed need for dental care, use of dental services and transportation to visits, and self-perceived oral health status. Respondent and dentist addresses were geocoded and used to calculate distance to the nearest DWP general dentist. A logistic regression model predicting utilization of dental care was developed using variables representing each domain of the behavioral model. Most respondents (57%) reported a dental visit since enrolling. Overall, 11% of respondents reported unmet dental need due to transportation problems. Median distance to the nearest general dentist was 1.5 miles. In the adjusted model, travel distance was not significantly associated with the likelihood of dental utilization. However, other transportation-related issues were significantly associated with utilization, including concern about cost of transportation and driver/passenger status. As concern about transportation cost increased, likelihood of having a dental visit decreased. Targeted approaches to assisting low-income populations with transportation barriers should be considered in designing policies and interventions to improve access to dental care.

Knowledge Transfer Statement: The results of this study can be used by policy makers and public health planners when designing programs and interventions to improve access to dental care. Consideration of transportation availability and costs could improve utilization of routine dental care, especially among low-income populations.

Barriers to Care and Health Care Utilization Among the Publicly Insured

BACKGROUND

Although the Affordable Care Act has been successful in expanding Medicaid to >17 million people, insurance alone may not translate into access to health care. Even among the insured, substantial barriers to accessing services inhibit health care utilization.

OBJECTIVES

We examined the effect of selected barriers to health care access and the magnitude of those barriers on health care utilization.

RESEARCH DESIGN

Data come from a 2008 survey of adult enrollees in Minnesota's public health care programs. We used multivariate logistic regression to estimate the effects of perceived patient, provider, and system-level barriers on past year delayed, foregone, and lack of preventive care.

SUBJECTS

A total of 2194 adults enrolled in Minnesota Health Care Programs who were mostly female (66%), high school graduates (76%), unemployed (62%), and living in metro areas (67%) were included in the analysis.

RESULTS

Reporting problems across all barriers increased the odds of delayed care from 2 times for provider-related barriers (OR=2.0; 95% CI, 1.2-3.3) to >6 times for access barriers (OR=6.2; 95% CI, 3.8-10.2) and foregone care from 2.6 times for family/work barriers (OR=2.6; 95% CI, 1.3-5.1) to >7 times for access barriers (OR=7.1; 95% CI, 3.9-13.1). Perceived discrimination was the only barrier consistently associated with all 3 utilization outcomes.

CONCLUSIONS

Multiple types of barriers are associated with delayed and foregone care. System-level barriers and discrimination have the greatest effect on health care seeking behavior.

An examination of perceived health care availability and unmet health care need in the City of Toronto, Ontario, Canada

OBJECTIVES

Although timely access to health care is a top priority, a burgeoning body of research highlights the important role of neighbourhood environments on unmet health care needs. This study aimed to examine an association between perceptions of neighbourhood availability of health care services and experience of unmet health care needs by gender in an urban city setting.

METHODS

A total of 2338 participants from the Neighbourhood Effects on Health and Well-being (NEHW) study, between 25 and 64 years of age and dwelling in the City of Toronto, Ontario, Canada, were included in the analyses. Four different logistic regression models stratified by gender were used to examine the relationship between neighbourhood health care availability and unmet health care need as well as the impact of neighbourhood perception of health care availability on the three different types of unmet needs.

RESULTS

Perceived health care availability was associated with higher likelihood of experiencing unmet health care needs in both women and men (women = OR: 1.58, 95% CI: 1.09-2.28; men = OR: 1.92, 95% CI: 1.23-2.99). In addition, perceived health care availability was associated with barrier- and wait times-related unmet health care need among women (OR: 1.83, 95% CI: 1.13-2.97; OR: 1.93, 95% CI: 1.10-3.40 respectively), and personal choice- and wait times-related unmet need among men (OR: 1.99, 95% CI: 1.10-3.58).

CONCLUSION

Individuals' perception of health care availability plays a crucial role in the experience of unmet health care needs, suggesting the importance of community-based policy development for improving physical conditions and the social aspect of health care services.

Postponing a General Practitioner Visit: Describing Social Differences in Thirty-One European Countries

OBJECTIVE

To describe social differences in postponing a general practitioner visit in 31 European countries and to explore whether primary care strength is associated with postponement rates.

DATA SOURCES

Between October 2011 and December 2013, the multicountry QUALICOPC study collected data on 61,931 patients and 7,183 general practitioners throughout Europe.

STUDY DESIGN

Access to primary care was measured by asking the patients whether they postponed a general practitioner visit in the past year. Social differences were described according to patients' self-rated household income, education, ethnicity, and gender.

DATA COLLECTION/EXTRACTION METHODS

Data were analyzed using multivariable and multilevel binomial logistic regression analyses.

PRINCIPAL FINDINGS

According to the variance-decomposition in the multilevel analysis, most of the variance can be explained by patient characteristics. Postponement of general practitioner care is higher for patients with a low self-rated household income, a low education level, and a migration background. In addition, although the point estimates are consistent with a substantial effect, no statistically significant association between primary care strength and postponement in the 31 countries is determined.

CONCLUSIONS

Despite the universal and egalitarian goals of health care systems, access to general practitioner care in Europe is still determined by patients' socioeconomic status (self-rated household income and education) and migration background.