The role of usual source of care in cholesterol treatment

Comparison of Health Care Utilization in Different Usual Sources of Care Among Older People With Cardiovascular Disease in China: Evidence From the Study on Global Ageing and Adult Health

Objectives: To compare the health care utilization in different usual sources of care (USCs) among the elderly population with cardiovascular disease in China. Methods: Cross-sectional data for 3,340 participants aged ≥50 years with cardiovascular disease from Global AGEing and Adult Health (2010)-China were used. Using the inverse probability of treatment weighting on the propensity score with survey weighting, combined with negative binomial regression and logistic regression models, the correlation between USCs and health care utilization was assessed. Results: Patients using primary care facilities as their USC had fewer hospital admissions (IRR = 0.507, 95% CI = 0.413, 0.623) but more unmet health needs (OR = 1.657, 95% CI = 1.108, 2.478) than those using public hospitals. Patients using public clinics as their USC had higher outpatient visits (IRR = 2.188, 95% CI = 1.630, 2.939) than the private clinics' group. Conclusion: The difference in inpatient care utilization and unmet health care needs between public hospitals and primary care facilities, and the difference in outpatient care utilization between public and private clinics were significant. Using primary care facilities as USCs, particularly public ones, appeared to increase care accessibility, but it still should be strengthened to better address patients' health care needs.

The Association Between Self-Reported Hearing Loss and Loss of Usual Source of Health Care Among Older Medicare Beneficiaries: Evidence From the National Health and Aging Trends Study

Background and Objectives

The purpose of the study is to investigate the association of hearing loss (HL) with maintaining a usual source of care (USOC).

Research Design and Methods

In this study we implemented a time-to-event analysis using data from the National Health and Aging Trends Study (NHATS), a nationally representative study of older Medicare beneficiaries in the United States. The study sample included 2 114 older adults, aged 65+ years, 58.9% female, 20.4% Black, who reported having a USOC during the baseline round of NHATS and who remained community-dwelling during the 2011-2018 study period. Based on self-report measures at baseline, individuals' hearing status was classified into 3 categories: no HL, treated HL (hearing aids users), and untreated HL (nonhearing aid users who reported having hearing difficulties). Time-to-event was computed as the time elapsed between baseline and the study round in which the respondent first reported no longer having a USOC. Discrete-time proportional hazard models were estimated.

Results

In fully adjusted models, untreated HL at baseline was associated with a hazard ratio (HR) for losing one's USOC 1.60 (95% confidence interval: 1.01, 2.56) times higher than that of participants with no HL. We found no HR differences between the treated- and no-HL group.

Discussion and Implications

Untreated HL at baseline was associated with a higher probability of losing one's USOC over time. Noninvasive interventions such as hearing aids may be beneficial for maintaining a USOC.

Determinants of choice of usual source of care among older people with cardiovascular diseases in China: evidence from the Study on Global Ageing and Adult Health

BACKGROUND

Cardiovascular diseases (CVD) are emerging as the leading contributor to death globally. The usual source of care (USC) has been proven to generate significant benefits for the elderly with CVD. Understanding the choice of USC would generate important knowledge to guide the ongoing primary care-based integrated health system building in China. This study aimed to analyze the individual-level determinants of USC choices among the Chinese elderly with CVD and to generate two exemplary patient profiles: one who is most likely to choose a public hospital as the USC, the other one who is most likely to choose a public primary care facility as the USC.

METHODS

This study was a secondary analysis using data from the World Health Organization's Study on Global AGEing and Adult Health (SAGE) Wave 1 in China. 3,309 individuals aged 50 years old and over living with CVD were included in our final analysis. Multivariable logistic regression was built to analyze the determinants of USC choice. Nomogram was used to predict the probability of patients' choice of USC.

RESULTS

Most of the elderly suffering from CVD had a preference for public hospitals as their USC compared with primary care facilities. The elderly with CVD aged 50 years old, being illiterate, residing in rural areas, within the poorest income quintile, having functional deficiencies in instrumental activities of daily living and suffering one chronic condition were found to be more likely to choose primary care facilities as their USC with the probability of 0.85. Among those choosing primary care facilities as their USC, older CVD patients with the following characteristics had the highest probability of choosing public primary care facilities as their USC, with the probability of 0.77: aged 95 years old, being married, residing in urban areas, being in the richest income quintile, being insured, having a high school or above level of education, and being able to manage activities living.

CONCLUSIONS

Whilst public primary care facilities are the optimal USC for the elderly with CVD in China, most of them preferred to receive health care in public hospitals. This study suggests that the choice of USC for the elderly living with CVD was determined by different individual characteristics. It provides evidence regarding the choice of USC among older Chinese patients living with CVD.

Association between Having a Regular Health Provider and Access to Services Linked to Electronic Health Records

OBJECTIVE

A regular care provider is an important measure of access to health services, but little is known about the association between having a regular provider and patients' access to services associated with electronic health records (EHR). Furthermore, the composition of the additional electronic services made available to patients is not well studied.

METHODS

We analyzed the most recent data from the Health Information National Trends Survey (HINTS5-Cycle1, 2017, n = 3,285). We estimated a weighted multivariable logistic regression model to assess the association between having a regular provider (65.3%) and access to EHR (29%). Control variables were selected based on Andersen's Behavioral Model.

RESULTS

In the adjusted model, participants with a regular provider had significantly greater access to an EHR (aOR 2.91, p < .001) compared to participants without a regular provider. Participants were more likely to have access to an EHR if they were females (aOR 1.56, p < .01), had a tablet computer (aOR 1.55, p < .05), smartphone (aOR 2.27, p < .01), a former smoker (aOR 1.67, p < .05) or had two or more chronic medical conditions (aOR 1.79, p < .01).

DISCUSSION

Individuals who have a regular provider are roughly three times as likely to have access to services linked to an EHR. Access to an EHR enhances both potential and realized access to many healthcare services.

CONCLUSION

The availability of a regular care provider impacts the "digital divide." The expansion of electronic health services intensifies the importance of a regular care provider.

Disparities in Statin Use in New York City: Implications for Health Reform

Heart disease is the leading cause of death in the USA, and there is an extensive literature describing disparities in the treatment of the disease. Cholesterol-lowering medications are an effective strategy for reducing the risk of cardiovascular diseases for many patients, but some who are prescribed these medications fail to take them. We examine data from the 2014 New York City Community Health Survey to investigate the factors that influence why patients are not compliant in following the prescribed regimen. We focus on adults age 45 and older who report that they are diagnosed with elevated cholesterol levels and were told by a health professional they needed to take cholesterol-lowering medication. We find that evident disparities: individuals with low incomes, those who rely on emergency departments for their healthcare, have not received medical care within the past year, are depressed, and identify as black non-Hispanic and Hispanic are less likely to adhere to a cholesterol-lowering medication program. Although Medicare beneficiaries are less likely to take cholesterol-lowering medication than those with private insurance, those who were on Medicaid or were uninsured did not report lower rates of adherence.

Factors Associated With Loss of Usual Source of Care Among Older Adults

PURPOSE

Access to a usual source of care (USC) is associated with better preventive health and chronic disease treatment. Although most older adults have a USC, loss of USC, and factors associated with loss of USC, have not previously been examined.

METHODS

We followed 7,609 participants of the National Health and Aging Trends Study annually for up to 6 years (2011-2016). Discrete time-to-event techniques and pooled logistic regression were used to identify demographic, clinical, and social factors associated with loss of USC.

RESULTS

Ninety-five percent of older adults reported having a USC in 2011, of whom 5% subsequently did not. Odds of losing a USC were higher among older adults with unmet transportation needs (adjusted odds ratio [aOR] 1.67), who moved to a new residence (aOR 2.08), and who reported depressive symptoms (aOR 1.40). Odds of losing a USC were lower for those who had ≥4 chronic conditions (vs 0-1; aOR 0.42) and with supplemental (aOR 0.52) or Medicaid (aOR 0.67) insurance coverage.

CONCLUSIONS

We identified factors associated with older adults' loss of a USC. Potentially modifiable factors, such as access to transportation and supplemental insurance, deserve further investigation to potentially assist older adults with continuous access to care.

Cholesterol Control Among Uninsured Adults Did Not Improve From 2001-2004 to 2009-2012 as Disparities With Both Publicly and Privately Insured Adults Doubled

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) control is higher among insured than uninsured adults, but data on time trends and contributing factors are incomplete and important for improving health equity.

METHODS AND RESULTS

Awareness, treatment, and control of elevated LDL-C were compared among insured versus uninsured and publicly versus privately insured adults, aged 21 to 64 years, in National Health and Nutrition Examination Surveys from 2001 to 2004, 2005 to 2008, and 2009 to 2012 using Adult Treatment Panel-3 criteria. Compared with insured adults, uninsured adults were younger; were more often minority; reported lower incomes, less education, and fewer healthcare encounters; and had lower awareness and treatment of elevated LDL-C (P<0.0001). LDL-C control was higher among insured than uninsured adults in 2001 to 2004 (mean±SEM, 21.4±1.6% versus 10.5±2.6%; P<0.01), and the gap widened by 2009 to 2012 (35.1±1.9% versus 11.3±2.2%; P<0.0001). Despite more minorities (P<0.01), greater poverty, and less education (P<0.001), publicly insured adults had more healthcare visits/year than privately insured adults (P<0.001) and similar awareness, treatment, and control of LDL-C from 2001 to 2012. In multivariable logistic regression, significant positive predictors of cholesterol awareness, treatment, and control included more frequent health care (strongest), increasing age, private healthcare insurance versus uninsured, and hypertension. Public insurance (versus uninsured) was a significant positive predictor of LDL-C control, whereas income <200% versus ≥200% of federal poverty was a significant negative predictor.

CONCLUSIONS

LDL-C control improved similarly over time in publicly and privately insured adults but was stagnant among the uninsured. Healthcare insurance largely addresses socioeconomic barriers to effective LDL-C management, yet poverty retains an independent adverse effect.

High Cholesterol Awareness, Treatment, and Control Among Hispanic/Latinos: Results From the Hispanic Community Health Study/Study of Latinos

BACKGROUND

We assessed high cholesterol (HC) awareness, treatment, and control rates among US Hispanic/Latino adults and describe factors associated with HC awareness and management.

METHODS AND RESULTS

Baseline data (collected 2008-2011) from a multisite probability sample of Hispanic/Latino adults in the Hispanic Community Health Study/Study of Latinos (18 to 74 years old; N=16 207) were analyzed. HC was defined as low-density lipoprotein-cholesterol ≥130 mg/dL and/or total cholesterol ≥240 mg/dL or use of cholesterol-lowering medication. Among Hispanic/Latino adults with HC, almost half (49.3%) were not aware of their condition and only 29.5% were receiving treatment. Men had a higher HC prevalence than women (44.0% versus 40.5%) but a lower rate of treatment (28.1% versus 30.6%). Younger adults were significantly less likely to be HC aware compared to those who were older. Those with hypertension, diabetes, and high socioeconomic position were more likely to be HC aware. US-born Hispanic/Latino were more likely to be HC unaware than foreign-born Hispanics/Latinos, but longer US residency was significantly associated with being HC aware, treated, and controlled. Cholesterol control was achieved among 64.3% of those who were HC treated. However, younger adults, women, those with lower income, those uninsured, and more recent immigrants were less likely to be HC controlled. Individuals of Puerto Rican or Dominican background were most likely to be HC aware and treated, whereas those of Mexican or Central American background were least likely to be HC treated. Individuals of Cuban and South American background had the lowest rates of HC control, whereas Puerto Ricans had the highest.

CONCLUSIONS

Understanding gaps in HC awareness, treatment, and control among US Hispanic/Latino adults can help inform physicians and policymakers to improve disease management and patient education programs.

The Relation Between Having a Usual Source of Care and Ratings of Care Quality: Does Patient-Centered Communication Play a Role?

Having a usual source of health care has been consistently associated with greater use of preventive services, decreased use of emergency services, and with patients' ratings of quality and satisfaction with care. Ongoing patient-provider relationships may be, in part, fostered by patient-centered communication. Growing evidence demonstrates that positive patient-centered communication improves adherence to treatment recommendations, management of chronic disease, quality of life, and disease-related outcomes. We aimed to determine how patient-centered communication between patients and physicians might mediate the relation between having a source of usual care and ratings of health care quality. We analyzed data from Cycle 1 of the fourth iteration of the Health Information National Trends Survey. Data were collected through mailed questionnaire in October 2011 through February 2012 (N = 3,959). Overall, individuals with a usual source of care reported more patient-centered communication experiences and had higher ratings of quality of care. Parameter estimates for each pathway in the mediation model were estimated through regression analysis. Results confirm the importance of patient-centered communication in shaping patients' perceptions of the quality of their care, accounting for a significant portion of the observed relation between having a usual source of care and ratings of quality.

Effects of having usual source of care on preventive services and chronic disease control: a systematic review

Background

Having usual source of care has been associated with improved receipt of preventive services and control of chronic diseases (such as hypertension, diabetes, and hypercholesterolemia). The objective of this study was to examine whether having usual source of care is associated with improved receipt of preventive services and control of chronic diseases.

Methods

We searched MEDLINE, EMBASE, Cochrane, CINAHL, KMbase, KoreaMed, RiSS4U, National Assembly Library, and KISS for studies released through May 31st 2011. Two authors independently extracted the data. We manually searched the references and twenty recent related articles on PubMed. To assess the risk of bias RoBANS tool was used.

Results

We identified 10 studies. Most having usual source of care were associated with improved receipt of preventive services (cervical cancer screening, clinical breast exam, mammogram, prostate cancer screening, and flu shot) compared with no usual source of care. However, gastric cancer and colon cancer screening were difficult to conclude and blood pressure checkup showed mixed results. Overall there was no association between having usual source of care and smoking behaviors and the effect on chronic disease control was difficult to conclude.

Conclusion

Having usual source of care was associated with improved receipt of preventive services and overall the results were consistent. So, the results suggested that having usual source of care may help to receive preventive services. Hereafter, cohort studies are needed to evaluate casual relationships and more studies are needed in various countries and systems.

Usual source of care for adults with and without back pain: medical expenditures panel survey data pooled for years 2000 to 2006

OBJECTIVES

The purpose of this study was to explore the extent to which individuals with back pain or other health conditions and individuals with no health problems report having a usual source of care (USC) for their health care needs.

METHODS

This study evaluated longitudinal Medical Expenditures Panel Survey data (data pooled for survey calendar years 2000-2006). Comparisons were made between adult Medical Expenditures Panel Survey respondents identified as having a back pain condition (n = 10 194) compared with those without back pain but with other health condition (n = 45 541) and those with no back pain and no other condition (n = 5497).

RESULTS

Compared with individuals with no health problems, those with back pain were almost 8 times more likely (odds ratio, 7.8; P < .001) to report having a USC, and those with other health problems besides back pain were 5 times more likely (odds ratio, 5.4; P < .001). For those with a USC, individuals with back pain and those with other problems but not back pain were both approximately one-and-a-half times more likely than those without any health problems to report a specific provider type as their USC (P < .001).

CONCLUSION

Study findings suggest that relatively healthy adults without back pain are less likely to have a USC than those with back pain or other health problems.

Do changes in traditional coronary heart disease risk factors over time explain the association between socio-economic status and coronary heart disease?

Background

Socioeconomic status (SES) predicts coronary heart disease independently of the traditional risk factors included in the Framingham risk score. However, it is unknown whether changes in Framingham risk score variables over time explain the association between SES and coronary heart disease. We examined this question given its relevance to risk assessment in clinical decision making.

Methods

The Atherosclerosis Risk in Communities study data (initiated in 1987 with 10-years follow-up of 15,495 adults aged 45-64 years in four Southern and Mid-Western communities) were used. SES was assessed at baseline, dichotomized as low SES (defined as low education and/or low income) or not. The time dependent variables - smoking, total and high density lipoprotein cholesterol, systolic blood pressure and use of blood pressure lowering medication - were assessed every three years. Ten-year incidence of coronary heart disease was based on EKG and cardiac enzyme criteria, or adjudicated death certificate data. Cox survival analyses examined the contribution of SES to heart disease risk independent of baseline Framingham risk score, without and with further adjustment for the time dependent variables.

Results

Adjusting for baseline Framingham risk score, low SES was associated with an increased coronary heart disease risk (hazard ratio [HR] = 1.53; 95% Confidence Interval [CI], 1.27 to1.85). After further adjustment for the time dependent variables, the SES effect remained significant (HR = 1.44; 95% CI, 1.19 to1.74).

Conclusion

Using Framingham Risk Score alone under estimated the coronary heart disease risk in low SES persons. This bias was not eliminated by subsequent changes in Framingham risk score variables.

Including socioeconomic status in coronary heart disease risk estimation

PURPOSE

Socioeconomic status (SES) predicts coronary heart disease independently of the Framingham risk-scoring factors included in cholesterol treatment guidelines, possibly resulting in undertreatment of lower SES persons. We examined whether hybrid SES measures (based on area measures of income and individual education) address this bias and derived an approach to incorporating SES information into treatment guidelines.

METHODS

The Atherosclerosis Risk in Communities study data (initiated in 1987 with a 10-year follow-up of 15,495 adults aged 45 to 64 years in 4 southern and midwestern communities) were used to assess the calibration bias of 4 Cox models predicting 10-year coronary heart disease risk: Framingham risk score alone, and Framingham risk score plus SES using an individual-based measure (income less than 150% federal poverty level or less then 12 years of schooling), and 2 hybrid SES measures substituting area-based income measures (block group or zip code median incomes of less than 25th national percentiles) for the individual income component. Revised cholesterol treatment thresholds based on SES risk were also derived.

RESULTS

Use of either the block group hybrid or individual-based SES measures eliminated the significant SES bias observed using Framingham risk score alone. Cholesterol treatment guideline thresholds of 10% and 20% coronary heart disease risk (based on the Framingham risk score) were reduced to 6% and 13% for those with low SES.

CONCLUSIONS

Using patient income based on block group and individual education minimizes the SES bias in Framingham risk scoring and suggests more aggressive cholesterol treatment thresholds for low-SES persons.

Beyond insurance coverage: usual source of care in the treatment of hypertension and hypercholesterolemia. Data from the 2003-2006 National Health and Nutrition Examination Survey

BACKGROUND

Expanding insurance coverage, while necessary, may not be sufficient to ensure high-quality care for adults with cardiovascular disease. We sought to examine the association between having a usual source of care (USOC) and receiving medication treatment of hypertension and hypercholesterolemia.

METHODS

Using the 2003-2006 National Health and Nutrition Examination Survey, we categorized USOC (a place to go when sick or need medical advice) and insurance status in adults >or=35 years old with an indication for medication treatment of hypertension (n = 3,142) and hypercholesterolemia (n = 1,134), determined using the Joint National Committee 7 and Adult Treatment Panel III recommendations, respectively. Multivariable logistic regression modeling was used to determine the independent effect of USOC on receiving treatment of hypertension and hypercholesterolemia, controlling for age, sex, race/ethnicity, insurance status, and comorbidities. Separate multivariable models were examined stratified by insurance status.

RESULTS

Among subjects with an indication for treatment of hypertension and hypercholesterolemia, 32.4% and 42.0% were untreated, respectively. When compared with adults with a USOC, adults without a USOC were more likely to be untreated for hypertension (adjusted prevalence ratio [aPR] 2.43, 95% CI 1.88-2.85) and hypercholesterolemia (aPR 1.79, 95% CI 1.31-2.13). In stratified analyses among subjects with insurance, no USOC remained associated with being untreated (hypertension, aPR 2.58, 95% CI 1.88-3.08; hypercholesterolemia, aPR 1.65, 95% CI 0.97-2.18).

CONCLUSIONS

Absence of a USOC was associated with being untreated for hypertension and hypercholesterolemia, even among individuals with insurance, suggesting that efforts to improve chronic disease management should also facilitate access to a regular source of care.