Social determinants and access to health services in patients with COVID-19: a cross-sectional study

OBJECTIVE

To verify the association between social determinants of health and access to health services for COVID-19 patients.

METHOD

Analytical, cross-sectional study, carried out in three states in the Northeast of Brazil (Ceará, Maranhão and Pernambuco), with 968 patients, using questionnaires with sociodemographic data, determinants and the Primary Care Assessment Tool, adapted to the reality of COVID-19, with 58 items, classified as high (score ≥ 6.6) and low (score < 6.6), whose high value reveals better standards of access to health services. The Chi-square test was used for comparative analysis.

RESULTS

There was a significant difference (p < 0.05) between the domains of the instrument and the following determinants: age, skin color, body mass index, origin, schooling, employment, services close to home, first service, income and means of transport.

CONCLUSION

Access to health services for people with COVID-19 was associated with various determinants, including individual, behavioural and social ones, correlated with the structural and organizational aspects of the health services offered by the three states of Northeastern Brazil.

A New Statistical Method to Detect Disease Outbreaks from Hospital Emergency Department Data

Early detection and prediction of disease outbreaks are crucial for public health service delivery, containment response, saving patient lives, and reducing costs. We propose a new data-driven statistical methodology for outbreak detection and prediction based on routinely collected hospital Emergency Department data. The time between consecutive ED presentations matching a diagnosis of interest forms the basis of a novel index measure to signal that an outbreak has occurred. We validate the method using historical presentations of influenza-like illness made to a large sample of public hospital EDs in 2020 and compare outbreaks identified by the method with the start of the first wave of COVID-19. The method shows promise within the field of disease outbreak detection.

Using Andersen's behavioural model to examine individual and contextual factors associated with dental service utilization in Brazil

OBJECTIVES

The study aimed to examine individual and contextual factors associated with the frequency of dental service utilization among adolescents, adults and older adults Brazilians.

METHODS

This cross-sectional study used secondary data from the Brazilian 2019 National Health Survey (94 114 individuals). The outcome 'when was your last dental appointment?' was categorized into three groups: up to 1 year, more than 1 year and never had a dental appointment. Andersen's behavioural model was used to select contextual and individual variables. Multinomial logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence intervals (95% CI).

RESULTS

The following variables showed increased probability to the outcome had the last dental appointment more than 1 year ago: older adult, illiterate or incomplete primary school, and without private dental insurance. The outcome never had a dental appointment was significantly associated with illiterate (OR 26.65; 95% CI 17.63-40.29), male (OR 2.38; 95% CI 2.17-2.61), without private dental insurance (OR 5.20; 95% CI 3.48-7.76), self-rated oral health as bad or very bad (OR 2.67; 95% CI 2.31-3.09), household not enrolled in primary care teams (OR 1.29; 95% CI 1.11-1.49), household in a rural area (OR 1.86; 95% CI 1.69-2.05), high household crowding (OR 1.08; 95% CI 1.04-1.14) and low household income per capita (OR 0.99; 95% CI 0.99-0.99).

CONCLUSIONS

This study showed that contextual and individual factors induce inequity in dental appointments. Moreover, Andersen's behavioural model demonstrated inequitable access for dental services in Brazil, in which social structure and enabling characteristics, rather than the need for the service, determine who receives health care. Living in a household enrolled in primary care teams favoured regular dental appointments. Thus, these findings may help policymakers improve health access by expanding coverage of dental services in primary health care.

Dental care utilization among persons with Parkinson's disease in Denmark

OBJECTIVES

Persons with Parkinson's disease (PD) have a higher prevalence of oral diseases and orofacial dysfunction, but knowledge about the use of dental care and whether their dental care needs are met is sparse. This study aimed to investigate the dental attendance and usage of dental care services of the total PD population in Denmark and compare it with a control group.

METHODS

National registers were used to identify the total PD population in Denmark (n = 6874) and to obtain data on their dental care from 2015 to 2019. These data were compared with a five-fold age-, gender- and geographically matched control group without PD (n = 34 285). Register data on age, gender, civil status, educational level, income, nursing homes status and mortality were also collected and adjusted for in the analyses. The dental attendance was analysed using χ² -test with Bonferroni correction, and the type of dental care services was analysed using negative binomial regression analysis.

RESULTS

A significantly higher proportion of persons with PD were irregular attenders of the dental care system (21.0%), compared with the control group (16.9%). Persons with PD had a significantly higher overall usage of dental cares services. Most prominent was the high usage of treatment services, where persons with PD had a 1.50 times higher incidence rate of tooth extractions and a 1.71 times higher incidence rate of tooth fillings in the five years compared with the control group.

CONCLUSION

Persons with PD are more often irregular users of dental care and receive more treatment services than the control group. This indicates a need for high-quality prophylactic initiatives to prevent high filling and tooth extraction rates. Furthermore, this knowledge can be used by clinicians and decision makers to ensure optimal dental care for persons with PD.

Health Care Use among Medicare Beneficiaries with HIV and Depression during the COVID-19 Pandemic-United States, 2020

Access and use of health care services are essential to health and well-being for people with HIV and HIV-related comorbidities. Health care use during the COVID-19 pandemic among Medicare beneficiaries (MBs) with concurrent HIV and depression has not been investigated. We used 2020 Medicare data to assess the percentage of MBs with claims for HIV and depression who also received hospitalization, outpatient diagnostic services, drug treatment, and outpatient procedures. We assessed person-level association between service receipt and HIV and depression, adjusting for known risk factors. MBs with claims for HIV and depression were more likely than those with neither claim to have claims for short-stay hospitalization, long-stay hospitalization, outpatient diagnostic services, prescription drugs, or outpatient procedures, supplies, and products. Non-White beneficiaries were more likely than White beneficiaries to be hospitalized but were less likely to receive drug treatment, outpatient diagnostic services, or outpatient procedures, supplies, and products during the pandemic. Significant disparities in health care use by race/ethnicity existed among MBs. Policymakers and practitioners can use these findings to implement public health policies and programs that reduce disparities in health care access and optimize use among vulnerable populations during a public health emergency.

Dental Utilization in a Pediatric Emergency Department and Urgent Care Centers Before, During, and After Shutdown of a Pediatric Dental Clinic During the COVID-19 Pandemic, 2019-2021

OBJECTIVES

Limited data are available on how the closure of pediatric dental clinics because of the COVID-19 pandemic affected hospital pediatric emergency department (ED) visits in the United States. We evaluated changes in dental-related visits at a pediatric ED and associated urgent care centers (UCCs) after the shutdown of a large pediatric dental clinic because of the COVID-19 pandemic.

METHODS

We conducted a single-center retrospective medical record review of 811 patients aged 0 to 17 years who presented to a pediatric ED or associated UCC at Rady Children's Hospital-San Diego for dental-related concerns from March 19, 2019, through January 17, 2021. Patients were classified into 3 periods: before shutdown, during shutdown, and after shutdown. We collected data on demographic characteristics; International Classification of Diseases, Tenth Revision codes; dental diagnosis; treatment; and COVID-19 test results. We compared the frequency and proportion of patients seen for dental-related concerns, dental diagnosis, and treatment during the 3 periods.

RESULTS

The proportion of dental-related concerns in the ED doubled during the shutdown (0.7%) and was 1.5 times higher after the shutdown (0.6%) compared with before the shutdown (0.4%; P < .001). Significantly more patients were seen in EDs than in UCCs during and after the shutdown than before the shutdown (P = .005). During and after the shutdown, admission to the hospital for antibiotic treatment increased significantly to 6.5% and 7.9%, respectively, compared with before the shutdown (2.8%; P = .022), and nonaerosolized procedures and ED/UCC discharge increased to 13.4% and 9.3%, respectively, compared with before the shutdown (6.2%; P = .015).

CONCLUSIONS

Mitigating future closures of dental offices is important given the shifted burden of dental care to the ED.

Barriers to access intimate partner violence services in female Romanian immigrants in Spain: A Delphi study

Immigrant women may be at higher risk of intimate partner violence (IPV) and may seek specialized services less frequently than other populations. In Spain, Romanian origin foreigners comprise the second-highest proportion among immigrant population. This study aimed to identify, from the perspective of experts, (1) the main barriers faced by immigrant women of Romanian origin in accessing specialized services for IPV in Spain; and (2) the most useful strategies to combat these barriers. A Delphi study was conducted with a panel of 23 experts. The coefficient r_WG was calculated to established agreement among participants. The results showed 58 barriers and 31 strategies with high agreement among the experts (r_WG  ≥ 0.80). Barriers in access to services that were considered to be highly influential included: having been in the host country for a short time; lack of language proficiency; job insecurity; difficulty with family-work reconciliation; and fear of the social consequences for help-seeking. The strategies considered most useful were: facilitating access to the job market and decent housing; promoting a social support network; translating material into Romanian; and increasing training among professionals. The findings offer guidelines for the improvement of the accessibility of specialized services to immigrant women of Romanian origin.

Association of Race and Neighborhood Disadvantage with Patient Engagement in a Home-Based COVID-19 Remote Monitoring Program

BACKGROUND

COVID-positive outpatients may benefit from remote monitoring, but such a program often relies on smartphone apps. This may introduce racial and socio-economic barriers to participation. Offering multiple methods for participation may address these barriers.

OBJECTIVES

(1) To examine associations of race and neighborhood disadvantage with patient retention in a monitoring program offering two participation methods. (2) To measure the association of the program with emergency department visits and hospital admissions.

DESIGN

Retrospective propensity-matched cohort study.

PARTICIPANTS

COVID-positive outpatients at a single university-affiliated healthcare system and propensity-matched controls.

INTERVENTIONS

A home monitoring program providing daily symptom tracking via patient portal app or telephone calls.

MAIN MEASURES

Among program enrollees, retention (until 14 days, symptom resolution, or hospital admission) by race and neighborhood disadvantage, with stratification by program arm. In enrollees versus matched controls, emergency department utilization and hospital admission within 30 days.

KEY RESULTS

There were 7592 enrolled patients and 9710 matched controls. Black enrollees chose the telephone arm more frequently than White enrollees (68% versus 44%, p = 0.009), as did those from more versus less disadvantaged neighborhoods (59% versus 43%, p = 0.02). Retention was similar in Black enrollees and White enrollees (63% versus 62%, p = 0.76) and in more versus less disadvantaged neighborhoods (63% versus 62%, p = 0.44). When stratified by program arm, Black enrollees had lower retention than White enrollees in the app arm (49% versus 55%, p = 0.01), but not in the telephone arm (69% versus 71%, p = 0.12). Compared to controls, enrollees more frequently visited the emergency department (HR 1.71 [95% CI 1.56-1.87]) and were admitted to the hospital (HR 1.16 [95% CI 1.02-1.31]).

CONCLUSIONS

In a COVID-19 remote patient monitoring program, Black enrollees preferentially selected, and had higher retention in, telephone- over app-based monitoring. As a result, overall retention was similar between races. Remote monitoring programs with multiple modes may reduce barriers to participation.

Factors influencing place of death and disenrollment among patients receiving specialist palliative care

BACKGROUND AND AIM OF THE WORK

Place of death and disenrollment from specialized palliative care services (SPCSs) are two aspects that determine service utilization. These aspects should be determined by patient needs and preferences, but they are often associated to patient sociodemographic or contextual characteristics. The aim of this study was to describe which factors are associated with utilizing SPCSs in terms of place of death and disenrollment.

METHODS

Retrospective cohort study. Patients (>18 years) who died or were disenrolled during SPCSs utilization. Two hierarchical regression models were performed, and variables were categorized in predisposing, enabling, and need factors according to the Andersen behavioral model of health services use.

RESULTS

We included 35,869 patients (52,5% male, mean age 74,6 ± 12,3 SD), where 17,225 patients died in hospice and 16,953 at home, while 1,691 patients were disenrolled. Dying at home was associated with older age, oncological diagnosis, painful symptoms and longer survival time. Instead, service disenrollment was associated with less education, longer wait time and longer length of stay.

CONCLUSIONS

SPCS utilization was not influenced only by patient need, but also by other factors, such as social and contextual factors. These factors need to be considered by health care providers and efforts are needed for 1) identifying barriers and implementing effective interventions to support patients and caregivers in their preferred place of care and death and 2) for avoiding SPCS disenrollment with an increased probability of aggressive treatments and worse quality of life for patients.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer's Disease Patients

BACKGROUND

Insomnia is associated with worsened clinical outcomes among Alzheimer's disease dementia (AD) patients, increased caregiver burden, and healthcare utilization.

OBJECTIVE

This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data.

METHODS

A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period.

RESULTS

A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001).

CONCLUSION

AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

Hospitalization Rates Are Highest in the First 5 Years of Systemic Sclerosis: Results From a Population-based Cohort (1980-2016)

OBJECTIVE

Few studies have estimated the healthcare resource usage of patients with systemic sclerosis (SSc). The purpose of this study was to compare hospitalization among incident cases of SSc vs age- and sex-matched comparators.

METHODS

A retrospective, population-based cohort of patients with SSc in Olmsted County, Minnesota, from January 1, 1980, to December 31, 2016, was assembled. A 2:1 cohort of age- and sex-matched patients without SSc from the same population was randomly selected for comparison. All hospitalizations in the geographic area from January 1, 1987, to September 30, 2018, were obtained. Rates of hospitalization, lengths of stay, and readmissions were compared between groups.

RESULTS

There were 76 incident SSc cases and 155 non-SSc comparators (mean age 56 ± 16 yrs at diagnosis/index, 91% female) included. Rates of hospitalization among cases and comparators were 31.9 and 17.9 per 100 person-years, respectively (rate ratio [RR] 1.78, 95% CI 1.52-2.08). Hospitalization rates were higher in patients with SSc than comparators during the first 5 years after SSc diagnosis (RR 2.16, 95% CI 1.70-2.74). This difference decreased over time and was no longer significant at ≥ 15 years after SSc incidence/index. Lengths of stay (median [IQR] 4 [2-6] vs 3 [2-6], P = 0.52) and readmission rates (25% vs 23%, P = 0.51) were similar between groups.

CONCLUSION

Patients with SSc were hospitalized more frequently than comparators, indicating high inpatient care needs in this population. Hospitalization rates were highest during the first 5 years following SSc diagnosis.

Pediatric asthma hospitalization: individual and environmental characteristics of high utilizers in South Texas

OBJECTIVE

Few studies have examined factors affecting the high frequency of hospitalization for pediatric asthma. This study identifies individual and environmental characteristics of children with asthma from a low-income community with a high number of hospitalizations.

METHODS

The study population included 902 children admitted at least once to a children's hospital in South Texas because of asthma from 2010 to 2016. The population was divided into three groups by utilization frequency (high: ≥4 times, medium: 2-3 times, or low: 1 time). Individual-level factors at index admission and environmental factors were included for the analysis. Unadjusted and adjusted multivariate ordered logistic regression models were applied to identify significant characteristics of high hospital utilizers.

RESULTS

The high utilization group comprised 2.4% of total patients and accounted for substantial hospital resource utilization: 10.8% of all admissions and 13.5% of days stayed in the hospital. Patients in the high utilization group showed longer length of stay (LOS) and shorter time between admissions on average than the other two groups. The multivariate ordered logistic regression models revealed that age of 5-11 years (OR = 0.57, 95%CI = 0.35-0.93), longer LOS (2 days: OR = 1.80, 95%CI = 1.15-2.84; ≥3 days: OR = 3.38, 95%CI = 2.10-5.46), warm season at index admission (OR = 1.49, 95%CI = 1.01-2.20), and higher average ozone level in children's residential neighborhoods (OR = 1.78, 95%CI = 1.01-3.14) were significantly associated with a higher number of asthma hospitalizations.

CONCLUSIONS

The findings suggest the importance of monitoring high hospital utilizers and establishing strategies for such patients based on their characteristics to reduce repeated hospitalizations and to increase optimal use of hospital resources.

Trends and Contributing Factors to Contraceptive Use in Kenya: A Large Population-Based Survey 1989 to 2014

Kenya is among the leading nations in family planning in Africa, having the first official nationwide family planning program in sub-Saharan Africa. However, Kenya is still one of the most highly populated countries in Africa with a population of more than 52 million. The objective of this study was to assess the trends and contributing factors of contraceptive use. We conducted a multi-wave cross-sectional study using both the demographic health survey (DHS) and family planning effort index (FPE) datasets, analyzing five-year waves from 1989 to 2014. This study indicates that contraceptive use increased from 24.0% to 42.6%, with a change % of 77.5%. Despite changes in women's characteristics, these characteristics posed little on the time trend of contraceptive use in Kenya. In addition, the policy component of FPE scores had a positive association with contraceptive use with negligible change after adjusting for social and demographic factors 1.055 (1.046-1.065). There was a fluctuating trend of the additional FPE components throughout the years. Women with lower education, those married to husbands with lower education, unmarried, and rural women remain behind in family planning service utilization. Targeted programs are still needed for these special groups. Policy adherence is vital for continued progress.

Service Use History of Individuals Enrolling in a Web-Based Suicidal Ideation Treatment Trial: Analysis of Baseline Data

BACKGROUND

A significant recent innovation is the development of internet-based psychological treatments for suicidal thinking. However, we know very little about individuals experiencing suicidal ideation who seek help through Web-based services and, in particular, their previous health service use patterns.

OBJECTIVE

We aimed to examine service use history and its correlates among adults experiencing suicidal ideation who enrolled in a Web-based suicidal ideation treatment trial.

METHODS

We used baseline data of 418 individuals seeking Web-based treatment for their suicidal ideation recruited into a randomized controlled trial of a 6-week Web-based self-help program. Participants at preintervention reported demographic information, clinical characteristics, and health service use over the previous 6 months.

RESULTS

Participants had a high rate of service use in the 6 months before enrolling in the treatment trial (404/418, 96.7% of participants had contact with services). The two most common contact points were general practitioners (385/418, 92.1% of participants) and mental health professionals (295/418, 70.6% of participants). Notably, those with a previous single suicide attempt had lower odds of contact with any service than those with no attempt (odds ratio [OR] 0.21, 95% CI 0.05-0.86; P=.03). Those living in rural or remote areas had lower odds of contacting general practitioners (OR 0.35, 95% CI 0.13-0.91; P=.03) or mental health professionals (OR 0.44, 95% CI 0.23-0.83; P=.01) than those living in metropolitan areas.

CONCLUSIONS

Individuals enrolling in an electronic health intervention trial have often received treatment from general practitioners or mental health professionals. These services can therefore play an important role in preventing the escalation of suicidal thinking. Enrollment in our Web-based treatment trial suggested, though, that face-to-face health services may not be enough. Our study also highlighted the need to improve the provision of coordinated and assertive care after a suicide attempt, as well as health service availability and utilization for those living in rural and remote areas.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595.