The influence of socioeconomic status on change in health status after hospitalization

Generating data to facilitate more equitable distribution of health resources: an illustration of how local health surveys can identify probable need in mixed socio-economic regions

OBJECTIVES

This study aimed to (1) encourage allocation of governmental and grant funds to the administration of local area health surveys and (2) illustrate the predictive impact of socio-economic resources on adult health status at the local area level to provide an example of how health surveys can identify residents with the greatest health needs.

STUDY DESIGN

Randomly sampled and weight-adjusted regional household health survey (7501 respondents) analyzed with categorical bivariate and multivariate statistics, combined with Census data. Survey sample consists of the lowest, highest, and near highest ranked counties in the County Health Rankings and Roadmaps for Pennsylvania.

METHODS

Socio-economic status (SES) is measured regionally with Census data consisting of seven indicators and individually with Health Survey data consisting of five indicators based on poverty level, overall household income, and education. Both of these composite measures are examined jointly for their predictive effects on a validated health status measure using binary logistic regression.

RESULTS

Once county-level measures of SES and health status are broken down into smaller areas, better identification of pockets of health need is possible. This was most strongly revealed in an urban county, Philadelphia, which is ranked lowest of 67 counties on health measures in the state of Pennsylvania, yet when broken down into 'neighborhood clusters' contained both the highest- and lowest-ranked local area in a five-county region. Overall, regardless of the SES level of the County subdivision one lives in, a low-SES adult has close to six times greater odds of reporting 'fair or poor health status' than does a high-SES adult.

CONCLUSION

Local health survey analysis can lead to a more precise identification of health needs than surveys attempting to cover broad areas. Low-SES communities within counties, and low-SES individuals, regardless of the community they live in, are substantially more likely to experience fair to poor health. This adds urgency to the need to implement and investigate socio-economic interventions, which can hopefully improve health and save healthcare costs. Novel local area research can identify the impact of intervening variables such as race in addition to SES to add more specificity in identifying populations with the greatest health needs.

Socioeconomic differences in patient-reported outcomes after a hip or knee replacement in the English National Health Service

BACKGROUND

We investigated socioeconomic differences in patient-reported outcomes after a hip or knee replacement and the contribution of health differences beforehand.

METHODS

Our sample included 121 983 patients in England who had an operation in 2009-2011. Socioeconomic status was measured with quintiles of the ranking of areas by the English Index of Multiple Deprivation. Outcomes at 6 months were the Oxford hip or knee score (OHS or OKS) that measure pain and disability on a scale from 0 (worst) to 48 (best), and the percentage reporting no improvement in problems. Adjustment was made for age, sex, ethnicity, comorbidity, general health, revision surgery, primary diagnosis, preoperative OHS or OKS and having longstanding problems.

RESULTS

Comparing the most- with the least-deprived group, the mean OHS was 5.0 points lower and the OKS 5.4 lower. Adjusted differences, reflecting the differences in improvement in the condition, were 2.8 [95% confidence interval (CI): 2.5-3.0] on OHS and 2.4 (95% CI: 2.2-2.7) on OKS. Adjusted odds ratios for reporting no improvement were 1.4 (1.2-1.6) for the hip and 1.4 (1.3-1.5) for the knee.

CONCLUSIONS

On average, patients living in socioeconomically deprived areas had worse outcomes after surgery, partly related to preoperative differences in health and disease severity and partly to less postoperative improvement.

Survival after coronary artery bypass graft surgery and community socioeconomic status: clinical and research implications

OBJECTIVES

Epidemiologic studies have linked adverse health outcomes to lower socioeconomic status (SES). To our knowledge, none have associated post-operative coronary artery bypass graft (CABG) surgery survival to this risk factor. To assess this, we compared post-operative survival among 771 CABG patients from different SES communities in a Southeastern state 36 months after surgery (mean follow-up = 30 months). All patients were admitted to the same tertiary care medical center for surgery in 1994 (mean age = 62; females = 214; African Americans = 13; person years of follow-up = 2,153; 36-month mortality = 8.8%).

METHODS

Data were extracted from the medical records of all CABG patients admitted in 1994 using the Society of Thoracic Surgeons' data-collection protocol. The study hypothesis was that patients from "disadvantaged" communities would have lower survival rates after surgery, controlling for the severity of the patient's medical condition. In this study, 181 patients were from an Appalachian county and 437 were from a medically under-served county. Post-discharge mortality was ascertained from state mortality files. Forward and backwards step-wise Cox proportional hazard regression models were used to select the most significant risk factors for mortality from 8 county-level community indicators and 32 clinical risk factor variables potentially associated with post-operative survival.

RESULTS

Controlling for traditional risk factors for post-operative CABG survival, patients from counties with the lowest housing values have a significant increased risk of death 36 months after CABG surgery (hazard ratio [HR] = 2.46, 95% CI = 1.26-4.78, P = 0.008). Being an African American also appeared to be a significant and independent risk factor for death 36 months after surgery, as well (HR = 4.55, 95% CI = 1.37-15.11, P = 0.013).

CONCLUSION

This study suggests that residence in a poor community and possibly African American status are significant and independent risk factors for mortality 36 months after CABG surgery, although the latter may have included too few cases (n = 13) to assess this effectively. Additional research is needed to determine why these associations exist and to develop specific interventions. In the mean time, closer surveillance is recommended for CABG patients admitted from lower SES communities and possibly for African American patients.

U.S. women physicians' assessment of the quality of healthcare they receive

Surveys of women's perceptions of quality and satisfaction with healthcare are widely administered and reported, yet no similar studies of women physicians' perceptions have been conducted. We analyzed related data from the Women Physicians' Health Study, a nationally representative sample of 4501 U.S. women physicians. Among U.S. women physicians, 39% thought the healthcare they personally received was excellent, 37% considered it to be very good, 19% good, 4% fair, and 1% judged their healthcare to be poor quality. Physicians may be especially rigorous judges of healthcare quality, and their assessment of the healthcare they receive is generally positive, an encouraging finding. However, as physicians are highly qualified to assess and potentially obtain high-quality healthcare and as they generally did not judge the care they received to be excellent, the findings also suggest that there are opportunities for improvements in the quality of women's healthcare.

Course of health status among chronically ill persons: differentials according to level of education

This article describes socioeconomic differences in the time course of several health indicators, encompassing perceived health and disabilities, among a population sample of persons reporting one or more chronic conditions. Data covering the period 1991-1993, were obtained from a Dutch follow-up study. Educational differences in the course of health status were estimated by ordinary least squares regression. The course of almost all health status measures was statistically significantly less favorable (p<0.05) for those with a low educational level compared to those with higher vocational training or a university degree, adjusting for age, sex, and marital status. After additional adjustment for health status in 1991, significant differences remained for perceived general health, long-term disabilities, and two subscales of the Nottingham Health Profile. These findings imply that socioeconomic differences in prevalence of health problems are not only attributable to differences in incidence of diseases by socioeconomic status, but also to a differential course of existing health problems. Implications for health care delivery are discussed.