Contribution of Social Determinant of Health Factors to Rural-Urban Preventive Care Differences Among Medicaid Enrollees

Urban Rural Differences on Accessing Patient- Centered Medical Home Among Children With Mental/Developmental Health Conditions/Disorders

INTRODUCTION

To address healthcare spending growth and coordinated primary care, most states in the United States have adopted patient-centered medical homes (PCMHs). To evaluate urban rural difference on accessing PCMH among US children, particularly for children with developmental disabilities (DDs) and mental health disorders (MHDs).

METHODS

This cross-sectional study used the 2016-2018 National Survey for Children's Health (NSCH). Multivariable adjusted logistic regression analyses were used to assess the association between accessing PCMHs and rurality and mental/developmental conditions/disorders.

RESULTS

Children with both DDs and MHDs were statistically significantly higher in rural areas (10.9% rural vs. 8.3% urban, p ≤ .001). Children in rural areas reported higher odds of accessing PCMHs (14%) among all U.S. children, but no differences by subgroups for children with MHDs and/or DDs. Compared with children without DDs/MHDs, the reduction in access to PCMHs varies by children's health status (41% reduction for children both DDs and MHDs, 25% reduction for children with MHDs without DDs) effects. Children with MHDs/DDs were less likely to receive family-centered care, care coordination, and referrals.

CONCLUSIONS

Quality improvements through PCMHs could focus on family-centered care, care coordination, and referrals. Patient-centered medical home performance measurement could be improved to better measure mental health integration and geographical differences.

Community social vulnerability and the 340B Drug Pricing Program: Evaluating predictors of 340B participation among critical access hospital

PURPOSE

The federal 340B Drug Pricing Program allows eligible hospitals, including critical access hospitals (CAHs), to obtain outpatient drugs at a discounted rate. CAHs likely benefit from 340B participation because they are often under-resourced and serve at-risk patient populations. The objective of this study was to understand predictors of 340B program participation among CAHs, and how participation varies with community-level social vulnerability.

METHODS

We used a cross-sectional study design to assess the relationship between 340B participation in 2019 and community vulnerability status using 2018 data from the CDC's social vulnerability index (SVI) among acute care CAHs. Analyses used linear probability models adjusted for hospital-level characteristics.

FINDINGS

In bivariate analyses, CAHs participating in the 340B program had lower overall social vulnerability scores, relative to nonparticipating, eligible, and ineligible CAHs, respectively (43.8 vs. 48.7 vs. 64.7, p < 0.10). In adjusted regression models, greater community vulnerability rankings due to socioeconomic status (-0.129, p < 0.05) and minority status and language (-0.092, p < 0.05) were associated with decreased 340B participation. Higher hospital operating margin was associated with increased 340B participation (0.163, p < 0.05). Although the number of for-profit CAHs ineligible for 340B was small, they had the highest community-level social vulnerability score and lowest hospital operating margin on average.

CONCLUSIONS

CAHs located in areas of high community vulnerability are less likely to participate in the 340B program. Some vulnerable patient populations served by CAHs may be excluded from 340B program benefits.

Health equity in pediatrics: Current concepts for the care of children in the 21st century (Dis Mon)

This is an analysis of important aspects of health equity in caring for children and adolescents written by a multidisciplinary team from different medical centers. In this discussion for clinicians, we look at definitions of pediatric health equity and the enormous impact of social determinants of health in this area. Factors involved with pediatric healthcare disparities that are considered include race, ethnicity, gender, age, poverty, socioeconomic status, LGBT status, living in rural communities, housing instability, food insecurity, access to transportation, availability of healthcare professionals, the status of education, and employment as well as immigration. Additional issues involved with health equity in pediatrics that are reviewed will include the impact of the COVID-19 pandemic, behavioral health concepts, and the negative health effects of climate change. Recommendations that are presented include reflection of one's own attitudes on as well as an understanding of these topics, consideration of the role of various healthcare providers (i.e., community health workers, peer health navigators, others), the impact of behavioral health integration, and the need for well-conceived curricula as well as multi-faceted training programs in pediatric health equity at the undergraduate and postgraduate medical education levels. Furthermore, ongoing research in pediatric health equity is needed to scrutinize current concepts and stimulate the development of ideas with an ever-greater positive influence on the health of our beloved children. Clinicians caring for children can serve as champions for the optimal health of children and their families; in addition, these healthcare professionals are uniquely positioned in their daily work to understand the drivers of health inequities and to be advocates for optimal health equity in the 21st century for all children and adolescents.

Rural Health Disparities in Allergy, Asthma, and Immunologic Diseases: The Current State and Future Direction for Clinical Care and Research

Rural health disparities are well documented and continue to jeopardize the long-term health and wellness for the millions of individuals who live in rural America. The disparities observed between urban and rural residents encompass numerous morbidity and mortality measures for several chronic diseases and have been referred to as the "rural mortality penalty." Although the unmet health needs of rural communities are widely acknowledged, little is known about rural health disparities in allergies, asthma, and immunologic diseases. Furthermore, the intersection between rural health disparities and social determinants of health has not been fully explored. To achieve a more complete understanding of the factors that perpetuate rural health disparities, greater research efforts followed by improved practice and policy are needed that account for the complex social context within rural communities rather than a general comparison between urban and rural environments or focusing on biomedical factors. Moreover, research efforts must prioritize community inclusion throughout rural areas through meaningful engagement of stakeholders in both clinical care and research. In this review, we examine the scope of health disparities in the rural United States and the impact of social determinants of health. We then detail the current state of rural health disparities in the field of allergy, asthma, and immunology. To close, we offer future considerations to address knowledge gaps and unmet needs for both clinical care and research in addressing rural health disparities.

Community-Level Social Determinants of Health and Well-Child Visits Among Alabama Medicaid Enrollees

Well-child visits focus on health promotion and disease detection and are critical to the appropriate provision of care. Evidence has shown that participation in well-child visits is associated with various patient-level factors; however, there has been an increasing focus on the influence of community-level social determinants of health (SDoH). This study explored associations between well-child visits and community-level SDoH at the census tract level among children enrolled in Alabama Medicaid. Through this analysis, it is possible to understand the distribution of care among this underserved population in different geographic settings, thus identifying potential disparities and areas for targeted intervention. Using administrative data from 2015 to 2017 enrollees in Alabama Medicaid that have been geographically linked to information on urbanicity and poverty, logistic regressions (both in total and stratified by age group) were estimated with separate community-level urbanicity, poverty variables, and individual characteristics. The regressions were repeated using a combined urbanicity/poverty variable. Looking at urbanicity and poverty together, with the exception of the least urban areas, it was those living in census tracts where there was discordance in urbanicity and poverty that had the highest likelihood of receiving well-child visits compared with those in census tracts classified as medium poverty (all urbanicity levels). There is a positive effect for Medicaid enrollees in the middle tertile of urbanicity in areas of low and high poverty and in wealthier more urban areas. If poverty and urbanicity were explored separately, some of the nuances would not have been apparent.

Cognition and Social Behaviors Related to COVID-19 Among Students in Medical Colleges: A Cross-Sectional Study in Guangdong Province of China

Background

The COVID-19 pandemic is a public health emergency of international concern. This study aimed to describe the cognition and social behaviors related to COVID-19 among medical college students in China and to explore the relevant factors that have affected individual social behaviors. The study could enrich practical research on the social behaviors of college students during the COVID-19 pandemic.

Methods

From February to April 2020, online questionnaire survey was conducted meticulously. Based on their majors, the students were divided into a medical student group (249 cases) and a near-peer medical student group (397 cases). Descriptive statistics was used to elaborate the cognition related to the pandemic and the status quo of social behaviors among these students. A multiple linear regression model was established to analyze the relevant factors affecting individual social behaviors from various perspectives during the pandemic.

Results

Regarding the cognition situation: 76.32% of those surveyed had good pandemic awareness, and the average general cognition score was 30.55 ± 3.17 points. In terms of social behaviors, the average scores for purposive rational actions and affective actions during the outbreak were relatively high, scoring 8.85 ± 1.72 points (>10 points) and 4.32 ± 1.41 points (>6 points), respectively, while the average value rational actions score was relatively low at 5.95 ± 1.90 points (>10 points). The results of the multiple linear regression model showed that urban college students had higher scores for purposive rational actions; college students with the CCP membership had higher value rational actions scores; school and major were also significant factors affecting affective actions scoring. The COVID-19 cognition score had a significant effect on the social behavior score in all dimensions (P < 0.001).

Conclusions

The cognition of COVID-19 among students in Chinese medical colleges was good, and pandemic cognition was an important factor that affected individual social behaviors. Universities and colleges should strengthen the publicity and education of knowledge related to COVID-19, guide students to internalize their knowledge of the pandemic into positive behaviors, and help to win the battle of pandemic prevention and control.

Patient-reported outcome measures can advance population health, but is access to instruments and use equitable?

Patient reported outcome measures (PROM) can engage patients and clinicians to improve health outcomes. Their population health impact may be limited by systematic barriers inhibiting access to completion. In this analysis we evaluated the association between individual parent/child characteristics and clinic factors with parental completion of a locally developed PROM, the Early Healthy Lifestyles (EHL) questionnaire. Participants included parent-child dyads who presented at 14 pediatric clinics for regularly scheduled well-child visits (WCV) prior to age 26 months. EHL items include feeding practices, diet, play time, screen exposure, and sleep. Completion was categorized at patient- (i.e., parent-child dyad) and clinic-levels. Parents completed the 15-item EHL in the patient portal before arrival or in the clinic; ninety-three percent of EHL questionnaires were completed in the clinic vs. 7% in the patient portal. High-completers completed EHL for half of WCVs; low-completers completed at least once; and non-completers never completed. Clinics were classified by EHL adoption level (% high completion): High-adoption: >50%; Moderate-adoption: 10%-50%; and Low-adoption: <10%. Individual-level factors had negligible impact on EHL completion within moderate/low EHL adoption sites; high-adoption sites were used to evaluate infant and maternal factors in association with EHL completion using hierarchical logistic regression. Noncompletion of EHL was significantly associated (p < 0.05) with infant use of public insurance (OR = 1.92 [1.42, 2.59]), >1 clinic site for WCV (OR = 1.83 [1.34, 2.50]), non-White birth mother (OR = 1.78 [1.28, 2.47]), and body weight <2,500 grams or gestational age <34 weeks (OR = 1.74 [1.05, 2.90]). The number of WCVs, a proxy for clinic size, was evaluated but was not associated with completion. Findings indicate potential disparities between populations exposed to, completing, and benefitting from these tools.