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Morenz AM, Liao JM, Au DH, Hayes SA. Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review. JAMA Netw Open 2024; 7:e2356121. [PMID: 38358740 PMCID: PMC10870184 DOI: 10.1001/jamanetworkopen.2023.56121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models. Objective To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost. Evidence Review A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023. Findings This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending. Conclusions and Relevance The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.
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Affiliation(s)
- Anna M. Morenz
- Department of Medicine, University of Washington, Seattle
- Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, Washington
| | - Joshua M. Liao
- Department of Medicine, University of Washington, Seattle
- Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, Washington
- Now with Department of Medicine, University of Texas Southwestern Medical Center, Dallas
- Now with Program on Policy Evaluation and Learning, Dallas, Texas
| | - David H. Au
- Department of Medicine, University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Sophia A. Hayes
- Department of Medicine, University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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2
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Rehkopf DH, Phillips RL. The Neighborhood Atlas Area Deprivation Index And Recommendations For Area-Based Deprivation Measures. Health Aff (Millwood) 2023; 42:710-711. [PMID: 37126740 DOI: 10.1377/hlthaff.2023.00282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Edward Hannan and colleagues found that a lack of standardization of input variables to the Area Deprivation Index (ADI) available from the Neighborhood Atlas overweights the index for median home value and thus potentially further disadvantages already disadvantaged communities. We recommend that a revised ADI be created that addresses the error, and we offer five steps to avoid future errors in the creation of area deprivation measures.
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Affiliation(s)
| | - Robert L Phillips
- Robert L. Phillips Jr. , American Board of Family Medicine, Washington, D.C
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3
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Diaz A, Lindau ST, Obeng-Gyasi S, Dimick JB, Scott JW, Ibrahim AM. Association of Hospital Quality and Neighborhood Deprivation With Mortality After Inpatient Surgery Among Medicare Beneficiaries. JAMA Netw Open 2023; 6:e2253620. [PMID: 36716028 PMCID: PMC9887494 DOI: 10.1001/jamanetworkopen.2022.53620] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023] Open
Abstract
Importance Although the hospital at which a patient is treated is a known source of variation in mortality after inpatient surgery, far less is known about how the neighborhoods from which patients come may also contribute. Objective To compare postoperative mortality among Medicare beneficiaries based on the level of neighborhood deprivation where they live and hospital quality where they received care. Design, Setting, and Participants This cross-sectional study examined outcomes among Medicare beneficiaries undergoing 1 of 5 common surgical procedures (colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair) between 2014 and 2018. Hospital quality was assigned using the Centers for Medicare & Medicaid Services Star Rating. Each beneficiary's neighborhood was identified at the census tract level and sorted in quintiles based on its Area Deprivation Index score, a composite measure of neighborhood quality, including education, employment, and housing quality. A risk matrix across hospital quality and neighborhood deprivation was created to determine the relative contribution of each to mortality after surgery. Data were analyzed from June 1 to December 31, 2021. Exposures Hospital quality and neighborhood deprivation. Main Outcomes and Measures The main outcome was risk-adjusted 30-day mortality after surgery using a multivariable logistic regression model taking into account patient factors and procedure type. Results A total of 1 898 829 Medicare beneficiaries (mean [SD] age, 74.8 [7.0] years; 961 216 [50.6%] male beneficiaries; 28 432 [1.5%] Asian, 145 160 [77%] Black, and 1 622 304 [86.5%] White beneficiaries) were included in analyses. Patients from all neighborhood deprivation group quintiles sought care at hospitals across hospital quality levels. For example, 9.1% of patients from the highest deprivation neighborhoods went to a hospital in the highest star rating of quality and 4.2% of patients from the lowest deprivation neighborhoods went to a hospital in the lowest star rating of quality. Thirty-day risk-adjusted mortality varied across high- and low-quality hospitals (4.3% vs 7.2%; adjusted odds ratio [aOR], 1.78; 95% CI, 1.66-1.92) and across the least and most deprived neighborhoods (4.5% vs 6.8%; aOR, 1.58; 95% CI, 1.53-1.64). When combined, comparing patients from the least deprived neighborhoods going to high-quality hospitals vs patients from the most deprived neighborhoods going to low-quality hospitals, the variation increased further (3.8% vs 8.1%; aOR, 2.20; 95% CI, 1.96-2.46). Conclusions and Relevance These findings suggest that characteristics of a patient's neighborhood and the hospital where they received treatment were both associated with risk of death after commonly performed inpatient surgical procedures. The associations of these factors on mortality may be additive. Efforts and investments to address variation in postoperative mortality should include both hospital quality improvement as well as addressing drivers of neighborhood deprivation.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Columbus
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Stacy Tessler Lindau
- Department of Obstetrics & Gynecology, University of Chicago, Chicago, Illinois
- Department of Medicine–Geriatrics, University of Chicago, Chicago, Illinois
| | | | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - John W. Scott
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture & Urban Planning, University of Michigan, Ann Arbor
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4
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Fabius CD, Okoye SM, Mulcahy J, Burgdorf JG, Wolff JL. Associations Between Use of Paid Help and Care Experiences Among Medicare-Medicaid Enrolled Older Adults With and Without Dementia. J Gerontol B Psychol Sci Soc Sci 2022; 77:e216-e225. [PMID: 35554530 PMCID: PMC9799184 DOI: 10.1093/geronb/gbac072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Community-living older Medicare and Medicaid enrollees ("dual-enrollees") have high care needs and commonly receive paid and unpaid long-term services and supports (LTSS) to help with routine activities. Little is known about whether receiving paid help or individuals' state and neighborhood environmental context ("LTSS environment") relates to dual-enrollees' care experiences. METHODS We examine a sample of n = 979 community-dwelling dual-enrollees with disabilities from 2011 to 2015 National Health and Aging Trends Study, linked to measures of neighborhood disadvantage and state Medicaid home and community-based services (HCBS) generosity. Logistic regression models stratified by dementia status assess associations between paid help and: (a) adverse consequences due to unmet care needs, and (b) participation restrictions in valued activities, among dual-enrollees with and without dementia, adjusting for individual and LTSS environmental characteristics. RESULTS Use of paid help was greater for those with (versus without) dementia (46.9% vs. 37.8%). Neighborhood disadvantage was associated with greater use of paid help among dual-enrollees living with dementia. High state Medicaid HCBS generosity was associated with the use of paid help, regardless of dementia status. Dual-enrollees with dementia receiving paid help had higher odds of experiencing adverse consequences due to unmet need (adjusted odds ratio = 2.05; 95% confidence interval 1.16-3.61; p = .02)-no significant associations were observed for participation restrictions. Use of paid help and LTSS environment were not significantly associated with care experiences for dual-enrollees without dementia. DISCUSSION Findings highlight the complexities of caring for dual-enrollees, particularly those with dementia, and emphasize the need to strengthen the delivery of paid care with considerations for the LTSS environment.
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Affiliation(s)
- Chanee D Fabius
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - John Mulcahy
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Julia G Burgdorf
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Visting Nurse Service of New York, New York, New York, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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5
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Preussler JM, Meyer CL, Sees Coles JA, Yoo D, Mau LW, Garrett ND, Auletta JJ. Enhancing Administrative Claims Data: Feasibility, Validation and Application of Linking Medicare Claims Data and National Marrow Donor Program Search Data. JCO Clin Cancer Inform 2022; 6:e2200069. [PMID: 36228178 PMCID: PMC9848571 DOI: 10.1200/cci.22.00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/22/2022] [Accepted: 08/26/2022] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Administrative claims data provide real-world service utilization of acute myeloid leukemia (AML) treatment, but lacks insight into treatment delays or barriers. The National Marrow Donor Program (NMDP)/Be The Match Search (Search) data contains information on donor search, but lacks information on treatment received if allogeneic hematopoietic cell transplant (HCT) is not performed. We hypothesized that linking these two data sets would create a rich resource to define factors associated with receiving HCT that could not be evaluated with either data set alone. METHODS A subset of 2010-2016 Medicare administrative claims data was linked with Search data. A total of 5,351 patients with AML age 65-74 years (HCT = 607, no HCT = 4,744) were identified using Medicare. These patients were then linked to 93,800 records with a donor search between 2009 and 2016. Patient date of birth, sex, disease, ZIP code, transplant center/hospital, and diagnosis date were used for matching. Exploratory analysis was conducted to identify predictors associated with receiving HCT for patients with AML who received a search. RESULTS The data sets were successfully linked, showing high sensitivity and specificity. The final cohort included 5,085 patients with AML (HCT = 533, no HCT = 4,552). Of 97 patients who received HCT without a matched search, more than 85% received a related donor HCT. Of those not receiving HCT, 609 had a matched NMDP search and 3,943 did not have a matched NMDP search. Multivariate analysis showed time to search, age, diagnosis year, race/ethnicity, and neighborhood education status associated with receiving HCT. CONCLUSION Methods herein demonstrate the feasibility of linking Search and Medicare data. Similar methods may be applied to answer critical questions regarding barriers to HCT, thereby identifying areas to improve access to care.
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Affiliation(s)
- Jaime M. Preussler
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Christa L. Meyer
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Jennifer A. Sees Coles
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Dana Yoo
- National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Lih-Wen Mau
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | | | - Jeffery J. Auletta
- National Marrow Donor Program/Be The Match, Minneapolis, MN
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
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6
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Carlson LC, Zachrison KS, Yun BJ, Ciccolo G, White BA, Camargo CA, Samuels-Kalow ME. The Association of Demographic, Socioeconomic, and Geographic Factors with Potentially Preventable Emergency Department Utilization. West J Emerg Med 2021; 22:1283-1290. [PMID: 34787552 PMCID: PMC8597685 DOI: 10.5811/westjem.2021.5.50233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/06/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Prevention quality indicators (PQI) are a set of measures used to characterize healthcare utilization for conditions identified as being potentially preventable with high quality ambulatory care. These indicators have recently been adapted for emergency department (ED) patient presentations. In this study the authors sought to identify opportunities to potentially prevent emergency conditions and to strengthen systems of ambulatory care by analyzing patterns of ED utilization for PQI conditions. Methods Using multivariable logistic regression, the authors analyzed the relationship of patient demographics and neighborhood-level socioeconomic indicators with ED utilization for PQI conditions based on ED visits at an urban, academic medical center in 2017. We also used multilevel modeling to assess the contribution of these variables to neighborhood-level variation in the likelihood of an ED visit for a PQI condition. Results Of the included 98,522 visits, 17.5% were categorized as potentially preventable based on the ED PQI definition. On multivariate analysis, age < 18 years, Black race, and Medicare insurance had the strongest positive associations with PQI visits, with adjusted odds ratios (aOR) of 1.41 (95% confidence interval [CI], 1.29, 1.56), 1.40 (95% CI, 1.22, 1.61), and 1.40 (95% CI, 1.28, 1.54), respectively. All included neighborhood-level socioeconomic variables were significantly associated with PQI visit likelihood on univariable analysis; however; only level of education attainment and private car ownership remained significantly associated in the multivariable model, with aOR of 1.13 (95% CI, 1.10, 1.17) and 0.96 (95% CI, 0.93, 0.99) per quartile increase, respectively. This multilevel model demonstrated significant variation in PQI visit likelihood attributable to neighborhood, with interclass correlation decreasing from 5.92% (95% CI, 5.20, 6.73) in our unadjusted model to 4.12% (95% CI, 3.47, 4.87) in our fully adjusted model and median OR similarly decreasing from 1.54 to 1.43. Conclusion Demographic and local socioeconomic factors were significantly associated with ED utilization for PQI conditions. Future public health efforts can bolster efforts to target underlying social drivers of health and support access to primary care for patients who are Black, Latino, pediatric, or Medicare-dependent to potentially prevent emergency conditions (and the need for emergency care). Further research is needed to explore other factors beyond demographics and socioeconomic characteristics driving spatial variation in ED PQI visit likelihood.
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Affiliation(s)
- Lucas C Carlson
- Partners HealthCare, Population Health Management, Somerville, Massachusetts.,Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Kori S Zachrison
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Brian J Yun
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Gia Ciccolo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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7
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Tucher E, Keeney T, Bélanger E. Leveraging survey and claims data to identify high-need Medicare beneficiaries in the National Health and Aging Trends Study. J Am Geriatr Soc 2021; 70:522-530. [PMID: 34687550 DOI: 10.1111/jgs.17517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multiple algorithms have been developed to identify and characterize the high-need (HN) Medicare population. However, they vary in components and yield different populations, and were developed for varying purposes. We compared the performance of existing survey and claims-based definitions in identifying HN beneficiaries and predicting poor outcomes among a community-dwelling population. METHODS A retrospective cohort study using Round 5 (2015) of the National Health and Aging Trends Study (NHATS) linked with Medicare claims. We applied HN definitions from previous studies to our cohort of community-dwelling, fee-for-service beneficiaries (n = 4201) using sampling weights to obtain nationally representative estimates. The Bélanger et al. (2019) definition defines HN as individuals with complex conditions, multi-morbidity, acute and post-acute healthcare utilization, dependency in activities of daily living, and frailty. The Hayes et al. (2016) definition defines HN as individuals with 3+ chronic conditions and a functional limitation. We applied each definition to survey and claims data. Outcomes were hospitalization or mortality in the subsequent year. RESULTS The proportion of NHATS respondents classified as HN varied greatly across definitions, ranging from 3.1% using the claims-based Hayes definition to 32.9% using the survey-based Bélanger definition. HN respondents had significantly higher mortality and hospitalization rates in 2016. Although all definitions had good specificity, none were able to predict outcomes in the following year with good accuracy. CONCLUSIONS While mortality and hospitalization rates were significantly higher among respondents classified as HN, existing claims and survey-based HN definitions were not able to accurately predict future outcomes in a community-dwelling, nationally representative sample measured by the area under the curve.
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Affiliation(s)
- Emma Tucher
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Tamra Keeney
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Emmanuelle Bélanger
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
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8
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Hughes K, Olufajo OA, White K, Roby DH, Fryer CS, Wright JL, Sehgal NJ. The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction. J Vasc Surg 2021; 75:168-176. [PMID: 34506895 DOI: 10.1016/j.jvs.2021.08.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 08/13/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction. METHODS Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses. RESULTS Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups. CONCLUSIONS Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.
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Affiliation(s)
- Kakra Hughes
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md; Department of Surgery, Howard University College of Medicine, Washington, DC.
| | - Olubode A Olufajo
- Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Kellee White
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md
| | - Dylan H Roby
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md
| | - Craig S Fryer
- Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, Md
| | - Joseph L Wright
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md; Executive Suite, University of Maryland Capital Region Health, Cheverly, Md
| | - Neil J Sehgal
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md
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9
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Sherry MK, Bishai DM, Padula WV, Weiner JP, Szanton SL, Wolff JL. Impact of Neighborhood Social and Environmental Resources on Medicaid Spending. Am J Prev Med 2021; 61:e93-e101. [PMID: 34039496 DOI: 10.1016/j.amepre.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. Research linking medical spending to variation in neighborhood resources is critical to building the case for increased funding for social conditions. However, few studies link neighborhood factors to medical spending. This study assesses the relationship between neighborhood social and environmental resources and medical spending across the spending distribution. METHODS Individual-level health outcomes were drawn from a sample of Medicaid enrollees living in Baltimore, Maryland during 2016. A multidimensional index of neighborhood social and environmental resources was created and stratified by tertile (high, medium, and low). Differences were examined in individual-level medical spending associated with living in high-, medium-, or low-resource neighborhoods in unadjusted and adjusted 2-part models and quantile regression models. Analyses were conducted in 2019. RESULTS Enrollees who live in neighborhoods with low social and environmental resources incur significantly higher spending at the mean and across the distribution of medical spending even after controlling for age, race, sex, and morbidity than those who live in neighborhoods with high social and environmental resources. On average, this spending difference between individuals in low- and those in high-resource neighborhoods is estimated to be $523.60 per person per year. CONCLUSIONS Living in neighborhoods with low (versus those with high) resources is associated with higher individual-level medical spending across the distribution of medical spending. Findings suggest potential benefits from efforts to address the social and environmental context of neighborhoods in addition to the traditional orientation to addressing individual behavior and risk.
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Affiliation(s)
- Melissa K Sherry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - David M Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - William V Padula
- Department of Pharmaceutical and Health Economics, USC School of Pharmacy, University of Southern California, Los Angeles, California; Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Jonathan P Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins Center for Population Health Information Technology (CPHIT), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah L Szanton
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Center on Innovative Care in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; The Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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10
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Fraser Doh K, Sheline E, Wetzel M, Simon HK, Morris CR. Comparison of cost and resource utilization between firearm injuries and motor vehicle collisions at pediatric hospitals. Acad Emerg Med 2021; 28:630-638. [PMID: 33599028 DOI: 10.1111/acem.14234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/31/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Firearm injuries are converging with motor vehicle collisions (MVC) as the number one cause of death for children in the United States. Thus we examine differences in hospital cost and hospital resource utilization between motor vehicle and firearm injury. METHODS This retrospective, cross-sectional study compares hospital costs and resource utilization of motor vehicle and firearm-injured children aged 0 to 19 years of age over a 5-year time frame (January 1, 2013-December 31, 2017) in 35 freestanding children's hospitals that submitted data to the Pediatric Health Information System. The primary outcome was hospital-adjusted comparative cost per patient presentation. Generalized linear mixed models were used to quantify the relationship between the type of injury and each outcome, adjusting for patient characteristics and hospital. RESULTS There were 89,133 emergency department (ED) visits attributed to MVCs and 3,235 for firearm injury. Of the youths who presented for firearm injury, 49% were hospitalized versus 14% of youths presenting with MVC (adjusted odds ratio [aOR] = 6.6, 95% confidence interval [CI] = 6.1 to 7.2). Youths with firearm injury were more likely to be admitted to an intensive care unit (aOR = 6.7, 95% CI = 5.9 to 7.7) and had longer lengths of stays (aOR = 2.2, 95% CI = 1.9 to 2.6) compared to their MVC counterparts. Children admitted for firearm injury had more imaging and ED return visits, along with subsequent inpatient admission within 3 days (aOR = 3.4, 95% CI = 2.1 to 5.5) and 1 year (aOR = 2.5, 95% CI = 2.1 to 2.9). The mean relative per-patient costs were nearly fivefold higher for the firearm-injured group. CONCLUSIONS Hospital costs and markers of resource utilization were higher for youths with firearm injury compared to MVC. High medical resource utilization is one of several important reasons to advocate for a comparable national focus and funding on firearm-related injury prevention.
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Affiliation(s)
- Kiesha Fraser Doh
- Departments of Pediatrics and Emergency Medicine Emory University School of Medicine Atlanta Georgia USA
- Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Erica Sheline
- Department of Pediatrics University of Colorado School of Medicine Aurora Colorado USA
| | - Martha Wetzel
- Department of Pediatrics Biostatistics Core Emory University School of Medicine Atlanta Georgia USA
| | - Harold K. Simon
- Departments of Pediatrics and Emergency Medicine Emory University School of Medicine Atlanta Georgia USA
- Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Claudia R. Morris
- Departments of Pediatrics and Emergency Medicine Emory University School of Medicine Atlanta Georgia USA
- Children's Healthcare of Atlanta Atlanta Georgia USA
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11
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Arora KS, Ascha M, Wilkinson B, Verbus E, Montague M, Morris J, Einstadter D. Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization. BMC Public Health 2020; 20:1440. [PMID: 32962666 PMCID: PMC7509918 DOI: 10.1186/s12889-020-09540-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization. METHODS Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression. RESULTS Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients. CONCLUSION Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.
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Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Mustafa Ascha
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Barbara Wilkinson
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Emily Verbus
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Mary Montague
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jane Morris
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Douglas Einstadter
- Center for Health Care Research and Policy and the Departments of Medicine, and Population and Quantitative Health Sciences, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Wadas TM, Andrabi MS, Appel SJ. Moving Beyond the Individual Level With Uncontrolled Diabetes. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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