Access to medical care, dental care, and prescription drugs: the roles of race/ethnicity, health insurance, and income

Association Between Median Household Income and Perioperative Outcomes of Lumbar Spinal Fusion: An Analysis of the National Inpatient Sample (2009-2020)

BACKGROUND

Relationships between low socioeconomic status and surgical outcomes are well established for certain procedures. However, scant literature has focused on relationships between median household income and lumbar fusion outcomes.

METHODS

Patients who underwent fusion procedures between January 1, 2009 and December 31, 2020 were identified from the National Inpatient Sample database. They were categorized into 4 quartiles, from lowest to highest, based on median household incomes in respective zip codes. We applied univariable and multivariable linear and logistic regression models to analyze perioperative data according to income quartiles.

RESULTS

We included 2,826,396 patients. In multivariable regression, patients in the 3 lowest income quartiles exhibited higher rates of in-hospital cardiac events perioperatively, with odds ratios (ORs) of 1.19 (95% confidence interval [CI]1.13-1.26, P < 0.001), 1.10 (95% CI 1.05-1.16, P < 0.001), and 1.06 (95% CI 1.01-1.12, P = 0.011) for the first, second, and third quartiles, respectively. Patients in the lowest income (first) quartile had a higher occurrence of perioperative urinary complications (OR = 1.07, 95% CI 1.03-1.12, P = 0.001), systemic infectious complications (OR = 1.17, 95% CI 1.04-1.32, P = 0.006), neurological deficit (OR = 1.17, 95% CI 1.06-1.30, P = 0.002), and wound infections (OR = 1.22, 95% CI 1.12-1.34, P < 0.001). Those in the 3 lowest income quartiles were less likely to experience respiratory, gastrointestinal, and venous thrombotic complications (P < 0.05). The lowest income quartile had protective associations for dural tears (OR 0.93, 95% CI 0.89-0.99, P = 0.038) and postprocedure anemia across all 3 lower quartiles, with OR < 1 and P < 0.001.

CONCLUSIONS

Reduced household income significantly affected perioperative outcomes after lumbar fusion and should be taken into consideration during the perioperative period.

Prescription medication use among patients with type 2 diabetes in the United States: 1999-2020

AIMS

We aimed to examine trends in overall prescription medication use among patients with type 2 diabetes in the United States to provide insights for patient care.

MATERIALS AND METHODS

We used nationally representative data from the National Health and Nutrition Examination Survey from 1999 to 2020 and included adult patients with type 2 diabetes. We examined the use of prescription drugs, overall and by drug class, polypharmacy (use of ≥5 medications), and number of medications attributed to specific classes.

RESULTS

In the period 2015-2020, the mean patient age was 59.6 (51.0-70.0) years, with 46.8% (43.6-49.9) being female and 57.8% (52.8-62.8) being non-Hispanic White. Among 9489 adults with type 2 diabetes, the prevalence of polypharmacy was high and increased from 35.1% (31.6-38.6) in 1999-2002 to 47.2% (43.7-50.7) in 2003-2006, and further to 51.1% (48.3-53.9) in 2015-2020 (p for trend <0.001). Increasing trends of polypharmacy were found across all population subgroups and across the majority of therapeutic classes. Use of non-cardiometabolic medications was common. Among them, the most common were antidepressants (19.8%), proton pump inhibitors (19.0%) and analgesics (16.2%). Among patients with polypharmacy, approximately 40% of medication use was attributed to non-cardiometabolic medications.

CONCLUSIONS

Prescription medication burden and complexity increased substantially among patients with type 2 diabetes, with more than 50% of patients with polypharmacy. Attention should be paid to this escalating medication use and regimen complexity, which requires multidisciplinary and coordinated care.

Trends in dental visits among US adults from 1997 through 2019: Implications for policy reform

BACKGROUND

Examination of serial cross-sectional national surveys from a representative sample of the population can identify patterns and help support policy development.

METHODS

The authors used data from the National Health Interview Survey on US adults reporting a dental visit in the past 12 months to examine trends from 1997 through 2019. Groups analyzed were based on sociodemographic factors including residence in a metropolitan statistical area, race and ethnicity, family income level, and geographic region.

RESULTS

Over the 23-year period, the authors found differences for family income level, living in a rural (nonmetropolitan vs metropolitan) area, race and ethnicity, and geographic region (P < .0001). When stratified by family income, racial disparities have diminished. Gaps in dental service use are long-standing for rural nonmetropolitan communities.

CONCLUSIONS

Relative to urban locales, rural communities experienced persistent disparities in the use of the oral health care delivery system throughout the 23 years measured. Strategies to create innovative models of care are needed to address oral health needs in underserved rural communities.

PRACTICAL IMPLICATIONS

Policy is needed to foster a shift toward population health that will incentivize a health care system that reduces financial barriers and enhances health outcomes for adult oral health, especially for rural areas.

Income and Insurance Status Impact Access to Health Care for Hip Osteoarthritis

Purpose

To explore differences in the affordability of and accessibility to health care among adults with hip osteoarthritis with respect to race/ethnicity, income, and insurance status.

Methods

This cross-sectional retrospective study was conducted using 2016 National Health Interview Survey (NHIS) data. NHIS data collection occurred continuously from January to December 2016. Individuals belonging to households and noninstitutionalized groups were included in the study. Because NHIS randomized surveys are conducted face-to-face on an annual basis, follow-up data are not collected.

Results

Answers from 38,158,634 weighted respondents with a mean age of 58.33 ± 0.33 years were assessed. Among adults with hip osteoarthritis, those with public insurance had increased odds of delaying care owing to lack of transportation and had decreased odds of delaying care and follow-up care owing to cost. Individuals who were uninsured or who belonged to lower income brackets were associated with increased odds of being unable to afford or utilize health care.

Conclusions

In this study, we found that income bracket and insurance status affect the accessibility to health care among adults with hip osteoarthritis in the United States.

Level of Evidence

Level IV, prognostic case series.

Factors Affecting Access to Public Healthcare Facilities in the City of Tshwane, South Africa

Access to healthcare services is largely determined by socioeconomic factors, with economically well-off individuals obtaining healthcare services more efficiently than those who are disadvantaged. This paper aims to assess the effects of socioeconomic and other related factors on access to healthcare facilities in the City of Tshwane, South Africa, during the COVID-19 pandemic. Data were sourced from the Gauteng City-Region Observatory (GCRO) quality of life survey (2020/2021). Multivariate logistic regression was applied. Results showed that 66.3% of the respondents reported that they had access to public healthcare facilities within their area. Furthermore, results showed that those who lived in informal houses were significantly (OR = 0.55, 95% CI [0.37-0.80], p < 0.01) less likely to report that they had access to public healthcare facilities in their area compared to those who lived in formal houses. More efforts need to be undertaken to ensure that all citizens have access to public healthcare facilities, especially among those who are disadvantaged, such as informal dwellers. In addition, future research should encompass locality in relation to the factors that affect access to public healthcare facilities, especially during pandemics such as the COVID-19 pandemic, in order to have geographically targeted interventions.

Preliminary Evaluation of a Citizen Scientist Educational Curriculum Aimed at Engaging Black Men in Lung Cancer Early Detection Screening

This article describes an educational program to engage African American men as citizen scientists (CSs) and future research partners in a lung cancer screening project. We provide an overview of the curriculum used, the structure and format of the educational sessions, and associated educational outcomes. Furthermore, we describe lessons learned in the engagement of African American men as CS in community-based lung-health equity research. The CS educational program included five group-based sessions delivered through zoom. The educational curriculum was adapted from the University of Florida Citizen Scientist program and tailored to address lung health and the contextual experiences of African American men. Each session lasted 90 minutes. Pre- and post-test measures were collected to examine changes in knowledge, comfort, health literacy, research interests, and medical mistrust. Eight African American men completed the CS educational program. Attendance rates were high for each session (100%). Seven participants completed additional human subject research certification. Improvements were observed from pre- to post-test in participants' level of knowledge, comfort, and health literacy but not medical mistrust. CS reported the most interest in participating in research aimed to identify important community strengths and problems. Study findings suggest that it was feasible to deliver an online citizen scientist educational program designed to prepare participants to serve as partners in a lung cancer screening intervention for African American men. Results suggest the educational program has the potential to improve key outcomes including completion of regulatory training and increased research-related knowledge, comfort, and health literacy.

Heat illness data strengthens vulnerability maps

Background

Previous extreme heat and human health studies have investigated associations either over time (e.g. case-crossover or time series analysis) or across geographic areas (e.g. spatial models), which may limit the study scope and regional variation. Our study combines a case-crossover design and spatial analysis to identify: 1) the most vulnerable counties to extreme heat; and 2) demographic and socioeconomic variables that are most strongly and consistently related to heat-sensitive health outcomes (cardiovascular disease, dehydration, heat-related illness, acute renal disease, and respiratory disease) across 67 counties in the state of Florida, U. S over 2008–2012.

Methods

We first used a case-crossover design to examine the effects of air temperature on daily counts of health outcomes. We employed a time-stratified design with a 28-day comparison window. Referent periods were extracted from ±7, ±14, or ± 21 days to address seasonality. The results are expressed as odds ratios, or the change in the likelihood of each health outcome for a unit change in heat exposure. We then spatially examined the case-crossover extreme heat and health odds ratios and county level demographic and socioeconomic variables with multiple linear regression or spatial lag models.

Results

Results indicated that southwest Florida has the highest risks of cardiovascular disease, dehydration, acute renal disease, and respiratory disease. Results also suggested demographic and socioeconomic variables were significantly associated with the magnitude of heat-related health risk. The counties with larger populations working in farming, fishing, mining, forestry, construction, and extraction tended to have higher risks of dehydration and acute renal disease, whereas counties with larger populations working in installation, maintenance, and repair workers tended to have lower risks of cardiovascular, dehydration, acute renal disease, and respiratory disease. Finally, our results showed that high income counties consistently have lower health risks of dehydration, heat-related illness, acute renal disease, and respiratory disease.

Conclusions

Our study identified different relationships with demographic/socioeconomic variables for each heat-sensitive health outcome. Results should be incorporated into vulnerability or risk indices for each health outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12097-6.

Characterizing Areas with Increased Burden of West Nile Virus Disease in California, 2009-2018

West Nile virus (WNV) is a mosquito-borne flavivirus that can cause severe neurological disease in humans, for which there is no treatment or vaccine. From 2009 to 2018, California has reported more human disease cases than any other state in the United States. We sought to identify smaller geographic areas within the 10 California counties with the highest number of WNV cases that accounted for disproportionately large numbers of human cases from 2009 to 2018. Eleven areas, consisting of groups of high-burden ZIP codes, were identified in nine counties within southern California and California's Central Valley. Despite containing only 2% of California's area and 17% of the state's population, these high-burden ZIP codes accounted for 44% of WNV cases reported and had a mean annual incidence that was 2.4 times the annual state incidence. Focusing mosquito control and public education efforts in these areas would lower WNV disease burden.

Disparities in Dental Service Use among Adult Populations in the United States

OBJECTIVES

This article aims to examine the disparities in dental service utilization among 3 age groups: younger adults (20-49 y), middle-aged adults (50-64 y), and older adults (65+ y), among Whites, Hispanics, Blacks, Asians, American Indians or Alaska Natives (AIAN), and Native Hawaiian or other Pacific Islanders (NHOPI).

METHODS

Weighted logistic regression models were conducted to analyze 9 waves of cross-sectional survey data (2002-2018) from the Behavioral Risk Factor Surveillance System. We estimated age group- and race/ethnic-specific prevalences of dental service utilization adjusting sociodemographics and self-rated health for each wave and compared with crude analysis. Next, we performed linear regression analysis of the trend of adjusted prevalences over time and the average level by race/ethnicity and age groups.

RESULTS

Racial/ethnic disparities increased with age, even though the adjusted prevalences of dental service utilization were less apparent than the crude analysis. The all-wave average prevalence was 71%. Black older adults had the lowest level of dental service utilization (65%) as compared with the 2 highest groups: White older adults (79%) and Asian older adults (76%). The general younger adult populations had low prevalences, with the lowest among Asian younger adults (65%). AIAN and NHOPI individuals from all age groups tended to have average or below average prevalences. In addition, a decreasing trend of dental service utilization was observed among White individuals of all age groups (0.2%-0.3% lower per year, P < 0.01) and AIAN younger adults (0.5% lower per year, P < 0.01).

CONCLUSION

Health policy, federal funding, and community-based programs should address the needs of dental service utilization for racial/ethnic minorities including Blacks, AIANs, and NHOPIs.

KNOWLEDGE TRANSFER STATEMENT

Our study offers insights into our understanding of disparities in dental service utilization among minority racial/ethnic groups. As health policy, federal funding, and community-based programs seek to improve oral health, there is a need to address access to and utilization of dental service for Blacks, American Indians or Alaska Natives, and Native Hawaiian or other Pacific Islanders.

Natural history of insomnia symptoms in the transition from childhood to adolescence: population rates, health disparities, and risk factors

STUDY OBJECTIVES

To determine the sociodemographic, behavioral, and clinical risk factors associated with the persistence, remission, and incidence of insomnia symptoms in the transition from childhood to adolescence.

METHODS

The Penn State Child Cohort is a random, population-based sample of 700 children (5-12 years at baseline), of whom 421 were followed-up as adolescents (12-23 years at follow-up). Subjects underwent polysomnography, clinical history, physical exam, and parent- and self-reported scales at baseline and follow-up. Insomnia symptoms were defined as a parent- or self-report of difficulty falling and/or staying asleep.

RESULTS

The 421 subjects with baseline (Mage = 8.8 years) and follow-up (Mage = 17 years) data were 53.9% male and 21.9% racial/ethnic minorities. The persistence of childhood insomnia symptoms (CIS) was 56% (95% CI = 46.5-65.4), with only 30.3% (95% CI = 21.5-39.0) fully remitting. The incidence of adolescent insomnia symptoms was 31.1% (95% CI = 25.9-36.3). Female sex, racial/ethnic minority, and low socioeconomic status as well as psychiatric/behavioral or neurological disorders, obesity, smoking, and evening chronotype were associated with a higher persistence or incidence of insomnia symptoms.

CONCLUSIONS

CIS are highly persistent, with full remission occurring in only a third of children in the transition to adolescence. Sex-, racial/ethnic-, and socioeconomic-related disparities in insomnia occur as early as childhood, while different mental/physical health and lifestyle/circadian risk factors play a key role in the chronicity of CIS versus their incidence in adolescence. CIS should not be expected to developmentally remit and should become a focus of integrated pediatric/behavioral health strategies.

Racial and Ethnic Disparities in Perceived Barriers to Health Care Among U.S. Adults With Intellectual and Developmental Disabilities

Barriers to health care access can greatly affect one's health status. Research shows that U.S. adults with intellectual and developmental disabilities (IDD) have poor health and face barriers such as long waits for appointments. However, whether barriers differ by race and ethnicity has not been examined. We conducted a secondary data analysis using the 2002-2011 Medical Expenditure Panel Survey dataset, and compared perceived barriers of community-living U.S. adults with IDD in three racial and ethnic groups (White, Black, and Latinx). Specifically, we examined the top reasons for not having usual source of care, delaying or foregoing medical care. For Black and Latinx adults with IDD, the most-mentioned reasons for not having usual source of care, delaying or foregoing medical care were "don't like/don't trust doctors," "don't use doctors," and "don't know where to get care." In comparison, the White adults with IDD group's biggest perceived barriers were location and insurance related. All groups cited that being unable to afford care was a top reason for delaying or foregoing care. Policies/interventions to improve health care access in racial/ethnic minorities with IDD must first address the topic of developing trust between patients and the health professions. Insurance and the rising costs of care are also key areas that need attention.

High 30-day readmission rates associated with Clostridiumdifficile infection

BACKGROUND

Clostridium difficile infection (CDI) is a leading cause of community-onset and healthcare-associated infection, with high recurrence rates, and associated high morbidity and mortality. We report national rates, leading causes, and predictors of hospital readmission for CDI.

METHODS

Retrospective study of data from the 2013 Nationwide Readmissions Database of patients with a primary diagnosis of CDI and re-hospitalization within 30-days. A multivariate regression model was used to identify predictors of readmission.

RESULTS

Of 38,409 patients admitted with a primary diagnosis of CDI, 21% were readmitted within 30-days, and 27% of those patients were readmitted with a primary diagnosis of CDI. Infections accounted for 47% of all readmissions. Female sex, anemia/coagulation defects, renal failure/electrolyte abnormalities and discharge to home (versus facility) were 12%, 13%, 15%, 36%, respectively, more likely to be readmitted with CDI.

CONCLUSIONS

We found that 1-in-5 patients hospitalized with CDI were readmitted to the hospital within 30-days. Infection comprised nearly half of these readmissions, with CDI being the most common etiology. Predictors of readmission with CDI include female sex, history of renal failure/electrolyte imbalances, anemia/coagulation defects, and being discharged home. CDI is associated with a high readmission risk, with evidence of several predictive risks for readmission.

Racial/Ethnic Disparities in Dental Service Utilization for Foreign-Born and U.S.-Born Middle-Aged and Older Adults

This study examines racial/ethnic disparities of dental service utilization for foreign-born and U.S.-born dentate residents aged 50 years and older. Generalized linear mixed-effects models (GLMM) were used to perform longitudinal analyses of five-wave data of dental service utilization from the Health and Retirement Study (HRS). We used stratified analyses for the foreign-born and U.S.-born and assessed the nonlinear trend in rates of dental service utilization for different racial/ethnic groups. Findings indicate that Whites had higher rates of service utilization than Blacks and Hispanics regardless of birthplace. For all groups, the rates of service utilization decreased around age 80, and the rates of decline for Whites were slower than others. The U.S.-born showed the trend of higher rates of service utilization than the foreign-born for all racial/ethnic groups. These findings suggest the importance of developing culturally competent programs to meet the dental needs of the increasingly diverse populations in the United States.

Association of Income Disparities with Patient-Reported Healthcare Experience

BACKGROUND

Disparities in health outcome exist among patients according to socioeconomic status. However, little is known regarding the differences in healthcare experiences across the various levels of income of patients. In a nationally representative US adult population, we evaluate the differences in healthcare experiences based on patient level of income.

OBJECTIVES

To evaluate the differences in patient healthcare experiences based on level of income.

PATIENTS AND METHODS

We identified 68,447 individuals (mean age, 48 ± 18 years; 55% female) representing 176.8 million US adults, who had an established healthcare provider in the 2010-2013 Medical Expenditure Panel Survey cohort. This retrospective study examined the differences in all five patient-reported healthcare experience measures (access to care, provider responsiveness, patient-provider communication, shared decision-making, and patient satisfaction) under the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We examined the relationship between patient income and their healthcare experience.

RESULTS

Overall, 32% of the study participants were high-income earners while 23% had very-low income. Lower income was consistently associated with poor patient report on healthcare experience. Compared with those with high income, very-low-income-earning participants had 1.63 times greater odds (OR 1.63, 95% CI 1.45-1.82) of experiencing difficulty accessing care, had 1.34 times higher odds (OR 1.34, 95% CI 1.25-1.45) of experiencing poor communication, had higher odds (OR 1.68, 95% CI 1.46-1.92) of experiencing delays in healthcare delivery, and were more likely to report poor provider satisfaction (OR 1.48, 95% CI 1.37-1.61).

CONCLUSION

Lower income-earning patients have poorer healthcare experience in all aspects of access and quality of care. Targeted policies focusing on improving communication, engagement, and satisfaction are needed to enhance patient healthcare experience for this vulnerable population.

Prevalence of insulin glargine vial use beyond 28 days in a Medicaid population

OBJECTIVES

Insulin glargine, one of the most commonly prescribed drugs for diabetes, has a 28-day limit on the use of a 10-mL (1000 units) multiple-dose vial once the bottle is punctured. If patients who are using smaller doses or are not adherent continue to use insulin glargine beyond the 28-day window, it can result in questionable stability and sterility of the product. The aim of this study was to determine the proportion of patients who used each insulin glargine vial for more than 28 days, the mean number of days the vial was used after 28 days, the reason for the extended use, and whether that use had any association with diabetes control and injection site infection.

METHODS

The study was conducted in 2 phases. Phase I was a retrospective database analysis of insulin glargine 10-mL vial use by the adult Medicaid population with type 2 diabetes served by Molina Healthcare to determine the proportion of patients who used each vial beyond 28 days. Phase II was a cross-sectional telephone interview to identify the reasons for the extended use.

RESULTS

Of the 269 patients identified, 81% used it for more than 28 days, with a mean of 43 days. Of the interviewed patients, 60% did not discard the vials after 28 days because of a lack of awareness. Patients who were aware of the 28-day limit were informed by a pharmacist or diabetes educator.

CONCLUSION

A large proportion of Medicaid patients were found to use insulin glargine past the recommended 28-day limit. More work is needed with a larger sample size to determine whether reasons besides lack of awareness affect the use of insulin glargine beyond its expiration and the role of pharmacists and diabetes educators in improving adherence to disposing of the drug after 28 days.

Association between race/ethnicity and disability status and receipt of vaccines among older adults in Florida

BACKGROUND

Individuals living with a disability or are a member of a certain racial/ethnic group may be at heightened risk for not receiving important vaccinations.

OBJECTIVE

This study examined whether race/ethnicity and disability status are associated with the receipt of two vaccines (influenza and pneumococcal) among older adults living in Florida.

METHODS

Using the 2011-2015 Florida Behavioral Risk Factor Surveillance System, a cross-sectional survey, we ran bivariate and multivariate analyses to determine the associations for race/ethnicity and disability status with receipt of vaccinations among individuals 65 years and older. Interactions between race/ethnicity and disability status were tested in each model.

RESULTS

Among our study sample, 68% received the pneumococcal vaccine in their lifetime and 54% of them received influenza vaccine in the past 12 months. Multivariate logistic regression indicated that Non-Hispanic Blacks and Hispanics were less likely to receive both vaccines compared to Non-Hispanic Whites. Older adults with a disability were more likely to receive influenza and pneumococcal vaccines compared to those without. A significant interaction was observed between race/ethnicity and disability status for predicting pneumococcal vaccination receipt.

CONCLUSIONS

Large proportions of older adults in Florida continue to go without needed vaccinations. Although race/ethnicity and disability status were shown to have some association with receipt of vaccines, having a regular source of care, employment and income also were shown to be important predictors.

Acculturation and Dental Service Use Among Asian Immigrants in the U.S

INTRODUCTION

The objective of this study was to assess dental service utilization across different Asian immigrant groups and to examine the relationship between acculturation and dental service utilization among Asian immigrants in the U.S.

METHODS

Data were from the 2013 and 2014 National Health Interview Surveys. Multiple logistic regression models were used to examine the association between acculturation and having a dental visit in the previous 12 months, controlling for predisposing, enabling, and need factors. Acculturation was measured by length of stay in the U.S., English language proficiency, and U.S. citizenship. The sample was 2,948 adult Asian immigrants who were dentate. Data were analyzed in 2016.

RESULTS

Dental service utilization varied across Asian immigrant groups. High English proficiency and longer length of stay were significantly associated with having a dental visit (p<0.05). In the final model, after adding enabling factors-dental insurance and family income levels-length of stay in the U.S. (≥5 years) remained significant, whereas English language proficiency was not a significant correlate of having a dental visit.

CONCLUSIONS

Length of stay in the U.S. is a significant factor affecting dental service utilization among Asian immigrants.

Self-Care Disparities Among Adults with Type 2 Diabetes in the USA

Suboptimal glycemic control is more common among non-Hispanic Blacks (NHBs) and Hispanics than non-Hispanic Whites (NHWs). Disparities in the performance of self-care behaviors may contribute to this. To synthesize knowledge on current self-care disparities, we reviewed studies from January 2011-March 2016 that included NHWs, NHBs, and Hispanics with type 2 diabetes in the USA. Self-care behaviors included diet, exercise, medications, self-monitoring of blood glucose (SMBG), self-foot exams, and not smoking. Of 1241 articles identified in PubMed, 25 met our inclusion criteria. These studies report consistent disparities in medication adherence. Surprisingly, we found consistent evidence of no disparities in exercise and some evidence of reverse disparities: compared to NHWs, Hispanics had healthier diets and NHBs had more regular SMBG. Consistent use of validated measures could further inform disparities in diet and exercise. Additional research is needed to test for disparities in self-foot exams, not smoking, and diabetes-specific problem solving and coping.

Clostridium difficile infection health disparities by race among hospitalized adults in the United States, 2001 to 2010

BACKGROUND

Recognition of health disparities in Clostridium difficile infection (CDI) is an initial step toward improved resource utilization and patient health. The purpose of this study was to identify health disparities by black vs. white race among hospitalized adults with CDI in the United States (U.S.) over 10 years.

METHODS

This was a retrospective analysis of the U.S. National Hospital Discharge Surveys from 2001 to 2010. Eligible cases included adults with an ICD-9-CM code for CDI (008.45). Patients with missing race or "other race" were excluded. The primary outcome, CDI incidence, was calculated as CDI discharges per 1,000 total discharges. Data weights were used to determine national estimates. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and severe CDI. Comparisons were made using bivariable analyses. Race was assessed as an independent risk factor for CDI outcomes using logistic regression or proportional hazards models.

RESULTS

These data represent 1.7 million CDI discharges, where 90 % of patients were identified as white and 10 % black. Blacks differed from whites with respect to all baseline characteristics (p <0.0001). CDI incidence was significantly higher in whites compared to blacks (7.7/1,000 discharges vs. 4.9/1,000 discharges, p < 0.0001). Blacks had higher mortality (7.4 % vs. 7.2 %, p < 0.0001), LOS >7 days (57 % vs. 52 %, p < 0.0001), and severe CDI (24 % vs. 19 %, p < 0.0001). In multivariable analyses, black race was a positive predictor of mortality (OR 1.12, 95 % CI 1.09-1.15) and severe CDI (OR 1.09, 95 % CI 1.07-1.11), and negative predictor for hospital LOS (OR 0.93, 95 % CI 0.93-0.94).

CONCLUSIONS

CDI incidence was higher for white patients; however, black race was independently associated with mortality and severe CDI.

Differentiation of self-rated oral health between American non-citizens and citizens

BACKGROUND

Oral health disparities exist in the USA. However, little is known of the relationship between oral health disparity and citizenship. The aims of this study were: (i) to describe the differences in self-rated oral health (SROH) between adult American citizens and non-citizens (>20 years of age); and (ii) to test whether factors such as frequency of dentist visits and socio-economic status (SES) are differently associated with SROH in these two groups.

METHODS

The data used in this study were drawn from the National Health and Nutrition Examination Survey conducted in 2011-2012. Weighted logistic regression models were used to detect the strengths of the association between a series of predictors and SROH.

RESULTS

More non-citizens (59.54%) than their citizen peers (26.24%) rated their oral health as fair/bad. All factors analysed in this study were differently associated with SROH based on citizenship. More specifically, natural characteristics, such as ethnicity and age, were significantly associated with SROH among non-citizens, and SES was significantly associated with American citizens. Among non-citizens, Hispanic, Non-Hispanic Black and Asian subjects were more likely than Non-Hispanic White subjects to report their oral health as being 'good'. Family poverty level, education and the frequency of dentist visits were significantly associated with SROH among citizens.

CONCLUSION

The findings of this study indicate that American immigrants report their oral health across most dimensions as being worse than do American citizens. Each explanatory factor may have a different strength of association with SROH in immigrants and citizens, which implies that different steps should be taken within these groups to reduce disparities in oral health.

Disparities in the prevalence of comorbidities among US adults by state Medicaid expansion status

INTRODUCTION

About 92% of US older adults have at least one chronic disease or medical condition and 77% have at least two. Low-income and uninsured adults in particular experience a higher burden of comorbidities, and the Medicaid expansion provision of the Affordable Care Act was designed to improve access to healthcare in this population group. However, a significant number of US states have declined expansion. The purpose of this study is to determine the distribution of low-income and uninsured adults in expanded versus non-expanded states, and evaluate the prevalence of comorbidities in both groups.

METHODS

Data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) dataset was analyzed, and Medicaid expansion status was assessed from the Center for Medicare and Medicaid Services report on State Medicaid and CHIP Income Eligibility Standards. Next, age adjusted mean number of comorbidities between expanded and non-expanded states was compared, with adjustment for socio-demographic differences.

RESULTS

Expanded states had a higher proportion of adults with income of at least $50,000 per year (39.6% vs. 35.5%, p<0.01) and a lower proportion of individuals with no health insurance coverage (15.2% vs. 20.3%, p<0.01) compared with non-expanded states. Among the uninsured, there was a higher proportion of obese (31.6% vs. 26.9%, p<001), and higher average number of comorbidities (1.62 vs. 1.52, p<0.01) in non-expanded states compared to expanded states. Overall, the prevalence of comorbidities was higher among BRFSS participants in states that did not expand Medicaid compared with those in expanded states.

CONCLUSION

States without Medicaid expansion have a greater proportion of poor, uninsured adults with more chronic diseases and conditions.

Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population

Adverse Childhood Experiences (ACEs), which include family dysfunction and community-level stressors, negatively impact the health and well being of children throughout the life course. While several studies have examined the impact of these childhood exposures amongst racially and socially diverse populations, the contribution of ACEs in the persistence of socioeconomic disparities in health is poorly understood. To determine the association between ACEs and health outcomes amongst a sample of adults living in Philadelphia and examine the moderating effect of Socioeconomic Status (SES) on this association, we conducted a cross-sectional survey of 1,784 Philadelphia adults, ages 18 and older, using random digit dialing methodology to assess Conventional ACEs (experiences related to family dysfunction), Expanded ACEs (community-level stressors), and health outcomes. Using weighted, multivariable logistic regression analyses along with SES stratified models, we examined the relationship between ACEs and health outcomes as well as the modifying effect of current SES. High Conventional ACE scores were significantly associated with health risk behaviors, physical and mental illness, while elevated Expanded ACE scores were associated only with substance abuse history and sexually transmitted infections. ACEs did have some differential impacts on health outcomes based on SES. Given the robust impact of Conventional ACEs on health, our results support prior research highlighting the primacy of family relationships on a child's life course trajectory and the importance of interventions designed to support families. Our findings related to the modifying effect of SES may provide additional insight into the complex relationship between poverty and childhood adversity.

Racial/Ethnic Disparity in Utilization of General Dental Care Services Among US Adults: Medical Expenditure Panel Survey 2012

OBJECTIVE

The objective of this study was to examine racial/ethnic disparity and associated factors in general dental care utilization among US adults.

METHODS

Data were adults 18-85 years old (N = 27,394) from the 2012 Medical Expenditure Panel Survey (MEPS). The outcome was the receipt of general dental care, measured by (1) whether the individual has ever had a general dental visit and (2) the number of general dental visits the individual has had during the past year. Race/ethnicity was the primary interest. Logistic regressions and negative binomial regressions were conducted using STATA version 12 to assess the effect of race/ethnicity on the receipt of general dental care both independently and adjusted for other demographic and socioeconomic factors.

RESULTS

Non-Hispanic blacks (odds ratio (OR) 0.39, 95 % confidence intervals (CI) 0.37-0.43), Hispanics (0.34, 0.43-0.37), and other minorities (0.61, 0.56-0.68) were less likely to report general dental visits both independently and adjusted for other demographic and socioeconomic factors, compared with non-Hispanic whites. General dental visits were more likely to be observed among individuals who were female, married, native speakers, living in a metropolitan statistical area, and with dental insurance, and the number of visits was increasing with age, educational level, and family income.

CONCLUSION

The race/ethnicity disparity in the utilization of general dental care still existed. Policy makers and dental care providers should promote dental insurance coverage and language support programs, and increase the diversity of dental professionals among minorities to encourage their visits to dentists.

Differences in Presentation and Management of Pediatric Facial Lacerations by Type of Health Insurance

Introduction

Limited data are available regarding differences in presentation and management of pediatric emergency department (PED) patients based on insurance status. The objective of the study was to assess the difference in management of pediatric facial lacerations based on medical insurance status.

Methods

We conducted a retrospective cohort study with universal sampling of patients with facial lacerations who were treated in an urban PED (45K visits/year) over a one-year period. Demographic features and injury characteristics for patients with commercial (private) insurance and those with Medicaid or Medicare (public) insurance were compared.

Results

Of 1235 children included in the study, 667 (54%) had private insurance and 485 (39%) had public insurance. The two groups did not differ in age or gender, arrival by ambulance, location of injury occurrence, mechanism of injury, part of face involved, length or depth of laceration, use of local anesthetic, or method of repair but differed in acuity assigned at triage. Patients with public insurance were found less likely to have subspecialty consultation in bivariable (OR=0.41, 95% CI [0.24–0.68]) and multivariable logistic regression analyses (OR=0.45, 95% CI [0.25–0.78]). Patients with public insurance received procedural sedation significantly less often than those with private insurance (OR=0.48, 95% CI [0.29–0.76]). This difference was not substantiated in multivariable models (OR=0.74, 95% CI [0.40–1.31]).

Conclusion

Patients with public insurance received less subspecialty consultation compared to privately insured patients despite a similarity in the presentation and characteristics of their facial lacerations. The reasons for these disparities require further investigation.

Influence of socio-demographic characteristics on eye care expenditure: data from the Medical Expenditure Panel Survey 2007

OBJECTIVE

To evaluate the association between sociodemographic factors and eye care expenditure and to assess the burden of ocular expenditure compared to total health care expenditure.

METHODS

A retrospective analysis of ocular expenditure in participants of the 2007 Medical Expenditure Panel Survey. Data from 20,620 unique participants aged ≥18 years were evaluated for eye care expenditure by demographic characteristics.

RESULTS

A total of 22% of the studied population had eye care expenditures in 2007. Demographic factors significantly associated with higher probability of having eye care expenditures included older age (65+ years 35%, 45-64 years 23%, <45 years 17%), female sex (female 26%, male 19%), higher educational attainment (greater than high school education 25%, less than high school education 17%), having insurance (private 24%, uninsured 13%), and visual impairment (mild 31%, none 22%). Older age, female sex, higher educational attainment, having insurance, and presence of visual impairment were also significantly associated with higher mean eye care expenditure. In those with eye care expenditure, the mean ratio between eye care and total medical expenditure was 24%, with uninsured patients spending 42% of their medical care expenditure on eye care.

CONCLUSIONS

Demographic factors are associated with both the probability of having ocular expenditure and the amount of expenditure. Of all factors examined, insurance status has the most potential for modification. Policy makers should consider these numbers when devising the terms by which eye care coverage will be provided under the Patient Protection and Affordable Care Act.

Comparison of Latino and non-Latino patients with Ewing sarcoma

BACKGROUND

Ewing sarcoma (ES) is a malignancy of bone and soft tissue in children and adults. Previous registry-based studies indicate that Latino patients with ES have inferior outcomes compared to non-Latino patients, though an etiology for this difference could not be identified. To explore possible differences that might underlie this disparity, we conducted a retrospective study to compare clinical characteristics, tumor features, healthcare access, and treatment outcomes between Latino and non-Latino patients with ES.

METHODS

Primary data for 218 ES patients treated at two academic medical centers between 1980 and 2010 were collected. Categorical data were compared using Fisher exact tests; Wilcoxon rank-sum tests were used for continuous variables. Survival was estimated using Kaplan-Meier analysis and compared using log-rank testing.

RESULTS

Latino patients were diagnosed at a younger age (P = 0.014). All other clinical and histological data were similar between groups, including radiologic and histologic response to neoadjuvant chemotherapy. Latino patients had lower socioeconomic status (P = 0.001), were less likely to have insurance (P = 0.001), and were more likely to present to the emergency room at onset of symptoms (P = 0.031) rather than to primary care physicians. Five-year event free survival (EFS) and overall survival (OS) were similar between Latino and non-Latino patients (EFS: 60.5% vs. 50.9% P = 0.37; OS: 77.6% vs. 68.6% P = 0.54).

CONCLUSION

Latino patients with ES present at a younger age, and have evidence of impaired access to healthcare. Response to initial therapy appears similar between Latino and non-Latino patients.

Perceived Barriers Affecting Access to Preventive Dental Services: Application of DEMATEL Method

Background

Identifying perceived access barriers to preventive dental services is one of the basic steps to improve the public health.

Objectives

This study aimed to determine the perceived barriers affecting access to preventive dental services in one of Tehran dental clinics in 2012.

Patients and Methods

This research was a cross-sectional descriptive-analytical study conducted in one of Tehran dental clinics in 2012 using decision–making trial and evaluation laboratory (DEMATEL) method. The study sample included all patients (100 patients) who had referred to the endodontic treatment department from 26 - 31 May, 2012. The required data were collected using a questionnaire. Collected data were analyzed using SPSS 18.0 and MATLAB 7.9.0 SPSSS 18.0, as well as, some descriptive and analytical tests including Mean, Standard Deviation (SD), and Independent T- Test.

Results

The five determinants of cost, inconvenience, fear, organization, and patient-dentist relationship were determined as barriers to access to dental services among which the cost and patient-dentist relationship were identified as the first and last priorities with the coordinates (1.4 and 1.4) and (1.25 and -0.65), respectively.

Conclusions

High cost of dental care has led to not referring patients to the clinic. Oral health costs are too high; however insurance organizations have no commitment to support such services. Policymakers, administrators, and insurance organizations have a major role in improving access to dental services. These decision-makers in making their policies can provide the required financial resources, shift the available resources towards preventive care and periodic checkups, and consider providing proper and sufficient places for dental care facilities.

Race/ethnicity, insurance, income and access to care: the influence of health status

OBJECTIVES

To examine health care access disparities with regard to health status and presence of functional limitations, a common measure of disability and multimorbidity, after controlling for individual's race/ethnicity, insurance status and income in the U.S. using the latest survey data.

METHODS

Using data from the 2009 Family Core component of the National Health Interview Survey (NHIS), we examined six measures of access to care in the twelve months prior to the interview. Covariates included self-perceived health status and the presence of functional limitations, race/ethnicity, insurance status, income, and other socioeconomic characteristics. Multiple logistic regressions were used to examine the associations.

RESULTS

People with functional limitations or worse health status experience greater barriers to access. Insurance status was the single factor that was associated with all six measures of access. Disparities among racial/ethnic groups in most access indicators as well as income levels were insignificant after taking into account individuals' health status measures.

CONCLUSIONS

Interventions to expand insurance coverage and the Patient Protection and Affordable Care Act are expected to contribute to reducing disparities in access to care. However, to further improve access to care, emphasis must be placed on those with poorer health status and functional limitations.

Self-reported oral cancer screening by smoking status in Maryland: trends over time

OBJECTIVES

The study aims to examine whether a higher proportion of current and former smokers reported having an oral cancer screening (OCS) exam in the past year compared with never smokers in Maryland between 2002 and 2008.

METHODS

Secondary analysis of the Maryland Cancer Surveys (conducted in 2002, 2004, 2006, and 2008), population-based, random-digit-dial surveys on cancer screening among adults age 40 years and older. Of 20,197 individuals who responded to the surveys, 19,054 answered questions on OCS and smoking. Results are weighted to the Maryland population.

RESULTS

Self-reported OCS in the past year increased from 33 percent in 2002 to 40 percent in 2008. Screening among never and former smokers increased from about 35 percent to 42 percent and from 35 percent to 43 percent, respectively; screening among current smokers remained between 23 percent and 25 percent. In the adjusted analysis, current smokers had decreased odds of screening compared with never smokers; no significant difference was observed between former and never smokers. When the variable dental visit in the last year was included in the adjusted analysis, it became the strongest predictor of OCS.

CONCLUSIONS

Between 2002 and 2008, self-reported OCS in the last year increased among former and never smokers, but remained unchanged for current smokers. A visit to a dental professional attenuated the difference in OCS between current and never smokers. Dental visit in the last year was the strongest predictor of OCS.

Racial and ethnic disparities in Alzheimer's disease pharmacotherapy exposure: an analysis across four state Medicaid populations

BACKGROUND

Treatment disparities in Alzheimer's disease (AD) have received little attention. Determining whether disparities exist in this subpopulation is an important health policy issue.

OBJECTIVE

The aim was to determine whether an association existed between race/ethnicity and exposure to AD pharmacotherapy across 4 state Medicaid populations.

METHODS

Data from the Centers for Medicare and Medicaid Services (CMS) were used in this retrospective study. Persons with AD enrolled in California, Florida, New Jersey, or New York Medicaid programs on January 1, 2004, and remained in that program for 1 year. Individuals had an AD diagnosis based on the ICD-9-CM code 331.0. Outcomes of interest were exposure to a cholinesterase inhibitor (ChEI) or memantine. Multivariate logistic regression was used to test for the association between race/ethnicity and exposure to a ChEI or memantine. Variables of interest included demographic characteristics and resource utilization factors. The Oaxaca-Blinder decomposition method was used to test for disparities to determine whether exposure to AD pharmacotherapy was influenced by race.

RESULTS

Race, age, long-term care admittance, inpatient care admittance, state of residence, and sex were significant predictors of AD pharmacotherapy exposure (P < 0.0001 for all variables). Racial/ethnic disparities were observed with respect to exposure to a ChEI or memantine between non-Hispanic whites and Hispanics (in favor of Hispanics) in Florida (P < 0.0001), between non-Hispanic blacks and Hispanics (in favor of Hispanics) in California (P < 0.0001) and Florida (P < 0.0001), between non-Hispanic blacks and non-Hispanic others (in favor of non-Hispanic others) in California (P < 0.0001) and New York (P < 0.0001), and between Hispanics and non-Hispanic others (in favor of non-Hispanic others) in California (P = 0.001) and New York (P < 0.0001).

CONCLUSIONS

Disparities in AD pharmacotherapy exposure among minority populations are just as prevalent, if not of greater magnitude, than minority/white disparities.

Racial difference in diabetes preventive care

BACKGROUND

Diabetes has long been a leading cause of death in the United States, and worldwide. Diabetes-related preventive services are recommended to delay or to avoid diabetes complications. Racial disparity in the receipt of diabetes preventive care is well documented; however, little is known about the contributors to this disparity.

OBJECTIVE

This study aims to explore potential mediators linking race/ethnic disparities to reduced receipt of preventive care, and to better understand the dynamics underlying the relationships between race/ethnic characteristics and preventive care. Implications for pharmacist roles are explored.

METHODS

This study used 2008 Medical Expenditure Panel Survey (MEPS) data. The outcome of diabetes preventive care was assessed by participants' self-reports in MEPS. Household income and health insurance coverage were identified as potential mediators based on Andersen's Health Care Utilization Behavior model. Logistic regression was used to examine the direct effects of study independent variables on diabetes preventive care. Path analysis was conducted to identify racial disparities' direct and indirect effects on diabetes preventive care via potential mediators. All estimates were weighted to the U.S. non-institutionalized population.

RESULTS

Racial differences occurred with respect to receiving A1C tests, diabetic foot exams, and eye exams. After controlling for patient age, gender, living area, income, and health insurance status, racial differences persisted in diabetes preventive care. Hispanics were the least likely to receive all three elements of diabetes preventive care. In addition, patients were less likely to receive diabetes preventive care who were younger, lived in rural areas, had lower family income and were uninsured. A lower rate of diabetes preventive care in minority patients was partially explained by their higher rate of being uninsured or having low family income.

CONCLUSION

The results suggest that minority, rural, low-income, uninsured, and young diabetes patients are at a higher risk of not receiving diabetes preventive care. This study is unique in its use of path analysis to assess racial disparities in diabetes preventive care and to do so drawing on Andersen's Health Care Utilization Behavior model. In response to the disparity findings which were reinforced in this study, pharmacists have a need and an opportunity to help identify and address important gaps in diabetes preventive care through diabetes patient assessment, education, referral, and monitoring.

Text messaging for enhancement of testing and treatment for tuberculosis, human immunodeficiency virus, and syphilis: a survey of attitudes toward cellular phones and healthcare

OBJECTIVES

The objective of this study was to assess knowledge, attitudes, and behaviors surrounding healthcare-related mobile phone use and text messaging among persons at risk for or infected with tuberculosis (TB) or the human immunodeficiency virus (HIV).

METHODS

An anonymous survey was conducted in three groups of subjects: (1) HIV-infected persons attending an HIV clinic; (2) persons with latent TB infection at a public health clinic; and (3) persons presenting for TB, HIV, and syphilis screening at a community screening site.

RESULTS

Three hundred fifteen (n  = 315) persons responded to the survey, of whom 241 (76.5%) owned a cell phone. Cell phone owners were younger and more educated than nonowners. Transportation difficulty and forgetting appointments were cited as significant barriers by 34.2% and 39.5% of respondents, respectively. Fifty-six percent of subjects felt it would be acceptable to receive text message appointment reminders, and 33% felt that text message reminders to take medications would be acceptable. Younger age and cell phone ownership were significantly associated with acceptance of text message reminders. Black and Hispanic subjects were more likely to feel that text message reminders for appointments or medications were helpful than White subjects. Further, Black and Hispanic subjects, as well as subjects with lower educational attainment, were more receptive to healthcare-related educational text messages.

CONCLUSIONS

Cell phones and text messaging were prevalent among our subjects attending HIV and TB clinics, and subjects were generally receptive to text messaging for healthcare-related communication. Interventions that explore the potential for text messaging to improve clinic attendance, medication adherence, and health knowledge should be explored.