Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review

The Value and Challenges of an Ambulatory Intermediate Care Clinic: A Mixed-Methods Analysis

BACKGROUND

Emergency department (ED) crowding is a persistent issue in health care, resulting in increased mortality and medical errors. This challenge is particularly pronounced in underserved populations, where a higher prevalence of chronic conditions and ED utilization exacerbates gaps in care. To address this, system-level strategies, including the establishment of intermediate care clinics, are essential. This study evaluates the first three years of a nurse-led ambulatory intermediate care clinic (AICC) in the Southern US, focusing on its role in enhancing care continuity and operational challenges for expansion.

METHODS

This study, conducted at the University of Alabama at Birmingham Medical Center in Birmingham, Alabama, the United States, used a convergent parallel mixed-methods design, analyzing quantitative data from 3137 AICC appointment records (May 2020-June 2023) and conducting qualitative interviews with AICC staff members. Quantitative data included patient demographics and appointment characteristics. Qualitative data were thematically analyzed to identify common themes around AICC benefits and challenges.

RESULTS

Our quantitative analysis showed that the AICC managed an increasing number of patient visits with a stable appointment adherence rate. However, rising clinic-initiated cancellations indicated resource limitations. Qualitative findings provided further context for these quantitative trends. Patients from racial minority groups and those with Medicaid insurance had significantly higher odds of missing appointments. The results highlighted the AICC's value in preventing ED visits but also revealed challenges related to patient acuity level, resource allocation, scheduling complexities, and appointment adherence barriers.

CONCLUSIONS

Establishing a nurse-led AICC is feasible and beneficial in alleviating the care gap between primary and acute care and reducing ED crowding. Key considerations for sustainable success include determining patient acuity thresholds, streamlining same-day referral processes, and addressing capacity issues. These findings can guide health systems in implementing intermediate care clinics in ambulatory settings, particularly for those serving underserved communities.

Low socioeconomic indicators correlate with critical preoperative glenoid bone loss and care delays

BACKGROUND

Chronic and recurrent shoulder dislocations prior to stabilization can increase the risk of glenoid bone loss. Glenoid bone loss exceeding critical levels can lead to further instability and decreased outcomes following arthroscopic labral repair. Indicators of low socioeconomic status (SES), such as high Area Deprivation Index (ADI) and noncommercial insurance, are related to generalized delays to orthopedic care, which can cause recurrent instability and increase glenoid bone loss.

HYPOTHESIS

Higher national ADI and noncommercial insurance would be associated with greater levels of radiographic glenoid bone loss after glenoid instability.

METHODS

A retrospective study was performed with patients who underwent anterior labral repair. Chart review included demographics, course of care data, preoperative instability data, national ADI, and insurance status. The Neighborhood Atlas Website and patients' home addresses were used to obtain national ADI. Glenoid bone loss was measured using the best-fit circle Pico method on three-dimensionally aligned magnetic resonance images. Researchers were blinded to SES indicators during radiographic analysis. Glenoid bone loss was compared between SES indicators using one-way analysis of variance.

RESULTS

One hundred forty-six patients met inclusion criteria and had complete datasets (23.3% female; 22.4 ± 7.0-year-old; national ADI = 16.1 ± 15.3). Patients experienced on average 9.12 ± 6.63% glenoid bone loss. A curve fitting tool determined a quadratic nonlinear regression best characterized the association of glenoid bone loss and ADI (R2 = 0.392, P < .001). Individuals with commercial insurance experienced 8.58% ± 6.69% glenoid bone loss as compared to 11.78% ± 6.30% in individuals with Medicaid insurance (P = .03). Critical bone loss at a threshold of 13.5% was more likely with higher national ADI (P < .001) and Medicaid insurance (OR = 2.49, CI = 1.02-6.09). However, only national ADI was predictive of subcritical bone loss at a threshold of 10% (P < .001).

CONCLUSION

Patients with greater national ADI and Medicaid insurance status had greater rates of critical preoperative glenoid bone loss at a threshold of 13.5%. Greater national ADI is also predictive of subcritical glenoid bone loss at a threshold of 10% and overall glenoid bone loss. Further study is needed to assess the postoperative implications of these findings in this population.

Trends in Treatment Choice for Early Glottic Cancer

Background/Objective: Systemic investigation into treatment for early-stage glottic cancer (EGC) has demonstrated similar functional and oncologic outcomes between transoral laser microsurgery (TLM) and external beam radiotherapy (XRT). In this study, we aim to identify longitudinal trends in treatment decisions and patient demographics. Methods: This is a retrospective longitudinal study on all cases of T1-2N0M0 glottic carcinoma queried from the NCDB between 2004 and 2017. The ratio of TLM to XRT (TLM/XRT) performed per year was calculated and further stratified by insurance status, education, income, and treatment facility location. Univariable and multivariable linear regressions were used to assess the trend of TLM/XRT over time and evaluate the effect of demographic characteristics on the TLM/XRT ratio. Results: A total of 38,428 EGC patients were analyzed: 2169 (5.6%) received TLM; 36,259 (94.4%) underwent XRT. The overall ratio of TLM/XRT increased over time from 0.04 in 2004 to 0.08 in 2017. Significant increases were observed in the higher-income quartiles (Q4: p < 0.001, Q3: p = 0.02, Q2 < 0.001) and among patients with private (p < 0.02) or public (p = 0.003) insurance. TLM/XRT rose significantly over time in the highest (Q4), third (Q3), and lowest (Q1) education quartiles but not in the second (Q2). Regionally, increases were observed in the Northeast (p < 0.001) and West (p = 0.008), with no significant change in the South or Midwest. By T stage, only T1 tumors showed a significant increase in TLM/XRT over time (p < 0.001). Conclusions: While the majority of patients receive XRT as the initial treatment for EGC, the proportion of TLM has been slowly increasing over time. Patient insurance status, education, income, facility geography, and T stage are correlated with increasing use of TLM.

Exploring patterns in pediatric type 1 diabetes care and the impact of socioeconomic status

BACKGROUND

Managing pediatric type 1 diabetes is complex and requires substantial parental involvement. Adherence to clinical guidelines is often inconsistent, and lower parental socioeconomic status is associated with worse outcomes in affected children. However, few studies have examined these children's care pathways multidimensionally over time. This study aims to identify latent clusters in the care pathways of pediatric patients with type 1 diabetes mellitus, evaluate guideline adherence and disease management within these clusters, and assess the influence of socioeconomic status on cluster membership.

METHODS

We analyzed care pathways for pediatric patients with type 1 diabetes from 2017 to 2019 in the German health system, which provides universal coverage. Using state sequence analysis and clustering algorithms from the TraMineR R package, we identified patient clusters based on healthcare utilization patterns. To assess care quality within these clusters, we compared observed care patterns to clinical guideline recommendations. Our analysis was based on health insurance claims data from Techniker Krankenkasse, a statutory health insurer. From the dataset, which encompassed more than three million patients under the age of 25 years, we derived an age-homogeneous cohort of continuously insured children aged 11 to 14 years with type 1 diabetes in 2017 and extracted relevant healthcare events over a 3-year period.

RESULTS

Based on care patterns, we identified two clusters of children, which we designated as the "guideline-adherent" and "care-with-gaps" clusters. Roughly 25% of our cohort (n = 890) fell into the latter cluster, consistently receiving care that fell short of guideline recommendations. For example, these patients had less than half as many quarters with hemoglobin A1c measurement. Lower parental educational attainment and unemployment were predictors of this suboptimal care. We also found that the average number of hospitalizations per child was almost 40% higher in the cluster with less guideline-adherent care.

CONCLUSIONS

Despite universal health coverage and frequent contact with the outpatient healthcare system, a substantial proportion of pediatric type 1 diabetes patients in Germany experience suboptimal care, particularly in glycemic diagnostics and screening for complications, leading to worse health outcomes. Higher socioeconomic status is associated with care that more closely adheres to clinical guidelines.

The 'hub' model for colorectal surgery: a viable paradigm shift?

INTRODUCTION

Nationally, in the aftermath of the first COVID-19 lockdown, the waiting list for elective surgery is approximately 7 million. To ameliorate an evolving crisis and improve system resilience, the Royal College of Surgeons of England proposed a 'New Deal for Surgery', promoting COVID-light sites and elective hubs. We evaluate the short-term outcomes, safety and sustainability of the hub model at a large National Health Service trust.

METHODS

All major elective colorectal operations performed at the hub between 8 March 2021 and 8 March 2022 were included for analysis. Pertinent data on patient demographics, operative performance and postoperative outcomes were analysed using SPSS 27.

RESULTS

In total, 401 cases were analysed. There was one same-day cancellation because of the unavailability of beds (0.2%). Median distance displacement for patients for their primary surgery was +3.2 miles. Twenty-one patients (5.2%) required postoperative blood transfusion. One patient had nosocomial COVID-19 (0.2%), severe complications of Clavien-Dindo grade ≥3 were observed in 33 patient (8.2%) and transfer-out for higher level care occurred in 34 cases (8.5%). Forty-six 30-day readmissions (11.5%) and two deaths (0.4%) were noted. Median length of stay was 6 days.

CONCLUSIONS

The volume of major colorectal surgery at the hub, with acceptable incidence of major complication, transfer-out and minimal patient displacement, attests to the efficacy and safety of the new model.

Nursing and medical students' views on their knowledge related to the Sustainable Development Goals - a mixed methods study at three Swedish universities

BACKGROUND

The challenges that the world faces to ensure good life for future generations are vast and complex. The United Nations Sustainable Development Goals (SDGs) aim to meet these challenges. A growing number of higher education institutions have integrated them within their curricula, but there are indications that health professional education has been lagging behind. Therefore, it is important to better understand the views of students in health professional education on the level and depth of their education on sustainable development.

METHODS

This sequential exploratory mixed methods study was based on survey responses from N = 294 nursing (N = 137) and medical (N = 157) students of first and last semesters from three Swedish universities. From the full group of survey responders, 21 students participated in 5 focus group discussions (FGDs) and 9 individual interviews. The survey findings were summarized through descriptive statistics and the interviews and FGDs were analyzed by qualitative content analysis.

RESULTS

The survey findings showed that most students (63%) perceived that they had not learned enough about the SDGs and Agenda 2030 during their education, or for the purposes of their future career. Most of the students (63%) also thought that Agenda 2030 and the SDGs should be a greater part of their education. The qualitative data gave a more in-depth understanding of the quantitative findings, forming two themes: The first theme revealed that the SDGs may be more relevant for health care practice than what the students initially thought, but that the education they had received was in most places superficial, or not tied to the SDGs. The second theme detailed what and how students wished to learn more about. Here, they called for a more in-depth understanding of how to promote equality, equity, inclusion and psychosocial aspects in health care. They also hoped for more knowledge about how to ensure a sustainable working life for themselves.

CONCLUSIONS

Nursing and medical students at three Swedish universities experience that they lack the knowledge necessary to face sustainability challenges they encounter in working life and give some suggestions about how this may be improved in future education.

Social Factors, Age, and Health at Time of Dementia Diagnosis

Importance

A timely diagnosis is crucial in ensuring high-quality care for individuals with dementia. Comparing age and health status at the time of dementia diagnosis across population subgroups can provide insights into vulnerable groups that may experience delayed diagnosis and/or a poorer prognosis.

Objective

To examine how age and health at the time of dementia diagnosis vary across sociodemographic subgroups.

Design, Setting, and Participants

A nationwide cross-sectional study of individuals with an incident dementia diagnosis from either specialist care or who were dispensed antidementia drugs, identified from the Swedish National Patient Register and the Prescribed Drug Register between January 2018 and December 2022.

Exposures

Sociodemographic status at the time of dementia diagnosis was assessed through linkage with national registers and included education, place of birth, living arrangement, family status, and family disposable income.

Main outcomes and measures

Health status was assessed by calculating the number of dispensed medications during the year preceding dementia diagnosis, as well as the Charlson Comorbidity Index (CCI) and Hospital Frailty Risk Score (HFRS) using specialist diagnoses during the preceding 5 years.

Results

Of the 107 707 individuals with a dementia diagnosis, 61 127 (56.8%) were women and the mean (SD) age at diagnosis was 82.0 (7.7) years. Individuals with lower education, living alone or in a care home, or without a close relative were a mean (SD) of 3.1 (7.3) years older when diagnosed with dementia compared with their counterparts. At the time of diagnosis, individuals who had lower than high school education had higher CCI (odds ratio [OR], 1.11; 95% CI, 1.07-1.15) and more medications (OR, 1.38; 95% CI, 1.33-1.44) compared with those with university education. Age and health status at dementia diagnosis did not differ significantly by place of birth or income.

Conclusions and relevance

This nationwide register-based study indicated that clinical diagnosis of dementia may be significantly delayed among individuals with low education, those living alone or in a care home, or those without a close relative. These groups also had poorer health at the time of dementia diagnosis, which may impact their prognosis negatively. Future efforts should focus on improving health services to better address the diagnostic and care needs of these vulnerable subgroups.

Physical activity, cathepsin B, and cognitive health

Regular physical activity (PA) is beneficial for cognitive health, and cathepsin B (CTSB) - a protease released by skeletal muscle during PA - acts as a potential molecular mediator of this association. PA-induced metabolic and mechanical stress appears to increase plasma/serum CTSB levels. CTSB facilitates neurogenesis and synaptic plasticity in brain regions (e.g., hippocampus and prefrontal cortex) that support performance in specific cognitive domains including memory, learning, and executive function. However, the evidence regarding the role of PA-induced changes in CTSB as a mediator of PA-induced cognitive health in humans is mixed. To guide future research, this article identifies key factors that may explain the observed heterogeneity in the findings from human studies and proposes a PA-CTSB-cognition model.

Diabetic Retinopathy Disease Burden in Patients With Lower Household Incomes vs Higher Household Incomes

Purpose: To assess the differences in measures of diabetic retinopathy (DR) disease burden between patients in high-income vs low-income ZIP codes when presenting to retina specialists. Methods: This retrospective cohort study comprised patients who presented to a retina specialist at Duke Eye Center between 2014 and 2023 for the management of DR. The quartile of patients with the highest income was compared with the quartile with the lowest income. Demographic data included age, sex, and race. Clinical data included glycosylated hemoglobin A1c (HbA1c), visual acuity (VA), DR diagnostic stage, presence of diabetic macular edema (DME) or vitreous hemorrhage, and whether treatment was indicated. Measures of DR disease burden included HbA1c, VA, presence of DME or vitreous hemorrhage, severity of DR, and need for intervention. Results: The analysis included 430 eyes of 215 patients. After controlling for age, sex, race, and glycemic control, it was found that patients in the low-income group were more likely to have DME at presentation (P < .01), to have more severe DR at presentation (P < .001), and to require an intervention for DR (P < .001). The VA was worse in the low-income group than in the high-income group (20/50 vs 20/32; P < .10); however, this did not reach statistical significance. Conclusions: Patients living in low-income ZIP codes have greater DR severity, prevalence of DME, and need for treatment than their high-income counterparts when first presenting to a retina specialist. These findings suggest that patients from low-income backgrounds may face additional barriers before being evaluated by a retina specialist, resulting in more clinically advanced stages of DR at presentation.

Barriers to Total Joint Arthroplasty: A Comparison of High-Poverty and Low-Poverty Communities

OBJECTIVE

Our aim was to determine the most significant barriers to total joint arthroplasty (TJA) for people living in high-poverty communities relative to low-poverty communities.

METHODS

We created a 21-question survey based on interviews with underrepresented minority patients with osteoarthritis targeting five barriers to TJA: trust in surgeon, recovery concerns, cost and/or insurance issues, fear of poor surgical outcomes, and timing considerations. Participants rated the importance of each barrier on a 5-point Likert scale, dichotomized into "very or extremely important" and "not as important." The survey was distributed at New York City clinics and nationally through an arthritis advocacy group. We used geocoding to link addresses to census tracts, defining high-poverty communities as those with ≥20% of residents living below the poverty level. Logistic regression models assessed the association between community poverty status and rating barriers as very or extremely important, with adjustment for demographic and clinical factors.

RESULTS

Of the 702 survey participants, 16.8% were residents of high-poverty communities. After adjustment, participants from high-poverty communities were more likely to rate trust in surgeon (adjusted odds ratio [aOR] 1.87, 95% confidence interval [CI] 1.24-2.82) and fear of poor surgical outcome (aOR 1.68, 95% CI 1.08-2.61) as very or extremely important.

CONCLUSION

People from high-poverty communities identified lack of trust in surgeons and fear of poor surgical outcomes as more significant barriers to TJA compared to people from low-poverty communities.

Area-Level Socioeconomic Status Impacts Health Care Visit Frequency by Australian Patients With Inflammatory Arthritis: Results From the Australian Rheumatology Association Database

OBJECTIVE

Individuals with inflammatory arthritis require long-term rheumatologist care for optimal outcomes. We sought to determine if socioeconomic status (SES) influences general practitioner (GP) and specialist physician visit frequency and out-of-pocket (OOP) visit costs.

METHODS

We linked data from Australian Rheumatology Association Database (ARAD) participants with rheumatoid arthritis or psoriatic arthritis to the Pharmaceutical Benefits (PBS) and Medicare Benefits Schedule from 2011 to 2018. Small-area SES was approximated as quintiles of the Index of Relative Socioeconomic Advantage and Disadvantage. A comorbidity index (Rx-Risk) was determined from PBS data. Analysis was performed using panel regression methods.

RESULTS

We included 1,916 ARAD participants (76.3% rheumatoid arthritis, 71.1% women, mean ± SD age 54 ± 12 years and disease duration 6 ± 4 years). Participants averaged 9.0 (95% confidence interval [CI] 8.6-9.4) annual GP visits and 3.9 (95% CI 3.8-4.1) annual specialist physician visits. After adjustment for sex, age, education, remoteness, and comorbidity, there was an inverse relationship between annual GP visit frequency and higher SES quintile (-0.6, 95% CI -0.9 to -0.3 visits per quintile) and a direct relationship between more frequent specialist visits and higher SES (linear slope 0.3, 95% CI 0.2-0.5 visits per quintile). Average OOP costs/visit were higher for specialist physician (AUD$38.43; 95% CI 37.34-39.53) versus GP visits (AUD$7.86; 95% CI 7.42-8.31), and higher SES was associated with greater OOP cost.

CONCLUSION

Patients with higher SES have relatively fewer GP visits and more specialist physician visits compared with patients with lower SES, suggesting individuals with lower SES may receive suboptimal specialist physician care. OOP costs may be a contributing factor.

Updated Results from the Retrospective CREST Study on the Safety and Effectiveness of 8-Week Glecaprevir/Pibrentasvir in HCV-Infected Treatment-Naïve Patients with Compensated Cirrhosis

INTRODUCTION

This brief report presents updated findings from the previously published CREST study evaluating the safety and effectiveness of 8-week glecaprevir/pibrentasvir (GLE/PIB) in treatment-naïve patients with chronic hepatitis C virus (HCV) infection and compensated cirrhosis. The current study includes an additional 51 patients, presents effectiveness data stratified by additional comorbidities and comedications, and offers insights into healthcare resource utilization.

METHODS

Analysis of treatment-naïve patients with HCV infection and compensated cirrhosis enrolled in the CREST study, a real-world, observational multicenter study. All enrolled patients were included in the full analysis set (FAS); the modified analysis set (MAS) excluded patients with missing SVR12 data, or who discontinued GLE/PIB for nonvirologic failure. The primary endpoint was sustained virologic response at posttreatment week 12 (SVR12) in the MAS. Safety and healthcare resource utilization were also assessed.

RESULTS

The FAS included 437 patients, and the MAS 375. Overall, the results were consistent with the previously published study, with 98.9% of patients in the MAS achieving SVR12. Patients with comorbidities such as alcoholism, diabetes, and hyperlipidemia achieved SVR12 rates > 94%. High SVR12 rates were also achieved by patients receiving comedications such as anxiolytics, antidepressants, and opioid agonists. Of the 26.8% of patients with an adverse event, 1.1% had a serious adverse event, none of which were deemed related to GLE/PIB. Healthcare resource utilization varied by employment status and history of drug use. Active drug users had more physician and nurse visits than specialist visits compared with former drug users.

CONCLUSION

This study provides further evidence on the safety and effectiveness of 8-week GLE/PIB, supporting the use of shorter treatment in treatment-naïve patients with Child-Pugh A cirrhosis including subgroups of interest, regardless of comorbidities and comedications observed in this population. The variable healthcare resource utilization in different patient types can help plan and resource linkage to care better, thus supporting HCV elimination efforts.

Influence of Health System Affiliation and Pain Manifestation on Advanced Oral Cavity Squamous Cell Carcinoma Risk: A Retrospective Cohort Study in a Latin American Population

Background/Objectives: Oral cavity cancer, a subtype of head and neck cancer, is one of the most common malignancies globally. This study assessed the influence of health system affiliation and pain manifestation on the risk of advanced oral cavity squamous cell carcinoma (OCSCC) in a Latin American population. Methods: In this retrospective cohort study, we analyzed medical records from 2015 to 2016, including data from the past 19 years, of 233 patients with OCSCC treated at a public hospital in Medellín, Colombia. Sociodemographic and clinical variables were evaluated, and multivariate regression models incorporated variables significant in bivariate analysis. Results: Among 233 patients, 196 (84.1%) had advanced OCSCC. The sample had a mean age of 63 ± 13 years, 53.6% were male, and 64% came from urban areas with predominantly low socioeconomic levels. Men showed a threefold increased risk of advanced OCSCC (95% CI: 1.3-6.8), while patients referred to pain clinics exhibited a 19.5 times higher risk (95% CI: 2.3-159.5). Patients in the subsidized health system or without health insurance had 2.6 (95% CI: 1.07-6.3) and 2.7 times (95% CI: 1.17-6.4) higher risks, respectively. Conclusions: This study found that male patients, referrals to pain clinics, and subsidized or no health system affiliation significantly increased the risk of advanced OCSCC.

Educational and income inequalities across diseases in Denmark: a register-based cohort study

BACKGROUND

Educational attainment and income are often, but not always, associated with disease incidence. Existing research typically examines single diseases, resulting in disparate analyses with little comparability. In this study, we aimed to assess educational and income inequalities across diseases in Denmark.

METHODS

This register-based study included all Danish residents aged at least 30 years between Jan 1, 2013, and Dec 31, 2022, who were born after 1920, and with known educational attainment and income. We used a disease-wide approach to assess associations between education and income and the incidence of 751 diagnostic codes determined upon hospital admission. We estimated age-standardised incidence rates and incidence rate ratios (IRRs) using Poisson regression, adjusted for birth cohort and stratified by sex. Participants were followed up until time of diagnosis, death, emigration, or until Dec 31, 2022.

FINDINGS

4 541 309 individuals aged 30 years and older were registered as living in Denmark between Jan 1, 2013, and Dec 31, 2022. 121 083 were excluded due to limited or missing information about educational attainment. 4 420 226 individuals were included in the analysis of educational inequalities (2 232 200 [50%] were female and 2 188 026 [50%] were male). 23 708 were excluded due to absence of income information, and 4 396 518 were included in the analysis of income inequalities (2 223 217 (51%) were female and 2 173 301 (49%) were male). Socioeconomic differences in incidence rates were observed across all disease groups; incidence rates of most diseases decreased with higher educational attainment and income. The magnitude of the socioeconomic inequalities varied substantially. Among non-communicable diseases, the strongest positive association with regard to education was observed in chronic obstructive pulmonary disease for female individuals (low education vs high education, IRR 2·7 [95% CI 2·4-3·0]) and schizophrenia for male inividuals (low education vs high education, IRR 4·4 [2·2-8·8]), and the strongest negative association was in melanoma and other skin cancers for females (low education vs high education, IRR 0·7 [0·7-0·8]) and melanoma and skin cancers for males (low education vs high education, 0·7 [0·6-0·8]). With regard to income, for females, the strongest positive association was observed in schizophrenia (quartile 1 [Q1] vs quartile 4 [Q4], IRR 10·1 [6·1-17·2]), whereas the strongest negative association was in melanoma and other skin cancers (Q1 vs Q4, IRR 0·5 [0·5-0·6]). For males, the strongest positive assocation was schizophrenia (Q1 vs Q4, IRR 18·4 [95% CI 8·5-39·9]) and the strongest negative association was also melanoma and other skin cancers (Q1 vs Q4, IRR 0·5 [0·5-0·6]). The most prevalent disease category, other digestive diseases, was also strongly positively associated with education (low education vs high education, IRR 1·6 [95% CI 1·6-1·6] for females; IRR 1·5 [1·4-1·5] for males) and income (Q1 vs Q4, IRR 1·5 [1·5-1·5] for females; IRR 1·3 [1·3-1·4] for males).

INTERPRETATION

Our study provides a detailed representation of the association between two socioeconomic indicators and disease incidence. A broad spectrum of diseases, and not only the most prevalent, show socioeconomic disparities. This finding highlights the need for not only policies that address specific diseases, but also universal policies addressing the root causes of socioeconomic disparities and their health consequences.

FUNDING

The Novo Nordisk Foundation.

Neighborhood Socioeconomic Deprivation and Health Care Costs in Older Community-Dwelling Adults: Importance of Functional Impairment and Frailty

BACKGROUND

Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain.

OBJECTIVES

To estimate the association of neighborhood Area Deprivation Index (ADI) with total, inpatient, outpatient, skilled nursing facility (SNF), and home health care (HHC) costs among older community-dwelling Medicare beneficiaries, and determine whether these associations are explained by multimorbidity, phenotypic frailty, or functional impairments.

DESIGN

Four prospective cohort studies linked with each other and with Medicare claims.

PARTICIPANTS

In total, 8165 community-dwelling fee-for-service beneficiaries (mean age 79.2 years, 52.9% female).

MAIN MEASURES

ADI of participant residence census tract, Hierarchical Conditions Category multimorbidity score, self-reported functional impairments (difficulty performing four activities of daily living), and frailty phenotype. Total, inpatient, outpatient, post-acute SNF, and HHC costs (US 2020 dollars) for 36 months after the index examination.

KEY RESULTS

Mean incremental annualized total health care costs adjusted for age, race/ethnicity, and sex increased with ADI ($3317 [95% CI 1274 to 5360] for the most deprived vs least deprived ADI quintile, and overall p-value for ADI variable 0.009). The incremental cost for the most deprived vs least deprived ADI quintile was increasingly attenuated after separate adjustment for multimorbidity ($2407 [95% CI 416 to 4398], overall ADI p-value 0.066), frailty phenotype ($1962 [95% CI 11 to 3913], overall ADI p-value 0.22), or functional impairments ($1246 [95% CI -706 to 3198], overall ADI p-value 0.29).

CONCLUSIONS

Total health care costs are higher for older community-dwelling Medicare beneficiaries residing in the most socioeconomically deprived areas compared to the least deprived areas. This association was not significant after accounting for the higher prevalence of phenotypic frailty and functional impairments among residents of socioeconomically deprived neighborhoods.

Regional socioeconomic characteristics and density of general practitioners in Germany: A nationwide cross-sectional and longitudinal spatial analysis

OBJECTIVES

Limited healthcare availability impacts population health. Regional disparities in GP density across Germany raise questions about their association with regional socioeconomic characteristics.

STUDY DESIGN

This longitudinal nationwide ecological German study used regional data at the county level (n = 401) from 2015 to 2019 provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). The outcome was general practitioners (GPs) density, defined as the number of GPs per 10,000 inhabitants.

METHODS

Univariate Moran's I, cluster analysis (LISA), and spatial lag of X (SLX) models were employed to analyse the spatial distribution of GP density and its correlation with various regional socioeconomic characteristics from a cross-sectional and longitudinal perspective.

RESULTS

In contrast to the univariate analysis, rural counties showed the highest GP density the multivariate model. Several counties were identified as embedded in low- or high-GP-density clusters. In 2015 and 2019, larger household size (2015: std. β = -2.31, p = 0.021; 2019: std. β = -4.14, p < 0.001) and higher unemployment rate (2015: std. β = -2.84, p = 0.005; 2019: std. β = -5.47, p < 0.001) were associated with lower GP density. In the longitudinal model, a greater increase in the unemployment rate was related to a greater decrease in GP density (std. β = -2.17, p = 0.030).

CONCLUSION

A higher regional unemployment rate is linked to lower GP availability in Germany, and a greater increase in the unemployment rate was related to a greater decrease in GP availability over time. This necessitates policy intervention to avoid socioeconomic disparities in GP care.

The Influences of SES on Patient Choice of Doctor: A Systematic Review

INTRODUCTION

As patients become increasingly involved in healthcare decision-making, it is important to examine the drivers behind patient choice of doctor (PCOD); the initial decision can have lasting impacts on patients' trust in providers and health outcomes. However, limited studies have explored PCOD relative to socioeconomic status (SES) or health disparity. This review identified similar preferences and varied decision criteria in PCOD across SES groups.

METHODS

PubMed, PsycINFO, Web of Science, and relevant cross-references were searched for articles published between January 2007-September 2022. Papers were screened using Covidence. Included studies examined PCOD by income and/or educational levels. Analysis was performed in 2022-2023.

RESULTS

From 4,449 search results, 29 articles were selected (16 countries, 14 medical specialties, total of 32,651 participants). Individuals of higher SES ranked physician characteristics (e.g., qualifications, empathy) or performance more important than cost or convenience. Individuals of lower SES often had to prioritize logistical factors (e.g., insurance coverage, distance) due to resource constraints and gaps in knowledge or awareness about options. Despite differing healthcare systems, such divergence in PCOD were relatively consistent across countries. Some patients, especially females and disadvantaged groups, favored gender-concordant physicians for intimate medical matters (e.g., gynecologist); this partiality was not limited to conservative cultures. Few researchers investigated the outcomes of PCOD and indicated that lower-SES populations inadvertently chose, experienced, or perceived lower quality of care.

DISCUSSION

Patients' decision criteria varied by SES, even under national systems intended for universal access, indicating the impacts of social determinants and structural inequities. Health education supporting patient decision-making and research on how SES affects PCOD and outcomes could help reduce health disparity.

Experiences in healthcare for weight management - a qualitative interview study of retired individuals with obesity and low or high education

BACKGROUND

Overweight and obesity are global health concerns, especially significant for older adults at higher risk for chronic diseases. The transition to retirement, altering daily routines, highlights the need for adequate weight management support. Since obesity is a challenging topic in healthcare and socioeconomic inequalities exist in access and utilization, we examined how retired individuals with obesity and low or high education describe their experiences of unmet needs, mismatches, and successes within the healthcare service system for weight management.

METHODS

This qualitative interview study is part of the Helsinki Health Study. The participants (N = 20, with a body mass index of at least 30 kg/m2) were selected from a cohort of retired former employees of the City of Helsinki. Half of the interviewees had low education, and the other half had high education. Women and men were equally represented. The interviews were conducted in 2023 and the data were analyzed using inductive thematic analysis.

RESULTS

Three main themes were formed: Deficiencies in engaged care, Services are mismatched with needs, and Facilitating conditions for individual successes. The first main theme had two sub-themes: Condescending attitude and Ignoring weight during the appointment. The second main theme had one sub-theme: Inadequate personnel resources. The third main theme had one sub-theme: Individual opportunities to acquire information and treatment. Educational differences were most clearly reflected in the sub-themes. Participants with low education more often described experiencing a condescending attitude towards them when seeking care and had had difficulties in obtaining time for appointments due to inadequate resources. Participants with high education described broader experiences related to individual opportunities to acquire information and treatment within the healthcare service system than participants with low education.

CONCLUSIONS

The participants in this study highlighted the importance of respectful engagement with the subject of their weight and felt that these kinds of interaction skills should still be developed in healthcare personnel. The participants articulated a need for approaches that are tailored to their unique circumstances. According to the participants, long-term group intervention, provided with peer support and supported by a multidisciplinary team, could sustain their weight management.

Perceived discrimination and refraining from seeking physician's care in Sweden: an intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA)

BACKGROUND

Discrimination may further impede access to medical care for individuals in socially disadvantaged positions. Sociodemographic information and perceived discrimination intersect and define multiple contexts or strata that condition the risk of refraining from seeking physician's care. By applying analysis of individual heterogeneity and discriminatory accuracy (AIHDA) we aimed to improve the mapping of risk by considering both strata average risk differences and the accuracy of such strata risks for distinguishing between individuals who did or did not refrain from seeking physician's care.

METHODS

We analysed nine annual National Public Health Surveys (2004, 2007-2014) in Sweden including 73,815 participants. We investigated the risk of refraining from seeking physician's care across 64 intersectional strata defined by sex, education, age, country of birth, and perceived discrimination. We calculated strata-specific prevalences and prevalence ratios (PR) with 95% confidence intervals (CI), and the area under the receiver operating characteristic curve (AUC) to evaluate the discriminatory accuracy (DA).

RESULTS

Discriminated foreign-born women aged 35-49 with a low educational level show a six times higher risk (PR = 6.07, 95% CI 5.05-7.30) than non-discriminated native men with a high educational level aged 35-49. However, the DA of the intersectional strata was small (AUC = 0.64). Overall, discrimination increased the absolute risk of refraining from seeking physician's care, over and above age, sex, and educational level.

CONCLUSIONS

AIHDA disclosed complex intersectional inequalities in the average risk of refraining from seeking physician's care. This risk was rather high in some strata, which is relevant from an individual perspective. However, from a population perspective, the low DA of the intersectional strata suggests that potential interventions to reduce such inequalities should be universal but tailored to the specific contextual characteristics of the strata. Discrimination impairs access to healthcare.

Socioeconomic inequalities in the uptake of postpartum care at home across Dutch neighbourhoods

BACKGROUND

Postpartum care focuses on prevention of health problems by performing medical check-ups and through enhancing maternal empowerment, the parent-infant interaction and knowledge about mother's own health and that of her newborn. We aimed to investigate whether there was significant clustering within neighbourhoods regarding the uptake of postpartum care and to what extent neighbourhood-level differences are explained by individual socio-demographic factors, pregnancy-related factors and neighbourhood-level determinants (i.e. deprivation and urbanization).

METHODS

A nationwide population-based observational study was carried out using linked routinely collected healthcare data from appropriate-for-gestational-age weight live-born term singleton deliveries (2015-18) in the Netherlands. We performed two-level multivariable logistic regression analyses, using three different models. Model 1 contained no explanatory variables and was used to assess clustering of postpartum care uptake within neighbourhoods. In model 2, individual-level determinants were added one by one and in model 3, neighbourhood-level determinants were added.

RESULTS

About 520 818 births were included. Multilevel modelling showed that 11% of the total variance in postpartum care uptake could be attributed to the neighbourhood of residence. Individual characteristics explained 38% of the neighbourhood variance, of which income and migration background were the most important contributors. An additional 6% of the variation could be explained by neighbourhood-level determinants.

CONCLUSION

We found substantial neighbourhood differences in postpartum care uptake. These differences are influenced by a complex interplay between individual-level and neighbourhood-level determinants, highlighting the importance of addressing both individual and neighbourhood-level determinants to improve the uptake of postpartum care and therewith overall community health.

Physician-to-Physician eConsultations to Ophthalmologists at an Academic Medical Center

Purpose

Physician-to-physician electronic consultation (eConsults) are used across specialties; however, their effectiveness in ophthalmology has not been reported. This study evaluated the feasibility and diagnostic accuracy of a physician-to-physician ophthalmology eConsult program, assessed the timeliness of in-person evaluation, and characterized the clinical questions of non-ophthalmology providers.

Methods

Retrospective review of patients for whom an ophthalmology eConsult was placed to Massachusetts Eye and Ear from February 2019-August 2021. The eConsults were reviewed to identify submission-to-response time, primary diagnoses by eConsultant, and referral outcomes. The eConsults were categorized based on clinical question, urgency, and ophthalmic condition addressed. Demographic data on patients and referring providers were collected.

Results

One hundred ophthalmology eConsults were placed, and 100% were responded to by an ophthalmologist. An average of 1.6 ± 1.9 days elapsed from the time of eConsult to completion. Of the 30 patients who presented for in-person evaluation at an ophthalmology clinic, diagnostic concordance between eConsultant and in-person ophthalmologist was observed in 93% of cases (n = 28 of 30). An average of 28.9 ± 27.4 days from eConsult response to in-person follow-up was observed. The most common clinical inquiries were about appropriate triage/referral (24.4%), management (22%), and diagnosis (19.7%). All eConsults were non-urgent. The most common ophthalmic condition addressed was chalazia/hordeola (14%). Only 5% of patients presented to an emergency department for the same ophthalmic concern addressed by eConsult.

Conclusions

Ophthalmology eConsults provide timely access to nonurgent ocular diagnosis, triage, and management and in our study seem to provide high rates of diagnostic accuracy for nonurgent ophthalmic conditions.

Translational Relevance

Using ophthalmic eConsults can facilitate timely access to specialty care and reduce patient and provider burden.

Health care utilization up to 11 years after diagnosis among patients with a hematologic malignancy and its association with socioeconomic position

PURPOSE

To investigate health care utilization among patients with hematologic malignancies and its association with socioeconomic position (SEP) and compare health care utilization with a cancer-free population.

METHODS

Patients with aggressive lymphoma, indolent lymphoma, or multiple myeloma (MM), diagnosed between 1999-2010 and 2015-2019, participated in longitudinal patient-reported outcome research, up to 11 years post-diagnosis. Questionnaires assessed health care utilization at the general practitioner (GP), medical specialist, and additional health care. SEP was based on education and income, categorized as low, medium, or high. Sociodemographic and clinical data were obtained from the Netherlands Cancer Registry. Mixed models and logistic regression analyses were performed.

RESULTS

The study included 2319 patients (71% response rate), who completed on average five measurements. Patients with MM reported the highest health care utilization, both at the GP and medical specialist. Low SEP was associated with higher utilization at the GP (medium education β =  - 0.72, p = 0.01; high education β =  - 1.15, p < 0.001) and lower utilization of additional physical (OR = 1.7, p = 0.01) and psychosocial (OR = 1.5, p < 0.05) care, among all patients. For patients with MM, high SEP was also associated with higher utilization of health care at the medical specialist (high education β = 2.56, p < 0.05).

CONCLUSION

Hematologic malignancy-related and SEP-related disparities in health care utilization were observed. To ensure equal access to health consumption, attention is needed for patients with a low SEP to provide better guidance in their cancer (survivorship) care.

IMPLICATIONS FOR CANCER SURVIVORS

Improving health literacy and involving informal caregivers and nurse-led patient navigation may help reduce disparities in access to (additional) health care.

A Decade of Monitoring Primary Healthcare Experiences through the Lens of Inequality

BACKGROUND

Health care is not exempt from harboring social inequalities, including in those countries with a universal public system. The objective was to ascertain whether the population's assessment of primary care (PC) changed between 2006 and 2016, the decade that included the economic crisis of 2008, and also if it exhibited patterns of social inequality in Barcelona (Spain).

METHODS

This was a cross-sectional study using Barcelona Health Surveys 2006 and 2016. Samples (4027 and 3082 respectively) comprised residents in Barcelona, over 15 years old.

DEPENDENT VARIABLE

Primary Care (PC) index.

INDEPENDENT VARIABLES

age, social class, and birthplace. Analyses included means and percentiles of PC index, and Somers' D test to compare the distribution of the groups.

RESULTS

Comparing 2016 with 2006, the distribution of the PC index remained in women (median of 73.3) and improved in men (from 70 to 73.3). By social class, the pattern of inequality observed in 2006 in men with perceived poor health status disappeared in 2016. Inequalities according to birthplace persisted in women, regardless of perceived health status, but disappeared in men.

CONCLUSIONS

In the 10 years between which the global economic crisis occurred, the assessment of PC did not worsen, and it did improve for men, but the study points to the need for more focus on people born abroad.

Disparities in relapsed or refractory multiple myeloma: recommendations from an interprofessional consensus panel

Many studies have documented racial, socioeconomic, geographic, and other disparities for United States (US) patients with multiple myeloma pertaining to diagnosis and frontline management. In contrast, very little is known about disparities in the management of relapsed/refractory multiple myeloma (RRMM) despite a plethora of novel treatment options. In this review, we discuss the manifestations of disparities in RRMM and strategies to mitigate their impact. Immunomodulatory drugs can create disparities on many axes, for example inappropriately low dosing due to Duffy-null status as well as time toxicity and financial toxicity from logistical hurdles for socioeconomically vulnerable patients. Access to myeloma expertise at high-volume centers is a critical consideration given the disconnect between how drugs like carfilzomib and dexamethasone are prescribed in trials versus optimized in real-world practice to lower toxicities. Disparities in chimeric antigen receptor T-cell therapy and bispecific antibody therapy span across racial, ethnic, and socioeconomic lines in large part due to their limited availability outside of high-volume centers. Another insidious source of disparities is supportive care in RRMM, ranging from inadequate pain control in Black patients to limited primary care provider access in rural settings. We discuss the rationales and evidence base for several solutions aimed at mitigating these disparities: for example, (1) bidirectional co-management with community-based oncologists, (2) screening for risk factors based on social determinants of health, (3) strategies to build patient trust with regard to clinical trials, and (4) longitudinal access to a primary care provider. As the treatment landscape for RRMM continues to expand, these types of efforts by the field will help ensure that this landscape is equally accessible and traversable for all US patients.

Psychological Factors Affecting Assertiveness in Subjects with Parkinson's Disease

Background/Objectives: Assertiveness, defined as the positive affirmation of oneself, encompasses the ability to refuse requests, express anger, disagree or oppose others, show affection, and uphold personal beliefs without causing conflict. Deficits in assertive behavior are often linked to pathological changes in the basal ganglia and prefrontal dopaminergic systems, commonly observed in Parkinson's disease (PD), and are predictive of poor clinical outcomes. Psychological factors such as mood alterations and cognitive dysfunction may also impact assertiveness. This study investigated the psychological factors influencing assertiveness in individuals with PD. Methods: A cross-sectional study was conducted, involving 160 patients with PD attending a movement disorders outpatient clinic. The participants underwent assessment using a battery of standardized neuropsychological tests to evaluate cognitive function, assertiveness, mood, dysarthria, and quality of life (QoL). Results: All dimensions of assertiveness correlated with depression and anxiety. Individuals experiencing mood disturbances may struggle to express themselves assertively. Similarly, some dimensions of assertiveness correlated also with the QoL, indicating that, overall, well-being affects assertive behavior. Gender emerged as a significant influencer of assertiveness across all dimensions. Specifically, in subjects with PD, the male gender was associated with lower scores in assertiveness compared to women. No significant correlations were found between assertiveness and dysarthria. Conclusions: The findings highlight the importance of adopting a holistic approach to PD management, addressing not only motor symptoms but also psychological challenges which patients may encounter in their daily lives.

Social inequity in chiropractic utilisation - a cross-sectional study in Denmark, 2010 and 2017

BACKGROUND

Inequity in healthcare utilisation refers to differences between groups that remain after adjustment for need for health care. To our knowledge, no previous studies have aimed to assess social inequity in chiropractic utilisation in a general population. Therefore, the objective of this study was to evaluate social inequity in chiropractic utilisation in the general Danish population adjusted for health status as a proxy of need for chiropractic care.

METHODS

A population-based repeated cross-sectional study design was used based on the Danish National Health Survey in 2010 and 2017. Overall, we included 288,099 individuals aged 30 years or older in 2010 or 2017. For each individual, information on chiropractic utilisation, socioeconomic status, and health status as a proxy of need for chiropractic care was retrieved from nationwide registers using the unique personal identification number. Measures of health status included demographics, poor self-rated physical health, activity limitations, musculoskeletal pain, number of musculoskeletal conditions, and number of chronic diseases. We investigated social inequity in chiropractic utilisation (yes, no) using logistic regression adjusted for health status, stratified by sex and year. Three characteristics of socioeconomic status (educational level, employment status and income) were investigated. To further quantify the degree of social inequity in chiropractic utilisation, we estimated the concentration index of inequity for each of the three characteristics of socioeconomic status.

RESULTS

We found significantly higher odds of chiropractic utilisation among individuals with short or medium/long education compared with individuals with elementary education, and among employed individuals compared with individuals who were unemployed, receiving disability pension or retired. Furthermore, the odds of chiropractic utilisation increased with higher income. The concentration index indicated social inequity in chiropractic utilisation in favour of individuals with higher socioeconomic status, with income and employment status contributing more to inequity than educational level.

CONCLUSION

The study demonstrated social inequity in chiropractic utilisation in Denmark beyond differences in health status as a proxy of need for chiropractic care in the general population. The results suggest that new strategies are required if equal treatment for equal need is the goal.

Opportunities and challenges of lupus care in Latin America, the Middle East, and Asia-Pacific: A call to action

Lupus remains a disease with a low prioritisation in the national agendas of many countries in Latin America, the Middle East, and Asia-Pacific, where there is a dearth of rheumatologists and limited access to new or even standard lupus treatments. There is thus an important need for education, advocacy, and outreach to prioritise lupus in these regions to ensure that patients receive the care they need. This article reviews some of the specific challenges facing the care and management of people with lupus in these regions and suggests strategies for improving patient outcomes. Specifically, we review and discuss (with a focus on the aforementioned regions) the epidemiology of lupus; economic costs, disease burden, and effects on quality of life; barriers to care related to disease assessment; barriers to effective treatment, including limitations of standard treatments, high glucocorticoid use, inadequate access to new treatments, and low adherence to medications; and strategies to improve lupus management and patient outcomes. We hope that this represents a call to action to come together and act now for the lupus community, policymakers, health authorities, and healthcare professionals to improve lupus management and patient outcomes in Latin America, the Middle East, and Asia-Pacific.

CT and MR utilization and morbidity metrics across Body Mass Index

OBJECTIVE

Obesity is a high-morbidity chronic condition and risk factor for multiple diseases that necessitate imaging. This study assesses the relationship between BMI and same-year utilization of CT and MR imaging in a large healthcare population.

METHODS

In this retrospective population-based study, all patients aged ≥18 years with a documented BMI in the multi-institutional Cosmos database were included. Cohorts were identified based on ≥1 documented BMI in 2021 within pre-defined ranges. For each cohort, we assessed the percentage of patients undergoing head, neck, chest, spine, or abdomen/pelvis CT and MR during the same year. Disease severity was quantified based on emergency department (ED) visits and mortality.

RESULTS

In our population of 49.6 million patients, same-year CT and MR utilization was 14.5 ±0.01% and 6.0±0.01%, respectively. The underweight cohort had the highest CT (25.8±0.1%) and MR (8.01 ± 0.05) imaging utilization. At high extremes of BMI (>50 kg/m2), CT utilization mildly increased (18.4±0.1%), but MR utilization decreased (5.3±0.04%). While morbidity differences may explain some BMI-utilization relationships, lower MR utilization in the BMI>50 cohort contrasts with higher age-adjusted mortality (1.8±0.03%) and ED utilization (32.4±0.1%) in this cohort relative to normal weight (1.5±0.01% and 25.7±0.02%, respectively).

CONCLUSION

Underweight patients had disproportionately high CT/MR utilization, and high extremes of BMI are associated with mildly higher CT and lower MR utilization than the normal weight cohort. The elevated mortality and ED utilization in severely obese patients contrasts with their lower MR imaging utilization. Our findings may assist public health efforts to accommodate obesity trends.

Education level and the use of coronary computed tomography, functional testing, coronary angiography, revascularization, and outcomes-a 10-year Danish, nationwide, registry-based follow-up study

BACKGROUND AND AIMS

Coronary computed tomography angiography (CCTA) can guide downstream preventive treatment and improve patient prognosis, but its use in relation to education level remains unexplored.

METHODS

This nationwide register-based cohort study assessed all residents in Denmark between 2008 and 2018 without coronary artery disease (CAD) and 50-80 years of age (n = 1 469 724). Residents were divided according to four levels of education: low, lower-mid, higher-mid, and high. Outcomes were CCTA, functional testing, invasive coronary angiography (ICA), revascularization, and major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Individuals with the lowest education level underwent CCTA (absolute risk [AR] 3.95% individuals aged ≥50-59, AR 3.62% individuals aged ≥60-69, and AR 2.19% individuals aged ≥70-80) less often than individuals of lower-mid (AR 4.16%, AR 3.90%, and AR 2.41%), higher-mid (AR 4.38%, AR 4.30%, and AR 2.45%) and highest education level (AR 3.98%, AR 4.37%, and AR 2.30%). Similar differences were observed for functional testing. Conversely, use of ICA, and risks of revascularization and MACCE were more common among individuals of lowest education level. Among patients examined with CCTA (n = 50 234), patients of lowest education level less often underwent functional testing and more likely initiated preventive medication, underwent ICA, revascularization, and experienced MACCE.

CONCLUSION

Despite tax-financed healthcare in Denmark, individuals of lowest education level were less likely to undergo CCTA and functional testing than persons of higher education level. Invasive coronary angiography utilization, revascularization, and MACCE risks were higher for individuals of lowest education level. Among CCTA-examined patients, patients of lowest education level were more likely to initiate preventive medication and had the highest risks of revascularization and MACCE when compared to higher education level groups. These findings suggest that the preventive potential of CCTA is underutilized in individuals of lower education level, a proxy for socioeconomic status. Socioeconomic differences in CAD assessment, care, and outcomes are likely even larger without tax-financed healthcare.

Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis

STUDY DESIGN

Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database.

OBJECTIVE

To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear.

MATERIALS AND METHODS

PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively.

RESULTS

On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW.

CONCLUSIONS

Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

Characteristics associated with perceived level of confidence managing diabetes among United States adults with diabetes: A retrospective cross-sectional study

Objectives

Identifying characteristics associated with patients' confidence managing diabetes may aid the primary care provider in offering diabetes self-management education and support to patients. This analysis assessed the relationship between demographic, health, economic, access to care, satisfaction with care, and healthcare utilization characteristics with patients' confidence managing diabetes.

Methods

United States adults with diabetes in the 2020 Medical Expenditure Panel Survey were included in this retrospective cross-sectional analysis. Characteristics related statistically to patients' confidence managing diabetes in multivariable logistic regression analysis were reported.

Results

Among the 1,516 eligible individuals, 76.3% stated they were very confident/confident with their diabetes management. Adults who perceived their health positively (odds ratio 2.3, 95% confidence interval [CI] 1.3-3.9), completed ≥30 min moderate/vigorous exercise five times weekly (odds ratio 1.6, 95% CI 1.0-2.6), had at least one inpatient discharge in 2020 (odds ratio 3.5, 95% CI 1.5-8.1), said it was not difficult to telephone their usual provider (odds ratio 3.3, 95% CI 1.4-7.8), and had no emergency room visits in 2020 (odds ratio 2, 95% CI 1.1-3.3) had higher odds of stating they were very confident or confident with their diabetes management.

Conclusion

The characteristics associated with being very confident/confident managing diabetes should be considered by primary healthcare physicians and other healthcare professionals when helping patients manage diabetes.

What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England

BACKGROUND

More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP.

METHODS

We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression.

RESULTS

Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it.

CONCLUSIONS

Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.

Variations in healthcare utilization for mental health problems prior to suicide by socioeconomic status: a Norwegian register-based population study

BACKGROUND

Suicide poses a major public health challenge, claiming around 650 lives annually in Norway. There is limited understanding of mental healthcare utilization patterns preceding suicide, particularly relating to socioeconomic status (SES). This study analyzes mental health service use among Norwegian citizens aged 20-64 from 2009 to 2021, emphasizing disparities related to SES.

METHODS

This is a population-wide registry-based study. We include mental health consultations with both primary and specialist healthcare services, and investigate patterns of service use regarding educational attainment, employment status and income and compare this to the population in general. All suicides in the period (N = 4731) are included in the study. The aim is to investigate potential discrepancies in service use the year and month preceding suicide, seeking to enhance targeted preventive interventions.

RESULTS

Our results show significant variations in healthcare use for mental health problems the last year preceding suicide, according to the components of SES, for both men and women. Those with higher education utilize the mental healthcare services prior to suicide to a higher degree than men and women with high school education or less, whereas employed men and men with high income level have significantly lower mental healthcare usage prior to suicide both the last year and month compared to the non-employed men and men with low-income level. Employed women also had a lower mental healthcare usage, whereas the results regarding income are not significant for women.

CONCLUSION

Mental healthcare use prior to suicide varies across the SES components. Notably, the SES groups exhibit heterogeneity, with gendered patterns. Targeted interventions for low consultation rates among employed men, and men with high income and lower education are needed, while women, and men in at-risk groups, such as the non-employed and those with low income, demonstrate higher mental healthcare utilization, warranting comprehensive suicide prevention measures.

Effect of GP visits in the compliance of preventive services: a cross-sectional study in Europe

BACKGROUND

Performing cardiovascular and cancer screenings in target populations can reduce mortality. Visiting a General Practitioner (GP) once a year is related to an increased likelihood of preventive care. The aim of this study was to analyse the influence of visiting a GP in the last year on the delivery of preventive services based on sex and household income.

METHODS

Cross-sectional study using data collected from the European Health Interview Survey 2013-2015 of individuals aged 40-74 years from 29 European countries. The variables included: sociodemographic factors (age, sex, and household income (HHI) quintiles [HHI 1: lowest income, HHI 5: more affluent]), lifestyle factors, comorbidities, and preventive care services (cardiometabolic, influenza vaccination, and cancer screening). Descriptive statistics, bivariate analyses and multilevel models (level 1: citizen, level 2: country) were performed.

RESULTS

242,212 subjects were included, 53.7% were female. The proportion of subjects who received any cardiometabolic screening (92.4%) was greater than cancer screening (colorectal cancer: 44.1%, gynaecologic cancer: 40.0%) and influenza vaccination. Individuals who visited a GP in the last year were more prone to receive preventive care services (cardiometabolic screening: adjusted OR (aOR): 7.78, 95% CI: 7.43-8.15; colorectal screening aOR: 1.87, 95% CI: 1.80-1.95; mammography aOR: 1.76, 95% CI: 1.69-1.83 and Pap smear test: aOR: 1.89, 95% CI:1.85-1.94). Among those who visited a GP in the last year, the highest ratios of cardiometabolic screening and cancer screening benefited those who were more affluent. Women underwent more blood pressure measurements than men regardless of the HHI. Men were more likely to undergo influenza vaccination than women regardless of the HHI. The highest differences between countries were observed for influenza vaccination, with a median odds ratio (MOR) of 6.36 (under 65 years with comorbidities) and 4.30 (over 65 years with comorbidities), followed by colorectal cancer screening with an MOR of 2.26.

CONCLUSIONS

Greater adherence to preventive services was linked to individuals who had visited a GP at least once in the past year. Disparities were evident among those with lower household incomes who visited a GP. The most significant variability among countries was observed in influenza vaccination and colorectal cancer screening.

Relationships between long-term exposure to major PM2.5 constituents and outpatient visits and hospitalizations in Guangdong, China

Ambient fine particulate matter (PM2.5) has attracted considerable attention due to its crucial role in the rising global disease burden. Evidence of health risks associated with exposure to PM2.5 and its major constituents is important for advancing hazard assessments and air pollution emission policies. We investigated the relationship between exposure to major constituents of PM2.5 and outpatient visits as well as hospitalizations in Guangdong Province, China, where 127 million residents live in a severe PM2.5 pollution environment. An approach that integrates the generalized weighted quantile sum (gWQS) regression with the difference-in-differences (DID) approach was used to assess the overall mixture effects and relative contributions of each constituent. We observed significant associations between long-term exposure to the mixture of PM2.5 constituents (WQS index) and outpatient visits (IR%, percentage increases in risk per unit WQS index increase:1.73, 95%CI: 1.72, 1.74) as well as hospitalizations (IR%:5.15, 95%CI: 5.11, 5.20). Black carbon (weight: 0.34) and nitrate (weight: 0.60) respectively exhibited the highest contributions to outpatient visits and hospitalizations. The overall mixture effects on outpatient visits and hospitalizations were higher with increased summer air temperatures (IR%: 7.54, 95%CI: 7.33, 7.74 and IR%: 9.55, 95%CI: 8.36, 10.75, respectively) or decreased winter air temperatures (IR%: 1.88, 95%CI: 1.68, 2.08 and IR%: 4.87, 95%CI: 3.73, 6.02, respectively). Furthermore, the overall mixture effects on outpatient visits and hospitalizations were significantly higher in populations with higher socioeconomic status (P < 0.01). It's crucial to address the primary sources of nitrate precursor substances and black carbon (mainly traffic-related and industrial-related air pollutants) and consider the complex interaction effects between air temperature and PM2.5 in the context of climate change. Of particular concern is the need to prioritize healthcare demands in economically disadvantaged regions and to address the health inequalities stemming from the uneven distribution of healthcare resources and PM2.5 pollution.

Gender health care inequalities in health crisis: when uncertainty can lead to inequality

BACKGROUND

In health crisis, inequalities in access to and use of health care services become more evident. The objective of this study is to analyse the existence and evolution of gender inequalities in access to and use of healthcare services in the context of the COVID-19 health crisis.

METHODS

Retrospective cohort study using data from all individuals with a confirmed COVID-19 infection from March 2020 to March 2022 in Aragón (Spain) (390,099 cases). Health care access and use was analysed by gender for the different pandemic waves. Univariate and multivariate analyses were conducted to evaluate the effect of sex in health care. Blinder-Oaxaca decomposition methods were performed to explain gender gaps observed.

RESULTS

The health care received throughout the COVID-19 pandemic differed between men and women. Women were admitted to hospital and intensive care units less frequently than men and their stays were shorter. Differences observed between men and women narrowed throughout the pandemic, but persisted even after adjusting for age, socioeconomic status, morbidity burden or the patient's place of residence. Differences in sociodemographic characteristics and morbidity burden could explain partially the gender inequalities found, mainly in the later phases of the pandemic, but not in the earlier waves.

CONCLUSIONS

There were gender inequalities in access to and use of health services during the COVID-19 pandemic. Inequalities were greater in the first waves of the pandemic, but did not disappear. Analysis of health crises must take into account an intersectional gender perspective to ensure equitable health care.

Spatio-temporal modelling of referrals to outpatient respiratory clinics in the integrated care system of the Morecambe Bay area, England

BACKGROUND

Promoting integrated care is a key goal of the NHS Long Term Plan to improve population respiratory health, yet there is limited data-driven evidence of its effectiveness. The Morecambe Bay Respiratory Network is an integrated care initiative operating in the North-West of England since 2017. A key target area has been reducing referrals to outpatient respiratory clinics by upskilling primary care teams. This study aims to explore space-time patterns in referrals from general practice in the Morecambe Bay area to evaluate the impact of the initiative.

METHODS

Data on referrals to outpatient clinics and chronic respiratory disease patient counts between 2012-2020 were obtained from the Morecambe Bay Community Data Warehouse, a large store of routinely collected healthcare data. For analysis, the data is aggregated by year and small area geography. The methodology comprises of two parts. The first explores the issues that can arise when using routinely collected primary care data for space-time analysis and applies spatio-temporal conditional autoregressive modelling to adjust for data complexities. The second part models the rate of outpatient referral via a Poisson generalised linear mixed model that adjusts for changes in demographic factors and number of respiratory disease patients.

RESULTS

The first year of the Morecambe Bay Respiratory Network was not associated with a significant difference in referral rate. However, the second and third years saw significant reductions in areas that had received intervention, with full intervention associated with a 31.8% (95% CI 17.0-43.9) and 40.5% (95% CI 27.5-50.9) decrease in referral rate in 2018 and 2019, respectively.

CONCLUSIONS

Routinely collected data can be used to robustly evaluate key outcome measures of integrated care. The results demonstrate that effective integrated care has real potential to ease the burden on respiratory outpatient services by reducing the need for an onward referral. This is of great relevance given the current pressure on outpatient services globally, particularly long waiting lists following the COVID-19 pandemic and the need for more innovative models of care.

Does use of GP and specialist services vary across areas and according to individual socioeconomic position? A multilevel analysis using linked data in Australia

OBJECTIVE

Timely access to primary care and supporting specialist care relative to need is essential for health equity. However, use of services can vary according to an individual's socioeconomic circumstances or where they live. This study aimed to quantify individual socioeconomic variation in general practitioner (GP) and specialist use in New South Wales (NSW), accounting for area-level variation in use.

DESIGN

Outcomes were GP use and quality-of-care and specialist use. Multilevel logistic regression was used to estimate: (1) median ORs (MORs) to quantify small area variation in outcomes, which gives the median increased risk of moving to an area of higher risk of an outcome, and (2) ORs to quantify associations between outcomes and individual education level, our main exposure variable. Analyses were adjusted for individual sociodemographic and health characteristics and performed separately by remoteness categories.

SETTING

Baseline data (2006-2009) from the 45 and Up Study, NSW, Australia, linked to Medicare Benefits Schedule and death data (to December 2012).

PARTICIPANTS

267 153 adults aged 45 years and older.

RESULTS

GP (MOR=1.32-1.35) and specialist use (1.16-1.18) varied between areas, accounting for individual characteristics. For a given level of need and accounting for area variation, low education-level individuals were more likely to be frequent users of GP services (no school certificate vs university, OR=1.63-1.91, depending on remoteness category) and have continuity of care (OR=1.14-1.24), but were less likely to see a specialist (OR=0.85-0.95).

CONCLUSION

GP and specialist use varied across small areas in NSW, independent of individual characteristics. Use of GP care was equitable, but specialist care was not. Failure to address inequitable specialist use may undermine equity gains within the primary care system. Policies should also focus on local variation.

Characteristics of employment history and self-perceived barriers to healthcare access

BACKGROUND

Research suggests that people in disadvantaged social positions are more likely to perceive barriers to accessing healthcare, especially to specialists and preventive services. In this study, we analyze if adversity during past employment histories (e.g. spells of unemployment) is linked to subsequent subjectively perceived barriers in healthcare access. Further, we investigate if the associations vary according to national healthcare access and quality indicators.

METHODS

We use data from the Survey of Health, Ageing and Retirement in Europe with a study sample of 31 616 men and women aged 52-80 from 25 countries. Data include retrospective information on employment histories allowing us to derive characteristics of past careers, including the number of unemployment periods, main occupational position and pension contributions. Barriers to healthcare access are measured by self-perceived forgone care due to costs and unavailability of services. We apply multilevel Poisson regression for binary outcomes and test for cross-level interactions between career characteristics and national healthcare system characteristics.

RESULTS

Career characteristics are linked to later self-perceived healthcare access barriers, consistently in the case of cost barriers and less consistently for unavailability of services. Associations are similar for men and women, and persist after controlling for current income, wealth and subjective health. We find no cross-level interactions between career characteristics and country-level healthcare access and quality indicators.

CONCLUSION

Self-perceived barriers to healthcare access are linked to people's past working lives. More in-depth investigation is needed to identify the reasons for the lingering effects of characteristics of employment history on reduced healthcare access.

[Development of an Index of Social Structures to Determine the Sociostructural Need for Physicians in Outpatient Care in Brandenburg]

INTRODUCTION

Despite the growing numbers of physicians in outpatient care, continuing discussion about the planning of physician requirements suggests remaining problems in this field, which could be due to focussing on the ratio of physician to population rather than on morbidity-based evaluations. Against this background, this paper tries to depict the latent need in outpatient care, illustrates supply and demand and further tests the hypothesis that there is a relative inequality in distribution due to physicians preferring to locate in socially privileged areas in the German state of Brandenburg.

METHODS

We aggregated all data available on a small scale with potential impact on demand and examined it via principal component analysis. The generated factor was mapped together with the locations of general practitioners and specialists in general care. Using linear regressions, the number of practitioners was compared to the local index value to determine regional inequalities.

RESULTS

The PCA suggested a one factor solution; that factor was designated Social Structure Index due to its values. The mapping showed a tendency of higher index values towards the central areas of Brandenburg surrounding Berlin. Regressions of the number of practitioners against the index values revealed no significant differences between communities with high and low index values.

CONCLUSION

The extension of factors concluding the evaluation of physician demand in outpatient care confirms the problems of physician supply in rural areas, where sparse populations meet social disadvantages and poor accessibility. An underlying inequality in distribution in terms of physicians preferring socially privileged areas could not be detected.

[Access to cardiological care infrastructure in the federal state of Brandenburg considering the local care needs]

AIM OF THE STUDY

In a nationwide comparison, the state of Brandenburg has one of the highest morbidity and mortality rates of ischemic heart disease. Access to medical care infrastructure is considered to be one possible explanation for regional health inequalities. Accordingly, the study aims to calculate the distances to different types of cardiology care at the community level and to consider these in the context of local care needs.

METHODOLOGY

Preventive sports facilities, general practitioners, outpatient specialist care, hospitals with cardiac catheterization laboratory and outpatient rehabilitation were chosen and mapped as essential facilities for cardiological care. Thereafter, the distances across the road network from the center of each Brandenburg community to the nearest location of each care facility was calculated and divided into quintiles. Medians and interquartile ranges of the German Index of Socioeconomic Deprivation and the proportion of the population over 65 were used as measures of the need for care. They were then related to the distance quintiles per type of care facility.

RESULTS

For 60% of Brandenburg's municipalities, general practitioners were found to be within 2.5 km, preventive sports facilities within 19.6 km, cardiology practices within 18.3 km, hospitals with cardiac catheterization laboratories within 22.7 km, and outpatient rehabilitation facilities within 14.7 km. The median of the German Index of Socioeconomic Deprivation rose with increasing distance for all types of care facilities. The median of the proportion of over 65-year-olds showed no significant variation between distance quintiles.

CONCLUSIONS

The results show that a high proportion of the population lives far away from cardiology care services, while a high proportion seems to be able to reach a general practitioner. In Brandenburg, a regional and locally oriented cross-sectoral care seems to be necessary.

Patterns of computed tomography utilisation in injury management: latent classes approach using linked administrative data in Western Australia

PURPOSE

Whilst computed tomography (CT) imaging has been a vital component of injury management, its increasing use has raised concern regarding ionising radiation exposure. This study aims to identify latent classes (underlying patterns) of CT use over a 3-year period following the incidence of injury and factors predicting the observed patterns.

METHOD

A retrospective observational cohort study was conducted in 21,544 individuals aged 18 + years presenting to emergency departments (ED) of four tertiary public hospitals with new injury in Western Australia. Mixture modelling approach was used to identify latent classes of CT use over a 3-year period post injury.

RESULTS

Amongst injured people with at least one CT scan, three latent classes of CT use were identified including a: temporarily high CT use (46.4%); consistently high CT use (2.6%); and low CT use class (51.1%). Being 65 + years or older, having 3 + comorbidities, history with 3 + hospitalisations and history of CT use before injury were associated with consistently high use of CT. Injury to the head, neck, thorax or abdomen, being admitted to hospital after the injury and arriving to ED by ambulance were predictors for the temporarily high use class. Living in areas of higher socio-economic disadvantage was a unique factor associated with the low CT use class.

CONCLUSIONS

Instead of assuming a single pattern of CT use for all patients with injury, the advanced latent class modelling approach has provided more nuanced understanding of the underlying patterns of CT use that may be useful for developing targeted interventions.

Income-based differences in healthcare utilization in relation to mortality in the Swedish population between 2004-2017: A nationwide register study

BACKGROUND

Despite universal healthcare, socioeconomic differences in healthcare utilization (HCU) persist in modern welfare states. However, little is known of how HCU inequalities has developed over time. The aim of this study is to assess time trends of differences in utilization of primary and specialized care for the lowest (Q1) and highest (Q5) income quantiles and compare these to mortality.

METHODS AND FINDINGS

Using a repeated cross-sectional register-based study design, data on utilization of (i) primary; (ii) specialized outpatient; and (iii) inpatient care, as well as (iv) cause of death, were linked to family income and sociodemographic control variables (for instance, country of origin and marital status). The study sample comprised all individuals 16 years or older residing in Sweden any year during the study period and ranged from 7.1 million in year 2004 to 8.0 million year 2017. HCU and mortality for all disease as well as for the 5 disease groups causing most deaths were compared for the Q1 and Q5 using logistic regression, adjusting for sex, age, marital status, and birth country. The primary outcome measures were adjusted odds ratios (ORs), and regression coefficients of annual changes in these ORs log-transformed. Additionally, we conducted negative binominal regression to calculate adjusted rate ratios (RRs) comparing Q1 and Q5 with regard to number of disease specific healthcare encounters ≤5 years prior to death. In 2017, for all diseases combined, Q1 utilized marginally more primary and specialized outpatient care than Q5 (OR 1.07, 95% CI [1.07, 1.08]; p < 0.001, and OR 1.04, 95% CI [1.04, 1.05]; p < 0.001, respectively), and considerably more inpatient care (OR 1.44, 95% CI [1.43, 1.45]; p < 0.001). The largest relative inequality was observed for mortality (OR 1.78, 95% CI [1.74, 1.82]; p < 0.001). This pattern was broadly reproduced for each of the 5 disease groups. Time trends in HCU inequality varied by level of care. Each year, Q1 (versus Q5) used more inpatient care and suffered increasing mortality rates. However, utilization of primary and specialized outpatient care increased more among Q5 than in Q1. Finally, group differences in number of healthcare encounters ≤5 years prior to death demonstrated a similar pattern. For each disease group, primary and outpatient care encounters were fewer in Q1 than in Q5, while inpatient encounters were similar or higher in Q1. A main limitation of this study is the absence of data on self-reported need for care, which impedes quantifications of HCU inequalities each year.

CONCLUSIONS

Income-related differences in the utilization of primary and specialized outpatient care were considerably smaller than for mortality, and this discrepancy widened with time. Facilitating motivated use of primary and outpatient care among low-income groups could help mitigate the growing health inequalities.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.

Impact of socioeconomics and race on clinical follow-up and trial enrollment and adherence in cerebral cavernous malformation

OBJECTIVES

Cerebral cavernous malformation (CCM) affects more than a million Americans but advanced care for symptomatic lesions and access to research studies is largely limited to referral academic centers MATERIALS AND METHODS: A cohort of CCM patients screened for research studies at an accredited center of excellence for CCM was analyzed. Demographics, lesion location, history of hemorrhage, insurance type and area of deprivation index (ADI) were collected. Primary outcomes were clinical follow-up within a year from initial evaluation, and enrollment and adherence in clinical trials among eligible subjects RESULTS: A majority (52.8%) of CCM patients evaluated had a high socioeconomic status (SES) (ADI 1-3), and only 11.5% were African American. Patients who had a symptomatic bleed were more likely to follow-up (p=0.01), and those with brainstem lesion were more likely to enroll/adhere in a clinical trial (p=0.02). Rates of clinical follow-up were similar across different ADI groups, insurance coverage and race. Patients who were uninsured/self-paying, and African Americans were more likely to decline/drop from clinical trials (OR 2.4, 95% CI 0.46-10.20 and OR 2.2, 95% CI 0.33-10.75, respectively), but differences were not statistically significant CONCLUSIONS: Access of disadvantaged patients to center of excellence care and research remains limited despite geographic proximity to their community. Patients with lower SES and African Americans are as likely to follow-up clinically, but there were trends of differences in enrollment/adherence in clinical trials. Mitigation efforts should target systemic causes of low access to specialized care among uninsured and African American patients.

Impact of the COVID-19 pandemic upon a universal electronic consultation program (e-consultation) between general practitioners and cardiologists

BACKGROUND AND OBJECTIVE

Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are no data corresponding to models between clinicians. An analysis was made of the impact of the COVID-19 pandemic upon the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our healthcare area.

METHODS

Patients with at least one e-consultation between 2018 and 2021 were selected. We analyzed the impact of the COVID-19 pandemic upon activity and waiting time for care, hospitalizations and mortality, taking as reference the consultations carried out during 2018.

RESULTS

A total of 25,121 patients were analyzed. Logistic regression analysis showed a shorter delay in care and resolution of the e-consultation without the need for face-to-face care to be associated to a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated to poorer health outcomes compared to 2018.

CONCLUSIONS

The results of our study show a significant reduction in e-consultation referrals during the first year of the COVID-19 pandemic, with a subsequent recovery in the demand for care, and without the pandemic periods being associated to poorer outcomes. The reduction in time elapsed for resolving the e-consultations and no need for face-to-face visits were associated to improved outcomes.

Factors Associated With Asthma Biologic Prescribing and Primary Adherence Among Adults in a Large Health System

BACKGROUND

The availability of asthma biologics may not benefit all patients equally.

OBJECTIVE

We sought to identify patient characteristics associated with asthma biologic prescribing, primary adherence, and effectiveness.

METHODS

A retrospective, observational cohort study of 9,147 adults with asthma who established care with a Penn Medicine asthma subspecialist was conducted using Electronic Health Record data from January 1, 2016, to October 18, 2021. Multivariable regression models were used to identify factors associated with (1) receipt of a new biologic prescription; (2) primary adherence, defined as receiving a dose in the year after receiving the prescription, and (3) oral corticosteroid (OCS) bursts in the year after the prescription.

RESULTS

Factors associated with a new prescription, which was received by 335 patients, included being a woman (odds ratio [OR] 0.66; P = .002), smoking currently (OR 0.50; P = .04), having an asthma hospitalization in the prior year (OR 2.91; P < .001), and having 4+ OCS bursts in the prior year (OR 3.01; P < .001). Reduced primary adherence was associated with Black race (incidence rate ratio 0.85; P < .001) and Medicaid insurance (incidence rate ratio 0.86; P < .001), although most in these groups, 77.6% and 74.3%, respectively, still received a dose. Nonadherence was associated with patient-level barriers in 72.2% of cases and health insurance denial in 22.2%. Having more OCS bursts after receiving a biologic prescription was associated with Medicaid insurance (OR 2.69; P = .047) and biologic days covered (OR 0.32 for 300-364 d vs 14-56 d; P = .03).

CONCLUSIONS

In a large health system, primary adherence to asthma biologics varied by race and insurance type, whereas nonadherence was primarily explained by patient-level barriers.

[Impact of the COVID-19 pandemic above a universal electronic consultation program (e-consultation) between general practitioners and cardiologists]

Blackground and objective

Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are not data of models between clinicians. Our objective is to analyse the impact of the COVID-19 pandemic on the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our area.

Methods

Patients with at least one e-consultation between 2018 and 2021 were selected. We analysed the impact of the COVID-19 pandemic on activity and waiting time for care, hospitalizations and mortality, taking as a reference the consultations carried out during 2018.

Results

We analysed 25,121 patients. Through logistic regression analysis, it was observed that a shorter delay in care and resolution of the e-consultation without the need for face-to-face care were associated with a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated with worse health outcomes compared to 2018.

Conclusions

The results of our study show a significant reduction in e-consult referrals during the first year of the COVID-19 pandemic with a subsequent recovery in the demand for care without the pandemic periods being associated with worse outcomes. The reduction in the time elapsed for solving the e-consult and no need for in-person visit were associated with better outcomes.