Racial and ethnic disparities in use of a personal health record by veterans living with HIV

Examining health apps and wearable use in improving physical and mental well-being across U.S., China, and Singapore

Health apps and wearables are touted to improve physical health and mental well-being. However, it is unclear from existing research the extent to which these health technologies are efficacious in improving physical and mental well-being at a population level, particularly for the underserved groups from the perspective of health equity and social determinants. Also, it is unclear if the relationship between health apps and wearables use and physical and mental well-being differs across individualistic, collectivistic, and a mix of individual-collectivistic cultures. A large-scale online survey was conducted in the U.S. (individualist culture), China (collectivist culture), and Singapore (mix of individual-collectivist culture) using quota sampling after obtaining ethical approval from the Institutional Review Board (IRB-2021-262) of Nanyang Technological University (NTU), Singapore. There was a total of 1004 respondents from the U.S., 1072 from China, and 1017 from Singapore. Data were analyzed using multiple regression and negative binomial regression. The study found that income consistently had the strongest relationship with physical and mental well-being measures in all three countries, while the use of health apps and wearables only had a moderate association with psychological well-being only in the US. Health apps and wearables were associated with the number of times people spent exercising and some mental health outcomes in China and Singapore, but they were only positively associated with psychological well-being in the US. The study emphasizes the importance of considering the social determinants, social-cultural context of the population, and the facilitating conditions for the effective use of digital health technologies. The study suggests that the combined use of both health apps and wearables is most strongly associated with better physical and mental health, though this association is less pronounced when individuals use only apps or wearables.

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

BACKGROUND AND OBJECTIVE

COVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.

DESIGN AND PARTICIPANTS

This was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19-2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18-2/28-19; n = 1,536,954).

MAIN MEASURES

We assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.

KEY RESULTS

Prior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.

CONCLUSIONS

Disparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Relationship Between Patient Portal Tool Use and Medication Adherence and Viral Load Among Patients Living with HIV

BACKGROUND

Patient portals play an increasingly critical role in engaging patients in their health care. They have the potential to significantly impact the health of those living with chronic diseases, such as HIV, for whom consistent care engagement is both critical and complex.

OBJECTIVE

The primary aim was to examine the longitudinal relationships between individual portal tool use and health-related outcomes in patients living with HIV.

DESIGN

Retrospective cohort study using electronic health record data to examine the relationship between patient portal tool use and key HIV-specific, health-related outcomes in patients engaged in care in the Veterans Health Administration (VA) through the application of marginal structural models.

PARTICIPANTS

A national sample of patients living with HIV (PLWH) active in VA care who were registered to use the VA's patient portal, My HealtheVet (MHV; n = 18,390) between 10/1/2012 and 4/1/2017.

MAIN MEASURES

The MHV tools examined were prescription refill (including prescription refill of an antiretroviral (ART) medication and any medication), secure messaging, view appointments, and view labs. Primary outcomes were viral load test receipt, viral load suppression, and ART medication adherence (measured as proportion of days covered).

KEY RESULTS

The use of prescription refill for any medication or for ART was positively associated with ART adherence. Secure messaging was positively associated with ART adherence but not with viral load test receipt or viral load suppression. The use of view appointments was positively associated with ART adherence and viral load test receipt but not viral load suppression. The use of view labs was positively associated with viral load suppression but not ART adherence or viral load test receipt.

CONCLUSIONS

These findings highlight the valuable role patient portals may play in improving health-related outcomes among PLWH and have implications for patients living with other types of chronic disease.

Use of the Veterans Health Administration online patient portal among Veterans with spinal cord injuries and disorders

CONTEXT/OBJECTIVE

Online patient portals like the Veteran Health Administration's (VA) My HealtheVet (MHV) may be particularly useful for Veterans with spinal cord injuries/disorders (SCI/D), many of whom experience barriers to care. The objective of this analysis was to examine MHV use among Veterans with SCI/D.

DESIGN

Retrospective database analysis.

SETTING

VA SCI/D System of Care.

PARTICIPANTS

Veterans with SCI/D who utilize VA care.

INTERVENTIONS

N/A.

OUTCOME MEASURES

MHV registration and use of key portal features among Veterans who newly registered for MHV. Veteran characteristics associated with registration and use of portal features using multiple logistic regression.

RESULTS

14.6% of Veterans with SCI/D in our sample registered to use MHV. 48.7% used the medication refill feature, 28.7% used the appointment view feature, 25.0% sent or read at least one secure message and 10.8% used the Blue Button feature. Adjusted analyses indicate that having a C5-8 (OR: 1.36, CI95%: 1.06-1.76, P < 0.05) or T1-S5 (OR: 1.41, CI95%: 1.13-1.78, P < 0.01) (vs. C1-C4), having (vs. not having) neurogenic bladder (OR: 1.45, CI95%: 1.18-1.77, P < 0.01), being married (vs. not married) (OR: 2.00, CI95%: 1.67-2.39, P < 0.01), and increased healthcare utilization in the third (OR: 1.71, CI95%: 1.31-2.24, P < 0.01) and fourth (OR: 1.73, CI95%: 1.27-2.34, P < 0.01) quartiles (vs. first quartile) were associated with increased odds of MHV registration. We also identified factors associated with use of key MHV features.

CONCLUSIONS

Our results suggest that MHV registration and use of key portal features was limited among Veterans with SCI/D. Effort to increase portal use in this population are warranted.

Towards Understanding Disparities in Using Technology to Access Health Care Information: African American Veterans' Sociocultural Perspectives on Using My HealtheVet for Diabetes Management

The digital divide, a racial disparity in computer and internet use, persists among Veterans. This study examined African American Veterans' experiences with and attitudes about using My HealtheVet (MHV), the online patient portal used in the Department of Veterans Affairs (VA) health care system. Semi-structured interviews were conducted with 35 non-Hispanic African American Veterans about preferences for health information, use of web-enabled devices, and experiences with and preferences for using MHV. Twenty-nine men and 6 women, ranging 35 to 73 years old, participated in this study. About 75% (n = 26) had completed some college or more, and about 75% (n = 26) considered their families financially comfortable. Ninety-one percent (n = 32) of participants were aware of MHV, and 78% (n = 25) of those who were aware reported having enrolled for an account. Data revealed participants valued that MHV provided realistic solutions to cumbersome aspects (e.g., phone call hold-times) of receiving care at the VA. However, participants admitted to not using the patient portal at all or to its full potential for two reasons: a) preference for their pre-MHV routine, b) distrust in the institutional, technological, and organizational aspects surrounding MHV. By highlighting the sociocultural aspects of patient portal use, this study provides a meaningful explanation for barriers and facilitators of health information technology adoption, particularly for MHV among African American Veterans, and ways practitioners may influence uptake.

Patient and provider perspectives of personal health record use: a multisite qualitative study in HIV care settings

Use of tethered personal health records (PHRs) can streamline care, reduce unnecessary care utilization, and improve health outcomes for people living with human immunodeficiency virus (HIV). Providers play a role in influencing patients' decision to adopt and use PHRs. To explore patient and provider acceptance and use of PHRs in an HIV care setting. We used a qualitative study design guided by the Unified Theory of Acceptance and Use of Technology. Participants included providers of HIV care, patients living with HIV, and PHR coordinating and support staff in the Veterans Health Administration (VA). Interviews were analyzed using directed content analysis. We interviewed providers (n = 41), patients living with HIV (n = 60), and PHR coordinating and support staff (n = 16) at six VA Medical Centers between June and December 2019. Providers perceived PHR use could enhance care continuity, appointment efficiency, and patient engagement. Yet, some expressed concerns that patient PHR use would increase provider workload and detract from clinical care. Concerns about poor PHR interoperability with existing clinical tools further eroded acceptance and use of PHRs. PHR use can enhance care for patients with HIV and other complex, chronic conditions. Negative provider attitudes toward PHRs may impact providers' encouragement of use among patients, consequently limiting patient uptake. Multipronged interventions at the individual, institutional, and system level are needed to enhance PHR engagement among both providers and patients.

The Use of a Technology Acceptance Model (TAM) to Predict Patients' Usage of a Personal Health Record System: The Role of Security, Privacy, and Usability

Personal health records (PHR) systems are designed to ensure that individuals have access and control over their health information and to support them in being active participants rather than passive ones in their healthcare process. Yet, PHR systems have not yet been widely adopted or used by consumers despite their benefits. For these advantages to be realized, adoption of the system is necessary. In this study, we examined how self-determination of health management influences individuals' intention to implement a PHR system, i.e., their ability to actively manage their health. Using an extended technology acceptance model (TAM), the researchers developed and empirically tested a model explaining public adoption of PHRs. In total, 389 Saudi Arabian respondents were surveyed in a quantitative cross-sectional design. The hypotheses were analysed using structural equation modelling-partial least squares (SEM-PLS4). Results indicate that PHR system usage was influenced by three major factors: perceived ease of use (PEOU), perceived usefulness (PU), and security towards intention to use. PHR PEOU and PHR intention to use were also found to be moderated by privacy, whereas usability positively moderated PHR PEOU and PHR intention to use and negatively moderated PHR PU and PHR intention to use. For the first time, this study examined the use of personal health records in Saudi Arabia, including the extension of the TAM model as well as development of a context-driven model that examines the relationship between privacy, security, usability, and the use of PHRs. Furthermore, this study fills a gap in the literature regarding the moderating effects of privacy influence on PEOU and intention to use. Further, the moderating effects of usability on the relationship between PEOU, PU, and intention to use. Study findings are expected to assist government agencies, health policymakers, and health organizations around the world, including Saudi Arabia, in understanding the adoption of personal health records.

Tablet distribution to veterans: an opportunity to increase patient portal adoption and use

OBJECTIVE

Examine whether distribution of tablets to patients with access barriers influences their adoption and use of patient portals.

MATERIALS AND METHODS

This retrospective cohort study included Veterans Affairs (VA) patients (n = 28 659) who received a VA-issued tablet between November 1, 2020 and April 30, 2021. Tablets included an app for VA's My HealtheVet (MHV) portal. Veterans were grouped into 3 MHV baseline user types (non-users, inactive users, and active users) based on MHV registration status and feature use pre-tablet receipt. Three multivariable models were estimated to examine the factors predicting (1) MHV registration among non-users, (2) any MHV feature use among inactive users, and (3) more MHV use among active users post-tablet receipt. Differences in feature use during the 6 months pre-/post-tablet were examined with McNemar chi-squared tests of proportions.

RESULTS

In the 6 months post-tablet, 1298 (8%) non-users registered for MHV, 525 (24%) inactive users used at least one MHV feature, and 4234 (46%) active users increased feature use. Across veteran characteristics, there were differences in registration and feature use post-tablet, particularly among older adults and those without prior use of video visits (P < .01). Among active users, use of all features increased during the 6 months post-tablet, with the greatest differences in viewing prescription refills and scheduling appointments (P < .01).

CONCLUSION

Providing patients who experience barriers to in-person care with a portal-enabled device supports engagement in health information and management tasks. Additional strategies are needed to promote registration and digital inclusion among inactive and non-users of portals.

Electronic Patient Portal Access, Retention in Care, and Viral Suppression Among People Living With HIV in Southeastern United States: Observational Study

BACKGROUND

Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression-measures of engagement in HIV care-are associated with decreased HIV transmission, morbidity, and mortality.

OBJECTIVE

We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression.

METHODS

We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression.

RESULTS

We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22).

CONCLUSIONS

In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.

Association of Race and Ethnicity With Incidence of Dementia Among Older Adults

IMPORTANCE

The racial and ethnic diversity of the US, including among patients receiving their care at the Veterans Health Administration (VHA), is increasing. Dementia is a significant public health challenge and may have greater incidence among older adults from underrepresented racial and ethnic minority groups.

OBJECTIVE

To determine dementia incidence across 5 racial and ethnic groups and by US geographical region within a large, diverse, national cohort of older veterans who received care in the largest integrated health care system in the US.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study within the VHA of a random sample (5% sample selected for each fiscal year) of 1 869 090 participants aged 55 years or older evaluated from October 1, 1999, to September 30, 2019 (the date of final follow-up).

EXPOSURES

Self-reported racial and ethnic data were obtained from the National Patient Care Database. US region was determined using Centers for Disease Control and Prevention (CDC) regions from residential zip codes.

MAIN OUTCOMES AND MEASURES

Incident diagnosis of dementia (9th and 10th editions of the International Classification of Diseases). Fine-Gray proportional hazards models were used to examine time to diagnosis, with age as the time scale and accounting for competing risk of death.

RESULTS

Among the 1 869 090 study participants (mean age, 69.4 [SD, 7.9] years; 42 870 women [2%]; 6865 American Indian or Alaska Native [0.4%], 9391 Asian [0.5%], 176 795 Black [9.5%], 20 663 Hispanic [1.0%], and 1 655 376 White [88.6%]), 13% received a diagnosis of dementia over a mean follow-up of 10.1 years. Age-adjusted incidence of dementia per 1000 person-years was 14.2 (95% CI, 13.3-15.1) for American Indian or Alaska Native participants, 12.4 (95% CI, 11.7-13.1) for Asian participants, 19.4 (95% CI, 19.2-19.6) for Black participants, 20.7 (95% CI, 20.1-21.3) for Hispanic participants, and 11.5 (95% CI, 11.4-11.6) for White participants. Compared with White participants, the fully adjusted hazard ratios were 1.05 (95% CI, 0.98-1.13) for American Indian or Alaska Native participants, 1.20 (95% CI, 1.13-1.28) for Asian participants, 1.54 (95% CI, 1.51-1.57) for Black participants, and 1.92 (95% CI, 1.82-2.02) for Hispanic participants. Across most US regions, age-adjusted dementia incidence rates were highest for Black and Hispanic participants, with rates similar among American Indian or Alaska Native, Asian, and White participants.

CONCLUSIONS AND RELEVANCE

Among older adults who received care at VHA medical centers, there were significant differences in dementia incidence based on race and ethnicity. Further research is needed to understand the mechanisms responsible for these differences.

Socio-technical drivers and barriers in the consumer adoption of personal health records: An empirical investigation

BACKGROUND

Increasingly popular in the healthcare domain, electronic personal health records (PHRs) have the potential to foster engagement towards improving health outcomes, achieve efficiencies in care, and reducing costs. Despite touted benefits, the uptake of PHRs is lackluster, with low adoption rates.

OBJECTIVE

This paper reports findings from an empirical investigation on socio-technical factors affecting the adoption of PHRs.

METHODS

A research model comprising personal and technological determinants of PHR adoption is developed and validated in this study. Demographic, technographic and psychographic data pertaining to the use of PHRs was collected through an online questionnaire for past, current, and potential users. Partial least squares (PLS) based structural equation modeling (SEM) was used to estimate a structural model of cognitive and affective factors impacting intentions to use PHRs.

RESULTS

Analysis reveal that in addition to the expected positive impact of a PHR system's usefulness and usability, system integration also positively effects consumer intention to adopt. Results also suggest that higher levels of perceived usability and integration do not translate into higher levels of perceived usefulness. The study also highlights the importance of subjective norm, technology awareness, and technology anxiety as direct antecedents of intention to adopt PHRs. Differential effects of adoption factors are also discussed.

CONCLUSIONS

Our study hopes to contribute to an understanding of consumer adoption of PHRs, and to help improve the design and delivery of consumer-centric healthcare technologies. After implications for research, we provide suggestions and guidelines for PHR technology developers and constituents in the healthcare delivery chain.

CLINICALTRIAL

Functionalities and Issues in the Implementation of Personal Health Records: Systematic Review

Background

Functionalities of personal health record (PHR) are evolving, and continued discussions about PHR functionalities need to be performed to keep it up-to-date. Technological issues such as nonfunctional requirements should also be discussed in the implementation of PHR.

Objective

This study systematically reviewed the main functionalities and issues in implementing the PHR.

Methods

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search is performed using the online databases Scopus, ScienceDirect, IEEE, MEDLINE, CINAHL, and PubMed for English journal articles and conference proceedings published between 2015 and 2020.

Results

A total of 105 articles were selected in the review. Seven function categories were identified in this review, which is grouped into basic and advanced functions. Health records and administrative records were grouped into basic functions. Medication management, communication, appointment management, education, and self-health monitoring were grouped into advanced functions. The issues found in this study include interoperability, security and privacy, usability, data quality, and personalization.

Conclusions

In addition to PHR basic and advanced functions, other supporting functionalities may also need to be developed based on the issues identified in this study. This paper provides an integrated PHR architectural model that describes the functional requirements and data sources of PHRs.

Persistent inequitable design and implementation of patient portals for users at the margins

Objective

Diane Forsythe and other feminist scholars have long shown how system builders’ tacit assumptions lead to the systematic erasure of certain users from the design process. In spite of this phenomena being known in the health informatics literature for decades, recent research shows how patient portals and electronic patients health records continue to reproduce health inequalities in Western societies. To better understand this discrepancy between scholarly awareness of such inequities and mainstream design, this study unravels the (conceptual) assumptions and practices of designers and others responsible for portal implementation in the Netherlands and how citizens living in vulnerable circumstances are included in this process.

Materials and methods

We conducted semistructured interviews (n = 24) and questionnaires (n = 14) with portal designers, health professionals, and policy advisors.

Results

In daily design practices, equity is seen as an “end-of-the-pipeline” concern. Respondents identify health care professionals rather than patients as their main users. If patients are included in the design, this generally entails patients in privileged positions. The needs of citizens living in vulnerable circumstances are not prioritized in design processes. Developers legitimize their focus with reference to the innovation-theoretical approach of the Diffusion of Innovations.

Discussion and conclusion

Although feminist scholars have developed important understandings of the exclusion of citizens living in vulnerable circumstances from portal design, other academic efforts have profoundly shaped daily practices of portal development. Diane Forsythe would likely have taken up this discrepancy as a challenge by finding ways to translate these insights into mainstream systems design.

Correlates of personal health record registration and utilization among veterans with HIV

Objective

We examined correlates of registration and utilization of the Veteran Health Administration's (VHA) personal health record (PHR), My HealtheVet (MHV), among a national cohort of veterans living with HIV.

Materials and Methods

Using VHA administrative data, we matched veterans with HIV who registered for MHV in fiscal year 2012-2018 (n = 8589) to 8589 veterans with HIV who did not register for MHV. We compared demographic and geographic characteristics, housing status, comorbidities, and non-VHA care between MHV registrants and nonregistrants to identify correlates of MHV registration. Among registrants, we examined the association between these characteristics and MHV tool use (prescription refill, record download, secure messaging, view labs, and view appointments).

Results

MHV registrants were more likely to be younger, women, White, and to have bipolar disorder, depression, or post-traumatic stress disorder diagnosis than nonregistrants. Having a substance use disorder (SUD) diagnosis or a higher Elixhauser score was associated with lower odds of MHV registration. Among registrants, women were less likely to use prescription refill. Patients who were at risk of homelessness in the past year were less likely to use secure messaging and, along with those who were homeless, were less likely to use view labs and prescription refill. Bipolar disorder and depression were associated with increased secure messaging use. Diagnoses of SUD and alcohol use disorder were both associated with lower rates of prescription refill.

Discussion

Among veterans living with HIV, we identified significant differences in PHR registration and utilization by race, sex, age, housing status, and diagnosis.

Health informatics and health equity: improving our reach and impact

Health informatics studies the use of information technology to improve human health. As informaticists, we seek to reduce the gaps between current healthcare practices and our societal goals for better health and healthcare quality, safety, or cost. It is time to recognize health equity as one of these societal goals-a point underscored by this Journal of the American Medical Informatics Association Special Focus Issue, "Health Informatics and Health Equity: Improving our Reach and Impact." This Special Issue highlights health informatics research that focuses on marginalized and underserved groups, health disparities, and health equity. In particular, this Special Issue intentionally showcases high-quality research and professional experiences that encompass a broad range of subdisciplines, methods, marginalized populations, and approaches to disparities. Building on this variety of submissions and other recent developments, we highlight contents of the Special Issue and offer an assessment of the state of research at the intersection of health informatics and health equity.

Health care utilization and HIV clinical outcomes among newly enrolled patients following Affordable Care Act implementation in a California integrated health system: a longitudinal study

BACKGROUND

The Affordable Care Act (ACA) has increased insurance coverage for people with HIV (PWH) in the United States. To inform health policy, it is useful to investigate how enrollment through ACA Exchanges, deductible levels, and demographic factors are associated with health care utilization and HIV clinical outcomes among individuals newly enrolled in insurance coverage following implementation of the ACA.

METHODS

Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N = 880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and > = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL).

RESULTS

Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed.

CONCLUSIONS

In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage.

Examining multimorbidity differences across racial groups: a network analysis of electronic medical records

Health disparities across ethnic or racial groups are typically examined through single behavior at a time. The syndemics and multimorbidity health disparities have not been well examined by race. In this study, we study health disparities by identifying the networks of multimorbidities among individuals from seven population groups based on race, including White, African American, Asian, Hispanic, Native American, Bi- or Multi-racial and Pacific Islander. We examined a large electronic medical record (EMR) containing health records of more than 18.7 million patients and created multimorbidity networks considering their lifetime history from medical records in order to compare the network properties among seven population groups. In addition, the networks at organ system level depicting the relationship among disorders belonging to different organ systems are also compared. Our macro analysis at the organ-level indicates that African-Americans have a stronger multimorbidity network followed by Whites and Native Americans. The networks of Asians and Hispanics are sparse. Specifically, the relationship of infectious and parasitic disorders with respiratory, circulatory and genitourinary system disorders is stronger among African Americans than others. On the other hand, the relationship of mental disorders with respiratory, musculoskeletal system and connective tissue disorders is more prevalent in Whites. Similar other disparities are discussed. Recognition and explanation of such differences in multimorbidities inform the public health policies, and can inform clinical decisions as well. Our multimorbidity network analysis identifies specific differences in diagnoses among different population groups, and presents questions for biological, behavioral, clinical, social science, and policy research.