Disparities In Health Care Utilization Research Articles

Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey

BackgroundKenya is experiencing persistently high levels of inequity in health and access to care services. In 2018, decades of sustained policy efforts to promote equitable, affordable and quality health services have culminated in the launch of a universal health coverage scheme, initially piloted in four Kenyan counties and planned for national rollout by 2022. Our study aims to contribute to monitoring and evaluation efforts alongside policy implementation, by establishing a detailed, baseline assessment of socio-economic inequality and inequity in health care utilization in Kenya shortly before the policy launch.MethodsWe use concentration curves and corrected concentration indexes to measure socio-economic inequality in care use and the horizontal inequity index as a measure of inequity in care utilization for three types of care services: outpatient care, inpatient care and preventive and promotive care. Further insights into the individual and household level characteristics that determine observed inequality are derived through decomposition analysis.ResultsWe find significant inequality and inequity in the use of all types of care services favouring richer population groups, with particularly pronounced levels for preventive and inpatient care services. These are driven primarily by differences in living standards and educational achievement, while the region of residence is a key driver for inequality in preventive care use only. Pro-rich inequalities are particularly pronounced for care provided in privately owned facilities, while public providers serve a much larger share of individuals from lower socio-economic groups.ConclusionsThrough its focus on increasing affordability of care for all Kenyans, the newly launched universal health coverage scheme represents a crucial step towards reducing disparities in health care utilization. However in order to achieve equity in health and access to care such efforts must be paralleled by multi-sectoral approaches to address all key drivers of inequity: persistent poverty, disparities in living standards and educational achievement, as well as regional differences in availability and accessibility of care.

Educational level and first-time PSA testing in general practice

Introduction: Different patterns in the use of prostate-specific antigen (PSA) testing might explain socioeconomic differences in prostate cancer incidence and mortality. We examined the association between socioeconomic position, measured as education and first-time PSA testing in general practice.Material and Methods: A population-based cohort study of men aged 45–79 years without prior prostate cancer diagnosis living in the Capital Region of Denmark between 2000 and 2014. Information on socioeconomic indicators (education, income, cohabitation status and work market affiliation), prostate cancer diagnoses, and vital status were obtained from national registries. Date of first PSA test was obtained from the Copenhagen Primary Care Laboratory database. Temporal trends of PSA testing were calculated as annual age-standardised incidence rates and the association was examined by a multivariable Cox proportional hazards model.Results: The cohort consists of 431,997 men of which 105,476 (24%) had a first-time PSA test in the study period. Men with longer education, higher income, living with a partner, and employed had higher rates of PSA testing. For men with short education, the rate of PSA test was 28.3 tests per 1000 person-years compared to 31.2 tests among men with long education. The fully adjusted hazard ratio for a first PSA test among men with short education was 0.87 (95% CI, 0.85–0.89) compared to men with long education.Conclusion: The association between education and first-time PSA testing indicates socioeconomic disparities in health care utilisation, which could explain part of the observed socioeconomic difference in prostate cancer incidence and mortality.

Disparities in Health Care Utilization Between Asian Immigrant Women and Non-Hispanic White Women in the United States.

Background: Asians accounted for 30% of all U.S. immigrants in 2014, of which 53% were women. Foreign-born Asian immigrant (FBAI) women experience difficulties in obtaining timely and needed health care due to multifaceted barriers. This study examined factors influencing health service utilization among FBAI women compared with native-born (non-Hispanic) White American (NBWA) women. Materials and Methods: A secondary data analysis was conducted using the 2014-2015 California Health Interview Survey. Guided by a modified version of Andersen's behavioral model of health service utilization, FBAI women aged 18 to 64 (n = 1,021) were compared with NBWA women of the same ages (n = 7,086). Outcome variables included having at least one doctor's visit in the past year and having an emergency room (ER) visit in the past year. Analyses included descriptive statistics, t-tests, chi-square tests, and multivariate logistic regressions. Results: FBAI women were significantly less likely to have at least one doctor's visit in the past year and were less likely to have a usual source of care than NBWA women. Significant predictors of having at least one doctor's visit for FBAI women were having high school education, having a usual source of care, having medical insurance, and having a chronic disease. The only significant predictor of having an ER visit for FBAI women was having a chronic disease. Conclusions: Health care providers must be aware of lower levels of health service utilization among FBAI women than NBWA women regardless of whether or not the FBAI women have chronic conditions. It is important to educate these women on the importance of regular health care visits.

Mini Review: Socio-Cultural Influences on the Link Between ADHD and SUD.

Attention-deficit/hyperactivity disorder (ADHD) is a risk factor for the development and persistence of substance use disorders (SUD). The prevalence of ADHD in patients with SUD varies across countries and cultures. So far, cross-cultural variance in ADHD prevalence rates among SUD patients was mainly ascribed to methodological differences between studies, leaving the role of societal and cultural practices in the ADHD-SUD link hardly acknowledged. The aim of the present mini review is to address this gap in the literature by providing evidence for the effect of socio-cultural practices on the ADHD-SUD link and suggesting directions for future research. To achieve this goal, we map the influence of socio-cultural factors on the ADHD-SUD link along three lines of research. The first line is concerned with the role of socio-cultural factors in the recognition, diagnosis and treatment of childhood ADHD. The second line of research is concerned with socio-cultural influences on substance use (e.g., religion, ethnic identity, acculturation, and socio-economic status). Finally, we describe potential socio-cultural factors which may operate as mechanisms for reducing or increasing access to substance abuse treatment (e.g., ethnic disparities in health care utilization). Identifying socio-cultural influences on the ADHD-SUD link may provide further insight into the bidirectional association between ADHD and SUD in different contexts and encourage future research in the field.

The Impact of Patient-Provider Race/Ethnicity Concordance on Provider Visits: Updated Evidence from the Medical Expenditure Panel Survey.

To examine the association between race/ethnicity concordance and in-person provider visits following the implementation of the Affordable Care Act. Using 2014-2015 data from the Medical Expenditure Panel Survey, we examine whether having a provider of the same race or ethnicity ("race/ethnicity concordance") affects the probability that an individual will visit a provider. Multivariate probit models are estimated to adjust for demographic, socioeconomic, and health factors. Race/ethnicity concordance significantly increases the likelihood of seeking preventative care for Hispanic, African-American, and Asian patients relative to White patients (coef = 1.46, P < 0.001; coef = 0.71, P = 0.09; coef = 1.70, P < 0.001, respectively). Race/ethnicity concordance also increases the likelihood that Hispanic and Asian patients visit their provider for new health problems (coef = 2.14, P < 0.001 and coef = 1.49, P < 0.05, respectively). We find that race/ethnicity concordance is also associated with an increase in the likelihood that Hispanic and Asian patients continue to visit their provider for ongoing medical problems (Hispanic coef = 1.06, P < 0.001; Asian coef = 1.24, P < 0.05). There is an association between race/ethnicity concordance and the likelihood of patients visiting their provider. Our results demonstrate that racial disparities in health care utilization may be partially explained by race/ethnicity concordance.

Educational expansion and health disparities in Ethiopia, 2005–2016

Research shows that basic education improves population health, yet it remains unclear whether the expansion of primary education decreases health disparities. In this paper, I assess whether disparities in healthcare utilization decreased in conjunction with educational expansion among women of reproductive age in Ethiopia. Healthcare utilization rates in low-resource countries are often confounded with simultaneous developments in education and access to basic healthcare. Using decomposition of rates, I first disentangle the changes in health disparities induced by educational expansion from the overall increase in healthcare utilization. Then, I use the Blinder-Oaxaca decomposition method to investigate the determinants of disparities in healthcare utilization and how these determinants changed over a 10-year period as primary education became more prevalent. Overall, disparities in healthcare utilization in Ethiopia decreased over time, yet the association between educational expansion and health disparities varies by region. Literacy explains much of the disparities in healthcare utilization, yet it loses significance over time as primary education becomes widespread. Economic factors remain persistent sources of disparities, and non-financial barriers such as the distance to travel and women's ability to travel alone become more significant. Heterogeneity in healthcare utilization across regions has distinct implications for how educational expansion may shift health disparities.

Su1585 – Racial Disparity in Health Care Utilization Amongst Patients with Irritable Bowel Syndrome: Results from a Multicenter Cohort

Su1585 – Racial Disparity in Health Care Utilization Amongst Patients with Irritable Bowel Syndrome: Results from a Multicenter Cohort

267 Regional disparities in healthcare utilization and costs of atopic dermatitis

267 Regional disparities in healthcare utilization and costs of atopic dermatitis

Correction to: Disparities in Healthcare Utilization Among Adults with Obesity in the United States, Findings from the NHIS: 2006–2015

In the original publication of the article the Table 1 header has been switched. The corrected Table is provided in this correction article.

Racial/Ethnic Variation in Use of Ambulatory and Emergency Care for Atopic Dermatitis among US Children

Previous studies indicate racial/ethnic differences in health care utilization for pediatric atopic dermatitis (AD), but do not account for disease severity impact. We sought to examine the relationship between race/ethnicity and health care utilization, both overall and by specific visit type, while accounting for AD control. A longitudinal cohort study of children with AD in the United States was performed to evaluate the association between race/ethnicity and health care utilization for AD. AD control and health care utilization were assessed biannually. Our study included 7,522 children (34.2% white, 54.2% black, and 11.5% Hispanic) who were followed for a median of 4 years (interquartile range 0.9-8.4 years). After adjusting for sociodemographic and other factors, black and Hispanic children were up to nearly threefold more likely than white children to receive medical care for AD across almost all levels of AD control. Black and Hispanic children had higher odds of primary care and emergency visits compared to whites. Black children with poorly controlled AD were significantly less likely to see a dermatologist than white children with similarly poorly controlled AD (odds ratio= 0.74, 95% confidence interval= 0.64-0.85 for limited control; odds ratio= 0.59, 95% confidence interval= 0.47-0.76 for uncontrolled AD). Together, these findings suggest the presence of racial/ethnic disparities in health care utilization for AD.

Disparities in Healthcare Utilization Among Adults with Obesity in the United States, Findings from the NHIS: 2006–2015

Few studies of disparities consider logistical hurdles faced by adults with obesity in obtaining needed healthcare. This study compared adults with obesity to adults without obesity on self-reported practical aspects of receiving healthcare including ease of seeing a doctor and wait times for appointments. Serious psychological distress and chronic health conditions are prevalent in adults with obesity. Because serious psychological distress and number of chronic health conditions can act as confounders in any observed differences between the adults with and without obesity in their use of healthcare, we have examined these differences independent of serious psychological distress and chronic health conditions. Adults 18 to 64 years sampled from the 2006–2015 National Health Interview Survey (NHIS) (n = 74,598) were examined on five self-reported indicators: does not need a doctor, waited too long in the doctor’s office, and to get an appointment, year since having seen a doctor, and saw a doctor ten times or more in the last 12 months. Multivariable models adjusted for serious psychological distress, chronic health conditions, gender, age, race/ethnicity, income, health coverage, and survey year demonstrated that adults with obesity were more likely to wait too long to get an appointment, and in the waiting room. Adults with obesity report not needing doctors despite seeing doctors frequently. Greater attention is needed to understand barriers to health care utilization in adults with obesity.

Differences in Perioperative Outcomes and Complications Between African American and White Patients After Total Joint Arthroplasty

BackgroundRacial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA). MethodsSingle institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor. ResultsIn total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002). ConclusionAA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity.

Disparity in Health Care Utilization by Income Level and Insurance Status at Gamping Muhammadiyah Hospital, Yogyakarta, Indonesia

Background: Ideal equity in health is defined as each individual has the same opportunity to get the best health and not be harmed in the process of obtaining the health services. Communities with different socio-economic status should receive the same health services according to their needs, including equal access rights in the utilization of health services. Nowadays, the quality health services cannot be enjoyed equally by the Indonesian. The purpose of this study was to examine disparity in health care utilization by income level and insurance status at Gamping Muhammadiyah Hospital, Yogyakarta, Indonesia. Subjects and Method: This study was an observational analytic study with a cross-sectional design. The study was conducted at PKU Muhammadiyah Gamping Hospital, Sleman Yogyakarta. 200 subjects were selected using simple random sampling. The dependent variable was the frequency of use of health services. The independent variables were the health insurance (BPJS) status, patient income, patient education level, and residence. The data were collected by questionnaire and analyzed by a multiple linear regression. Results : Frequency of health care utilization decreased with health insurance membership status (b= -4.49; 95% CI= -1.53 to -0.60; p <0.001) and longer distance (b= -7.33; 95% CI= -0.07 to -0.04; p<0.001). Frequency of health care utilization increased with patient age (b= 10.20; 95% CI= 0.06 to 0.09; p<0.001), family income (b= 3.30; 95% CI= 0.00 to 0.01; p = 0.001), and residence (b= 3.11; 95% CI= 0.33 to 1.47; p= 0.002). Conclusion : Frequency of health care utilization decreases with health insurance membership status and longer distance. Frequency of health care utilization increases with patient age, family income, and residence. Keywords : disparity, health insurance Correspondence: R. Haryo Nugroho. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta 57126, Central Java, Indonesia. Email: haryo_sleman@yahoo.co.id. Journal of Health Policy and Management (2019), 4(3): 195-203 https://doi.org/10.26911/thejhpm.2019.04.03.07

Access to health care, medical progress and the emergence of the longevity gap: A general equilibrium analysis

We study skill- and income-related differences in the access to health care as drivers of longevity inequality from a theoretical life-cycle as well as from a macroeconomic perspective. To do so, we develop an overlapping generations model populated by heterogeneous agents subject to endogenous mortality. We model two groups of individuals for whom differences in skills translate into differences in income and in the ability to use medical technology effectively in curbing mortality. We derive the skill- and age-specific individual demand for health care based on the value of life, the level of medical technology and the market prices. Calibrating the model to the development of the US economy and the longevity gap between the skilled and unskilled, we study the impact of rising effectiveness of medical care in improving individual health and examine how disparities in health care utilisation and mortality emerge as a consequence. In so doing, we explore the role of skill-biased earnings growth, skill-bias in the ability to access state-of-the art health care and to use it effectively, and skill-related differences in health insurance coverage. We pay attention to the macroeconomic feedback, especially to medical price inflation. Our findings indicate that skill-bias related to the effectiveness of health care explains a large part of the increase in the longevity with earnings-related differences in the utilisation of health care taking second place. Both channels tend to be reinforced by medical progress.

The impact of ACA Medicaid expansion on socioeconomic inequality in health care services utilization.

ObjectiveWe examined whether the Affordable Care Act (ACA) Medicaid expansion reduced socioeconomic inequalities in health care utilization.MethodsWe used data from the Behavioral Risk Factor Surveillance System, covering the 50 U.S. states and the District of Columbia, between 2011 and 2016. We selected outcome indicators, viz. ability to afford needed health care, having a personal doctor, use of health services in the past year (routine check-up, flu shot and dental visits), and attending screenings for breast, cervical, and colon cancers. Socioeconomic status was measured by household income. We calculated two indices of inequality by household income for each outcome: Slope Index of Inequality (SII) and Relative Index of Inequality (RII). We estimated difference-in-differences models to examine the impact of ACA Medicaid expansion on socioeconomic inequality in use of health care services.ResultsThe ACA Medicaid expansion appeared to reduce the socioeconomic gap in individuals reporting financial ability in accessing health care (difference-in-differences estimators, -0.045 for SII and RII), having a personal doctor (-0.037 for SII and RII), and receiving routine check-ups (-0.027 for SII and -0.039 for RII). However, the expansion was not associated with reduction in the socioeconomic gap for preventive health care visits or dental care.ConclusionsThe ACA Medicaid expansion had mixed effects on socioeconomic disparities in health care utilization. Medicaid expansion may not be sufficient to address socioeconomic disparities in preventive services uptake.

Preventive healthcare-seeking behavior among poor older adults in Mexico: the impact of Seguro Popular, 2000-2012.

Determine the effect of Seguro Popular (SP) on preventive care utilization among low-income SP beneficiaries and uninsured elders in Mexico. Fixed-effects instrumental-variable (FE-IV) pseudo-panel estimation from three rounds of the Mexican National Health and Nutrition Survey (2000, 2006 and 2012). Our findings suggest that SP has no significant effect on the use of preventive services, including screening for diabetes, hypertension, breast cancer and cervical cancer, by adults aged 50 to 75 years. Despite the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in healthcare access and utilization still exist in Mexico. The Mexican government must keep working on extending health insurance coverage to vulnerable adults. Additional efforts to increase health care coverage and to support preventive care are needed to reduce persistent disparities in healthcare utilization.

SOCIO-DEMOGRAPHIC DIFFERENCES IN PATIENTS HOSPITALIZED FOR ANAPHYLAXIS IN THE UNITED STATES

Introduction Anaphylactic shock is a life-threatening emergency that can lead to significant morbidity and mortality. Data from European studies have shown significant disparities in healthcare utilization for anaphylaxis, however there are limited studies describing the association between socioeconomic status and patient characteristics for hospitalizations related to anaphylaxis in the United States. Methods We utilized the National Inpatient Sample database years 2005-2014 to identify hospitalizations for anaphylactic shock (ICD-9 codes 995.0, 995.6x). The analysis focused on socio-demographic characteristics, medical comorbidities, and in-hospital death. We also performed an unadjusted analysis of trends in hospital costs and mortality rate. Results Between 2005 and 2014, anaphylaxis hospitalizations increased from 6,351 to 8,075. Of these, most were experienced by women (56.7%), whites (55.1%), paid for by private insurance (46.5%), and were more frequent in patients residing in areas with the highest income quartile (26.9%). Comorbidities frequently present in patients hospitalized for anaphylaxis were hypertension (36.6%), chronic pulmonary disease (28.8%), and electrolyte disorders (20.0%). Costs per hospitalization increased from $4,521 to $6,672 (2006-2015). The percentage of in hospital deaths rose from 0.86 (2006) to 0.93 (2015) and mean length of stay rose from 2.5 days (2005) to 2.7 days (2015). Conclusions There has been a modest increase in hospitalizations and in-hospital deaths from anaphylaxis in the last decade. In this study, more hospitalizations were associated with top-quartile income zip codes and private insurance. Further study is needed to determine whether these trends reflect disparities in access to healthcare or other factors that could affect health outcomes.

The Relationship Between Residential Mobility and Behavioral Health Service Use in a National Sample of Adults With Mental Health and/or Substance Abuse Problems

Objective: Individuals with mental health and/or substance abuse problems experience disparities in health care utilization. While previous studies have focused on individual and social determinants of health care use in these populations, few have investigated the role of residential stability, especially in relation to different types of service use (i.e., inpatient vs. outpatient treatment). The present study examined the relationship between residential mobility, defined as the number of residential relocations in the past year, and past-year use of four types of behavioral services (i.e., inpatient and outpatient mental health services, inpatient and outpatient substance abuse services) among a national sample of adults with mental health and/or substance abuse problems. Methods: Data were drawn from the 2011–2014 National Survey of Drug Use and Health (unweighted N = 43,411). Based on prior literature and theory, we hypothesized that individuals who frequently relocate are more likely to use inpatient services and are less likely to use outpatient services. Logistic regression analyses were conducted and all models controlled for predisposing, need, and enabling factors. Results: Compared to individuals who did not move in the past year, those who moved three or more times were more likely to report using inpatient mental health and substance abuse services. The relationship between residential mobility and outpatient mental health and substance use service use is not significant. Conclusions: The findings highlight the importance of understanding housing stability as a predictor factor of service use and access. Future research is needed to shed light on the pathway through which residential mobility affects behavioral health service utilization.

Rural-urban disparities in family physician practice patterns: A nationwide survey in Taiwan.

In a world with increasing urbanization, rural-urban disparities in health care utilization have been a long-term concern. However, the details regarding the practice patterns of family physicians in Taiwan have not received sufficient attention thus far. The National Health Insurance Research Database of Taiwan offered 0.2% of the total ambulatory visit records for Taiwan in 2013. Records from community clinics of family medicine were collected, with the clinics categorized as rural, suburban, or urban area clinics according to their locations. Among 100334 visits to family medicine clinics, the median patient age was 50years for urban clinics, 51 for suburban clinics, and 58 for rural clinics. The distributions of patient ages differed in the three areas (P<0.001). Four types of chronic diseases (cardiovascular diseases, diabetes, chronic respiratory diseases, and cancers) accounted for 10.8%, 11.3%, and 13.6%, of the visits to urban, suburban, and rural clinics, respectively. The most common procedure was wound treatment, and the pattern of the top 10 procedures was similar in the three areas. Although rural patients in Taiwan were older and had more chronic diseases than urban and suburban patients, the pattern of procedures undertaken by rural family physicians did not differ from those of urban and suburban family physicians.

Social Determinants of Neighborhood Psychiatric Admissions: the Role of Open Data

Open data programs offer health care planners the opportunity to investigate disparities in health care utilization in a simple and cost-effective manner. This study employs publicly available census and psychiatric inpatient admission data for a large North American city to explore the association between sociodemographic characteristics and admissions, with an emphasis on housing-related factors. A regression model demonstrates that adult neighborhood inpatient admissions are significantly associated with the proportions of residents in collective dwellings (including homeless shelters and group homes) and in deteriorated housing. Other significant predictors are the population proportions of those married or co-habiting and of visible minorities, as well as neighborhood crime rate. These findings suggest the role of housing as a social determinant of psychiatric inpatient treatment. The open data approach used can be applied to local efforts to address imbalance in inpatient treatment and to equitably allocate hospital beds.