Access To Hospital Care Research Articles

Hospitals and Superutilization

A small percentage of patients consume most of the health services in the US. These cases of superutilization affect hospitals, but little is known about what it is, the impact on hospitals, or how hospitals can identify potential cases of superutilization. We conducted exploratory research using the Medical Expenditure Panel Survey (MEPS) datasets for 2019 to examine superutilization as it relates to hospitals. Using total charges for health services to identify superutilization, we found a surprising amount of superutilization was not related to hospital care. When superutilization did occur in hospitals, there was reduced reimbursement for care in superutilization as measured by the reimbursement relative to charges. Demographic variables had limited utility in predicting superutilization. Our demographic analysis suggested that there are potential cases of superutilization that are not accessing hospital care. Our analyses suggest that given the amount of care that cases of superutilization require, the decreased reimbursement for the high levels of care and the untapped potential of superutilization, hospitals should consider developing capabilities to manage these challenging cases.

Comparison of perinatal outcome and mode of birth of twin and singleton pregnancies in migrant and refugee populations on the Thai Myanmar border: A population cohort.

In low- and middle-income countries twin births have a high risk of complications partly due to barriers to accessing hospital care. This study compares pregnancy outcomes, maternal and neonatal morbidity and mortality of twin to singleton pregnancy in refugee and migrant clinics on the Thai Myanmar border. A retrospective review of medical records of all singleton and twin pregnancies delivered or followed at antenatal clinics of the Shoklo Malaria Research Unit from 1986 to 2020, with a known outcome and estimated gestational age. Logistic regression was done to compare the odds of maternal and neonatal outcomes between twin and singleton pregnancies. Between 1986 and 2020 this unstable and migratory population had a recorded outcome of pregnancy of 28 weeks or more for 597 twin births and 59,005 singleton births. Twinning rate was low and stable (<9 per 1,000) over 30 years. Three-quarters (446/597) of the twin pregnancies and 96% (56,626/59,005) of singletons birthed vaginally. During pregnancy, a significantly higher proportion of twin pregnancies compared to singleton had pre-eclampsia (7.0% versus 1.7%), gestational hypertension (9.9% versus 3.9%) and eclampsia (1.0% versus 0.2%). The stillbirth rate of twin 1 and twin 2 was higher compared to singletons: twin 1 25 per 1,000 (15/595), twin 2 64 per 1,000 (38/595) and singletons 12 per 1,000 (680/58,781). The estimated odds ratio (95% confidence interval (CI)) for stillbirth of twin 1 and twin 2 compared to singletons was 2.2 (95% CI 1.3-3.6) and 5.8 (95% CI 4.1-8.1); and maternal death 2.0 (0.95-11.4), respectively, As expected most perinatal deaths were 28 to <32 week gestation. In this fragile setting where access to hospital care is difficult, three in four twins birthed vaginally. Twin pregnancies have a higher maternal morbidity and perinatal mortality, especially the second twin, compared to singleton pregnancies.

Hand Trauma and Reconstructive Microsurgery during the COVID-19 Emergency in the Marche Region (Italy): What Has Changed?

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19, has spread across the globe. To limit the spread of COVID-19, the Italian government imposed various restrictions (lockdowns). These restrictions had an impact on the flow of patients accessing hospital care. Our aim in this study was to analyze the impact of lockdowns on the epidemiology of patients suffering from hand trauma. Our work analyzed the variation in the number and characteristics of hand trauma patients during the lockdown and half-lockdowns in 2020 compared to the same periods in the previous and subsequent years. In 2020, during the lockdown period, 107 patients were treated by our department for hand trauma, amounting to a 2% increase compared to the average number of patients treated in the pre-pandemic period. In 2020, during the half-lockdown period, 158 patients were treated, amounting to a 6.8% increase in comparison to the pre-pandemic period. During the lockdown period in Italy, the flow of patients suffering from hand trauma referred to our hub center remained stable. Given the restrictions imposed by the lockdown, we expected a consequent reduction in the number of work-related injuries, which did occur, while there was a surprising increase in the number of traffic-related injuries. The number of domestic accidents remained stable.

Cost savings associated with palliative care among patients with genitourinary malignancies.

474 Background: The cost of cancer treatment has increased significantly in recent decades, and highest costs incurred in the last 6-months of life. Patients’ health insurance status is a factor influencing to cost of care in different from individuals’ ability to access hospital care. 80% of Thai people use the Thailand’s Universal Coverage Scheme (UCS), about 15% use the Civil Servants Medical Benefit Scheme (CSMBS). Only CSMBS can reimburse all costs of in-patient care, but UCS had to co-pay at some cost. All health scheme is equality accessibility to palliative care. Early integrated palliative care services improve the GU malignancy patients care experience, decreases healthcare utilization, and improved quality of life. Study aim was to examine Hospital-based palliative care interventions in GU malignancy patients may reduce costs. Methods: A retrospective claims database in Ramathibodi Hospital was analyzed, that included cancer patients had a medical claim for death between Jan 1, 2016 - Dec 31, 2020. Our study compared cost in patients receiving palliative care (PC) and patients receiving usual care. Costs were determined by summing paid amounts on all hospital services used within the last 6, 3 and 1 months before death, including cancer-related inpatient service, emergency room visits, cancer-related outpatient services and other hospital services with cancer diagnosis. Results: Of the 1,772 cancer patients who died, 289 (16.3%) integrated treated with PC matched to 1,483 (83.7%) were usual care patients. 107 Genitourinary Malignancies patients including 44 TCC, 36 Prostate, 22 RCC and 2 Testicular cancer, that 22 (20.6%) integrated treated with PC. Median age was 72.4 years. Patients categorized as CSMBS 48% and UCS 44.4%. The PC group had $10,244.1 (+/- 8,705.6) in last 3 months hospital costs that significantly less than in usual care $(17,174.3 +/-14,262.5) (P= 0.032) that PC group had significant reductions in medications, laboratory, and intensive care unit costs compared with usual care patients. Direct costs of inpatient care in the last 3 months of life for patients were lower in patient who received earlier PC that patients who received PC consults &lt; 90 days was $9,728.8 (+/- 1,044.5) and patients received PC consults &lt; 30 days cost was $12,517.7 +/- 1,476. Patients in SSS and UCS had a significantly saving cost when they received PC consultation, P=0.032. However, there was no difference in CSMBS. Conclusions: Integrated palliative care in caring GU malignant patients associates with significant hospital cost savings. Insurance status not limited in access to palliative care consultation, but influences in cost of end-of-life care.

Effect of COVID-19 lockdown on hospital admissions and mortality in rural KwaZulu-Natal, South Africa: interrupted time series analysis

ObjectiveTo assess the effect of lockdown during the 2020 COVID-19 pandemic on daily all-cause admissions, and by age and diagnosis subgroups, and the odds of all-cause mortality in a hospital...

Geographical disparities in access to hospital care in Ontario, Canada: a spatial coverage modelling approach

ObjectivesPrevious studies on geographical disparities in healthcare access have been limited by not accounting for the healthcare provider’s capacity, a key determinant of supply and demand relationships.DesignThis study proposed a...

The cost of waiting: Association of ED boarding with hospitalization costs.

Emergency Department (ED) boarding, the practice of holding patients in the ED after they have been admitted to the hospital due to unavailability of inpatient beds, is common and contributes to the public health crisis of ED crowding. Prior work has documented the harms of ED boarding on access and quality of care. Limited studies examine the relationship between ED boarding and an equally important domain of quality-the cost of care. This study evaluates the relationship between ED boarding, ED characteristics and risk-adjusted hospitalization costs utilizing national publicly-reported measures. We conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear regression analysis to examine the association between ED boarding and Medicare spending per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation time, and ED patient volume. A total of 2903 hospitals were included in the analysis. ED boarding was significantly correlated with MSPB (r=0.1774; p-value: <0.0001). In multivariate regression, ED boarding was also positively associated with MSPB (Beta: 0.00015; p<0.0001) after adjustment for other hospital level crowding indicators. We found a strong relationship between measures of ED crowding, including ED boarding, and risk-adjusted hospital spending. Future work should elucidate the mediators of this relationship. Policymakers and administrators should consider the financial harms of ED boarding when devising strategies to improve hospital care access and flow.

Mapping physical access to health care for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross-sectional analysis

BackgroundSevere acute respiratory syndrome coronavirus 2, the virus causing COVID-19, is rapidly spreading across sub-Saharan Africa. Hospital-based care for COVID-19 is often needed, particularly among older adults. However, a key barrier to accessing hospital care in sub-Saharan Africa is travel time to the nearest health-care facility. To inform the geographical targeting of additional health-care resources, we aimed to estimate travel time at a 1 km × 1 km resolution to the nearest hospital and to the nearest health-care facility of any type for adults aged 60 years and older in sub-Saharan Africa.MethodsWe assembled a dataset on the geolocation of health-care facilities, separately for hospitals and any type of health-care facility and including both private-sector and public-sector facilities, using data from the OpenStreetMap project and the Kenya Medical Research Institute–Wellcome Trust Programme. Population data at a 1 km × 1 km resolution were obtained from WorldPop. We estimated travel time to the nearest health-care facility for each 1 km × 1 km grid using a cost–distance algorithm.Findings9·6% (95% CI 5·2–16·9) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time to the nearest hospital of 6 h or longer, varying from 0·0% (0·0–3·7) in Burundi and The Gambia to 40·9% (31·8–50·7) in Sudan. For the nearest health-care facility of any type (whether primary, secondary, or tertiary care), 15·9% (95% CI 10·1–24·4) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time of 2 h or longer, ranging from 0·4% (0·0–4·4) in Burundi to 59·4% (50·1–69·0) in Sudan. Most countries in sub-Saharan Africa contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of 12 h or longer and to the nearest health-care facility of any type of 6 h or longer. The median travel time to the nearest hospital for the fifth of adults aged 60 years or older with the longest travel times was 348 min (IQR 240–576; equal to 5·8 h) for the entire population of sub-Saharan Africa, ranging from 41 min (34–54) in Burundi to 1655 min (1065–2440; equal to 27·6 h) in Gabon.InterpretationOur high-resolution maps of estimated travel times to both hospitals and health-care facilities of any type can be used by policy makers and non-governmental organisations to help target additional health-care resources, such as makeshift hospitals or transport programmes to existing health-care facilities, to older adults with the least physical access to care. In addition, this analysis shows the locations of population groups most likely to under-report COVID-19 symptoms because of low physical access to health-care facilities. Beyond the COVID-19 response, this study can inform the efforts of countries to improve physical access to care for conditions that are common among older adults in the region, such as chronic non-communicable diseases.FundingBill & Melinda Gates Foundation.

Development and Implementation of a Community Paramedicine Program in Rural United States.

IntroductionCommunity paramedicine (CP) is an innovative care model focused on medical management for patients suffering from chronic diseases or other conditions that result in over-utilization of healthcare services. Despite their value, CP care models are not widely used in United States healthcare settings. More research is needed to understand the feasibility and effectiveness of implementing CP programs. Our objective was to develop a CP program to better meet the needs of complex, high-utilizer patients in a rural setting.MethodsWe conducted an observational descriptive case series in a community, 25-bed, critical access hospital and primary care clinic in a rural Wisconsin county. Multiple stakeholders from the local health system and associated ambulance service were active participants in program development and implementation. Eligible patients receiving the intervention were identified as complex or high need by a referring physician. Primary outcomes included measures of emergency department, hospital, and clinic utilization. Secondary measures included provider and patient satisfaction.ResultsWe characterized 32 unique patients as high utilizers requiring assistance in medical management. These patients were enrolled into the program and categorized as high utilizers requiring assistance in medical management. The median age was 76 years, and 68.8% were female. After six months, we found a statistically significant decline in patient utilization for primary care (53.3%, p = .006) and ED visits (59.3%, p = .007), but not for hospitalizations (60%, p = .13, non-significant (NS), compared to the six months preceding enrollment. Overall, the total number of healthcare contacts was increased after implementation (623 before vs 790 after, + 167, +26.8%). Implementation of the CP program resulted in increased overall use of local healthcare resources in patients referred by physicians as high utilizers.ConclusionThe implementation of an in-home CP program targeting high users of healthcare resources resulted in a decrease in utilization in the hospital, ED, and primary care settings; however, it was balanced and exceeded by the number of CP visits. CP programs align well with population health strategies and could be better leveraged to fill gaps in care and promote appropriate access to healthcare services. Further study is required to determine whether the shift in type of healthcare access reduces or increases cost.

Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals

While current reports suggest that a disproportionate share of US coronavirus disease 2019 (COVID-19) cases and deaths are among Black residents, little information is available regarding how race is associated with in-hospital mortality. To evaluate the association of race, adjusting for sociodemographic and clinical factors, on all-cause, in-hospital mortality for patients with COVID-19. This cohort study included 11 210 adult patients (age ≥18 years) hospitalized with confirmed severe acute respiratory coronavirus 2 (SARS-CoV-2) between February 19, 2020, and May 31, 2020, in 92 hospitals in 12 states: Alabama (6 hospitals), Maryland (1 hospital), Florida (5 hospitals), Illinois (8 hospitals), Indiana (14 hospitals), Kansas (4 hospitals), Michigan (13 hospitals), New York (2 hospitals), Oklahoma (6 hospitals), Tennessee (4 hospitals), Texas (11 hospitals), and Wisconsin (18 hospitals). Confirmed SARS-CoV-2 infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample. Death during hospitalization was examined overall and by race. Race was self-reported and categorized as Black, White, and other or missing. Cox proportional hazards regression with mixed effects was used to evaluate associations between all-cause in-hospital mortality and patient characteristics while accounting for the random effects of hospital on the outcome. Of 11 210 patients with confirmed COVID-19 presenting to hospitals, 4180 (37.3%) were Black patients and 5583 (49.8%) were men. The median (interquartile range) age was 61 (46 to 74) years. Compared with White patients, Black patients were younger (median [interquartile range] age, 66 [50 to 80] years vs 61 [46 to 72] years), were more likely to be women (2259 [49.0%] vs 2293 [54.9%]), were more likely to have Medicaid insurance (611 [13.3%] vs 1031 [24.7%]), and had higher median (interquartile range) scores on the Neighborhood Deprivation Index (-0.11 [-0.70 to 0.56] vs 0.82 [0.08 to 1.76]) and the Elixhauser Comorbidity Index (21 [0 to 44] vs 22 [0 to 46]). All-cause in-hospital mortality among hospitalized White and Black patients was 23.1% (724 of 3218) and 19.2% (540 of 2812), respectively. After adjustment for age, sex, insurance, comorbidities, neighborhood deprivation, and site of care, there was no statistically significant difference in risk of mortality between Black and White patients (hazard ratio, 0.93; 95% CI, 0.80 to 1.09). Although current reports suggest that Black patients represent a disproportionate share of COVID-19 infections and death in the United States, in this study, mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities.

Delays to accessing healthcare and rehabilitation following trauma in Madagascar – a qualitative study

Purpose To explore the factors affecting access to timely trauma care and rehabilitation in Madagascar. Materials and methods A qualitative study based in the outpatient departments of two large rehabilitation centres. Semi-structured interviews and focus groups were conducted with 12 patients or family members and 11 healthcare professionals. Interviews and focus groups were conducted with a local interpreter and were audio-recorded and transcribed. The data were analysed deductively with thematic content analysis, utilising the Health Care Access Barriers model. Results Participants experienced delays in deciding to seek treatment, accessing healthcare facilities and in receiving appropriate treatment. Cognitive barriers included understanding and awareness of healthcare, structural barriers included distance and transportation to health facilities, financial barriers included affordability of healthcare and difficulty accessing funds. Conclusions Delays to accessing healthcare may result in increased mortality and disability following trauma, as well as increased financial burden. Addressing the acceptability of services should be a focus for future service development, through training and education schemes. More importantly, improving both physical and financial accessibility of services must be a long-term priority. These findings may help to guide the ongoing development of trauma and rehabilitation pathways in Madagascar. IMPLICATIONS FOR REHABILITATION Delays in accessing timely trauma care and rehabilitation can lead to complications such as pain, infection, malunion of fractures and loss of function, with devastating financial and social consequences for patients and their families. The acceptability of services is a key barrier to accessing hospital care and may be targeted through training schemes for healthcare professionals and education for the public. Improving the physical and financial accessibility of services in the long-term is paramount. Consideration should be given to these issues in the future development of co-ordinated trauma care and rehabilitation pathways in Madagascar.

Challenges, constraints and failures that are related to the posterior sagittal anorectoplasty approach to anorectal malformations in a low-resource context: An experience from a sudanese tertiary referral centre.

Background:Anorectal malformations (ARMs) in the sub-Saharan Africa are a common cause of neonatal referral for intestinal obstruction, and the posterior sagittal anorectoplasty (PSARP) approach is rapidly spreading. The small number of paediatric surgeons and the low-resource context limit children's access to care and constrain the quality of results. A retrospective, observational study has been done on a consecutive series of ARM cases admitted to a Sudanese tertiary paediatric surgical centre within the framework of a partnership between Italian and Sudanese academic institutions addressed to review and upgrade the standard of care of major congenital anomalies.Materials and Methods:The authors collected 94 ARM cases in a 3 years' period. Conditions on referral, operative procedures, post-operative course and follow-up were recorded and examined. Their correlations with complications and outcome were analysed.Results:The male/female ratio was 47/47. Eighty patients presented with an untreated ARM; 66 had a divided stoma and 14 had already a PSARP procedure, followed by a poor outcome or sequelae. In 25% of the cases, colostomy required re-doing. In 57 cases, a staged PSARP (primary or re-do) was done. Surgical-site infections occurred in nine patients. Some patients were lost to follow-up after preliminary colostomy. Post-operative dilatation programme suffered from the lack of systematic follow-up, and colostomy closure was possible in 46% of the cases due to problems in travelling and accessing hospital care. Anal stenosis was frequently observed among unfollowed patients.Conclusion:Despite PSARP's widespread adoption in Africa, the risk of complications and failures is high. Primary management is often inappropriate, and a high rate of colostomy-related complications is observed. Poverty and lack of transportation reduce attendance to follow-up, hampering the final results. Investments in healthcare facilities and retention of trained health providers are needed to improve the standard of care.

Cerebral palsy prevalence, subtypes, and associated impairments: a population‐based comparison study of adults and children

To describe the prevalence of cerebral palsy (CP), subtype distribution, motor and intellectual impairment, and epilepsy in adults with CP compared with children with CP. CP subtype and impairment data from the population-based CP register of western Sweden and population data from Statistics Sweden were used to compare surviving adults (n=581; 244 females, 337 males) born between 1959 and 1978, with the same cohort as children (n=723; 307 females, 416 males), andwiththe most recent cohort, born from 2007 to 2010 (n=205; 84 females, 121 males). Prevalence of CP in adults born between 1959 and 1978 was 1.14 per 1000. The occurrence of impairments differed between CP subtypes. Motor and intellectual impairment were closely related, regardless of subtype. Subtype distribution among survivors differed significantly from the original cohorts (p=0.002), and the most recent cohort (p<0.01), tetraplegia and dyskinetic CP being less common in survivors. Severe motor impairment, intellectual disability, and epilepsy were less common among survivors than in the original cohorts (p=0.004, p=0.002, p=0.037) and the most recent cohort (p=0.004, p=0.008, p<0.01). Data on prevalence, subtype distribution, and impairments in children with CP are not applicable to adults with CP. Population-based studies of adults with CP are needed. Cerebral palsy (CP) subtypes are differently distributed in adults compared to children. The prevalence of impairments in adults with CP is related to CP subtype. Spastic tetraplegia and dyskinetic CP are less common in adults than children. Severe motor impairment, intellectual disability, and epilepsy are less common in adults.

Disabled people\u2019s experiences of accessing reasonable adjustments in hospitals: a qualitative study

BackgroundThe UK Equality Act 2010 requires providers of health services to make changes or ‘reasonable adjustments’ to their practices in order to protect disabled people from discrimination or disadvantage when accessing care. Existing evidence suggests that despite this legislation, health services are not always providing reasonably adjusted care for disabled people. This paper presents the perspectives of disabled people themselves in relation to their experiences of accessing reasonable adjustments in hospitals in England.MethodsTwenty-one semi-structured interviews were held with disabled people who had a recent experience of hospital care in England. Participants were asked about the extent to which the hospital provided reasonably adjusted care, and if necessary, how they thought the provision of reasonable adjustments could be improved. Each interview was anonymised and transcribed, and the data analysed using thematic analysis.ResultsParticipants reported mixed experiences about whether and how reasonable adjustments were provided: some shared positive examples of good practice; others spoke about difficult encounters and limited provision. Recommendations made include a need for culture change in how reasonable adjustments are perceived and enacted; improvements in identifying the needs of disabled people; improvements to the hospital environment and the provision of information; and the need to involve disabled people themselves in the process of change.ConclusionsGaps remain in how reasonable adjustments are provided for disabled people accessing hospital care. It is important for hospital staff to listen to the perspectives of disabled people about the provision of reasonable adjustments, and make improvements as necessary. Hospital staff could also do more to share good practice in relation to the provision of reasonable adjustments to effectively inspire and embed positive change.

Alternative to supply of health services in physical medicine and rehabilitation: From mobile team to home hospitalization

In France, the notion of care pathway is enshrined in the circular of March, 2012 relative to the organization of care for patients’ victim of stroke. The rehabilitation-reinsertion mobile team of the pole Saint-Helier (EM2R) was created in 2012 in this context, with support from the Regional Health Agency of Brittany. The main mission of this newly created team is to implement the necessary devices to facilitate the home returning of people hospitalized after a neurological event or maintain home people with neurological disorders (more than 200 coverage a year). The neurodegenerative diseases plan of 2014–2019 points, especially in its 15th measure, that we shall remove all things slowing down the hospital care access at home for people with neurodegenerative diseases and this no matter where they live. And this is done mainly through mobile teams and home medical care (HAD in France) activities. In coherence with the activities recently developed “outside the walls” by the pole Saint Helier (EM2R and telemedicine), the establishment of a HAD-SSR (home medical care of rehabilitation care), further consolidated the healthcare pathway for people with disabilities.This activity has been developing since September, 2017 in relation with the HAD 35 and two rehabilitation centers which provide reeducation professionals’. 15 patients have already been cared, mostly persons with stroke. The aim is to ensure a global, coordinated and specialized care by bringing to patients’ home a variety of expertise in the field of rehabilitation: doctors of physical medicine and rehabilitation, physiotherapists, occupational therapists, speech therapists, neuropsychologists… and to propose an additional alternative to hospitalization in rehabilitation care when the situation permits it in the healthcare pathway of people with disabilities.

Childhood Trauma and the Inability to Access Hospital Care Among People who Inject Drugs.

Childhood traumatic experiences can disrupt attachment, influence personality development, and precipitate chronic disease. Although the repercussions of these experiences may also pose a barrier to healthcare, few studies have examined the association between childhood trauma and access to healthcare. Therefore, we sought to investigate whether a history of childhood trauma is associated with self-reported inability to access hospital care among persons who inject drugs (PWID). Data were derived from two prospective cohorts of PWID in Vancouver, Canada. We used multivariable generalized estimating equations to examine associations between five types of childhood trauma and self-reported inability to access hospital care, both overall and specifically due to perceived mistreatment by hospital staff. In total, 300 participants (18.3%) reported having tried but being unable to access hospital care in the previous 6 months at some point during the study period; the primary reason was perceived mistreatment by hospital staff (32.1%). In multivariable analyses, childhood emotional abuse was independently associated with self-reported inability to access hospital care, adjusted odds ratio (AOR) = 1.51, 95% CI [1.03, 2.20]. Childhood physical neglect was also independently associated with inability to access care due to perceived mistreatment by hospital staff, AOR = 1.80, 95% CI [1.11, 2.93]. This suggests potentially damaging consequences of early trauma in adult PWID populations. Further, this study emphasizes the need for trauma-informed models of care as well as the need to improve therapeutic alliances with survivors of childhood trauma in the PWID population.

Being a Disabled Patient: Negotiating the Social Practices of Hospitals in England

Accessing hospital care and being a patient is a highly individualised process, but it is also dependent on the culture and practices of the hospital and the staff who run it. Each hospital usually has a standard way of ‘doing things’, and a lack of flexibility in this may mean that there are challenges in effectively responding to the needs of disabled people who require ‘reasonably adjusted’ care. Based on qualitative stories told by disabled people accessing hospital services in England, this article describes how hospital practices have the potential to shape a person’s health care experiences. This article uses insights from social practice theories to argue that in order to address the potential problems of ‘misfitting’ that disabled people can experience, we first need to understand and challenge the embedded hospital practices that can continue to disadvantage disabled people.

Accessibility to primary health care and emergency department visits

Background: It is widely acknowledged in many countries that the delivery of accessible primary health care (PHC) is one of the most important national priorities. On the other hand, frequent complaints relating to longer waits to access hospital care and overutilization of emergency services are still common. Objectives: The objective of this study was to determine patients' accessibility to PHC nonurgent emergency department (ED) and its influence factors to improve primary care quality and reduce ED crowding. Subjects and Methods: This was an observational cross-sectional study. Convenience sample of ED patients was chosen from the Prince Sultan Military Medical City hospital ED in Riyadh, Saudi Arabia. An interview questionnaire was designed to collect the data. The data were analyzed using SPSS software, version 24. Results: A total of 89 nonurgent ED patients participated in this study and their mean age was 36.45 (standard deviation = 14.8). Most of the participants (70.8%) were male and half of them (51.7%) had “secondary or diploma” degree. Most of the participants (85.4%) mentioned that they never visited PHCs. Almost half of the participants (51.7%) mentioned that they visited ED only one time in the last 12 months. About fifth (20.2%) of the patients mentioned that they did not access to PHC due to long waiting in the doctor's office. Patients' education status and duration of presenting complaint were significantly associated with their trying to go to PHC and visiting ED in the last year. Conclusion: According to the results of this study, it is necessary to develop strategies to implement policies aimed at reducing nonurgent ER use as well as make health-care services more available to the population.

Health care access, concentrated poverty, and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach

ABSTRACTBackground: California's San Joaquin Valley is a region with a history of poverty, low health care access, and high rates of pediatric asthma. It is important to understand the potential barriers to care that challenge vulnerable populations. Objective: The objective was to describe pediatric asthma-related utilization patterns in the emergency department (ED) and hospital by insurance coverage as well as to identify contributing individual-level indicators (age, sex, race/ethnicity, and insurance coverage) and neighborhood-level indicators of health care access. Methods: This was a retrospective study based on secondary data from California hospital and ED records 2007–2012. Children who used services for asthma-related conditions, were aged 0–14 years, Hispanic or non-Hispanic white, and resided in the San Joaquin Valley were included in the analysis. Poisson multilevel modeling was used to control for individual- and neighborhood-level factors. Results: The effect of insurance coverage on asthma ED visits and hospitalizations was modified by the neighborhood-level percentage of concentrated poverty (RR = 1.01, 95% CI = 1.01–1.02; RR = 1.03, 95% CI = 1.02–1.04, respectively). The effect of insurance coverage on asthma hospitalizations was completely explained by the neighborhood-level percentage of concentrated poverty. Conclusions: Observed effects of insurance coverage on hospital care use were significantly modified by neighborhood-level measures of health care access and concentrated poverty. This suggests not only an overall greater risk for poor children on Medi-Cal, but also a greater vulnerability or response to neighborhood social factors such as socioeconomic status, community cohesiveness, crime, and racial/ethnic segregation.

Awareness and utilization of Rashtriya Swasthaya Bima Yojana and its implications for access to health care by the poor in slum areas of Delhi

Rashtriya Swasthya Bima Yojana (RSBY), a national flagship health insurance scheme of India, was launched in 2008 with an aim to improve access to cashless inpatient care for the families below poverty line. Delhi being the national capital of India was one of the first states where this scheme was implemented. The objectives of this study were to find out the awareness of the scheme among the enrolled families, utilization of its services, and the extent to which RSBY provided cost-free access to inpatient care to its enrolled beneficiaries. A mixed method study was conducted in ten slum areas of East and North East Delhi. Data were collected through the household survey with 120 families having RSBY cards (service recipients) and qualitative interviews with 30 professionals responsible for managing various aspects of the RSBY program. Quantitative data were analysed using statistical package of social sciences (SPSS) whereas thematic analysis was done for qualitative data. The findings suggest that RSBY benefitted only 20% of the families among the total sample. It appeared that families who were relatively more aware about the range of benefits and operational mechanisms of the scheme were able to utilize its benefits as compared to others who were not. However, the families who utilized or tried to utilize the RSBY benefits were not satisfied with the scheme and faced many problems while accessing hospital care through RSBY. They faced refusals for the treatment by RSBY empaneled hospitals, demands for extra money, and poor quality treatment provided to them. These situations forced few families to approach another public or private hospitals in case of illness and incur significant out-of-pocket expenditure on emergency health care despite having RSBY insurance coverage. The data obtained through the interviews illuminated the challenges associated with the implementation of RSBY from service provider’s perspective. The study recommends that if RSBY scheme aspires to cover the entire Indian poor population under its umbrella of risk protection, the government should adopt rigorous administrative mechanisms with robust monitoring and evaluation systems at different levels to ensure quality and timely healthcare is provided to the beneficiaries.