Inequalities In Access To Care Research Articles

An examination of referrals declined for chronic pain care: There is increasing mental health complexity within care-seeking patients with chronic pain over time

ABSTRACT Background Chronic pain is a complex disease that requires interprofessional care for effective management. Despite the need for multidisciplinary care, disease and health care inequities can prevent individuals from attaining adequate treatment. Factors such as mental health, cost, and distance to a health care center can contribute to health care accessibility inequality. The aim of this study is to examine declined referrals at the Toronto Academic Pain Medicine Institute (TAPMI) to determine the reason for declining care and number of declined referrals. Methods A retrospective chart review of all declined referrals at TAPMI in 2018 and 2022 was conducted. Referral documentation and the intake decision were extracted from the electronic medical charts by the research team and verified by the clinical intake team. Chi-square tests were conducted to determine whether the proportion of declined referrals changed between the years reviewed. Results The number of declined referrals due to mental health complexities increased significantly from 51 (11%) in 2018 to 180 (18%) in 2022 (χ2 = 10.9, P = 0.0009). A significant rise in the number of declines due to mental health service requests was also observed (χ2 = 24.53, P < 0.00001). Other common reasons for declined referrals in 2018 and 2022 included duplicate service, no primary care provider, and health care service changes. Conclusion Mental health complexities continue to be a significant barrier to health care service acquisition for individuals living with chronic pain. The increase in patient complexity from 2018 to 2022 highlights the need for integrated health care resources.

Social Determinants of Health and Cerebral Small Vessel Disease: Is Epigenetics a Key Mediator?

Cerebral small vessel disease is highly prevalent, particularly in marginalized communities, and its incidence is expected to increase given the aging global population. Cerebral small vessel disease contributes to risk for stroke, vascular cognitive impairment and dementia, late-life depression, and gait disorders. A growing body of evidence suggests that adverse outcomes, including cerebral small vessel disease, caused by traditional cardiovascular risk factors are at least partly mediated by epigenetic changes, some of them already beginning during fetal development. Societal and health care access inequities, summarized under the umbrella term social determinants of health, put a higher burden of cardiovascular risk factors on marginalized populations and expose them to an increased risk for adverse outcomes. Social epigenetics has begun to deliver solid evidence that social determinants of health lead to distinct epigenetic signatures that potentially mediate the biological effect of environmental exposures on cardiovascular risk factors. Here, we provide a review of the most recent advances in the epigenetics of cerebral small vessel disease risk factors and social determinants of health and call for research efforts combining insights from both fields to reach a deeper understanding of the causal pathways, ultimately facilitating discovery of new treatment targets for a disease whose burden is magnified by existing health disparities.

Trends in Health Care Access/Experiences: Differential Gains across Sexuality and Sex Intersections before and after Marriage Equality

Background: Sexual minority adults experience several health care access inequities compared to their heterosexual peers; such inequities may be affected by LGBTQ+ legislation, such as the 2015 national marriage equality ruling. Methods: Using population-based data (n = 28,463) from the Association of American Medical Colleges biannual Consumer Survey of Health Care Access, we calculated trend ratios (TR) for indicators of health care access (e.g., insurance coverage, delaying or forgoing care due to cost) and satisfaction (e.g., general satisfaction, being mistreated due to sexual orientation) from 2013 to 2018 across sexuality and sex. We also tested for changes in trends related to the 2015 marriage equality ruling using interrupted time series trend interactions (TRInt). Results: The largest increases in access were observed in gay men (TR = 2.42, 95% CI 1.28, 4.57). Bisexual men had decreases in access over this period (TR = 0.47, 95% CI 0.22, 0.99). Only gay men had a significant increase in the health care access trend after U.S. national marriage equality (TRInt = 5.59, 95% CI 2.00, 9.18), while other sexual minority groups did not. Conclusions: We found that trends in health care access and satisfaction varied significantly across sexualities and sex. Our findings highlight important disparities in how federal marriage equality has benefited sexual minority groups.

Abstract P082: Racial/ethnical Disparities In The Utilization Of Telehealth Services Among Medicare Beneficiaries With Atrial Fibrillation Before The Covid-19 Pandemic

Introduction: Telemedicine facilitates continued access to care for management of chronic diseases while preventing exposure to health care facilities; however, reliance on telemedicine may exacerbate disparities based on the persistent digital divide. Documenting racial variation in the uptake of telemedicine is crucial to understand the potential aggravation of health care access inequities in the era of COVID-19. We used a nationally representative sample of Medicare beneficiaries with atrial fibrillation (AF) to quantify racial disparities in telehealth utilization before the COVID-19 pandemic. Hypothesis: Black patients are less likely to be engaged with telehealth services than White patients. Methods: Using a 5% random sample of Medicare claims data, we extracted telehealth visits in 2016 using modifiers GT, 95, and GQ and place of service code 2 in medical claims. We used multivariate Poisson models to estimate incidence rate ratios (IRR) comparing the number of telehealth visits across White, Black, and patients of other races. Results: Among 135,164 patients with AF, 404 (0.3%) had a total of 1420 telehealth visits in 2016. After adjusting for age, sex, AF duration, rurality, CHA2DS2-VASc score, Alzheimer's disease, use of direct oral anticoagulants and warfarin, and receipt of low-income subsidy, Black were 60% less likely than White to receive telehealth services (IRR 0.4 [0.3, 0.5]), and the ‘others’ group were 70% less likely to receive telehealth services (0.3 [0.2, 0.5]). Among rural residents, however, the racial difference in telehealth use was only seen in Black (0.4 [0.2, 0.6]) but not in the ‘others’ group (0.9 [0.6, 1.4]). The gap in telehealth use between White and Black was larger among those with higher CHA2DS2-VASc scores ( Figure) . Conclusion: Before the COVID-19 pandemic, telehealth service use was rare overall in patients with AF. However, Black patients, especially those with increased stroke risk, were still significantly less likely to have access to telemedicine than White patients.

Immigrant Status and Unmet Home Care Needs: Results from the Canadian Community Health Survey.

This study assessed the relationship between immigration status, including recency, and unmet home care needs. Data from the 2015-2016 Canadian Community Health Survey (CCHS) was used to analyze the relationship between immigration status and unmet home care needs. Descriptive analyses and multivariable logistic regression controlling for age, sex, marital status, and education were calculated. Of the study sample of 5976 respondents, 34.5% had unmet home care needs. Prevalence of unmet needs was highest among recent immigrants (43.8%), compared with long-time immigrants (40.5%) and non-immigrants (32.7%). Adjusted odds of unmet needs was higher for both immigrant categories than non-immigrants, and stronger for long-time immigrants (OR = 1.58, 95% CI: 1.14, 2.20) than recent immigrants (OR = 1.42, 95% CI: 0.67, 3.00). The finding that immigrants are more likely to experience unmet home care needs, with a slight difference between recent and long-time immigrants, suggests home care access inequities exist between immigrants and non-immigrants, and among immigrants.

Planning universal accessibility to public health care in sub-Saharan Africa

Achieving universal health care coverage-a key target of the United Nations Sustainable Development Goal number 3-requires accessibility to health care services for all. Currently, in sub-Saharan Africa, at least one-sixth of the population lives more than 2 h away from a public hospital, and one in eight people is no less than 1 h away from the nearest health center. We combine high-resolution data on the location of different typologies of public health care facilities [J. Maina et al., Sci. Data 6, 134 (2019)] with population distribution maps and terrain-specific accessibility algorithms to develop a multiobjective geographic information system framework for assessing the optimal allocation of new health care facilities and assessing hospitals expansion requirements. The proposed methodology ensures universal accessibility to public health care services within prespecified travel times while guaranteeing sufficient available hospital beds. Our analysis suggests that to meet commonly accepted universal health care accessibility targets, sub-Saharan African countries will need to build ∼6,200 new facilities by 2030. We also estimate that about 2.5 million new hospital beds need to be allocated between new facilities and ∼1,100 existing structures that require expansion or densification. Optimized location, type, and capacity of each facility can be explored in an interactive dashboard. Our methodology and the results of our analysis can inform local policy makers in their assessment and prioritization of health care infrastructure. This is particularly relevant to tackle health care accessibility inequality, which is not only prominent within and between countries of sub-Saharan Africa but also, relative to the level of service provided by health care facilities.

The Use of Social Deprivation Index to Examine Nursing Home Quality

Health and health care access inequities vary along social and economic gradients. The Social Deprivation Index, is a composite measure of socio-economic factors (schooling, living conditions, transportation, home ownership, marital status). Using this index, we can explore how nursing home performance can be influenced by the resources available in the environment. The purpose of this paper is to explore the relationship of social deprivation and quality of care. Secondary data for 2011-2014 from Brown University’s Long-Term Care Focus, CASPER (Certification and Survey Provider Enhanced Reporting), and the Census American Community Survey was used. Structural equation modeling with maximum likelihood estimation was used to examine the total, direct, and indirect effects of the variables as conceptualized using Donabedian’s structure, process, and outcomes framework. In this study, structure consisted of RN staffing mix and RN, LPN, and CNA staff intensity; process was conceptualized as anti-psychotic medications, and outcomes as re-hospitalizations, falls, and pressure ulcers. Control variables included organizational level (total beds, percentage of Medicare and Medicaid, occupancy, percentage of minorities, multi-facility and for-profit status) and market level (Hirschman Herfinadahl Index for competition). We found as the munificence of the environment decreases, organizations will substitute out highly compensated and trained RNs and increase the staffing levels of LPNs and/or CNAs. All nurses, regardless of skill mix, are associated with decreased use of anti-psychotic medications; however, RNs have the greatest impact. Higher uses of anti-psychotic medication is associated with greater prevalence of re-hospitalizations, falls and pressure ulcers. This study illustrated that organizations are responsive to the resources available in their environment. All levels of nurse staffing can have a positive impact on improving processes, like decreasing the use of anti-psychotic medications. Nursing homes located in socially deprived areas may lack the staff mix to reduce the use of anti-psychotic medications, which in turn, has a detrimental effect on resident quality of care outcomes.

Index of Access: a new innovative and dynamic tool for rural health service and workforce planning.

Objective Improving access to primary health care (PHC) remains a key issue for rural residents and health service planners. This study aims to show that how access to PHC services is measured has important implications for rural health service and workforce planning. Methods A more sophisticated tool to measure access to PHC services is proposed, which can help health service planners overcome the shortcomings of existing measures and long-standing access barriers to PHC. Critically, the proposed Index of Access captures key components of access and uses a floating catchment approach to better define service areas and population accessibility levels. Moreover, as demonstrated through a case study, the Index of Access enables modelling of the effects of workforce supply variations. Results Hypothetical increases in supply are modelled for a range of regional centres, medium and small rural towns, with resulting changes of access scores valuable to informing health service and workforce planning decisions. Conclusions The availability and application of a specific 'fit-for-purpose' access measure enables a more accurate empirical basis for service planning and allocation of health resources. This measure has great potential for improved identification of PHC access inequities and guiding redistribution of PHC services to correct such inequities. What is known about the topic? Resource allocation and health service planning decisions for rural and remote health settings are currently based on either simple measures of access (e.g. provider-to-population ratios) or proxy measures of access (e.g. standard geographical classifications). Both approaches have substantial limitations for informing rural health service planning and decision making. What does this paper add? The adoption of a new improved tool to measure access to PHC services, the Index of Access, is proposed to assist health service and workforce planning. Its usefulness for health service planning is demonstrated using a case study to hypothetically model changes in rural PHC workforce supply. What are the implications for practitioners? The Index of Access has significant potential for identifying how rural and remote primary health care access inequities can be addressed. This critically important information can assist health service planners, for example those working in primary health networks, to determine where and how much redistribution of PHC services is needed to correct existing inequities.