Significant Inequalities In Access Research Articles

A Summary Prospecting of Possibilities of Providing Public Health Services at the Level of North-East Region of Romania

This paper investigates issues related to the public health system in the North-East Region of Romania, focusing on possibilities for addressing/improving specific deficiencies/difficulties. The concerned region is characterized by the highest and densest population in the country, with a significant proportion of residents in rural areas (55%) and a high level of poverty. Population health indicators are among the weakest nationally, and the healthcare infrastructure is inadequate for the population's needs, with an uneven distribution that generates significant inequalities in access to medical services in the respective counties. Starting from the (statistical) certainty that Romania ranks among EU member states with the highest avoidable mortality, the paper addresses both preventable causes through public health interventions and treatable causes through quality care. After a brief introduction, the overall state of the public health system in Romania is examined, followed by a detailed analysis of the main issue stated in the title, highlighting multiple critical aspects based on data and information from official reports of prestigious institutions. Special attention is given to specific issues in local communities related to healthcare infrastructure and the provision of medical services, as well as possible solutions offered through the implementation of the General Regional Health Services Plan 2021-2027 in the North-East Region. The paper concludes with a section of conclusions, which includes perspectives on the future development of the analyzed sector.

Identifying Longer-Term Health Events and Outcomes and Health Service Use of Low Birthweight CALD Infants in Australia

IntroductionApproximately one-third of all births in Australia each year are by culturally and linguistically diverse (CALD) women. CALD women are at an increased risk of adverse pregnancy and birth outcomes including prematurity and low birthweight. Infants born weighing less than 2500 g are susceptible to increased risk of ill health and morbidities such as cognitive defects including cerebral palsy, and neuro-motor functioning.MethodsAn existing linked administrative dataset, Maternity 1000 was utilized for this study which has identified all children born in Queensland (QLD), Australia, between 1st July 2012 to 30th June 2018 from the QLD Perinatal Data Collection. This has then been linked to the QLD Hospital Admitted Patient Data Collection, QLD Hospital Non-Admitted Patient Data Collection, QLD Emergency Department Data Collection, and Medicare Benefits Schedule and Pharmaceutical Benefits Scheme Claims Records between 1 and 2012 to 30th June 2019.ResultsCulturally and linguistically diverse infants born with low birthweight had higher mean and standard deviation of all health events and outcomes; potentially preventable hospitalisations, hospital re-admissions, ED presentations without admissions, and development of chronic diseases compared to non-CALD infants born with low birthweight.DiscussionResults from this study highlight the disparities in health service use and health events and outcomes associated with low birthweight infants, between both CALD and Australian born women. This study has responded to the knowledge gap of low birthweight on the Australian economy by identifying that there are significant inequalities in access to health services for CALD women in Australia, as well as increased health events and poor birth outcomes for these infants when compared to those of mothers born in Australia.

A testimony about home dialysis in Tougué (Guinea) using the NxStage® portable haemodialysis system

Several testimonials have already appeared in the Bulletin de la Dialyse à Domicile or the website of the French-language Peritoneal Dialysis Registry detailing patient experiences remarkable for their empowerment at home (1), or for the achievement of sports and human challenges such as that of Fabrice HURE (2) or Jean Louis CLEMENDOT (3). The testimony we report is the travel story of Mr Alhassane DIALLO, a dialysis patient who wanted to join his family in Guinea at a great distance from any dialysis clinic, a journey that home dialysis allowed, but not without hardships. We hope that this experience can help other patients with independent travel plans. The success of this project was due to the unwavering determination of Mr DIALLO but also to a collective organization that requested the administrative, logistical and pharmacy services of the AUB Santé Foundation and close cooperation between the French and Guinean medical teams. This experience shows us how important travel limitations are in the experience of dialysis patients, and particularly in that of expatriate patients. In addition, it highlights the significant inequalities in access to care in the world: Guinea has only one dialysis centre, in Conakry.
 Eric LARUELLE, MD, Nephrologist, AUB Santé Foundation*
 Picault, Christelle. 2019. « Dialyse Longue Nocturne à Domicile à Bas débit De Dialysat. ». Bulletin De La Dialyse à Domicile 2 (1), 33-36. https://doi.org/10.25796/bdd.v2i1.19143.
 2/ Fabrice Huré. La montagne dans le sang. Un témoignage humain d’un patient dialysé de nuit pour les autres patients. Bulletin Dialyse Domicile N°1.Vol 2. Avril 2019 DOI : https://doi.org/10.25796/bdd.v2i1.19153
 3/ Témoignages : la traversée de l'Atlantique en solitaire en dialyse péritonéale.https://www.rdplf.org/information-patients/temoignages-patients.html?id=337

Access to insulin: a comparison between low‐ and middle‐income countries and the United Kingdom

Insulin was discovered 100 years ago but, sadly, across the globe there are significant inequities in access to this life‐saving medicine.Here, the authors investigate such inequities, the challenges of available and affordable insulin, its delivery systems and blood glucose monitoring. Challenges not only include costs but also the lack of expertise in managing diabetes care.Now is the time for those in the diabetes community to come together to address the global issue of access to insulin for all.

Improving provision of family planning among pastoralists in Kenya: Perspectives from health care providers, community and religious leaders

ABSTRACT There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women’s decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.

Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d'Ivoire.

Postabortion care (PAC) is an essential component of emergency obstetric care (EmOC) and is necessary to prevent unsafe abortion-related maternal mortality, but we know little regarding the preparedness of facilities to provide PAC services, the distribution of these services and disparities in their accessibility in low-resource settings. To address this knowledge gap, this study aims to describe PAC service availability, evaluate PAC readiness and measure inequities in access to PAC services in seven states of Nigeria and nationally in Côte d’Ivoire. We used survey data from reproductive-age women and the health facilities that serve the areas where they live. We linked facility readiness information, including PAC-specific signal functions, to female data using geospatial information. Findings revealed less than half of facilities provide basic PAC services in Nigeria (48.4%) but greater PAC availability in Côte d’Ivoire (70.5%). Only 33.5% and 36.9% of facilities with the capacity to provide basic PAC and only 23.9% and 37.5% of facilities with the capacity to provide comprehensive PAC had all the corresponding signal functions in Nigeria and Côte d’Ivoire, respectively. With regard to access, while ∼8 out of 10 women of reproductive age in Nigeria (81.3%) and Côte d’Ivoire (79.9%) lived within 10 km of a facility providing any PAC services, significantly lower levels of the population lived <10 km from a facility with all basic or comprehensive PAC signal functions, and we observed significant inequities in access for poor, rural and less educated women. Addressing facilities’ service readiness will improve the quality of PAC provided and ensure postabortion complications can be treated in a timely and effective manner, while expanding the availability of services to additional primary-level facilities would increase access—both of which could help to reduce avoidable abortion-related maternal morbidity and mortality and associated inequities.

Assessing the inequalities in access to online delivery services and the way COVID-19 pandemic affects marginalization

This paper discusses the importance of incorporating online home delivery services (OHDS) into the concept of accessibility and marginalization. The authors propose a method to quantify access to OHDS and assess levels of inequalities in access to OHDS using data from OHDS providers in the pharmaceutical and food sectors, as well as from transport operators delivering parcels. The Västra Götaland Region in the West coast of Sweden is used as a case study. The results show significant inequalities in access to OHDS. Moreover, there are segments of population under a compound marginalization during the COVID-19 pandemic due to (i) limited accessibility to OHDS services, (ii) high incidence of COVID-19 cases in their area that makes physical visits to a store a risk activity, and (iii) high vulnerability (e.g., high share of individuals older than 65). These results reveal a need for the public sector to prioritize innovations in services that target specific clusters of the population that are vulnerable and marginalized, but also shows the imminent risk for some of these segments during the pandemic.

ROLE OF POLICY AND POLICY ADVOCACY IN PALLIATIVE AND END-OF-LIFE CARE FOR LGBTQ PERSONS

The role of policy in shaping the experience of LGBTQ persons in serious illness and at end of life has received scant attention. A growing body of literature recognizes gender identity as a contributor to significant inequities in access to care, and calls attention to the important role of family members of choice in end-of-life care planning and decision processes. This paper will examine the goals of policy in addressing the human rights and needs of LGBTQ older persons, and will place such goals in the context of changing social and cultural contexts, as well as existing statutory frameworks at both federal and state levels governing palliative and end-of-life care. Examples of progressive policy making in both New York State and through the World Health Organization’s public health initiative for strengthening palliative and end-of-life care will be examined. Implications for future directions in gerontology and gerontological research will be discussed.

Prospects for progress on health inequalities in England in the post-primary care trust era: professional views on challenges, risks and opportunities

BackgroundAddressing health inequalities remains a prominent policy objective of the current UK government, but current NHS reforms involve a significant shift in roles and responsibilities. Clinicians are now placed at the heart of healthcare commissioning through which significant inequalities in access, uptake and impact of healthcare services must be addressed. Questions arise as to whether these new arrangements will help or hinder progress on health inequalities. This paper explores the perspectives of experienced healthcare professionals working within the commissioning arena; many of whom are likely to remain key actors in this unfolding scenario.MethodsSemi-structured interviews were conducted with 42 professionals involved with health and social care commissioning at national and local levels. These included representatives from the Department of Health, Primary Care Trusts, Strategic Health Authorities, Local Authorities, and third sector organisations.ResultsIn general, respondents lamented the lack of progress on health inequalities during the PCT commissioning era, where strong policy had not resulted in measurable improvements. However, there was concern that GP-led commissioning will fare little better, particularly in a time of reduced spending. Specific concerns centred on: reduced commitment to a health inequalities agenda; inadequate skills and loss of expertise; and weakened partnership working and engagement. There were more mixed opinions as to whether GP commissioners would be better able than their predecessors to challenge large provider trusts and shift spend towards prevention and early intervention, and whether GPs’ clinical experience would support commissioning action on inequalities. Though largely pessimistic, respondents highlighted some opportunities, including the potential for greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards.ConclusionsThere is doubt about the ability of GP commissioners to take clearer action on health inequalities than PCTs have historically achieved. Key actors expect the contribution from commissioning to address health inequalities to become even more piecemeal in the new arrangements, as it will be dependent upon the interest and agency of particular individuals within the new commissioning groups to engage and influence a wider range of stakeholders.

Abstract A93: Contextualizing early detection: Lessons from lay definitions of colorectal cancer early detection.

Abstract Purpose of study: Practitioners and researchers often promote “early detection” as a key message in colorectal cancer (CRC) screening programs and as a strategy to reduce disparities in CRC mortality. To better understand the experience of CRC for individuals who face substantial health and income inequalities, this qualitatively research examines the meanings and understandings of “early detection” that may be overlooked by quantitative approaches. This study suggests that early detection messages are contextualized and interpreted within lived experiences. Procedures: Six focus groups and 21 open-ended interviews were conducted during 2006 and 2007 to examine understandings of CRC screening and detection. The study took place at an urban community health center in a U.S. Midwestern city and focused on adults age 45 years and older. Most participants were female, African American, unemployed, and had no more than a high school education. Nearly half were without any type of health insurance. Transcripts were analyzed by two coders, who used an inductive data analysis approach. Summary of Data: Four key findings were identified throughout the transcripts. First, participants made sense of CRC through comparisons to a range of diseases experienced in their families and communities and seen in public health campaigns. Second, they utilized statements about early and late detection of cancer to make sense of past personal and family experiences with cancer. Most participants had experienced multiple deaths of family and friends to cancer and were drawing on early detection messages to grapple with their sadness, guilt, and blame over why loved ones had died. Third, CRC screening and detection were viewed within the context of possible treatments and treatment outcomes. Ideas about treatment accessibility and effectiveness heavily influenced participants' approaches to accessing screenings. Finally, rather than an avoidance of health-seeking behavior, participants demonstrated and discussed their persistence in attempting to achieve diagnoses and treatment with limited resources. Conclusion: The study findings suggest that frequently invoked constructs in preventive health, such as early detection and the treatability of cancer in its earliest stages, take on much more complex meanings than researchers, practitioners, and clinicians may expect. Examining these meanings offers a starting point for understanding and redressing CRC disparities in populations that have experienced significant inequities in access to quality healthcare, which have sometimes endured over generations. Researchers should consider social contexts and deeper meanings when developing communications that emphasize early detection and when using measures that ask individuals about early detection beliefs and behaviors. Citation Format: Jean M. Hunleth, Nancy Mueller, Aimee James. Contextualizing early detection: Lessons from lay definitions of colorectal cancer early detection. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A93.

An American Future? Contingency Fees, Claims Explosions and Evidence from Employment Tribunals

This article looks empirically at the notion of ‘American-style’ problems with contingency fees: in particular, the purported link between contingency fees and claims explosions. It does so in the light of renewed interest in contingency fees as a vehicle for access to justice and the resolution of costs problems in the civil justice system prompted by Jackson LJ and others. The article sheds light on the considerable debate about the (de)merits of contingency fees in one of the main – and most controversial – contexts where they are permitted: employment tribunals. The evidence casts doubt on the claim that contingency fees, coupled with US-style costs rules, lead inexorably to an explosion in litigation. The article also examines the significant inequalities in access to justice experienced by claimants and considers how far contingency fees address those concerns, suggesting limits to Kritzer's portfolio theory in relation to employment cases in England and Wales.

Increasing uptake of HIV testing and counseling among the poorest in sub-Saharan countries through home-based service provision.

Uptake of HIV testing and counseling (HTC) is lower among members of the poorest households in sub-Saharan countries, thereby creating significant inequalities in access to HTC and possibly antiretroviral treatment. To measure uptake of home-based HTC and estimate HIV prevalence among members of the poorest households in a sub-Saharan population. Residents of 6 villages of Likoma Island (Malawi) aged 18-35 and their spouses were offered home-based HTC services. Socioeconomic status, HIV testing history, and HIV risk factors were assessed. Differences in HTC uptake and HIV infection rates between members of households in the lowest income quartile and the rest of the population were estimated using logistic regression. Members of households in the lowest income quartile were significantly less likely to have ever used facility-based HTC services than the rest of the population (odds ratio = 0.60, 95% confidence interval (CI): 0.36 to 0.97). In contrast, they were significantly more likely to use home-based HTC services provided during the study (adjusted odds ratio = 1.70, 95% CI: 1.04 to 2.79). Socioeconomic differences in uptake of home-based HTC were not due to underlying differences in socioeconomic characteristics or HIV risk factors. The prevalence of HIV was significantly lower among members of the poorest households tested during home-based HTC than among the rest of the population (adjusted odds ratio = 0.37, 95% CI: 0.14 to 0.96). HTC uptake was high during a home-based HTC campaign on Likoma Island, particularly among the poorest. Home-based HTC has the potential to significantly reduce existing socioeconomic gradients in HTC uptake and help mitigate the impact of AIDS on the most vulnerable households.

Challenges to Pediatric HIV Care and Treatment in South Africa

It is estimated that almost 300,000 children in South Africa have human immunodeficiency virus (HIV) infection. The disease is responsible for reversing decreases in child mortality. Few data exist evaluating the outcomes of the prevention of mother-to-child transmission of HIV (PMTCT) program, although PMTCT coverage appears to be low. Hospitals are still witnessing large numbers of admissions of HIV-infected children. Postnatal transmission of HIV is high, reflecting poor education of and support for women in their infant feeding choices. Too few infants and children are entering care through early diagnosis, which should be widely available. Cotrimoxazole prophylaxis coverage is inadequate, contributing to high morbidity and mortality in infants. The number of children receiving antiretroviral therapy (ART) is increasing steadily. However, significant inequalities in access to ART exist between and within provinces. Challenges for pediatric ART include a lack of sufficiently trained health care personnel and inadequate facilities, as well as the complexity of drug regimens and formulations. The compartmentalization of the ART rollout program hinders PMTCT and makes it difficult for children to be identified and referred into appropriate services. This article delineates the challenges to pediatric HIV care in South Africa and provides some practical recommendations to improve it.

Access to Osteoporosis Treatment is Critically Linked to Access to Dual-Energy X-ray Absorptiometry Testing

To determine if inequities in access to osteoporosis investigation [dual-energy x-ray absorptiometry (DXA) testing] and treatment (bisphosphonate, calcitonin, and/or raloxifene) exist among older women in a region with universal health care coverage. Community-dwelling women aged 65-89 years residing within 2 regions of Ontario, Canada were randomly sampled. Data were collected by standardized telephone interview. Potential correlates of DXA testing (verified by physician records), and current treatment were grouped by type as: "predisposing characteristics," "enabling resources," or "need factors" based on hypothesized relationships formulated before data collection. Variables associated with each outcome independent of "need factors" identified inequities in the system. Of the 871 participants (72% response rate), 55% had been tested by DXA and 20% were receiving treatment. Using multiple variable logistic regression to adjust for need factors, significant inequities in access to DXA testing existed by age, health beliefs, education, income, use of preventive health services, region, and provider sex. DXA testing mediated access to treatment; 34% of those having had a DXA were treated compared with 2% of those who did not. Among women with osteoporosis, correctly reporting that their DXA test indicated osteoporosis and higher perceived benefits of taking pharmacological agents for osteoporosis were associated with treatment. Significant inequities in access to fracture prevention exist in a region with universal health care coverage. Improved access to DXA and better communication to patients of both their DXA results and the benefits of treatment has the potential to reduce the burden of osteoporosis.

Unintended Consequences of Regionalizing Specialized VA Addiction Services

Back to table of contents Previous article Next article ArticleFull AccessUnintended Consequences of Regionalizing Specialized VA Addiction ServicesAmy E. Wallace M.D., M.P.H.Alan N. West Ph.D.Brenda M. Booth Ph.D.William B. Weeks M.D., M.B.A.Amy E. Wallace M.D., M.P.H.Search for more papers by this authorAlan N. West Ph.D.Search for more papers by this authorBrenda M. Booth Ph.D.Search for more papers by this authorWilliam B. Weeks M.D., M.B.A.Search for more papers by this authorPublished Online:1 May 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Driven primarily by budgetary reforms, the Department of Veterans Affairs (VA) began shifting services in 1995 from hospital-based care to outpatient-based care. Then-Under Secretary for Health Kenneth Kizer aimed to decrease per-patient expenditures by 30% while increasing the number of veterans served by 20% ( 1 ). Subsequently, VA addiction services, consisting of traditional inpatient treatment models located at most parent VA facilities, were reorganized into predominantly outpatient and residential programs. As a result of this transition from inpatient care, VA spending on specialized addiction services fell from $360 million in 1995 (2.4% of total VA health care spending that year) to $226 million in 2000 (1.2% of that year's total) ( 2 ). With the shift to outpatient care, the VA was reorganized into 22 Veterans Integrated Service Networks (VISNs). The intent was that each network would offer a full continuum of specialized medical, surgical, psychiatric, and substance abuse care, the components of which would be accessible to all eligible veterans within the VISN boundaries. Most facilities within each VISN retained general medical inpatient capabilities, including provision of alcohol and drug detoxification services; however, most inpatient specialized addiction (rehabilitation) services were closed or converted to outpatient or residential services ( 3 ). The few remaining inpatient programs for specialized addiction services were located in larger urban centers within selected VISNs. Of the 70 inpatient programs available nationwide in 1997, only 21 remained in 2000, and all but 15 programs were eliminated by 2003 ( 4 ). In New York State, there were eight VA facilities where veterans could access specialized inpatient care in 1997, but by 2000 only two inpatient rehabilitation programs remained. Although residential programs and intensive outpatient programs were planned to be established and standard outpatient services expanded to fill treatment gaps at lower cost, overall the VA saw a 19% reduction in addiction treatment programs ( 5 ). Between 1997 and 2000 eight new residential programs were established nationwide, but 12 intensive outpatient programs and six standard outpatient programs were lost ( 5 ). New York gained four residential programs but lost three intensive outpatient programs and one standard outpatient program over the same period ( 5 ). As the number and intensity of programs declined, the severity of problems among veterans seeking treatment increased and waiting lists expanded ( 5 ). Although remaining services are theoretically accessible to all eligible veterans, for this study we hypothesized that veterans who live in rural settings, who would likely experience greater travel distances to remaining facilities with specialized inpatient addiction services, may have greater difficulty accessing these services because of potential travel-time barriers and a lower "nonlocal" priority compared with veterans living near these facilities. Having previously developed a unique data set that included all VA and non-VA hospitalizations for New York veterans between 1998 and 2000 ( 6 ), we were able to assess whether rural veterans altered their use of VA nonspecialized (detoxification) inpatient addiction services, specialized (rehabilitation) inpatient addiction services, or both. We also examined whether rural veterans or urban veterans increased their use of non-VA inpatient addiction services to compensate for the loss of available VA inpatient addiction services. In addition, we examined the characteristics of VA enrollees who accessed addiction and nonaddiction inpatient services in VA facilities and non-VA facilities and across rural and urban settings. MethodsWe conducted a retrospective cohort study of New York veterans who were enrolled in the VA health care system and admitted to either VA facilities or non-VA facilities for inpatient drug or alcohol detoxification or rehabilitation in New York State during years in which the data for both VA services and non-VA services were available: 1998 through 2000. We linked data from multiple sources to address three questions: Where did VA patients access nonspecialized (detoxification) and specialized (rehabilitation) inpatient addiction services—in VA or non-VA facilities? Did veterans' use of either system change over the three-year interval as the VA reduced budgets and regionalized addiction care? Did rural veterans and urban veterans differ in their use of VA and non-VA inpatient addiction services? This study was approved by Dartmouth Medical School's Committee for the Protection of Human Subjects.Identification of patients admitted to a VA facility From VA administrative databases, we identified 353,570 veterans who were enrolled in the VA system and were residents of New York State at any time between 1998 and 2000. We defined enrollment on the basis of two criteria: being listed in the VA enrollment file and using VA health services in the prior three years. These criteria were adopted for two reasons. First, the VA enrollment file identifies patients for whom the VA has an obligation to provide a medical benefits package ( 7 ). Second, service utilization within three years "vests" patients for the purposes of administering the Veterans Equitable Resource Allocation system. Both enrollment and vesting are used to define the VA service population or "covered lives" for whom the VA has a potential medical benefits liability. Our criteria for enrolled patients replicate methods used previously ( 6 , 8 , 9 ). Identification of addiction admissions We used ICD-9-CM procedure codes to identify admissions in VA facilities and non-VA facilities for alcohol or drug detoxification only (detoxification only— ICD-9-CM procedure codes 94.62, 94.65, and 94.68) and alcohol or drug rehabilitation with or without detoxification (rehabilitation— ICD-9-CM codes 94.60, 94.61, 94.63. 94.66, 94.67, and 94.69). VA use. To determine whether patients admitted to a VA facility accessed inpatient addiction services in New York's VA system, we used ICD-9-CM codes from the VA's patient treatment file to identify patients who obtained detoxification or rehabilitation services in any VA facilities that provide these services in New York. Non-VA use. We obtained information on enrolled veterans' non-VA admissions from New York's Statewide Planning and Research Cooperative System (SPARCS) data set, a system that collects discharge information, including ICD-9-CM procedure codes and payer information, from all non-VA New York hospitals. The SPARCS data set identifies patients by using a combination of letters from patients' first and last names and digits from their Social Security numbers. We linked the SPARCS and VA data sets by obtaining the same data elements from the VA enrollment file, mimicking the SPARCS algorithm, and using the generated unique identifier to capture information on non-VA admissions. We used ICD-9-CM procedure codes from the SPARCS data set to identify veterans who obtained inpatient detoxification only or who received rehabilitation in any non-VA facilities that provide these services in New York. Defining rural and urban service populations To classify veterans as rural or urban, we matched their ZIP codes to Rural-Urban Commuting Area (RUCA) codes that were developed by the Health Resources and Service Administration's Federal Office of Rural Health Policy, the Department of Agriculture's Economic Research Service, and the WWAMI [Washington, Wyoming, Alaska, Montana, and Idaho] Rural Health Research Center at the University of Washington School of Medicine ( 10 ). We used the Washington State Department of Health's RUCA consolidation system ( 11 ) to classify and compare veterans who lived in urban settings (areas of 500,000 persons or more, corresponding with U.S. Bureau of the Census-defined urbanized areas; RUCA code 1.0) to those who lived in rural settings (small towns with populations below 10,000 and isolated rural areas; RUCA codes 7.0, 7.3, 7.4, 8.0, 8.3, 8.4, 9.0, 9.1, 9.2, 10.0, 10.3, 10.4, and 10.5). Statistical analysisFor each system of care (VA or non-VA), level of care (detoxification only or rehabilitation), and patient residence (urban or rural), we calculated average annual admissions per unique enrolled veteran by dividing the overall number of admissions by the number of unique VA enrollees in New York State applicable to each analysis. Using chi square analysis, we tested for the relative reliance on VA versus non-VA addiction and nonaddiction inpatient services for rural and urban veterans by individual year and all years combined, and we tested for rural and urban differences in annual admission rates for detoxification only or rehabilitation at either non-VA or VA hospitals across years 1998–2000. Using 1998 as the reference year, we used the standard dichotomous variable-dichotomous endpoint formula to calculate odds ratios with 95% confidence intervals for each admission category (detoxification or rehabilitation) and system of care (VA or non-VA) to estimate temporal trends in admissions rates.Results As shown in Table 1 and Table 2 , the correlates of residence and system of care were different between patients admitted for inpatient addiction treatment and those admitted for nonaddiction inpatient services. Among veterans hospitalized for care other than addiction treatment, private-sector patients were older than patients admitted to a VA facility, rural residents were more likely to be white, regardless of system of care, and private-sector patients were more likely to be white, regardless of rural or urban residence (p<.001 for all). In addition, patients admitted to a non-VA facility, either urban or rural, were more likely to be enrolled in Medicare, and rural VA patients were more likely to be enrolled in Medicare than their urban counterparts (p<.001 for all). Finally, patients admitted to a VA facility, either urban or rural, were more likely to have a service-connected disability, and rural patients admitted to a non-VA facility were less likely than their urban counterparts to have a service-connected disability (p<.001 for all). Table 1 Characteristics of veterans in urban areas of New York who used addiction and medical inpatient services in Department of Veterans Affairs (VA) hospitals and in private-sector hospitalsTable 1 Characteristics of veterans in urban areas of New York who used addiction and medical inpatient services in Department of Veterans Affairs (VA) hospitals and in private-sector hospitalsEnlarge tableTable 2 Characteristics of veterans in rural areas of New York who used addiction and medical inpatient services in Department of Veterans Affairs (VA) hospitals and in private-sector hosTable 2 Characteristics of veterans in rural areas of New York who used addiction and medical inpatient services in Department of Veterans Affairs (VA) hospitals and in private-sector hosEnlarge tableTable 1 and Table 2 also show that among patients admitted for addiction treatment, patients admitted to a non-VA facility were older than those admitted to a VA facility (p<.001), but rural patients admitted to a VA facility were older than urban patients admitted to a VA facility (p<.001). They also show that although rural residents, compared with urban residents, admitted for inpatient addiction treatment were more likely to be white, regardless of system of care, patients admitted to a non-VA facility were less likely to be white, regardless of residence (p<.001 for all). In addition, the tables show that among patients admitted for inpatient addiction treatment, rural patients were more likely to be enrolled in Medicare, regardless of system of care, but both urban patients and rural patients admitted to a non-VA facility were less likely to be enrolled in Medicare (p<.001 for all). Finally, the tables show that both urban patients and rural patients admitted to a VA facility for addiction treatment were more likely than those admitted to a non-VA facility to have a service-connected disability (have military-related disabilities), but rural patients admitted to a VA facility were more likely to have a service-connected disability than their urban counterparts (p<.001 for all). Regardless of rural or urban residence, VA enrollees who were hospitalized for nonaddiction treatment received it in VA facilities less often than in non-VA facilities. In contrast, VA enrollees received addiction treatment services more often in VA facilities than in non-VA facilities (p<.001 for the chi square test of relative reliance on VA for addiction versus nonaddiction care for all years individually and combined). Urban veterans in New York used inpatient addiction services (detoxification only, rehabilitation, or both) in both VA facilities and non-VA facilities at higher rates than rural veterans did (p<.001 for all). Although less likely to receive addiction treatment, rural veterans obtained a higher proportion of these services from VA facilities. Over the three years, VA facilities provided 67% of rural veterans' addiction treatment compared with 54% of urban veterans' addiction treatment (p< .001). Rural veterans' relative reliance on addiction care in VA facilities remained stable from 1998 to 2000, whereas urban veterans used increasingly more addiction care in non-VA facilities. As shown in Table 3 , admission rates to VA facilities for inpatient addiction services fell for both rural and urban VA enrollees from 1998 to 2000. Specifically, in 1998 detoxification admissions in VA facilities averaged 13 per 1,000 enrolled urban veterans and nine per 1,000 enrolled rural veterans, whereas in 2000 they averaged nine per 1,000 for urban veterans and six per 1,000 for rural veterans. Rehabilitation admissions to VA hospitals fell from six per 1,000 urban veterans and two per 1,000 rural veterans in 1998 to two per 1,000 urban veterans and .3 per 1,000 rural veterans in year 2000. Table 3 Rates of admissions to Department of Veterans Affairs (VA) hospitals and to private-sector hospitals for nonspecialized (detoxification) and specialized (rehabilitation) addiction services for veterans in New YorkTable 3 Rates of admissions to Department of Veterans Affairs (VA) hospitals and to private-sector hospitals for nonspecialized (detoxification) and specialized (rehabilitation) addiction services for veterans in New YorkEnlarge table Rates of admission for addiction treatment to VA facilities exceeded those to non-VA facilities in every year and regardless of patient residence (with the exceptions of detoxification admissions in years 1999 and 2000 for urban VA enrollees) ( Table 3 ). Urban veterans' admission rates to non-VA facilities for addiction services remained stable throughout the three years, at 11 per 1,000 for detoxification only and two per 1,000 for rehabilitation. Rural veterans' admission rates fell, however, from four per 1,000 for detoxification only and 1.2 per 1,000 for rehabilitation admissions in 1998 to three per 1,000 for detoxification only and .6 per 1,000 for rehabilitation admissions in 2000 ( Table 3 ). Compared with 1998 levels, odds ratios of accessing the VA for detoxification fell to approximately .80 in 1999 and approximately .65 in 2000 (both p<.01) for both rural and urban veterans. Odds ratios for urban veterans' use of detoxification services in non-VA facilities remained fairly constant from 1998 to 2000, but odds ratios for rural veterans' use of detoxification services in non-VA facilities fell to .76 of 1998 levels in 1999 (not significant) and .62 in 2000 (p<.001). Compared with 1998 levels, odds ratios for admission to VA hospitals for substance abuse rehabilitation fell to .52 in 1999 and .38 in 2000 for urban residents, but for rural residents they fell more, to .31 and .16, respectively (all p<.001). Odds ratios for rehabilitation admission to non-VA facilities changed little for urban veterans, and the change was not significant (1.01 in 1999 and .90 in 2000) but fell substantially for rural veterans, to .66 in 1999 (not significant) and .51 in 2000 (p<.05) ( Table 3 ). DiscussionAfter VA's reorganization in the mid-1990s, both rural veterans and urban veterans in New York reduced their use of inpatient nonspecialized and specialized addiction services. However, several trends suggest that rural New York veterans disproportionately felt the effects of addiction service cutbacks and regionalization. Since 1998 use of inpatient VA addiction services, particularly specialized services, declined more dramatically for rural veterans than for urban veterans.The disproportionate burden that reductions imposed on rural veterans can be explained simply. Because nonspecialized inpatient addiction care (detoxification) can be accomplished on most general medical or psychiatric wards, one would anticipate that the reduction in general medical inpatient beds would affect rural VA facilities and urban VA facilities similarly. But although urban veterans appeared to compensate for loss of VA detoxification services somewhat by increasing their use of non-VA detoxification services, the same was not true of rural veterans. In fact, from 1998 to 2000 the number of non-VA hospitals in New York providing detoxification in urban areas fell 4% (from 98 to 94 hospitals), while hospitals providing detoxification in rural areas fell 25% (from 40 to 30 hospitals); hence, rural veterans experienced the additional reduction in non-VA detoxification sites during the study period. There are three potential reasons why rural veterans disproportionately suffered from reductions in specialized inpatient VA addiction treatment (rehabilitation). First, although regionalized services were meant to be accessible to all veterans within a network, facilities may prioritize veterans from their own catchment area or local referral sources. Second, distance to care is a barrier to accessing health care services ( 12 , 13 , 14 ); regionalization to urban sites undoubtedly increased driving time for rural veterans. Third, lack of public transportation in rural areas further restricts access to treatment, over and above barriers based on distance alone ( 15 ). These distance and transportation barriers are further compounded for patients with substance use disorders, who commonly lose driver's licensure and lack the means to transport themselves to a distant facility. Although the VA intended for the additional outpatient and residential services to replace lost inpatient services, these are likely to be inadequate substitutes, especially for rural veterans. Guideline-concordant outpatient addiction treatment requires multiple visits. Because fewer visits are likely to be completed by patients living at greater distances from care ( 16 ), rural veterans are less likely to receive the required number of addiction visits defining guideline-concordant treatment. Our study has several limitations. Our analysis focused on inpatient care only. Lack of outpatient, residential, and domiciliary data limits our ability to make rural-urban comparisons about overall addiction care. However, similar comparison of outpatient addiction treatment would be virtually impossible given the absence of a uniform collection methodology for non-VA outpatient treatment. Acknowledging this limitation, we feel our findings are useful in describing an important aspect of addiction treatment for rural and urban veterans.Second, our analysis is limited to VA users who live within the confines of New York State and who used New York State hospitals. Rural or urban VA users in New York may not be representative of all rural or urban VA users nationwide. Likewise, administrative and clinical changes to inpatient addiction services within New York VA facilities at the time studied may not reflect those of VA facilities in other regions. Third, we were unable to assess rural-urban differences in substance use disorder prevalence or to track changes in prevalence among VA users for the years examined. The overall higher use of inpatient addiction services by urban veterans may be warranted. A large national survey of veterans from the same period suggests that urban veterans have a higher prevalence of alcohol use disorder compared with rural veterans ( 17 ). Although the sample used in a telephone health survey of residents of six Southern states was perhaps not similar to the New York veteran population examined herein, the survey likewise found lower rates of at-risk drinking among rural residents compared with their urban counterparts ( 18 ). Likewise, the 2001 National Household Survey on Drug Abuse found higher rates of both alcohol abuse and illicit drug abuse among metropolitan respondents compared with nonmetropolitan respondents ( 19 ). It is possible that the observed reduction in admission rates for inpatient addiction services in New York from 1998 to 2000 merely reflects a decline in need for those services. However, others have shown that veterans' needs for addiction services remained high from 1994 to 2001, making this explanation unlikely ( 20 ). Fourth, we were unable to assess potentially independent effects of geographic variation in admission rates on our findings. Geographic variation in medical, surgical, and psychiatric services has been well described in the private sector and is thought to be mediated by regional practice patterns and supplier-induced demand ( 21 , 22 ). Theoretically, the VA should be less prone to geographic variation given its centralized planning and lack of economic incentives; however, variation in admission rates and length of stay has been described in the VA as well ( 23 , 24 , 25 ). Given that our sample reflects a relatively small geographic region, all predominantly controlled by two VISN authorities, and assuming any variations remained stable over the period examined, geographic variation alone is unlikely to explain the differences we found. Finally, as with all administrative data sets, our data may be incomplete or include incorrectly coded events. However, other studies using this database found that 98% of events that were captured in this data set were also captured in a clinical registry, and no events that occurred outside of New York were captured in the New York data set ( 6 , 26 ). Our findings suggest that rural veterans have disproportionately suffered from reductions in addiction services. Perhaps recognizing that its reductions in addiction services in the 1990s were too extreme, the VA allocated $9.5 million for addiction treatment expansion through the Veterans Millennium Health Care and Benefits Act of 2000 (Public Law 106–117). Although this additional funding may have slowed further reductions, it did not reverse the trend. The number of veterans with substance use disorders increased by 31% between 2000 and 2003, while the average number of veterans treated in VA addiction services decreased by 8% over the same period ( 4 ). In April 2003 American Psychiatric Association Trustee Joseph English, M.D., urged the House VA-HUD [Department of Veterans Affairs and Housing and Urban Development] Appropriations Subcommittee to include an additional $2 billion to restore mental health and substance abuse services and to correct "significant inequalities in access and quality of care of specialized treatment service" ( 27 ). In order to correct these disparities, VA medical centers that serve rural veterans should be given funding priority with regard to reestablishing addiction services. ConclusionsOur study suggests that the VA's well-intended plan to cut costs while serving more veterans resulted in the unintended consequence of reducing access to VA inpatient addiction treatment. This was especially true for rural veterans, who experienced concurrent reductions in access to these services in non-VA facilities. Although we focused on the plight of a select group—rural veterans seeking inpatient addiction treatment in the era of VA downsizing—our study is relevant to overall rural health policy in two ways. First, research is lacking on the impact of changes in health system structures on rural-urban disparities in access to health care in general U.S. populations. Our study suggests that examining combined VA and private-sector data sets can shed light on differences in rural and urban consumer responses to changes in health systems policies. Second, the VA is a large, highly coordinated system of care that is less influenced by economic incentives that drive most private-sector health care systems. The access disparities that exist in the VA may be magnified in smaller health care systems for which locating treatments in less populous areas may lack political appeal or result in loss of revenue. Our results advise health care policy makers to consider the needs of identified vulnerable populations before policies are implemented and to monitor those needs afterward to avoid creating unintended inequities in access to care.Acknowledgments and disclosuresThe authors report no competing interests.Dr. Wallace, Dr. West, and Dr. Weeks are affiliated with the Administration Medical Center, Department of Veterans Affairs (VA) Outcomes Group Research Enhancement Awards Program, 215 North Hartland Rd., White River Junction, VT 05009 (e-mail: [email protected]). Dr. Wallace is also with the Department of Psychiatry and Dr. Weeks is also with the Center for Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire. Dr. Booth is with Central Arkansas Veterans Health Care System, Health Services Research and Development Center for Mental Healthcare Outcomes and Research, Little Rock, Arkansas, and with the Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock.

Access to and use of ambulatory health care by a vulnerable Mexican American population on the U.S.-Mexico border.

The objective of this study was to determine if health care access is equitable and effective for Mexican Americans at the U.S.-Mexico border. The design was a cross-sectional telephone and door-to-door survey using the Behavioral Risk Factor Surveillance System, and the subjects were 1,409 El Paso County residents, ages 18 to 64 years. After controlling for other predisposing, enabling, and need characteristics, the presence of health insurance was significantly associated with health care use in the past year, both for a checkup (odds ratio [OR] = 2.48; 95 percent confidence interval [CI] = 1.83, 3.38) and a visit for any reason (OR = 2.20; 95 percent CI = 1.60, 3.04). Findings were similar for a regular source of care. Those who reported a checkup in the past year were significantly more likely to receive clinical preventive services. The lack of health insurance and a regular source of care for Mexican Americans on the U.S.-Mexico border creates significant inequalities in access to care.

The Polish country profile: Economic crisis and inequalities in health

Class position based on educational level is strongly associated with health status in Poland. Whilst infant mortality continues to fall, life expectancy at age 45 is lower particularly for males. Cause of death analysis shows a steady but slow fall in poverty-type diseases and a big increase in deaths from circulatory diseases and malignant neoplasms. Multiple regression analyses suggest that the main causal factors in inequality result from economic failure, differences in living conditions and lifestyles rather than from the evident inefficiences in the health-care system itself. But there are significant inequalities in access to health care and especially to quality care.