Years of life lost to prison: racial and gender gradients in the United States of America

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The devil is in the details: trends in avoidable hospitalization rates by geography in British Columbia, 1990–2000

BACKGROUND: Researchers and policy makers have focussed on the development of indicators to help monitor the success of regionalization, primary care reform and other health sector restructuring initiatives. Certain indicators are useful in examining issues of equity in service provision, especially among older populations, regardless of where they live. AHRs are used as an indicator of primary care system efficiency and thus reveal information about access to general practitioners. The purpose of this paper is to examine trends in avoidable hospitalization rates (AHRs) during a period of time characterized by several waves of health sector restructuring and regionalization in British Columbia. AHRs are examined in relation to non-avoidable and total hospitalization rates as well as by urban and rural geography across the province. METHODS: Analyses draw on linked administrative health data from the province of British Columbia for 1990 through 2000 for the population aged 50 and over. Joinpoint regression analyses and t-tests are used to detect and describe trends in the data. RESULTS: Generally speaking, non-avoidable hospitalizations constitute the vast majority of hospitalizations in a given year (i.e. around 95%) with AHRs constituting the remaining 5% of hospitalizations. Comparing rural areas and urban areas reveals that standardized rates of avoidable, non-avoidable and total hospitalizations are consistently higher in rural areas. Joinpoint regression results show significantly decreasing trends overall; lines are parallel in the case of avoidable hospitalizations, and lines are diverging for non-avoidable and total hospitalizations, with the gap between rural and urban areas being wider at the end of the time interval than at the beginning. CONCLUSION: These data suggest that access to effective primary care in rural communities remains problematic in BC given that rural areas did not make any gains in AHRs relative to urban areas under recent health sector restructuring initiatives. It remains important to continue to monitor the discrepancy between them as a reflection of inequity in service provision. In addition, it is important to consider alternative explanations for the observed trends paying particular attention to the needs of rural and urban populations and the factors influencing local service provision

Determinants of Treatment Access in a Population-based Cohort of HIV-positive Men and Women Living in Argentina

Objective: To report emerging data on the use of highly active antiretroviral therapy (HAART)in Argentina by assessing patterns of HAART access and late vs early treatment initiation in apopulation-based cohort of adults infected with HIV type-1.Design: The Prospective Study on the Use and Monitoring of Antiretroviral Therapy (PUMA) is astudy of 883 HIV-positive individuals enrolled in the Argentinean drug treatment program.Individuals were 16 years of age and older and were recruited from 10 clinics across Argentina.Methods: Sociodemographic and clinical characteristics were examined using contingency tables(Pearson chi-square test and Fisher exact test) for categoric variables and Wilcoxon rank-sum testfor continuous variables. To analyze time to initiation of HAART we used Kaplan-Meier methodsand Cox regression.Results: Patients who initiated HAART were more likely to be older, have an AIDS-defining illness,be an injection drug user (IDU), have a lower median CD4 cell count, have a higher median viralload, and be less likely to be men who have sex with men (MSM). In multivariate analysis, AIDSdefiningillness and plasma viral load were significantly associated with time to starting therapy.Patients who received late access were more likely to be diagnosed with AIDS and have highermedian plasma viral loads than those receiving early access.Conclusion: Our results indicate that despite free availability of treatment, monitoring, and carein Argentina, a significant proportion of men and women are accessing HAART late in the courseof HIV disease. Further characterization of the HIV-positive population will allow for a morecomprehensive evaluation of the impact of HAART within the Argentinean drug treatmentprogram