Using hospitalization for ambulatory care sensitive conditions to measure access to primary health care: an application of spatial structural equation modeling

BACKGROUND: In data commonly used for health services research, a number of relevant variables are unobservable. These include population lifestyle and socio-economic status, physician practice behaviors, population tendency to use health care resources, and disease prevalence. These variables may be considered latent constructs of many observed variables. Using health care data from South Carolina, we show an application of spatial structural equation modeling to identify how these latent constructs are associated with access to primary health care, as measured by hospitalizations for ambulatory care sensitive conditions. We applied the confirmatory factor analysis approach, using the Bayesian paradigm, to identify the spatial distribution of these latent factors. We then applied cluster detection tools to identify counties that have a higher probability of hospitalization for each of the twelve adult ambulatory care sensitive conditions, using a multivariate approach that incorporated the correlation structure among the ambulatory care sensitive conditions into the model. RESULTS: For the South Carolina population ages 18 and over, we found that counties with high rates of emergency department visits also had less access to primary health care. We also observed that in those counties there are no community health centers. CONCLUSION: Locating such clusters will be useful to health services researchers and health policy makers; doing so enables targeted policy interventions to efficiently improve access to primary care

Duration Data from the National Long-Term Care Survey: Foundation for a Dynamic Multiple-Indicator Model of ADL Dependency

This report describes preparation of data from the National Long-Term Care Survey (NLTCS) fur use in a dynamic multiple-indicator model of dependency in Activities of Daily Living (ADLs). The data set described makes use of all functional status information available across four NLTCS waves for six ADLs, including information from screening interviews, detailed interviews in the community, and institutional interviews. Importantly, it also captures all available information elicited from respondents about the *duration* of any impairment in these ADLs. The data was prepared as described in this report to enable the calculation of improved estimates of the probabilities that an older individual will transition from one functional status state to another in any of six ADLs. These probabilities can then be used to improve estimates of active life expectancy

Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states

<p>Abstract</p> <p>Background</p> <p>Federally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions.</p> <p>Methods</p> <p>We conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties). Counties were categorized by facility availability: CHC(s) only, RHC(s) only, both (CHC and RHC), and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individual's county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios.</p> <p>Results</p> <p>Among working age adults, rate ratio (RR) comparing ACS hospitalization rates for CHC-only counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78–0.95). Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81–0.87); for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84–0.92). No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations.</p> <p>Conclusion</p> <p>Our results suggest that CHCs and RHCs may play a useful role in providing access to primary health care. Their presence in a county may help to limit the county's rate of hospitalization for ACS diagnoses, particularly among older people.</p

Cardiorespiratory Fitness as a Predictor of Fatal and Nonfatal Stroke in Asymptomatic Women and Men

Background and Purpose - Prospective data on the association between cardiorespiratory fitness (CRF) and stroke are largely limited to studies in men or do not separately examine risks for fatal and nonfatal stroke. This study examined the association between CRF and fatal and nonfatal stroke in a large cohort of asymptomatic women and men. Methods - A total of 46,405 men and 15,282 women without known myocardial infarction or stroke at baseline completed a maximal treadmill exercise test between 1970 and 2001. CRF was grouped as quartiles of the sex-specific distribution of maximal metabolic equivalents achieved. Mortality follow-up was through December 31, 2003, using the National Death Index. Nonfatal stroke, defined as physician-diagnosed stroke, was ascertained from surveys during 1982 to 2004. Cox regression models quantified the pattern and magnitude of association between CRF and stroke. Results - There were 692 strokes during 813,944 man-years of exposure and 171 strokes during 248,902 woman-years of exposure. Significant inverse associations between CRF and age-adjusted fatal, nonfatal, and total stroke rates were observed for women and men (Ptrend≤0.05 each). After adjusting for several cardiovascular disease risk factors, the inverse association between CRF and each stroke outcome remained significant (Ptrend\u3c0.05 each) in men. In women, the multivariable-adjusted relationship between CRF and nonfatal and total stroke remained significant (Ptrend≤0.01 each), but not between CRF and fatal stroke (Ptrend=0.18). A CRF threshold of 7 to 8 maximal metabolic equivalents was associated with a substantially reduced rate of total stroke in both men and women. Conclusions - These findings suggest that CRF is an independent determinant of stroke incidence in initially asymptomatic and cardiovascular disease-free adults, and the strength and pattern of the association is similar for men and women

Work disability in the United States, 1968–2015: Prevalence, duration, recovery, and trends

The United States workforce is aging. At the same time more people have chronic conditions, for longer periods. Given these trends the importance of work disability, physical or nervous problems that limit a person’s type or amount of work, is increasing. No research has examined transitions among multiple levels of work disability, recovery from work disability, or trends. Limited research has focused on work disability among African Americans and Hispanics, or separately for women and men. We examined these areas using data from 30,563 adults in the 1968–2015 Panel Study of Income Dynamics. We estimated annual probabilities of work disability, recovery, and death with multinomial logistic Markov models. Microsimulations accounting for age and education estimated outcomes for African American, Hispanic, and non-Hispanic white women and men. Results from these nationally representative data suggested that the majority of Americans experience work disability during working life. Most spells ended with recovery or reduced severity. Among women, African Americans and Hispanics had less moderate and severe work disability than whites. Among men, African Americans became severely work disabled more often than whites, recovered from severe spells more often and had shorter severe spells, yet had more severe work disability at age 65. Hispanic men were more likely to report at least one spell of severe work disability than whites; they also had substantially more recovery from severe work disability, and a lower percentage of working years with work disability. Among African Americans and Hispanics, men were considerably more likely than women to have severe work disability at age 65. Work disability declined significantly across the study period for all groups. Although work disability has declined over several decades, it remains common. Results suggest that the majority of work disability spells end with recovery, underscoring the importance of rehabilitation and workplace accommodation. Keywords: United States, African Americans, Hispanics, Disability, Recovery, Work disability, Microsimulatio

Health outcome disparities associated with access to primary care for vulnerable groups: Hospitalization for ambulatory care sensitive conditions

Eliminating health disparities is a federal and state policy goal. Accessible primary health care may reduce health disparities. Existing policies work to improve access by expanding insurance coverage, increasing physician supply in some areas, and enhancing physician workforce diversity. Hospitalization for Ambulatory Care Sensitive (ACS) conditions is an indicator of primary care access. This study examines associations between race, ethnicity, being a Medicaid recipient, or being uninsured, and ACS hospitalization. The study populations include working age adults and individuals age 65 or older. The 1997 Medical Expenditure Panel Survey, the 1997 Nationwide Inpatient Sample, and the U.S. Census are used to calculate rates of these hospitalizations. The sensitivity of these rates to degrees of physician discretion is investigated. These analyses are supplemented with estimates of the likelihood that a hospitalization will be for an ACS condition. The impact of state health policies that promote access is examined. The 1984-1990 Longitudinal Study of Aging (LSOA) and Medicare claims are used to identify hazards of ACS hospitalization for older individuals, focusing on disparities for nonwhites. The LSOA, linked with the 1984 National Health Interview Survey, is also used to examine associations between both physician supply and physician workforce diversity and the hazards of ACS hospitalization in urban areas. Methods used account for unmeasured heterogeneity. These methods include the Mantel-Haenszel chi-square, multilevel GLS and logistic analysis, and discrete time hazard models incorporating time-varying covariates, duration dependence measures, and random disturbance terms. The analyses consistently show that working age African Americans and Hispanics have significantly higher rates of ACS hospitalization than non-Hispanic whites. Older nonwhites have a significantly greater hazard of such hospitalizations than older whites. Medicaid recipients and the uninsured have significantly higher rates of these hospitalizations than the insured. These results indicate disparities in access to primary care. The policy analyses provide evidence that policies fostering access may reduce disparities. The analysis of physician supply suggests that areas with the fewest physicians have high rates of hospitalization for ACS conditions. Greater physician workforce diversity may be associated with reduced hazards of these hospitalizations for both whites and nonwhites