Measuring the impact of the Affordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach.

BACKGROUND: The Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act (ACA), was created to increase access to primary care, improve quality of care, and decrease healthcare costs. A key provision in the law that mandated expansion of state Medicaid programme changed when states were given the option to voluntarily expand Medicaid. Our study sought to measure the impact of ACA Medicaid expansion on preventable hospitalization (PH) rates, a measure of access to primary care. METHODS: We performed an interrupted time series analysis of quarterly hospitalization rates across eight states from 2012 to 2015. Segmented regression analysis was utilized to determine the impact of policy reform on PH rates. RESULTS: The Affordable Care Act's Medicaid expansion led to decreased rates of PH (improved access to care); however, the finding was not significant (coefficient estimate: -0.0059, CI -0.0225, 0.0107, p = 0.4856). Healthcare system characteristics, such as Medicaid spending per enrollee and Medicaid income eligibility, were associated with a significant decrease in rates of PH (improved access to care). However, the Medicaid-to-Medicare fee index (physician reimbursement) and states with a Democratic state legislature had a significant increase in rates of PH (poor access to care). CONCLUSION: Health policy reform and healthcare delivery characteristics impact access to care. Researchers should continue evaluating such policy changes across more states over longer periods of time. Researchers should translate these findings into cost analysis for state policy-makers to make better-informed decisions for their constituents. CONTRIBUTION TO KNOWLEDGE: Ambulatory care-sensitive conditions are a feasible method for evaluating policy and measuring access to primary care. Policy alone cannot improve access to care. Other factors (trust, communication, policy-makers' motivations and objectives, etc.) must be addressed to improve access.

Dietary Practices Among Stroke-survivors-Racial/Ethnic Differences.

BACKGROUND: Healthy lifestyle choices, particularly optimal nutrition, are crucial to stroke prevention and reducing risk of recurrent stroke. Racial differences exist in poststroke outcomes; however, few studies have examined the influence of race on poststroke diet or nutrition practices, despite nutrition being critical to stroke recovery. The objective of this analyzes was therefore to examine racial/ ethnic differences in nutrition activities among stroke survivors using data from the National Health and Nutrition Examination Surveys. METHODS: Cross-sectional data from National Health and Nutrition Examination Surveys (2011-2014) were analyzed for adults (n = 431) who responded "yes" that they had been told by a health professional that they had a stroke. The main outcome measure was food consumption/nutrition behavior. Descriptive statistics were conducted for demographic characteristics. Pearson Chi square statistics were performed for baseline demographic and clinical comparisons. A negative binomial regression analysis was utilized for racial/ethnic comparisons of dietary/nutrition behaviors. RESULTS: The mean age of the sample was 66.6 years (Standard Deviation, 12.7) but the mean age of stroke onset was 57.9 years (Standard Deviation, 15.8), with Mexican American/Hispanics experiencing their strokes at a younger age than other racial groups (P < .007). After controlling for baseline differences in key demographic and clinical covariates variables, Blacks consumed a higher number of ready-to-eat foods (P = .000) in the past 30 days while Mexican American/Hispanics consumed a higher number of frozen meals/pizza in the past 30 days (P = .004). CONCLUSIONS: Racial/ethnic differences in poststroke nutrition practices, highlight a potential need for focused nutrition counseling for minority population at higher risk of poor poststroke outcomes.

The Monetary Cost of Sexual Assault to Privately Insured US Women in 2013.

OBJECTIVES: To determine whether privately insured female rape victims were billed for charges associated with a specific rape in the United States. METHODS: We examined 2013 de-identified patient data from Truven Analytics Health MarketScan database for an assault that occurred by using International Classification of Diseases, Ninth Revision, code E960.1. RESULTS: Analysis of insurance providers' payment patterns for 1355 incident events to female victims aged between 16 and 61 years revealed that victims remit, on average, 14% or $948 of the rape cost, whereas insurance providers pay 86% or $5789 of the total cost. CONCLUSIONS: Hospital billing procedures for privately insured victims of rape across the United States are not separate from billing procedures for privately insured nonrape patients. This standardized procedure leads hospitals to bill victims directly for services not paid under the victims' insurance policy. Public Health Implications. The Violence Against Women Act (passed in 1994, reauthorized in 2000, 2005, and 2013) must be amended to mandate that all costs incurred because of rape are not passed on to the victim.

Access to Diabetes Care for Populations Experiencing Homelessness: an Integrated Review.

Populations experiencing homelessness with diabetes may encounter barriers to accessing comprehensive diabetes care to manage the condition, yet it is unclear to what extent this population is able to access care. We reviewed the literature to identify and describe the barriers and facilitators to accessing diabetes care and managing diabetes for homeless populations using the Equity of Access to Medical Care Framework. An integrated review of the literature was conducted and yielded 10 articles that met inclusion criteria. Integrated reviews search, summarize, and critique the state of the research evidence. Findings were organized using the dimensions of a comprehensive conceptual framework, the Equity of Access to Medical Care Framework, to identify barriers and facilitators to accessing care and managing diabetes. Barriers included competing priorities, limited access to healthy food, and inadequate healthcare resources. Facilitators to care included integrated delivery systems that provided both social and health-related services, and increased patient knowledge. Recommendations are provided for healthcare providers and public health practitioners to optimize diabetes outcomes for this population.

Perceptions of environmental health risks among residents in the "Toxic Doughnut": opportunities for risk screening and community mobilization.

BACKGROUND: Surrounded by landfills, and toxic and hazardous facilities, Altgeld Gardens is located in a "toxic doughnut". With high rates of environmentally-related conditions, residents have called for a community-based environmental health assessment to improve overall health in their community. The purpose of this study was to investigate the attitudes and beliefs of environmental health risks of Altgeld's residents which would assist community organizing efforts and provide the groundwork for a community-based environmental health assessment. METHODS: A questionnaire was designed and administered to 42 Altgeld residents who also participated in focus groups to assess their perceptions of environmental health risks. RESULTS: All participants were Altgeld residents for at least two years and were fairly representative of the broader community. Physical and social hazards were primarily identified as posing risks to participants' family and the broader community. Physical hazards included the dumping of hazardous waste and landfills; social hazards were crime and drugs. CONCLUSIONS: These findings have been useful in community organizing efforts and in program planning for local community-based organizations and public health agencies. The results have also been used to prioritize health and environmental risk issues impacting the community.

Preventable hospital admissions among the homeless in California: a retrospective analysis of care for ambulatory care sensitive conditions.

BACKGROUND: Limited research exists that investigates hospital admissions for ambulatory care sensitive conditions (ACSCs) among the homeless, who frequently lack a usual source of care. This study profiled ACSC admissions for homeless patients. METHODS: Bivariate analyses and logistic regression were completed to investigate ACSC and non-ACSC admissions among homeless patients using the 2010 California State Inpatient Database. RESULTS: Homeless patients admitted for an ACSC were mostly male, non-Hispanic white, and on average 49.9 years old. In the predictive model, the odds of an ACSC admission among homeless patients increased when they were black, admitted to the emergency department or transferred from another health facility. Having Medicare was associated with a decreased odds of an ACSC admission. CONCLUSIONS: Specific characteristics are associated with a greater likelihood of an ACSC admission. Research should examine how these characteristics contribute to ACSC hospitalizations and findings should be linked to programs designed to serve as a safety-net for homeless patients to reduce hospitalizations.

Environmental health literacy in support of social action: an environmental justice perspective.

Different demographic groups in the U.S. experience unequal exposures to environmental hazards, i.e., 56% of the population in neighborhoods containing commercial waste facilities are people of color, with the associated poverty rates in those communities being 50% higher than in neighborhoods without commercial waste facilities. Developing programs to educate communities about environmental hazards affecting their health and quality of life is an essential component for a community to understand their true risk. The study described in this article examined the risk of environmental hazards as perceived by public housing residents and assessed the residents' preference for educational programs on environmental hazards. Residents perceived their risk factors in a broad context and they included environmental health risks caused by pollutants along with physical safety concerns from crime and law enforcement interactions. The most trusted sources of information on environmental health include community organizations, trusted individuals in the community, and television programs. Recommendations for developing community-specific environmental health education programs include using sources of environmental health information that community members trust.

Attitudes Toward Injury-Prevention Program Participation Based on Race and Collegiate Division in Female Athletes.

CONTEXT: Injury-prevention programs (IPPs) have been effective in reducing lower extremity injury rates, but user compliance plays a major role in their effectiveness. Race and collegiate division may affect attitudes toward participation in IPPs and compliance in female collegiate athletes. OBJECTIVE: To compare attitudes toward IPPs based on race and collegiate division. DESIGN: Cross-sectional study. SETTING: Survey. PATIENTS OR OTHER PARTICIPANTS: A total of 118 female collegiate athletes (age = 19.71 ± 1.47 years, height = 169.46 ± 9.09 cm, mass = 69.57 ± 11.57 kg) volunteered. MAIN OUTCOME MEASURE(S): Participants completed the Health Belief Model Scale and the Theory of Planned Behavior Scale (TPBS) on 1 occasion. The Health Belief Model Scale contains 9 subscales (perceived susceptibility, perceived consequences, fear of injury, perceived benefits, perceived barriers, community-led self-efficacy, individual self-efficacy, general health cues, external health cues), whereas the TPBS has 5 subscales (perceived benefits, perceived barriers, perceived social norms, social influence, intention to participate). The independent variables were race (White versus Black, Indigenous, and other people of color [BIPOC]) and National Collegiate Athletic Association division (I and III). Mann-Whitney U tests were used to detect differences in attitudes toward IPP participation based on race and collegiate division. RESULTS: White female athletes perceived fewer TPBS barriers to participation in IPPs (P = .003) and more community-led self-efficacy when compared with BIPOC female athletes (P = .009). Division I athletes perceived a greater fear of injury (P = .002) and more general health cues (P = .01) than Division III athletes. CONCLUSIONS: For lower extremity IPPs, BIPOC and Division III female collegiate athletes may need different implementation strategies. Individuals who identify as BIPOC may benefit from interventions focusing on solutions for common barriers to participation and improving community-led self-efficacy, and Division III athletes may benefit from interventions focusing on education related to the risk of injury and general preventive health behaviors.

Barriers and Facilitators to Adhering to the American Heart Association's Life's Simple 7 for African American Women Living in Public Housing.

African American (AA) women living in public housing have some of the highest risk factors for cardiovascular disease (CVD). Limited information exists on this population's perceived barriers and facilitators to achieving optimal heart health and adhering to practices known to lower risk factors for CVD. Six 1.5-hour long focus groups among 32 AA women living in public housing (mean age = 49.9±10.3) were conducted, audiotaped, and transcribed. Participants' quotes were analyzed using the American Heart Association Life's Simple 7 as a guideline for optimal heart health. Focus groups revealed stress and finances as primary barriers, and family/friends/social support as primary facilitators. Participants also mentioned a lack of community involvement and limited government assistance focused on making healthy foods affordable. The information gained from this study can help future programs more adequately assist this underserved group in pursuing heart healthy behaviors and lowering their disproportionately high CVD risk.

Approaches to Teaching Social Determinants of Health to Undergraduate Health Care Students.

BACKGROUND: There is an increasing call for health care professionals to understand social determinants of health (SDOH); however, there is little consensus on what to teach, how to teach SDOH, or how to assess the material and assignments. This study involved restructuring weekly topics and assignments based on a SDOH framework and literature review to effectively teach allied health care students in an online SDOH undergraduate course about SDOH and their impact on health and well-being. Authors also implemented pre- and post-surveys to assess how students view various SDOH. METHODS: In fall 2019, undergraduate allied health students completed a pre-survey before their first SDOH class and in the last 2 weeks of class completed a post-survey to assess how they view SDOH over time. Based on a literature review, new assignments were added to the course: Modified Privilege Walk, photography essay, case study, and a service-learning project. Pre- and post-survey mean scores were compared using a Wilcoxon signed-rank test. RESULTS: Data from 18 matched pre-and post-surveys were analyzed. Many students were non-Hispanic White and female. Students rated the overall SDOH course and service-learning experience as very effective in teaching SDOH; however, students rated the case study slightly lower. Course feedback illustrated strengths and areas for improvement in the course, including adding more volunteer hours and depicting more actual patient stories demonstrating SDOH and the impact on health and well-being. CONCLUSIONS: A combination of various assignments, including photo essays, service-learning projects, and critical reflection writing, from medicine and nursing SDOH curricula are feasible to implement in an online program that teaches primarily allied health professional students. Teaching SDOH for a semester (versus one class setting), linking SDOH to the "real world," and creating awareness about SDOH and privilege may lead to more empathetic health care providers who can better understand and advocate for their patients.

Recognizing Privilege as a Social Determinant of Health During COVID-19.

There is a need for health professionals to identify social determinants of health (SDOH) and understand the role they play in patients' health. In fall 2019, authors taught health care studies students about SDOH using a modified privilege walk to show how privilege as SDOH can impact health. This novel approach to teach about privilege and SDOH is even more relevant in today's COVID-19 world. It is our hope that those with more privilege will (1) have increased awareness and sensitivity and (2) use their voice and power to advocate for underserved communities who are disproportionately affected by historical injustices.

Disparities in Bariatric Surgery Utilization in Underserved Diabetes Populations.

INTRODUCTION: Bariatric surgery is cost-effective for treating obesity and diabetes. There are higher rates of obesity and diabetes in medically-underserved populations, yet it is unclear if disparities in bariatric surgery utilization exist in this population. METHODS: Bariatric surgery rates were calculated for underserved populations with obesity and diabetes using secondary data sets of four states in the diabetes belt (Florida, Georgia, Kentucky, South Carolina), a region in the southeast United States with higher rates of diabetes and obesity. Surgery rates were compared across states and demographic groups. RESULTS: Males, Blacks, and patients in rural areas had lower rates of bariatric surgery compared to females, Whites, and patients in urban areas. Payer rates were mixed across states. Surprisingly, minorities in Florida had higher surgery rates. DISCUSSION: Disparities exist in bariatric surgery rates in underserved populations with obesity and diabetes. It is vital to improve surgery access to this population to promote health equity.

Promoting Cardiovascular Health for African American Women: An Integrative Review of Interventions.

Background: African American (AA) women bear a disproportionate burden of cardiovascular disease. Promoting ideal cardiovascular health is one strategy to promote health equity for this disparate population. The goal of this integrative review was to summarize and evaluate the research evidence for cardiovascular risk reduction interventions specifically targeting, tailored, or adapted for AA women. Materials and Methods: A review of the literature was conducted using the EBSCOHost platform. Study elements from articles in the final analysis were extracted. Results: Fourteen interventions were included in the final analysis (16 peer-reviewed articles). Most studies targeted two or more areas of cardiovascular health with the most common areas being physical activity and diet. Primary and secondary outcome measures varied; the most common measures were self-reported dietary intake, physical activity, and knowledge-related measures. Eleven studies reported health outcomes; only five reported long-term intervention effects. Most studies employed at least one cultural tailoring or adaptation strategy for AA women. The most common strategies included incorporating feedback from the target population before implementation and tailoring intervention material to reflect the target population. Conclusions: There is a need to develop and evaluate tailored or adapted evidence-based interventions for AA women. Additional research is needed to design interventions for subgroups of the population such as low-income or rural AA women.

Examining Racial Differences in Access to Primary Care for People Living with Lupus: Use of Ambulatory Care Sensitive Conditions to Measure Access.

Background: People living with lupus may experience poor access to primary care and delayed specialty care. Purpose: To identify characteristics that lead to increased odds of poor access to primary care for minorities hospitalized with lupus. Methods: Cross-sectional design with 2011-2012 hospitalization data from South Carolina, North Carolina, and Florida. We used ICD-9 codes to identify lupus hospitalizations. Ambulatory care sensitive conditions were used to identify preventable lupus hospitalizations and measure access to primary care. Logistic regression was used to estimate the odds ratio for the association between predictors and having poor access to primary care. Sensitivity analysis excluded patients aged >65 years. Results: There were 23,154 total lupus hospitalizations, and 2,094 (9.04%) were preventable. An adjusted model showed minorities aged ≥65 years (OR 2.501, CI 1.501, 4.169), minorities aged 40-64 years (OR 2.248, CI: 1.394, 3.627), minorities with Medicare insurance (OR 1.669, CI:1.353,2.059) and minorities with Medicaid (OR 1.662,CI:1.321, 2.092) had the highest odds for a preventable lupus hospitalization. Minorities with Medicare had significantly higher odds for ≥3 hospital days (OR 1.275, CI: 1.149, 1.415). Whites with Medicare (OR 1.291, CI: 1.164, 1.432) had the highest odds for ≥3 days. Conclusions: Our data show that middle-aged minorities living with lupus and on public health insurance have a higher likelihood of poor access to primary care. Health care workers and policymakers should develop plans to identify patients, explore issues affecting access, and place patients with a community health worker or social worker to promote better access to primary care.

Admissions for Ischemic Stroke Among Younger Adults in Kentucky: A Comparison of Appalachian and Non-Appalachian Counties.

Residents of Appalachian counties have worse health outcomes compared to non-Appalachian counties. It is unclear to what extent disparities exist for younger adults in this region who have experienced an ischemic stroke (IS). This study compared sociodemographic characteristics of younger adults (ages 20-64 yrs) who experienced an IS in Appalachian and non-Appalachian counties in Kentucky using the 2014 State Inpatient Database. Admissions were higher among Appalachian patients of lower income and Appalachian patients who resided in rural areas. Admissions were also higher among Appalachian patients with heart disease. These findings indicate sociodemographic differences may exist among younger adults admitted for IS in the Kentucky Appalachian region. These findings improve our understanding of how stroke is distributed among younger adults in Appalachia.

Racial and ethnic differences in post-stroke subjective cognitive decline exist.

BACKGROUND: Racial and ethnic minorities consistently demonstrate disparate post-stroke outcomes. However, there is a paucity of literature related to whether this disparity exists specifically in post-stroke cognitive decline. OBJECTIVE: To determine if racial and ethnic disparities exist in post-stroke subjective cognitive decline (SCD) among non-Hispanic Blacks (Blacks), American Indians or Alaska Natives (AI/ANs), Hispanics, and non-Hispanic Whites (Whites) in the United States using data from the Behavioral Risk Factor Surveillance System (BRFSS). METHODS: A retrospective analysis was completed using the 2016 BRFSS data in adults who self-reported stroke and SCD. Descriptive statistics were completed for baseline comparisons using chi squared tests for categorical variables. A binary logistic regression controlling for baseline differences was completed to examine racial and ethnic differences in SCD. RESULTS: Significant differences in SCD were identified across all racial and ethnic groups. When compared to Whites, Blacks, AI/ANs, and Hispanics more frequently reported worsening confusion or memory loss that interfered with day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home. AI/ANs who reported SCD were more likely than Whites to have help available. Hispanic persons with SCD or their family members were most likely to discuss SCD with a healthcare provider. CONCLUSION: Although persons from all racial and ethnic groups in this study experienced some degree of SCD, Blacks, AI/ANs, and Hispanics most frequently reported worsening confusion or memory loss impacting engagement in day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools.

Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.

Rationale, Design and Methods of "Set the Rules": A Tailored Peer-to-Peer Health Information Intervention.

Ensuring equitable access to health information is one strategy to promote health equity for underserved communities, especially for low-income African Americans (AAs). Childcare centers are one viable site to deliver health information to address this disparity. This paper describes the methods used in a community-based participatory research project with a childcare facility that aimed to reduce environmental tobacco smoke (ETS) exposure among low-income AA children. Through collaboration and multiple data collection methods, partners identified communication strategies to overcome informational barriers. These initial findings indicated a peer-to-peer health information intervention, entitled "Set the Rules", as the best strategy to increase awareness. The goal of the intervention was to build knowledge in reducing the harms of ETS exposure. Twelve community members were trained as parent leaders for the "Set the Rules" workshops and conducted workshops with parents. Even though there were barriers interfacing with all centers, parents that attended the workshop (n = 32) found the peer-to-peer intervention novel and quite helpful and will share the information learned with others. This intervention suggests that a childcare setting is a relevant space to increase access to health information to optimize child health outcomes. More research is necessary to determine if this intervention has salience in other childcare settings and across racial/ethnic groups.

Sex Differences in Patient-Reported Poststroke Disability.

BACKGROUND: Recent studies have shown that stroke has a differential impact in women compared to men. Women are more likely to survive strokes than men, yet they experience more severe strokes resulting in greater poststroke disability. However, few studies have characterized sex differences in functional ability after stroke. This study examined sex differences in long-term disability among stroke survivors. METHODS: This was a retrospective analysis of the 2015 National Health Interview Survey. Respondents were asked to rate their ability to perform 11 functional tasks. Univariate comparisons were completed to evaluate sex differences in performance, and multinomial logistic regression was used to determine the odds of reporting functional limitations. RESULTS: Five hundred fourteen men and 641 women stroke survivors completed the survey (mean age: 66.9 years). Approximately 75% of the sample reported having hypertension, 61% high cholesterol, 33% diabetes, 24% heart disease, 21% heart attack, and 16% chronic obstructive pulmonary disease. In the predictive models, men were less likely to report "very difficult/can't do at all" in walking » mile (odds ratios [OR] = 0.68, 95% CI 0.51-0.90), climbing 10 steps (OR = 0.65, 95% CI 0.49-0.85), standing 2 hours (OR = 0.66, 95% CI 0.50-0.87), stooping (OR = 0.51, 95% CI 0.39-0.68), reaching overhead (OR = 0.69, 95% CI 0.49-0.97), carrying 10 pounds (OR = 0.45, 95% CI 0.34-0.59), and pushing large objects (OR = 0.37, 95% CI 0.28-0.5) compared to women. CONCLUSIONS: The functional outcomes of men stroke survivors were significantly greater than women. The specific factors that contribute to sex differences in stroke-related outcomes are not entirely clear. Future research is needed to better understand these differences to ensure that equity of care is received.