Comparison of Use of Health Care Services and Spending for Unauthorized Immigrants vs Authorized Immigrants or US Citizens Using a Machine Learning Model.

Importance: Knowledge about use of health care services (health care utilization) and expenditures among unauthorized immigrant populations is uncertain because of limitations in ascertaining legal status in population data. Objective: To examine health care utilization and expenditures that are attributable to unauthorized and authorized immigrants vs US-born individuals. Design, Setting, and Participants: This cross-sectional study used the data on documentation status from the Los Angeles Family and Neighborhood Survey (LAFANS) to develop a random forest classifier machine learning model. K-fold cross-validation was used to test model performance. The LAFANS is a randomized, multilevel, in-person survey of households residing in Los Angeles County, California, consisting of 2 waves. Wave 1 began in April 2000 and ended in January 2002, and wave 2 began in August 2006 and ended in December 2008. The machine learning model was then applied to a nationally representative database, the 2016-2017 Medical Expenditure Panel Survey (MEPS), to predict health care expenditures and utilization among unauthorized and authorized immigrants and US-born individuals. A generalized linear model analyzed health care expenditures. Logistic regression modeling estimated dichotomous use of emergency department (ED), inpatient, outpatient, and office-based physician visits by immigrant groups with adjusting for confounding factors. Data were analyzed from May 1, 2019, to October 14, 2020. Exposures: Self-reported immigration status (US-born, authorized, and unauthorized status). Main Outcomes and Measures: Annual health care expenditures per capita and use of ED, outpatient, inpatient, and office-based physician care. Results: Of 47 199 MEPS respondents with nonmissing data, 35 079 (74.3%) were US born, 10 816 (22.9%) were authorized immigrants, and 1304 (2.8%) were unauthorized immigrants (51.7% female; mean age, 47.6 [95% CI, 47.4-47.8] years). Compared with authorized immigrants and US-born individuals, unauthorized immigrants were more likely to be aged 18 to 44 years (80.8%), Latino (96.3%), and Spanish speaking (95.2%) and to have less than 12 years of education (53.7%). Half of unauthorized immigrants (47.1%) were uninsured compared with 15.9% of authorized immigrants and 6.0% of US-born individuals. Mean annual health care expenditures per person were $1629 (95% CI, $1330-$1928) for unauthorized immigrants, $3795 (95% CI, $3555-$4035) for authorized immigrants, and $6088 (95% CI, $5935-$6242) for US-born individuals. Conclusions and Relevance: Contrary to much political discourse in the US, this cross-sectional study found no evidence that unauthorized immigrants are a substantial economic burden on safety net facilities such as EDs. This study illustrates the value of machine learning in the study of unauthorized immigrants using large-scale, secondary databases.

A Social Shift: COVID-19 Disparities Prompt Emphasis on Value-Based Care.

COVID-19 disparities prompt Medicare to call for stronger emphasis on value-based care.

NINR funding dedicated to sexual and gender minority health: 1987-2018.

BACKGROUND: Despite multiple federal initiatives and calls to action, nursing literature on the health of sexual and gender minority (SGM) populations remains sparse. Low levels of funding for SGM-focused research may be a factor. PURPOSE: To examine the proportion and focus of National Institute of Nursing Research (NINR)-funded projects that address SGM health, the number and type of publications arising from that funding, and the reach of those publications over time. METHODS: NINR-funded grants focused on SGM research and bibliometrics of resultant publications were identified using multiple search strategies in NIH RePORTER and PubMed and Scopus, respectively. FINDINGS: Since 1987, NINR has funded 25 projects addressing the health of SGM populations. Pre-doctoral fellowship funding resulted in more publications in nursing journals than research grant funding. DISCUSSION: There are clear differences in patterns of funding for fellowships and research grants with corresponding differences in publications and impact on the nursing literature.

Creating a community-based comprehensive intervention to improve asthma control in a low-income, low-resourced community.

Introduction: Asthma evidence-based interventions (EBI) are implemented in the home, school, community or primary care setting. Although families are engaged in one setting, they often have to navigate challenges in another setting.Objective: Our objective is to design and implement a comprehensive plan which integrates EBI's and connects the four sectors in underserved communities such as Philadelphia.Methods: September 2015-April 2016 we implemented a three-pronged strategy to understand needs and resources of the community including 1) focus groups and key informant interviews, 2) secondary data analysis and 3) pilot testing for implementation to determine gaps in care, and opportunities to overcome those gaps.Results: Analysis of the focus group and key informant responses showed themes: diagnosis fear, clinician time, home and school asthma trigger exposures, school personnel training and communication gaps across all four sectors. EBI's were evaluated and selected to address identified themes. Pilot testing of a community health worker (CHW) intervention to connect home, primary care and school resulted in an efficient transfer of asthma medications and medication administration forms to the school nurse office for students with uncontrolled asthma addressing a common delay leading to poor asthma management in school.Conclusion: Thus far there has been limited success in reducing asthma disparities for low-income minority children. This study offers hope that strategically positioning CHWs may work synergistically to close gaps in care and result in improved asthma control and reduced asthma disparities.

Inadequate screening for retinopathy among recent immigrants with type 2 diabetes despite universal health care: A population-based study.

AIMS: To examine retinopathy screening and treatment rates for recent immigrants compared to non-immigrants in a universal health care system. METHODS: Linked health care and immigration databases were used to identify all 771,564 adults diagnosed with diabetes between 1996 and 2007, in Ontario, Canada. The cohort was stratified by their immigration status and followed until 2013 for retinopathy screening and treatment visits. RESULTS: Retinopathy screening rates were low, and recent immigrants were considerably less likely to receive screening than long-term residents (≥1 examination within 1year: 37.5% vs. 50.5%, adjusted OR 0.76 [95% CI, 0.75-0.77]; ≥3 examinations within 6years: 46.6% vs. 61.9%, adjusted OR 0.77 [95% Cl, 0.76-0.79]). Immigrants were also less likely to receive surgical treatment for retinopathy, but adjustment for the frequency of screening attenuated these differences. CONCLUSIONS: Despite universal access to physician services, only half of all individuals with newly-diagnosed type 2 diabetes received retinopathy screening within the first year, and recent immigrants were markedly less likely to be screened. After adjusting for screening rates, gaps in surgical treatment for retinopathy were attenuated, suggesting that treatable retinopathy may be being missed among recent immigrants because of inadequate screening.

The Socioecology of Sexual and Reproductive Health Care Use Among Young Urban Minority Males.

PURPOSE: To explore perceptions of facilitators/barriers to sexual and reproductive health (SRH) care use among an urban sample of African-American and Hispanic young men aged 15-24 years, including sexual minorities. METHODS: Focus groups were conducted between April 2013 and May 2014 in one mid-Atlantic U.S. city. Young men aged 15-24 years were recruited from eight community settings to participate in 12 groups. Moderator guide explored facilitators/barriers to SRH care use. A brief pregroup self-administered survey assessed participants' sociodemographics and SRH information sources. Content analysis was conducted, and three investigators independently verified the themes that emerged. RESULTS: Participants included 70 males: 70% were aged 15-19 years, 66% African-American, 34% Hispanic, 83% heterosexual, and 16% gay/bisexual. Results indicated young men's perceptions of facilitators/barriers to their SRH care use come from multiple levels of their socioecology, including cultural, structural, social, and personal contexts, and dynamic inter-relationships existed across contexts. A health care culture focused on women's health and traditional masculinity scripts provided an overall background. Structural level concerns included cost, long visits, and confidentiality; social level concerns included stigma of being seen by community members and needs regarding health care provider interactions; and personal level concerns included self-risk assessments on decisions to seek care and fears/anxieties about sexually transmitted infection/HIV testing. Young men also discussed SRH care help-seeking sometimes involved family and/or other social network members and needs related to patient-provider interactions about SRH care. CONCLUSIONS: Study findings provide a foundation for better understanding young men's SRH care use and considering ways to engage them in care.

Puberty Experiences of Low-Income Girls in the United States: A Systematic Review of Qualitative Literature From 2000 to 2014.

PURPOSE: Puberty is a critical period of development that lays the foundation for future sexual and reproductive health. It is essential to learn about the puberty experiences of low-income girls in the United States given their increased vulnerability to negative sexual and reproductive health outcomes. To understand the present-day puberty experiences of this population, we conducted a qualitative systematic review. METHODS: We systematically searched the peer-reviewed literature published between 2000 and 2014 on the puberty experiences of low-income girls in the United States. Reviewers screened titles, abstracts, and the full texts of articles. Using standardized templates, reviewers assessed the methodologic quality and extracted data. Data were synthesized using thematic analysis. Confidence in each finding was assessed using Confidence in the Evidence from Reviews of Qualitative research. RESULTS: Twenty qualitative articles were included. They described the experiences of mostly African-American, Caucasian, and Hispanic girls living primarily in urban areas of Northeastern United States. Five overarching themes emerged: content of girls' puberty experiences, quality of girls' puberty experiences, messages girls receive about puberty, other factors that shape girls' puberty experiences, and relationships that shape girls' experiences of puberty. CONCLUSIONS: The limited existing evidence suggests that low-income girls in the United States are unprepared for puberty and have largely negative experiences of this transition.

Changing the realities of poverty in pregnancy.

Pregnant women from disadvantaged, vulnerable or excluded groups are more likely to have poorer maternal and neonatal outcomes. In Bradford, a three-year pilot project is targeting pregnant women in some of the poorest areas to improve the health of mothers and babies.

A comparison of diagnosed and undiagnosed diabetes patients and labor supply.

Using data from four waves of the National Health and Nutrition Examination Survey, we examine the difference between individuals with diagnosed and undiagnosed cases of type 2 diabetes and their labor supply decisions. We show that a diagnosis of type 2 diabetes is significantly associated with a reduction in both male and female employment probability by 11 and 19 percentage points, respectively. Additionally, hours worked by individuals with diagnosed type 2 diabetes are 7h lower per week for males and 8h lower per week for females. Further, individuals with undiagnosed type 2 diabetes experience a drop in labor supply somewhat smaller but similar to their diagnosed counterparts. This association may be driven by the similarities between undiagnosed and very recently diagnosed type 2 diabetes. In all estimations, we consistently find that type 1 diabetes has a different effect than either diagnosed or undiagnosed type 2 diabetes.

Medication adherence and healthcare disparities: impact of statin co-payment reduction.

OBJECTIVES: Minority patients have lower rates of cardiovascular medication adherence, which may be amenable to co-payment reductions. Our objective was to evaluate the effect of race on adherence changes following a statin co-payment reduction intervention. STUDY DESIGN: Retrospective analysis. METHODS: The intervention was implemented by a large self-insured employer. Eligible individuals in the intervention cohort (n = 1961) were compared with a control group of employees of other companies without such a policy (n = 37,320). As a proxy for race, we categorized patients into tertiles based on the proportion of black residents living in their zip code of residence. Analyses were performed using difference-in-differences design with generalized estimating equations. RESULTS: Prior to the new co-payment policy, adherence rates were higher for individuals living in areas with fewer black residents. In multivariable models adjusting for demographic factors, clinical covariates and baseline trends, the co-payment reduction increased adherence by 2.0% (P = .14), 2.1% (P = .15) and 6% (P < .0001) for intervention patients living in areas with the bottom, middle and top tertiles of the proportion of black residents. These results persisted after adjusting for income. CONCLUSIONS: Co-payment reduction for statins preferentially improved adherence among patients living in communities with a higher proportion of black residents. Further research is needed on the impact of value-based insurance design programs on reducing racial disparities in cardiovascular care.

Thirty-four Years Working Hand in Hand With Community Health Workers: A Doctor's Perspective.

The author, a physician, describes her long history of working with community health workers (CHWs), as well as her admiration for her colleagues in CHW programs and for the late Dr Eva Salber. CHWs have a unique capability not only to serve their communities but also to transform American health care and public health. It is in society's interest to utilize many more CHWs in diverse roles and settings. This requires thoughtful program design, recruitment, trust, support, and full integration of CHWs into professional teams.

Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000-2009.

OBJECTIVE: This study aimed to characterize premature mortality among people diagnosed with HIV infection from 2000 to 2009 in Florida, by sex and race/ethnicity, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment. METHODS: Florida surveillance data for HIV diagnoses (excluding concurrent AIDS diagnoses) were linked with vital records data to ascertain deaths through 2011. Years of potential life lost (YPLL) were obtained from the expected number of remaining years of life at a given age from the U.S. sex-specific period life tables. RESULTS: Among 41,565 people diagnosed with HIV infection during the study period, 5,249 died, and 2,563 (48.8%) deaths were due to HIV/AIDS. Age-standardized YPLL (aYPLL) due to HIV/AIDS per 1,000 person-years was significantly higher for females than males (372.6, 95% confidence interval [CI] 349.8, 396.2 vs. 295.2, 95% CI 278.4, 312.5); for non-Hispanic black (NHB) females than non-Hispanic white (NHW) and Hispanic females (388.2, 95% CI 360.7, 416.9; 294.3, 95% CI 239.8, 354.9; and 295.0, 95% CI 242.9, 352.5, respectively); and for NHB males compared with NHW and Hispanic males (378.7, 95% CI 353.7, 404.7; 210.6, 95% CI 174.3, 250.8; and 240.9, 95% CI 204.8, 280.2, respectively). In multilevel modeling controlling for individual factors, NHB race was associated with YPLL due to HIV/AIDS for women (p=0.04) and men (p<0.001). CONCLUSION: Among people diagnosed with HIV infection, females and NHB people had a disproportionately high premature mortality from HIV/AIDS, suggesting the need for enhanced efforts to improve linkage to and retention in care and medication adherence for these groups.

Spatial social polarisation: using the Index of Concentration at the Extremes jointly for income and race/ethnicity to analyse risk of hypertension.

BACKGROUND: Growing spatial social and economic polarisation may be an important societal determinant of health, but only a few studies have used the recently developed Index of Concentration at the Extremes (ICE) to analyse the impact of joint concentrations of privilege and privation on health outcomes. We explore use of the ICE to investigate risk of hypertension in an urban, multiracial/ethnic, and predominantly working-class study population of US adults. METHODS: We generated novel ICE measures at the census tract level that jointly assess extreme concentrations of both income and racial/ethnic composition. We then linked the ICE measures to data from two observational, cross-sectional studies conducted in the Boston metropolitan area (2003-2004; 2008-2010; N=2145). RESULTS: The ICE measure for extreme concentrations of white compared with black residents was independently associated with lower odds of hypertension (OR=0.76; 95% CI 0.62 to 0.93), controlling for race/ethnicity, age, gender, smoking, body mass index, household income, education and self-reported exposure to racial discrimination. Even stronger associations were observed for the ICE measures that compared concentrations of high-income white residents versus low-income residents of colour (OR=0.61; 95% CI 0.40 to 0.96) and high-income white versus low-income black residents (OR=0.48; 95% CI 0.29 to 0.81). CONCLUSIONS: Results suggest public health studies should explore the joint impact of racial/ethnic and economic spatial polarisation on population health.

Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act.

PURPOSE OF REVIEW: To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities. RECENT FINDINGS: Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities. SUMMARY: The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.

Using technology to promote postpartum weight loss in urban, low-income mothers: a pilot randomized controlled trial.

OBJECTIVE: To examine the feasibility, acceptability, and initial efficacy of a technology-based weight loss intervention for urban, low-income mothers. METHODS: Eighteen obese, ethnic minority, socioeconomically disadvantaged mothers in the first year after childbirth were randomly assigned to either: 1) technology-based intervention, which included empirically supported behavior-change strategies, daily skills, and self-monitoring text messages with personalized feedback, biweekly counseling calls from a health coach, and access to a Facebook support group, or 2) usual-care control. RESULTS: After 14 weeks of treatment, the technology-based intervention participants had significantly greater weight loss (-2.9 ± 3.6 kg) than usual care (0.5 ± 2.3 kg; adjusted mean difference: -3.2 kg, 95% confidence interval -6.2 to -0.1 kg, P = .04). One-third of intervention participants (3 of 9) and no control participants lost > 5% of their initial body weight at follow up. CONCLUSIONS AND IMPLICATIONS: Results suggest the potential for using technology to deliver a postpartum weight loss intervention among low-income racial/ethnic minorities.

The health status of Roma children--a medical or social issue?

BACKGROUND: Most studies dealing with health problems of the Roma population suggests that a low economic status significantly contributes to their overall poor health. In Serbia, Roma people are members of a marginalized ethnic group with a low socioeconomic status which contributes to their much higher morbidity and mortality rate compared with the majority population. The questions we asked in this paper were: Are Roma children discriminated during hospital care? Do they get the same treatment as the non-Roma children? PATIENTS AND METHODS: To answer these questions, we examined medical records of 59 Roma children and compared with 59 records of non-Roma children in order to determine whether there are any differences in the health status, as well as the length, course, outcome, and cost of treatment. RESULTS: Roma children have statistically significant more comorbidity, more malnutritions, more skin diseases (especially parasitic and fungal infections) and were more frequently anemic. Also, the length of hospitalization of Roma children was significantly higher, as well as the number of laboratory tests performed and number of drugs prescribed, which contribute to the significantly higher costs of treatment for Roma children compared to non-Roma children. However, a significantly lower number of Roma children were discharged as "completely cured". CONCLUSIONS: The results of our study does not support hypothesis of discrimination of Roma children concerning medical treatment in observed hospital. At the same time, our results suggests that social interventions (e.g. hygienic housing, water supply, etc.) and prevention measures could prevent necessity of hospitalized treatment of Roma children and could diminish the drain on the health budget spent on treating the consequences of social neglect.