Cross-national differences in wealth inequality in health services and caregiving used near the end of life.

Background: Socioeconomic inequality in access to and use of health services and social care provided near the end of life, or end-of-life care (EOLC), is not well understood in many countries. We examined wealth inequality in EOLC-hospital, nursing home, and hospice use and receipt of formal and informal caregiving-in 22 countries in Europe, Asia (South Korea), and North America (United States, Mexico). Methods: We used harmonized data from nationally representative studies of people aged 50 and older that collected information on healthcare utilisation and caregiving receipt in the time preceding death. We categorized countries according to their level of public long-term care (LTC) spending and examined EOLC prevalence across countries. We used logistic regression models to estimate wealth inequality in each type of EOLC. Findings: In the USA the least wealthy had more hospital (OR 1.30, p = 0.008) and nursing home/care use (OR 1.88, p < 0.001). In South Korea the least wealthy had more nursing home/care use (OR 2.24, p = 0.003). The least wealthy in high LTC Europe had less hospice use (OR 0.56, p = 0.003). The least wealthy were also less likely to be hospitalized in European countries with low LTC spending (OR 0.81, p = 0.04), but more likely to receive informal caregiving (OR 1.25, p = 0.033). Formal care was more common among the least wealthy in high LTC Europe (OR 1.57, p = 0.002), the USA (OR 1.42, p < 0.001) and South Korea (OR 1.69, p = 0.028), but less common among the least wealthy in Mexico (OR 0.17, p < 0.001). Interpretation: Wealth inequality in EOLC exists across countries and reflects differences in the organization, financing, and delivery of care in different countries. The findings highlight the need to consider equity in current and future plans to improve EOLC access. Funding: United States National Institute on Aging Grant R01AG030153.

Does the Use of Social Media Affect Online Health Information-Seeking Behaviors among Underserved African Americans in Rural Alabama?

PURPOSE: This study aimed (1) to investigate levels of technology device access and social media use among African Americans in rural Alabama, (2) to examine the prevalence of online health information-seeking behaviors, and (3) to identify associations of technology device access and social media use with online health information-seeking behaviors. METHODS: A convenience sample of 185 African Americans aged 18 and older was recruited from a rural county in Alabama. Multilinear regression was conducted to examine the associations. RESULTS: Nearly 60% of participants had access to the internet, smartphone, and tablets/computers. The prevalence of online health information-seeking behaviors was low. Technology device access was not associated with online health information-seeking behaviors, while more social networking sites were associated with more online health information-seeking behaviors. CONCLUSION: Public health interventions are needed to promote internet use for health purposes among rural African Americans. Offline health information services should also target those lacking internet access.

Social determinants of willingness to discuss end-of-life care with family and doctors among Korean American immigrants: Findings from a cross-sectional survey in Alabama.

Prior research reported lower engagement in end-of-life discussions and planning among Korean American (KA) immigrants; however, there is a dearth of research investigating factors associated with their willingness to discuss their end-of-life care wishes. This study aimed to examine the willingness to have end-of-life discussions with family and doctors among KA immigrants and social determinants of health (SDH) associated with willingness. A self-administered, cross-sectional survey was conducted with a convenience sample of 259 KA immigrants recruited from two counties in Alabama. Demographic, health, acculturation and SDH information were collected. Logistic regression analyses were conducted to examine associations between SDH and willingness for end-of-life discussion with family and doctors, respectively. The majority of the sample was willing to discuss end-of-life care with family (94%) and doctors (82%). Those with hospice awareness were more likely to have willingness for discussion with family (OR = 27.70, p < 0.001) and doctors (OR = 5.01, p < 0.001). Those who could not see a doctor because of cost (OR = 0.03, p < 0.01) and who had higher threats to interpersonal safety (OR = 0.74, p < 0.05) were less likely to have willingness for discussion with family. Those who had more chronic conditions (OR = 0.60, p < 0.05) and higher levels of social isolation (OR = 0.77, p < 0.05) were less likely to have willingness for discussion with doctors. The SDH identified in this study should be considered in developing interventions to promote end-of-life discussions in the KA immigrant community. Future research should investigate the associations explored in this study in a larger and more representative sample.

Relationship between continuity of care and clinical outcomes in patients with dyslipidemia in Korea: a real world claims database study.

Dyslipidemia is a risk factor for atherosclerotic cardiovascular disease and requires proactive management. This study aimed to investigate the association between care continuity and the outcomes of patients with dyslipidemia. We conducted a retrospective cohort study on patients with dyslipidemia by employing the Korea National Health Insurance claims database during the period 2007-2018. The Continuity of Care Index (COCI) was used to measure continuity of care. We considered incidence of atherosclerotic cardiovascular disease as a primary outcome. A Cox's proportional hazards regression model was used to quantify risks of primary outcome. There were 236,486 patients newly diagnosed with dyslipidemia in 2008 who were categorized into the high and low COC groups depending on their COCI. The adjusted hazard ratio for the primary outcome was 1.09 times higher (95% confidence interval: 1.06-1.12) in the low COC group than in the high COC group. The study shows that improved continuity of care for newly-diagnosed dyslipidemic patients might reduce the risk of atherosclerotic cardiovascular disease.

Assessment of the effects of methodological choice in continuity of care research: a real-world example with dyslipidaemia cohort.

OBJECTIVE: To determine if the choice of methodological elements affects the results in continuity of care studies. DESIGN: This is a retrospective cohort study. The association between continuity of care and clinical outcome was investigated using the Continuity of Care Index. The association was explored in 12 scenarios based on four definitions of the relative timing of continuity and outcome measurements in three populations (three Ps × four Ts). SETTING: National Health Insurance claims from all primary and secondary care facilities in South Korea between 2007 and 2015. PARTICIPANTS: Participants were patients diagnosed with dyslipidaemia, made ≥2 ambulatory visits and were newly prescribed with ≥1 antihyperlipidaemic agent at an ambulatory setting in 2008. Three study populations were defined based on the number of ambulatory visits: 10 084 patients in population 1 (P1), 8454 in population 2 (P2) and 4754 in population 3 (P3). MAIN OUTCOME MEASURE: Hospitalisation related to one of the four atherosclerotic cardiovascular diseases, including myocardial infarction, stable or unstable angina, ischaemic stroke and transient ischaemic attack. RESULTS: Concurrent measure of continuity and outcome (T1) showed a significantly higher risk of hospitalisation (adjusted HRs: 2.73-3.07, p<0.0001) in the low continuity of care group, whereas T2, which measured continuity until the outcome occurred, showed no risk difference between the continuity of care groups. T3, which measured continuity as a time-varying variable, had adjusted HRs of 1.31-1.55 (p<0.05), and T4, measuring continuity for a predefined period and measuring outcomes in the remaining period, had adjusted HRs of 1.34-1.46 (p<0.05) in the low continuity of care. Within each temporal relationship, the effect estimates became more substantial as the inclusion criteria became stricter. CONCLUSIONS: The study design in continuity of care studies should be planned carefully because the results are sensitive to the temporal relationship between continuity and outcome and the population selection criteria.