Poverty and population health - The need for A Paradigm shift to capture the working poor and better inform public health planning.

BACKGROUND: Community-level socioeconomic disparities have a significant impact on an individual's health and overall well-being. However, current estimates for poverty threshold, which are often used to assess community-level socioeconomic status, do not account for cost-of-living differences or geography variability. The goals of this study were to compare geographic county-level overlap and gaps in access to care for households within poverty and working poor designations. METHODS: Data were obtained for 21 continental United States (US) states from the United Way's Asset Limited, Income Constrained, Employed (ALICE) households for 2021. Raw data contained the percentage of households at the federal poverty level, the percentage of households at the ALICE designations (working poor), and the total households at the county level. Local Moran's I tests for spatial autocorrelation were performed to identify the clustering of poverty and ALICE households. These clusters were overlaid with a 30-min drive time from critical access hospitals' physical addresses. FINDINGS: County-level clusters of ALICE (working poor) households occurred in different areas than the clustering of poverty households. Of particular interest, the extent to which the 30-min drive time to critical care overlapped with clusters of ALICE or poverty changed depending on the state. Overall, clustering in ALICE and poverty overlapped with 30-min drive times to critical care between 46 and 90% of the time. However, the specific states where disparities in access to care were prominent differed between analyses focused on households in poverty versus the working poor. INTERPRETATIONS: Findings highlight a disparity in equitable inclusion of individuals across the spectrum of socioeconomic status. Furthermore, they suggest that current public health programming and benefits which support low socioeconomic populations may be missing a vulnerable sub-population of working families. Future studies are needed to better understand how to address the health disparities facing individuals who are above the poverty threshold but still struggle economically to meet based needs.

Disparities in healthcare utilization by insurance status among patients with symptomatic peripheral artery disease.

BACKGROUND: Peripheral artery disease (PAD) is a common circulatory disorder associated with increased hospitalizations and significant health care-related expenditures. Among patients with PAD, insurance status is an important determinant of health care utilization, treatment of disease, and treatment outcomes. However, little is known about PAD-costs differences across different insurance providers. In this study we examined possible disparities in length of stay and total charge of inpatient hospitalizations among patients with PAD by insurance type. METHODS: We conducted a cross-sectional analysis of length of stay and total charge by insurance provider for all hospitalizations for individuals with PAD in South Carolina (2010-2018). Cross-classified multilevel modeling was applied to account for the non-nested hierarchical structure of the data, with county and hospital included as random effects. Analyses were adjusted for patient age, race/ethnicity, county, year of admission, admission type, all-patient refined diagnostic groups, and Charlson comorbidity index. RESULTS: Among 385,018 hospitalizations for individuals with PAD in South Carolina, the median length of stay was 4 days (IQR: 5) and the median total charge of hospitalization was $43,232 (IQR: $52,405). Length of stay and total charge varied significantly by insurance provider. Medicare patients had increased length of stay (IRR = 1.08, 95 CI%: 1.07, 1.09) and higher total charges (ß: 0.012, 95% CI: 0.007, 0.178) than patients with private insurance. Medicaid patients also had increased length of stay (IRR = 1.26, 95% CI: 1.24,1.28) but had lower total charges (ß: -0.022, 95% CI: -0.003. -0.015) than patients with private insurance. CONCLUSIONS: Insurance status was associated with inpatient length of stay and total charges in patients with PAD. It is essential that Medicare and Medicaid individuals with PAD receive proper management and care of their PAD, particularly in the primary care settings, to prevent hospitalizations and reduce the excess burden on these patients.

Medical Expenditures Associated with Attention-Deficit/Hyperactivity Disorder Among Adults in the United States by Age, 2015-2019.

BACKGROUND: Attention-deficit hyperactivity disorder is a common disorder that affects both children and adults. However, for adults, little is known about ADHD-attributable medical expenditures. OBJECTIVE: To estimate the medical expenditures associated with ADHD, stratified by age, in the US adult population. DESIGN: Using a two-part model, we analyzed data from Medical Expenditure Panel Survey for 2015 to 2019. The first part of the model predicts the probability that individuals incurred any medical costs during the calendar year using a logit model. The second part of the model estimates the medical expenditures for individuals who incurred any medical expenses in the calendar year using a generalized linear model. Covariates included age, sex, race/ethnicity, geographic region, Charlson comorbidity index, insurance, asthma, anxiety, and mood disorders. PARTICIPANTS: Adults (18 +) who participated in the Medical Expenditure Panel Survey from 2015 to 2019 (N = 83,776). MAIN MEASURES: Overall and service specific direct ADHD-attributable medical expenditures. KEY RESULTS: A total of 1206 participants (1.44%) were classified as having ADHD. The estimated incremental costs of ADHD in adults were $2591.06 per person, amounting to $8.29 billion nationally. Significant adjusted incremental costs were prescription medication ($1347.06; 95% CI: $990.69-$1625.93), which accounted for the largest portion of total costs, and office-based visits ($724.86; 95% CI: $177.75-$1528.62). The adjusted incremental costs for outpatient visits, inpatient visits, emergency room visits, and home health visits were not significantly different. Among older adults (31 +), the incremental cost of ADHD was $2623.48, while in young adults (18-30), the incremental cost was $1856.66. CONCLUSIONS: The average medical expenditures for adults with ADHD in the US were substantially higher than those without ADHD and the incremental costs were higher in older adults (31 +) than younger adults (18-30). Future research is needed to understand the increasing trend in ADHD attributable cost.

Drive Times to Methadone Treatment among Medicaid Patients.

OBJECTIVE: To describe round-trip drive times and travel distance to methadone clinics among Medicaid enrollees in West Virginia, testing for differences between those in rural versus urban areas. FINDINGS: In this cross-sectional analysis of West Virginia Medicaid enrollees' claims from 2018-2019, methadone recipients on average traveled almost an hour round-trip to receive their daily treatment. The travel burden was substantially higher among those in more rural areas. Meaning. These findings indicate that it may be difficult for patients to adhere to their methadone treatment regimen, perhaps leading to suboptimal treatment rates and outcomes.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Clinical and demographic factors associated with stimulant use disorder in a rural heart failure population.

BACKGROUND: Heart failure is becoming increasingly common among patients under 50 years of age, particularly in African Americans and patients with stimulant use disorder. Yet the sources of these disparities remain poorly understood. This study identified key demographic and clinical factors associated with stimulant use disorder in a largely rural heart failure patient registry. METHODS: Patient records reporting a diagnosis of heart failure between January 2008 and March 2020 were requested from West Virginia University Hospital Systems (n=37,872). Odds of stimulant use disorder were estimated by demographic group (age, race, sex), insurance carrier, and clinical comorbidities using logistic regression. RESULTS: Multivariable regression analysis identified higher odds of stimulant use disorder among Black/African Americans (1.95 [1.32, 2.77]) and patients who report drinking one or more alcoholic drinks per week (2.23 [1.72, 2.88]). Lower odds of stimulant use disorder were identified among patients with hypertension (0.59 [0.47, 0.73]), or diabetes (0.65 [0.52, 0.81]).. Likewise, lower odds of stimulant use disorder were noted among females, patients older than 30 years of age and those not enrolled in Medicaid. CONCLUSION: These results highlight the alarming extent to which Medicaid enrollees, Black/African Americans, people aged 18-24 and 25-44, or persons with a past alcohol use disorder diagnosis are associated with stimulant use disorder among heart failure populations living in largely rural areas. Additionally, they emphasize the need to develop policies and refine clinical care that affects this vulnerable population's prognoses.

Coronavirus testing disparities associated with community level deprivation, racial inequalities, and food insecurity in West Virginia.

PURPOSE: Social determinants of health and racial inequalities impact healthcare access and subsequent coronavirus testing. Limited studies have described the impact of these inequities on rural minorities living in Appalachia. This study investigates factors affecting testing in rural communities. METHODS: PCR testing data were obtained for March through September 2020. Spatial regression analyses were fit at the census tract level. Model outcomes included testing and positivity rate. Covariates included rurality, percent Black population, food insecurity, and area deprivation index (a comprehensive indicator of socioeconomic status). RESULTS: Small clusters in coronavirus testing were detected sporadically, while test positivity clustered in mideastern and southwestern WV. In regression analyses, percent food insecurity (IRR = 3.69×109, [796, 1.92×1016]), rurality (IRR=1.28, [1.12, 1.48]), and percent population Black (IRR = 0.88, [0.84, 0.94]) had substantial effects on coronavirus testing. However, only percent food insecurity (IRR = 5.98 × 104, [3.59, 1.07×109]) and percent Black population (IRR = 0.94, [0.90, 0.97]) displayed substantial effects on the test positivity rate. CONCLUSIONS: Findings highlight disparities in coronavirus testing among communities with rural minorities. Limited testing in these communities may misrepresent coronavirus incidence.

Geographic Disparities in Readmissions for Peripheral Artery Disease in South Carolina.

Readmissions constitute a major health care burden among peripheral artery disease (PAD) patients. This study aimed to 1) estimate the zip code tabulation area (ZCTA)-level prevalence of readmission among PAD patients and characterize the effect of covariates on readmissions; and (2) identify hotspots of PAD based on estimated prevalence of readmission. Thirty-day readmissions among PAD patients were identified from the South Carolina Revenue and Fiscal Affairs Office All Payers Database (2010-2018). Bayesian spatial hierarchical modeling was conducted to identify areas of high risk, while controlling for confounders. We mapped the estimated readmission rates and identified hotspots using local Getis Ord (G*) statistics. Of the 232,731 individuals admitted to a hospital or outpatient surgery facility with PAD diagnosis, 30,366 (13.1%) experienced an unplanned readmission to a hospital within 30 days. Fitted readmission rates ranged from 35.3 per 1000 patients to 370.7 per 1000 patients and the risk of having a readmission was significantly associated with the percentage of patients who are 65 and older (0.992, 95%CI: 0.985-0.999), have Medicare insurance (1.013, 1.005-1.020), and have hypertension (1.014, 1.005-1.023). Geographic analysis found significant variation in readmission rates across the state and identified priority areas for targeted interventions to reduce readmissions.

Improving access and timeliness of care for veterans with head and neck squamous cell carcinoma: A multidisciplinary team's approach.

OBJECTIVES/HYPOTHESIS: With the prevalence of head and neck squamous cell carcinoma (HNSCC) nearly twice as high in veterans (6%) than general populations (3%), the noted problems of long waits and access to care in United States Veterans Affairs (VA) hospitals across the country are pressing. We examined primary outcome measures of timeliness and access to care for our patients with HNSCC assessing a multidisciplinary team approach at our VA hospital. STUDY DESIGN: Retrospective chart review. METHODS: Our patients newly diagnosed with HNSCC were identified from two 24-month periods: diagnosis before (group 1, 2005-2006) and after (group 2, 2008-2009) implementing our multidisciplinary team in 2007. No significant differences in age (P = .13) or disease stage (P = .18) occurred between groups. Primary and secondary outcomes (i.e., treatment modality, imaging, completion of treatment, survival) were compared. RESULTS: Timeliness to care improved for all measures. Improvement was significant for times from consult placed to seen in clinic (27.5-16.5 days; P < 0.0001) and from positive biopsy reported to date of initiating definitive treatment (35-27 days; P = 0.04). Pretreatment consults to various services represented by the multidisciplinary team increased from one to four (P < 0.0001). Two-year mortality was approximately the same between group 1 (33%) and group 2 (36%) (P = 0.035). Five-year mortality was slightly better in group 2 (50%) versus group 1 (61%), although not statistically significant. CONCLUSION: Our veteran population with HNSCC had improved timeliness and access to care with our multidisciplinary approach. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:627-631, 2016.