Community characteristics and mortality: the relative strength of association of different community characteristics.

OBJECTIVES: We compared the strength of association between average 5-year county-level mortality rates and area-level measures, including air quality, sociodemographic characteristics, violence, and economic distress. METHODS: . We obtained mortality data from the National Vital Statistics System and linked it to socioeconomic and demographic data from the Census Bureau, air quality data, violent crime statistics, and loan delinquency data. We modeled 5-year average mortality rates (1998-2002) for all-cause, cancer, heart disease, stroke, and respiratory diseases as a function of county-level characteristics using ordinary least squares regression models. We limited analyses to counties with population of 100,000 or greater (n = 458). RESULTS: Demographic and socioeconomic characteristics, particularly the percentage older than 65 years and near poor, were top predictors of all-cause and condition-specific mortality, as were a high concentration of construction and service workers. We found weaker associations for air quality, mortgage delinquencies, and violent crimes. Protective characteristics included the percentage of Hispanics, Asians, and married residents. CONCLUSIONS: Multiple factors influence county-level mortality. Although county demographic and socioeconomic characteristics are important, there are independent, although weaker, associations of other environmental characteristics. Future studies should investigate these factors to better understand community mortality risk.

Health Care Expenditures for Black and White US Adults Living Under Similar Conditions.

Importance: Evidence suggests that racial disparities in health outcomes disappear or diminish when Black and White adults in the US live under comparable living conditions; however, whether racial disparities in health care expenditures concomitantly disappear or diminish is unknown. Objective: To examine whether disparities in health care expenditures are minimized when Black and White US adults live in similar areas of racial composition and economic condition. Design, Setting, and Participants: This cross-sectional study used a nationally representative sample of 7062 non-Hispanic Black or White adults who live in 2238 of 2275 US census tracts with a 5% or greater Black population and who participated in the Medical Expenditure Panel Study (MEPS) in 2016. Differences in total health care expenditures and 6 specific categories of health care expenditures were assessed. Two-part regression models compared expenditures between Black and White adults living in the same Index of Concentration at the Extremes (ICE) quintile, a measure of racialized economic segregation. Estimated dollar amount differences in expenditures were calculated. All analyses were weighted to account for the complex sampling design of the MEPS. Data analysis was performed from December 1, 2019, to August 7, 2023. Exposure: Self-reported non-Hispanic Black or non-Hispanic White race. Main Outcomes and Measures: Presence and amount of patient out-of-pocket and insurance payments for annual total health care expenditures; office-based, outpatient, emergency department, inpatient hospital, or dental visits; and prescription medicines. ICE quintile 5 (Q5) reflected tracts that were mostly high income with mostly White individuals, whereas Q1 reflected tracts that were mostly low income with mostly Black individuals. Results: A total of 7062 MEPS respondents (mean [SD] age, 49 [18] years; 33.1% Black and 66.9% White; 56.1% female and 43.9% male) who lived in census tracts with a 5% or greater Black population in 2016 were studied. In Q5, Black adults had 56% reduced odds of having any health care expenditures (odds ratio, 0.44; 95% CI, 0.27-0.71) compared with White adults, at an estimated $2145 less per year, despite similar health status. Among those in Q5 with any expenditures, Black adults spent 30% less on care (cost ratio, 0.70; 95% CI, 0.56-0.86). In Q3 (most racially and economically integrated), differences in total annual health care spending were minimal ($79 annually; 95% CI, -$1187 to $1345). Conclusions and Relevance: In this cross-sectional study of Black and White adults in the US, health care expenditure disparities diminished or disappeared under conditions of both racial and economic equity and equitable health care access; in areas that were mostly high income and had mostly White residents, Black adults spent substantially less. Results underscore the continuing need to recognize place as a contributor to race-based differences in health care spending.

Do diabetic patients living in racially segregated neighborhoods experience different access and quality of care?

BACKGROUND: Place of residence, particularly residential segregation, has been implicated in health and health care disparities. However, prior studies have not focused on care for diabetes, a prevalent condition for minority populations. OBJECTIVE: To examine the association of residential segregation with a range of access and quality of care outcomes among black and Hispanics with diabetes using a nationally representative US sample. RESEARCH DESIGN: Cross-sectional study using data for 1598 adult patients with diabetes from the 2006 Medical Expenditure Panel Survey linked to residential segregation information for blacks and Hispanics on the basis of the 2000 census. Relationships of 5 dimensions of residential segregation (dissimilarity, isolation, clustering, concentration, and centralization) with access and quality of care outcomes were examined using linear, logistic, and multinomial logistic regression models, controlling for respondent characteristics and community utilization and hospital capacity. RESULTS: Black and Hispanics with diabetes had comparable or better access to providers, but received fewer recommended services. Living in a segregated community was associated with more recommended services received, but also problems with seeing a specialist. The relationship of residential segregation to diabetes care varied depending on type of segregation and race/ethnic group assessed. CONCLUSIONS: Residential segregation influences the care experience of patients with diabetes in the United States. Our study highlights the importance of investigating how different types of segregation may affect diabetes care received by patients from different race and ethnic groups.

Racial Disparities in Hypertension Prevalence within US Gentrifying Neighborhoods.

Racial disparities in hypertension remain a persistent public health concern in the US. While several studies report Black-White differences in the health impacts of gentrification, little is known concerning the impact of living in a gentrifying neighborhood on hypertension disparities. Data from the American Community Survey were used to identify gentrifying neighborhoods across the US from 2006 to 2017. Health and demographic data were obtained for non-Hispanic Black and White respondents of the 2014 Medical Expenditure Panel Survey (MEPS) residing in gentrifying neighborhoods. Modified Poisson models were used to determine whether there is a difference in the prevalence of hypertension of individuals by their race/ethnicity for those that live in gentrifying neighborhoods across the US. When compared to Whites living within gentrifying neighborhoods, Blacks living within gentrifying neighborhoods had a similar prevalence of hypertension. The non-existence of Black-White hypertension disparities within US gentrifying neighborhoods underscores the impact of neighborhood environment on race differences in hypertension.

Maryland dentists' perceptions and attitudes toward dental therapy.

OBJECTIVES: To learn dentists' perceptions, attitudes, and concerns about the problems of access to oral health care for low income and rural Marylanders and to ascertain whether the dentists believe dental therapy is a viable solution. METHODS: We conducted three focus group discussions of 27 dentists during August and September 2018 in three locations in urban and rural areas of Maryland. RESULTS: Focus group participants felt that problems with access to dental care for low income and rural Marylander were not due to a shortage of dental providers. They believed there are more than enough dentists in the state. Access problems in Maryland are due in large part to inadequate insurance coverage and low oral health literacy. With the exception of one participant, the dentists would not use dental therapists in their practices to expand access. CONCLUSIONS: Maryland dentists in our focus group strongly oppose the use of dental therapists to address the state's unmet oral health care needs. Any effort to expand the state's dental workforce using dental therapists must address Maryland dentists' concerns and opinions.

Availability of Health Care Provider Offices and Facilities in Minority and Integrated Communities in the U.S.

OBJECTIVE: To examine the availability of health care provider offices and facilities in predominantly White, minority, and integrated primary care service areas (PCSA). METHODS: National data from the American Community Survey and InfoUSA, linked at the PCSA-level, for 2005 (N=7,109) and 2014 (N=7,142). Associations between racial composition of PCSAs and numbers of health care offices and facilities were examined using multiple regression models. RESULTS: After adjustment for PCSA socio-demographic characteristics, predominantly minority PCSAs had fewer diagnostic imaging centers and offices for physicians, mental health providers, dentists, and other health practitioners than White PCSAs (Adj IRR range: 0.68-0.80, all p<.01). Availability was also lower for integrated PCSAs, but reductions were smaller and involved fewer service types (Adj IRR range: 0.85-0.91, all p<.05). CONCLUSION: Minority and integrated communities have fewer provider offices and facilities for important health services, which may contribute to the persistent racial/ethnic disparities in health care access and use.

No Man is an Island: The Impact of Neighborhood Disadvantage on Mortality.

This study's purpose is to determine if neighborhood disadvantage, air quality, economic distress, and violent crime are associated with mortality among term life insurance policyholders, after adjusting for individual demographics, health, and socioeconomic characteristics. We used a sample of approximately 38,000 term life policyholders, from a large national life insurance company, who purchased a policy from 2002 to 2010. We linked this data to area-level data on neighborhood disadvantage, economic distress, violent crime, and air pollution. The hazard of dying for policyholders increased by 9.8% (CI: 6.0­13.7%) as neighborhood disadvantage increased by one standard deviation. Area-level poverty and mortgage delinquency were important predictors of mortality, even after controlling for individual personal income and occupational status. County level pollution and violent crime rates were positively, but not statistically significantly, associated with the hazard of dying. Our study provides evidence that neighborhood disadvantage and economic stress impact individual mortality independently from individual socioeconomic characteristics. Future studies should investigate pathways by which these area-level factors influence mortality. Public policies that reduce poverty rates and address economic distress can benefit everyone's health.

The Maryland Health Enterprise Zone Initiative Reduced Hospital Cost And Utilization In Underserved Communities.

The State of Maryland implemented the Health Enterprise Zone Initiative in 2013 to improve access to health care and health outcomes in underserved communities and reduce health care costs and avoidable hospital admissions and readmissions. In each community the Health Enterprise Zone Initiative was a collaboration between the local health department or hospital and community-based organizations. The initiative was designed to attract primary care providers to underserved communities and support community efforts to improve health behaviors. It deployed community health workers and provided behavioral health care, dental services, health education, and school-based health services. We found that the initiative was associated with a reduction of 18,562 inpatient stays and an increase of 40,488 emergency department visits in the period 2013-16. The net cost savings from reduced inpatient stays far outweighed the initiative's cost to the state. Implementing such initiatives is a viable way to reduce inpatient admissions and reduce health care costs.

Racial disparities in disability among older adults: finding from the exploring health disparities in integrated communities study.

OBJECTIVE: Persistent and consistently observed racial disparities in physical functioning likely stem from racial differences in social resources and environmental conditions. METHOD: We examined the association between race and reported difficulty performing instrumental activities of daily living (IADL) in 347 African American (45.5%) and Whites aged 50 or above in the Exploring Health Disparities in Integrated Communities-Southwest Baltimore, Maryland Study (EHDIC-SWB). RESULTS: Contrary to previous studies, African Americans had lower rates of disability (women: 25.6% vs. 44.6%, p = .006; men: 15.7% vs. 32.9%; p = .017) than Whites. After adjusting for sociodemographics, health behaviors, and comorbidities, African American women (odds ratio [OR] = 0.32, 95% confidence interval [CI] = [0.14, 0.70]) and African American men (OR = 0.34, 95% CI = [0.13, 0.90]) retained their functional advantage compared with White women and men, respectively. CONCLUSION: These findings within an integrated, low-income urban sample support efforts to ameliorate health disparities by focusing on the social context in which people live.

The Association Between Educational Attainment and Diabetes Among Men in the United States.

Few studies have examined the relationship between education and diabetes among men in the United States and whether this relationship differs by race/ethnicity. This study examined whether racial disparities in diabetes existed by educational attainment in 336,746 non-Hispanic White, non-Hispanic Black, and Hispanic men 18 years of age and older in the United States. Logistic regression models were specified to examine the odds of reporting diabetes by educational attainment. Within race/ethnicity, both White and Hispanic men who had less than a high school education (odds ratio [OR] = 1.42, 95% confidence interval [CI] = [1.19, 1.69], and OR = 1.64, 95% CI = [1.22, 2.21], respectively) had consistently higher odds of diabetes than men with a bachelor's degree or higher level of educational attainment. Educational attainment did not appear to be associated with reporting a diagnosis of diabetes in non-Hispanic Black men. Identifying why educational attainment is associated with diabetes outcomes in some racial/ethnic groups but not others is essential for diabetes treatment and management.

Residential segregation and disparities in health care services utilization.

Using data from the 2006 Medical Expenditure Panel Survey and the 2000 Census, the authors explored whether race/ethnic disparities in health care use were associated with residential segregation. They used five measures of health care use: office-based physician visits, outpatient department physician visits, visits to nurses and physician's assistants, visits to other health professionals, and having a usual source of care. For each individual, the authors controlled for age, gender, marital status, insurance status, income, educational attainment, employment status, region, and health status. The authors used the racial-ethnic composition of the zip code to control for residential segregation. The findings suggest that disparities in health care utilization are related to both individuals' racial and ethnic identity and the racial and ethnic composition of their communities. Therefore, efforts to improve access to health care services and to eliminate health care disparities for African Americans and Hispanics should not only focus on individual-level factors but also include community-level factors.

Residential segregation and the availability of primary care physicians.

OBJECTIVE: To examine the association between residential segregation and geographic access to primary care physicians (PCPs) in metropolitan statistical areas (MSAs). DATA SOURCES: We combined zip code level data on primary care physicians from the 2006 American Medical Association master file with demographic, socioeconomic, and segregation measures from the 2000 U.S. Census. Our sample consisted of 15,465 zip codes located completely or partially in an MSA. METHODS: We defined PCP shortage areas as those zip codes with no PCP or a population to PCP ratio of >3,500. Using logistic regressions, we estimated the association between a zip code's odds of being a PCP shortage area and its minority composition and degree of segregation in its MSA. PRINCIPAL FINDINGS: We found that odds of being a PCP shortage area were 67 percent higher for majority African American zip codes but 27 percent lower for majority Hispanic zip codes. The association varied with the degree of segregation. As the degree of segregation increased, the odds of being a PCP shortage area increased for majority African American zip codes; however, the converse was true for majority Hispanic and Asian zip codes. CONCLUSIONS: Efforts to address PCP shortages should target African American communities especially in segregated MSAs.