Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990-2018.

BACKGROUND: Hospitalizations for chronic ambulatory care sensitive conditions are an important indicator of health system equity and performance. Chronic ambulatory care sensitive conditions refer to chronic diseases that can be managed in primary care settings, including angina, asthma, and diabetes, with hospitalizations for these conditions considered potentially avoidable with adequate primary care interventions. Socioeconomic inequities in the risk of hospitalization have been observed in several health systems globally. While there are multiple studies examining the association between socioeconomic status and hospitalizations for chronic ambulatory care sensitive conditions, these studies have not been systematically reviewed. The objective of this study is to systematically identify and describe socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions amongst adult populations in economically developed countries reported in high-quality observational studies published in the peer-reviewed literature. METHODS: Peer-reviewed literature was searched in six health and social science databases: MEDLINE, EMBASE, PsycInfo, CINAHL, ASSIA, and IBSS using search terms for hospitalization, socioeconomic status, and chronic ambulatory care sensitive conditions. Study titles and abstracts were first screened followed by full-text review according to the following eligibility criteria: 1) Study outcome is hospitalization for selected chronic ambulatory care sensitive conditions; 2) Primary exposure is individual- or area-level socioeconomic status; 3) Study population has a mean age ± 1 SD < 75 years of age; 4) Study setting is economically developed countries; and 5) Study type is observational. Relevant data was then extracted, and studies were critically appraised using appropriate tools from The Joanna Briggs Institute. Results were narratively synthesized according to socioeconomic constructs and type of adjustment (minimally versus fully adjusted). RESULTS: Of the 15,857 unique peer-reviewed studies identified, 31 studies met the eligibility criteria and were of sufficient quality for inclusion. Socioeconomic constructs and hospitalization outcomes varied across studies. However, despite this heterogeneity, a robust and consistent association between lower levels of socioeconomic status and higher risk of hospitalizations for chronic ambulatory care sensitive conditions was observed. CONCLUSIONS: This systematic review is the first to comprehensively identify and analyze literature on the relationship between SES and hospitalizations for chronic ambulatory care sensitive conditions, considering both aggregate and condition-specific outcomes that are common to several international health systems. The evidence consistently demonstrates that lower socioeconomic status is a risk factor for hospitalization across global settings. Effective health and social interventions are needed to reduce these inequities and ensure fair and adequate care across socioeconomic groups. TRIAL REGISTRATION: PROSPERO CRD42018088727.

Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study.

Hospitalizations for certain chronic conditions are considered avoidable for adult Canadians given effective and timely primary care management. Individual-level risk factors such as income and health behaviours are not routinely collected in most hospital databases and as a result, are largely uncharacterized for avoidable hospitalization at the national level. The aim of this study was to identify and describe demographic, socioeconomic, and health behavioural risk factors for avoidable hospitalizations in Canada using linked data. A national retrospective cohort study was conducted by pooling eight cycles of the Canadian Community Health Survey (2000/2001-2011) and linking to hospitalization records in the Discharge Abstract Database (1999/2000-2012/2013). Respondents who were younger than 18 years and older than 74 years of age, residing in Quebec, or pregnant at baseline were excluded yielding a final cohort of 389,065 individuals. The primary outcome measure was time-to index avoidable hospitalization. Sex-stratified Cox proportional hazard models were constructed to determine effect sizes adjusted for various factors and their associated 95% confidence intervals. Demographics, socioeconomic status, and health behaviours are associated with risk of avoidable hospitalizations in males and females. In fully adjusted models, health behavioural variables had the largest effect sizes including heavy smoking (Male HR 2.65 (95% CI 2.17-3.23); Female HR 3.41 (2.81-4.13)) and being underweight (Male HR 1.98 (1.14-3.43); Female HR 2.78 (1.61-4.81)). Immigrant status was protective in both sexes (Male HR 0.83 (0.69-0.98); (Female HR 0.69 (0.57-0.84)). Adjustment for behavioural and clinical variables attenuated the effect of individual-level socioeconomic status. This study identified several risk factors for time-to-avoidable hospitalizations by sex, using the largest national database of linked health survey and hospitalization records. The larger effect sizes of several modifiable risk factors highlights the importance of prevention in addressing avoidable hospitalizations in Canada.

Building Data and Information Capacity in Environmental Public Health: A Best-Worst Scaling Experiment.

CONTEXT: Environmental public health practitioners rely on information technology (IT) to maintain and improve environmental health. However, current systems have limited capacity. A better understanding of the importance of IT features is needed to enhance data and information capacity. OBJECTIVE: (1) Rank IT features according to the percentage of respondents who rated them as essential to an information management system and (2) quantify the relative importance of a subset of these features using best-worst scaling. DESIGN: Information technology features were initially identified from a previously published systematic review of software evaluation criteria and a list of software options from a private corporation specializing in inspection software. Duplicates and features unrelated to environmental public health were removed. The condensed list was refined by a working group of environmental public health management to a final list of 57 IT features. The essentialness of features was electronically rated by environmental public health managers. Features where 50% to 80% of respondents rated them as essential (n = 26) were subsequently evaluated using best-worst scaling. SETTING: Ontario, Canada. PARTICIPANTS: Environmental public health professionals in local public health. MAIN OUTCOME MEASURE: Importance scores of IT features. RESULTS: The majority of IT features (47/57) were considered essential to an information management system by at least half of the respondents (n = 52). The highest-rated features were delivery to printer, software encryption capability, and software maintenance services. Of the 26 features evaluated in the best-worst scaling exercise, the most important features were orientation to all practice areas, off-line capability, and ability to view past inspection reports and results. CONCLUSIONS: The development of a single, unified environmental public health information management system that fulfills the reporting and functionality needs of system users is recommended. This system should be implemented by all public health units to support data and information capacity in local environmental public health. This study can be used to guide vendor evaluation, negotiation, and selection in local environmental public health, and provides an example of academia-practice partnerships and the use of best-worst scaling in public health research.

Using core competencies to build an evaluative framework: outcome assessment of the University of Guelph Master of Public Health program.

BACKGROUND: Master of Public Health programs have been developed across Canada in response to the need for graduate-level trained professionals to work in the public health sector. The University of Guelph recently conducted a five-year outcome assessment using the Core Competencies for Public Health in Canada as an evaluative framework to determine whether graduates are receiving adequate training, and identify areas for improvement. METHODS: A curriculum map of core courses and an online survey of University of Guelph Master of Public Health graduates comprised the outcome assessment. The curriculum map was constructed by evaluating course outlines, assignments, and content to determine the extent to which the Core Competencies were covered in each course. Quantitative survey results were characterized using descriptive statistics. Qualitative survey results were analyzed to identify common themes and patterns in open-ended responses. RESULTS: The University of Guelph Master of Public Health program provided a positive learning environment in which graduates gained proficiency across the Core Competencies through core and elective courses, meaningful practicums, and competent faculty. Practice-based learning environments, particularly in collaboration with public health organizations, were deemed to be beneficial to students' learning experiences. CONCLUSIONS: The Core Competencies and graduate surveys can be used to conduct a meaningful and informative outcome assessment. We encourage other Master of Public Health programs to conduct their own outcome assessments using a similar framework, and disseminate these results in order to identify best practices and strengthen the Canadian graduate public health education system.

Analyzing exposure, use, and policies related to tobacco use on campus for the development of comprehensive tobacco policies at Canadian post-secondary institutions.

Canadians in their early twenties represent the highest prevalence of reported tobacco use among all age groups. With the majority of Canadian young adults accessing post-secondary education, post-secondary institutions can facilitate targeting of health promotion efforts to curb tobacco use among young adults. Effective targeting requires clear comprehensive campus tobacco policies. However, the development and implementation of comprehensive campus tobacco policies has been lacking among Canadian post-secondary institutions. As the first step towards the development of a comprehensive campus tobacco policy at the University of Guelph, an on-line survey of students, faculty and staff was conducted in November 2012. The objectives of this survey were two-fold: (1) Determine the current level of exposure to second-hand smoke on campus, the type and frequency of tobacco use, opinions on seven different tobacco policy options, and the level of awareness of current tobacco policies and programs and; (2) Determine if any associations between opinions on tobacco policy options and exposure to second-hand smoke and tobacco use existed. The results of this survey demonstrate that tobacco use is associated with opinions on tobacco policy options and that the level of awareness of tobacco policies and programs is relatively low and is not associated with tobacco use. This study represents one of the first studies to examine the association between tobacco use and support of policy options and awareness of tobacco policies and programs. As other post-secondary institutions develop comprehensive tobacco policies, these findings will serve as a comparison for other similar institutions.

The non-motile phenotype of Salmonella hha ydgT mutants is mediated through PefI-SrgD.

BACKGROUND: Two ancestral nucleoid-associated proteins called Hha and YdgT contribute to the negative regulation of several virulence-associated genes in Salmonella enterica serovar Typhimurium. Our previous work showed that Hha and YdgT proteins are required for negative regulation of Salmonella Pathogenicity Island-2 and that hha ydgT double mutants are attenuated for murine infection. Interestingly, hha ydgT mutant bacteria exhibited a non-motile phenotype suggesting that Hha and YdgT have a role in flagellar regulation. RESULTS: In this study we show that the non-motile phenotype of hha ydgT mutants is due to decreased levels of the master transcriptional regulator FlhD4C2 resulting in down-regulation of class II/III and class III flagellar promoters and lack of surface flagella on these cells. The horizontally acquired pefI-srgD region was found to be partially responsible for this phenotype since deletion of pefI-srgD in a hha ydgT deletion background resulted in transient restoration of class II/III and III transcription, expression of surface flagella, and motility in the quadruple mutant. CONCLUSION: These data extend our current understanding of the mechanisms through which Hha and YdgT regulate flagellar biosynthesis and further describe how S. Typhimurium has integrated horizontal gene acquisitions into ancestral regulatory networks.