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1.
Int J Equity Health ; 20(1): 91, 2021 04 06.
Artículo en Inglés | MEDLINE | ID: mdl-33823852

RESUMEN

BACKGROUND: COVID-19 has an inevitable burden on public health, potentially widening the gender gap in healthcare and the economy. We aimed to assess gender-based desparities during COVID-19 in Jordan in terms of health indices, mental well-being and economic burden. METHODS: A nationally representative sample of 1300 participants ≥18 years living in Jordan were selected using stratified random sampling. Data were collected via telephone interviews in this cross-sectional study. Chi-square was used to test age and gender differences according to demographics, economic burden, and health indices (access to healthcare, health insurance, antenatal and reproductive services). A multivariable logistic regression analysis was used to estimate the beta-coefficient (ß) and 95% confidence interval (CI) of factors correlated with mental well-being, assessed by patients' health questionnaire 4 (PHQ-4). RESULTS: 656 (50.5%) men and 644 (49.5%) women completed the interview. Three-fourths of the participants had health insurance during the COVID-19 crisis. There was no significant difference in healthcare coverage or access between women and men (p > 0.05). Half of pregnant women were unable to access antenatal care. Gender was a significant predictor of higher PHQ-4 scores (women vs. men: ß: 0.88, 95% CI: 0.54-1.22). Among women, age ≥ 60 years and being married were associated with significantly lower PHQ-4 scores. Only 0.38% of the overall participants lost their jobs; however, 8.3% reported a reduced payment. More women (13.89%) were not paid during the crisis as compared with men (6.92%) (P = 0.01). CONCLUSIONS: Our results showed no gender differences in healthcare coverage or access during the COVID-19 crisis generally. Women in Jordan are experiencing worse outcomes in terms of mental well-being and economic burden. Policymakers should give priority to women's mental health and antenatal and reproductive services. Financial security should be addressed in all Jordanian COVID-19 national plans because the crisis appears widening the gender gap in the economy.


Asunto(s)
/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en el Estado de Salud , Salud Mental/estadística & datos numéricos , Atención Prenatal/estadística & datos numéricos , Adulto , Estudios Transversales , Femenino , Humanos , Seguro de Salud/estadística & datos numéricos , Jordania , Masculino , Persona de Mediana Edad , Embarazo , Factores Sexuales
2.
MMWR Morb Mortal Wkly Rep ; 70(10): 337-341, 2021 Mar 12.
Artículo en Inglés | MEDLINE | ID: mdl-33705365

RESUMEN

Accidental consumption of poisonous mushrooms can result in serious illness and death (1). Reports of severe poisonings from consumption of foraged mushrooms for food or hallucinogenic purposes increased during 1999-2016 (2), and approximately 7,500 poisonous mushroom ingestions were reported annually to poison control centers across the United States (1). To estimate the frequency of emergency department (ED) visits, hospitalizations, and severe adverse outcomes associated with accidental poisonous mushroom ingestion in the United States, CDC analyzed 2016 data from the Healthcare Cost and Utilization Project's* Nationwide Emergency Department Sample (HCUP-NEDS) and National Inpatient Sample (HCUP-NIS) databases as well as 2016-2018 data from three IBM MarketScan sources: Commercial Claims and Encounters (CCAE), Medicare Supplemental and Coordination of Benefits (Medicare), and Multi-State Medicaid databases. During 2016, 1,328 (standard error [SE] = 100) ED visits and 100 (SE = 22) hospitalizations (HCUP data) were associated with accidental poisonous mushroom ingestion. Among 556 patients with a diagnosis of accidental poisonous mushroom ingestion, 48 (8.6%) patients experienced a serious adverse outcome during 2016-2018 (MarketScan data). Serious adverse outcomes were more common among Medicaid-insured patients than among patients with commercial insurance or Medicare (11.5% versus 6.7%, p = 0.049). Because most mushroom poisonings are preventable, wild mushrooms should not be consumed unless they are identified by an expert; increased public health messaging about the potential dangers of mushroom poisoning is needed.


Asunto(s)
Accidentes/estadística & datos numéricos , Intoxicación por Setas/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Preescolar , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Seguro de Salud/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Persona de Mediana Edad , Intoxicación por Setas/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto Joven
3.
CMAJ Open ; 9(1): E302-E308, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33785478

RESUMEN

BACKGROUND: It is unclear what the best strategy is for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among residents of homeless shelters and what individual factors are associated with testing positive for the virus. We sought to evaluate factors associated with testing positive for SARS-CoV-2 among residents of homeless shelters and to evaluate positivity rates in shelters where testing was conducted in response to coronavirus disease 2019 (COVID-19) outbreaks or for surveillance. METHODS: We conducted a retrospective chart audit to obtain repeated cross-sectional data from outreach testing done at homeless shelters between Apr. 1 and July 31, 2020, in Toronto, Ontario, Canada. We compared the SARS-CoV-2 positivity rate for shelters where testing was conducted because of an outbreak (at least 1 known case) with those tested for surveillance (no known cases). A patient-level analysis evaluated differences in demographic, health and behavioural characteristics of residents who did and did not test positive for SARS-CoV-2 at shelters with at least 2 positive cases. RESULTS: One thousand nasopharyngeal swabs were done on 872 unique residents at 20 shelter locations. Among the 504 tests done in outbreak settings, 69 (14%) were positive for SARS-CoV-2 and 1 (0.2%) was indeterminate. Among the 496 tests done for surveillance, 11 (2%) were positive and none were indeterminate. Shelter residents who tested positive for SARS-CoV-2 were significantly less likely to have a health insurance card (54% v. 72%, p = 0.03) or to have visited another shelter in the last 14 days (0% v. 18%, p < 0.01). There was no association between SARS-CoV-2 positivity and medical history or symptoms. INTERPRETATION: Our findings support testing of asymptomatic shelter residents for SARS-CoV-2 when a positive case is identified at the same shelter. Surveillance testing when there are no known positive cases may detect outbreaks, but further research should identify efficient strategies given scarce testing resources.


Asunto(s)
/estadística & datos numéricos , Personas sin Hogar/estadística & datos numéricos , /genética , Adolescente , Adulto , Anciano , /transmisión , Niño , Preescolar , Estudios Transversales , Brotes de Enfermedades/estadística & datos numéricos , Grupos Étnicos/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Seguro de Salud/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Ontario/epidemiología , Estudios Retrospectivos , Adulto Joven
4.
JAMA Netw Open ; 4(3): e212618, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33755167

RESUMEN

Importance: This study assesses the role of telehealth in the delivery of care at the start of the COVID-19 pandemic. Objectives: To document patterns and costs of ambulatory care in the US before and during the initial stage of the pandemic and to assess how patient, practitioner, community, and COVID-19-related factors are associated with telehealth adoption. Design, Setting, and Participants: This is a cohort study of working-age persons continuously enrolled in private health plans from March 2019 through June 2020. The comparison periods were March to June in 2019 and 2020. Claims data files were provided by Blue Health Intelligence, an independent licensee of the Blue Cross and Blue Shield Association. Data analysis was performed from June to October 2020. Main Outcomes and Measures: Ambulatory encounters (in-person and telehealth) and allowed charges, stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee's zip code. Results: A total of 36 568 010 individuals (mean [SD] age, 35.71 [18.77] years; 18 466 557 female individuals [50.5%]) were included in the analysis. In-person contacts decreased by 37% (from 1.63 to 1.02 contacts per enrollee) from 2019 to 2020. During 2020, telehealth visits (0.32 visit per person) accounted for 23.6% of all interactions compared with 0.3% of contacts in 2019. When these virtual contacts were added, the overall COVID-19 era patient and practitioner visit rate was 18% lower than that in 2019 (1.34 vs 1.64 visits per person). Behavioral health encounters were far more likely than medical contacts to take place virtually (46.1% vs 22.1%). COVID-19 prevalence in an area was associated with higher use of telehealth; patients from areas within the top quintile of COVID-19 prevalence during the week of their encounter were 1.34 times more likely to have a telehealth visit compared with those in the lowest quintile (the reference category). Persons living in areas with limited social resources were less likely to use telehealth (most vs least socially advantaged neighborhoods, 27.4% vs 19.9% usage rates). Per enrollee medical care costs decreased by 15% between 2019 and 2020 (from $358.32 to $306.04 per person per month). During 2020, those with 1 or more COVID-19-related service (1 470 721 members) had more than 3 times the medical costs ($1701 vs $544 per member per month) than those without COVID-19-related services. Persons with 1 or more telehealth visits in 2020 had considerably higher costs than persons having only in-person ambulatory contacts ($2214.10 vs $1337.78 for the COVID-19-related subgroup and $735.87 vs $456.41 for the non-COVID-19 subgroup). Conclusions and Relevance: This study of a large cohort of patients enrolled in US health plans documented patterns of care at the onset of COVID-19. The findings are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the pandemic and afterward.


Asunto(s)
Atención Ambulatoria , Pautas de la Práctica en Medicina , Telemedicina , Adulto , Atención Ambulatoria/economía , Atención Ambulatoria/métodos , Atención Ambulatoria/estadística & datos numéricos , /prevención & control , Estudios de Cohortes , Costos y Análisis de Costo , Femenino , Humanos , Control de Infecciones/métodos , Seguro de Salud/estadística & datos numéricos , Masculino , Innovación Organizacional/economía , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/organización & administración , Pautas de la Práctica en Medicina/estadística & datos numéricos , Telemedicina/economía , Telemedicina/organización & administración , Telemedicina/estadística & datos numéricos , Estados Unidos/epidemiología
5.
Am J Phys Med Rehabil ; 100(3): 288-291, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33595942

RESUMEN

ABSTRACT: This study characterizes the demographics and durable medical equipment needs of persons with disabilities to improve utilization and management of resources at a philanthropic rehabilitation clinic. Paper charts from all encounters between 2013 and 2018 were reviewed. Data collected include sex, age, ethnicity, insurance status, diagnoses, and durable medical equipment requested/received. Paper charts that were incomplete or illegible were excluded. Among 763 individuals, there were 1157 encounters for durable medical equipment requests. Forty-six percent of individuals were uninsured. Thirty-seven percent had federal insurance such as Medicare or Medicaid, and 6% private insurance. Fifty-five percent of individuals were Hispanic, 28% African American, and 14% White. Fifty-six percent of encounters were with individuals with a neurological diagnosis, 18% medical diagnosis, 17% musculoskeletal/autoimmune diagnosis, 6% amputation diagnosis, and 3% cancer diagnosis. Of the 2680 items distributed, 34% were wheelchair parts and repair, 30% personal hygiene/incontinence supplies, 25% mobility equipment, and 11% bathroom equipment. Of the 513 unmet items requested, 49% were mobility equipment, 24% wheelchair parts and repair, 17% personal hygiene/incontinence supplies, and 11% bathroom equipment. More than a third (43%) of durable medical equipment requests were from individuals with either private insurance or federal payers, which implies lack of adequate coverage on durable medical equipment to maintain mobility and independence.


Asunto(s)
Personas con Discapacidad/rehabilitación , Personas con Discapacidad/estadística & datos numéricos , Equipo Médico Durable/provisión & distribución , Necesidades y Demandas de Servicios de Salud , Seguro de Salud/estadística & datos numéricos , Evaluación de Necesidades , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Centros de Rehabilitación , Adulto Joven
6.
Epidemiol Health ; 43: e2021007, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33445821

RESUMEN

OBJECTIVES: This study explored socioeconomic disparities in Korea using health insurance type as a proxy during the ongoing coronavirus disease 2019 (COVID-19) pandemic. METHODS: We conducted a retrospective cohort study using Korea's nationwide healthcare database, which contained all individuals who received a diagnostic test for COVID-19 (n=232,390) as of May 15, 2020. We classified our cohort by health insurance type into beneficiaries of the National Health Insurance (NHI) or Medicaid programs. Our study outcomes were infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19-related outcomes, a composite of all-cause death, intensive care unit admission, and mechanical ventilation use. We estimated age-, sex-, and Charlson comorbidity index score-adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using a multivariable logistic regression analysis. RESULTS: Of the 218,070 NHI and 14,320 Medicaid beneficiaries who received COVID-19 tests, 7,777 and 738 tested positive, respectively. The Medicaid beneficiaries were older (mean age, 57.5 vs. 47.8 years), more likely to be males (47.2 vs. 40.2%), and had a higher comorbidity burden (mean CCI, 2.0 vs. 1.7) than NHI beneficiaries. Compared to NHI beneficiaries, Medicaid beneficiaries had a 22% increased risk of SARS-CoV-2 infection (aOR, 1.22; 95% CI, 1.09 to 1.38), but had no significantly elevated risk of COVID-19-related outcomes (aOR 1.10, 95% CI 0.77 to 1.57); the individual events of the composite outcome yielded similar findings. CONCLUSIONS: As socioeconomic factors, with health insurance as a proxy, could serve as determinants during the current pandemic, pre-emptive support is needed for high-risk groups to slow its spread.


Asunto(s)
/estadística & datos numéricos , Disparidades en Atención de Salud/economía , Seguro de Salud/estadística & datos numéricos , Pandemias , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Revisión de Utilización de Seguros , Masculino , Persona de Mediana Edad , República de Corea/epidemiología , Estudios Retrospectivos , Factores Socioeconómicos , Adulto Joven
7.
South Med J ; 114(1): 35-40, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33398359

RESUMEN

OBJECTIVES: Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared with patients with private insurance. Whether variables such as geographic location, state expansion versus nonexpansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. The purpose of this study was to assess the differences in access to care between patients who are privately insured and those with Medicaid in need of foot and ankle consultation. Secondary objectives include assessment of whether access to care for foot and ankle patients with Medicaid differs between those with acute and chronic conditions, Medicaid expanded and unexpanded states, geographic regions within the United States, and academic versus private practices. METHODS: Twenty providers from each of five Medicaid-expanded and five nonexpanded states in different US geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative's acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of the telephone calls and Blue Cross Blue Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic nonurgent injury (hallux valgus). RESULTS: Appointments were successful for all 100 (100%) calls made with BCBS as the insurer, in comparison to 73 of 100 calls (73%) with Medicaid (P < 0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (P < 0.001). The appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ 0.01) in all of the geographic regions. The success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, P < 0.001) for private practice offices, but not for academic practices. CONCLUSIONS: Patients with Medicaid experience fewer options when obtaining appointments for common nonemergent foot and ankle problems and may experience less difficulty scheduling appointments at academic rather than private institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopedic care for all patients and increase the visibility of practices that accept Medicaid.


Asunto(s)
Tobillo/cirugía , Pie/cirugía , Mapeo Geográfico , Accesibilidad a los Servicios de Salud/normas , Seguro de Salud/normas , Enfermedad Crónica/epidemiología , Enfermedad Crónica/terapia , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Seguro de Salud/economía , Seguro de Salud/estadística & datos numéricos , Medicaid/organización & administración , Medicaid/estadística & datos numéricos , Procedimientos Ortopédicos/métodos , Procedimientos Ortopédicos/normas , Procedimientos Ortopédicos/estadística & datos numéricos , Estados Unidos/epidemiología
9.
Lancet Child Adolesc Health ; 5(2): 103-112, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33333071

RESUMEN

BACKGROUND: Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position. METHODS: This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk. FINDINGS: 12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021). INTERPRETATION: In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children. FUNDING: None.


Asunto(s)
Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Sepsis/etnología , Sepsis/mortalidad , Adolescente , Adulto , Niño , Preescolar , Bases de Datos Factuales , Femenino , Disparidades en Atención de Salud , Mortalidad Hospitalaria/etnología , Humanos , Lactante , Recién Nacido , Masculino , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Factores Socioeconómicos , Estados Unidos , Adulto Joven
10.
Evid. actual. práct. ambul ; 24(1): e002113, 2021. tab
Artículo en Español | LILACS | ID: biblio-1179134

RESUMEN

Antecedentes. La continuidad del cuidado (CoC) suele describir en qué medida los pacientes ven al mismo profesional a lo largo del tiempo. Constituye un elemento necesario para garantizar la longitudinalidad en la atención, elemento clave dela atención primaria y de la medicina familiar en particular, entendido como el cuidado centrado en la persona a lo largo del tiempo, independientemente del tipo de problema consultado. Esta ha sido vinculada con una serie de beneficios para los pacientes y algunos indicadores duros de utilización de servicios de salud, por ejemplo visitas a la central de emergencias(CE), internaciones hospitalarias y mortalidad. En Argentina y América Latina no habíamos podido identificar estudios que dieran cuenta del nivel local de CoC o de su impacto en la utilización de los servicios de salud. Objetivo. Cuantificar los niveles de CoC de los afiliados de un Seguro de Salud de un Hospital Universitario Privado y describir su asociación con la utilización de servicios de salud, tales como consultas a la CE e internaciones hospitalarias. Métodos. Estudio observacional, descriptivo, de cohorte retrospectiva; realizado sobre la totalidad de afiliados que hubieran realizado al menos dos consultas programadas con un médico de atención primaria entre 2015 y 2016.Las mediciones principales consistieron dos indicadores: el índice del proveedor usual de cuidados y el índice de continuidad del cuidado (UPC y COC, respectivamente, por sus iniciales en inglés) -cuyos valores oscilan entre 0 y 1, y se interpretan como: el paciente siempre fue atendido por diferentes médicos vs siempre por el mismo médico-y el recuento de visitas a la CE e internaciones hospitalarias. Resultados. Fueron identificados 112.062 pacientes con una mediana de edad de 59 (P5-P95;4 a 87) años. Las medianas(P5-P95) de los indicadores de continuidad, UPC y COC, fueron 0,66 (0,25 a 1) y 0,33 (0,04 a 1), respectivamente. Se observó una asociación inversa y estadísticamente significativa entre los indicadores de CoC y la cantidad de visitas a la CE, evidenciada por una razón de incidencia decreciente de consultas contra quintilos crecientes de COC (tomando como referencia el quintilo más bajo de continuidad). Esta asociación no pudo demostrarse para las internaciones. Conclusiones. Los niveles de CoC alcanzados y su impacto en la utilización de servicios de salud reflejan valores semejantes a los de otros estudios publicados fuera de nuestra región y podrían aportar elementos útiles para delinear estrategias tendientes a la mejora de la calidad de la atención médica. (AU)


Background. Continuity of care (CoC) usually describes the extent to which patients see the same professional over time. It is a necessary element to ensure continuity of care, a key element of primary care and family medicine, in particular, understood as person-centred care over time, regardless of the type of problem consulted. It has been linked to a series of benefits for patients as well as to hard indicators of health services utilization (e.g. emergency room [ER] visits, hospitalizations) and mortality. In Argentina and Latin America, we have not been able to identify studies that account for the local level of CoC and its impact. Objective. To quantify the CoC levels among members of a private university hospital's health insurance scheme and to describe its association with the use of health services, such as ER visits and hospitalizations. Methods. Observational, descriptive, retrospective cohort study; conducted on the total number of members who hadmade at least two schedurivled consultations with a primary care physician between 2015 and 2016.The main outcomes were two indicators: the usual provider continuity index and the continuity of care index (UPC and COC, respectively) -both range between 0 and 1, and are interpreted as: the patient was always treated by different doctorsvs. always by the same doctor- and the number of visits to the ER and hospitalizations. Results. A total of 112,062 patients with a median age of 59 (P5-P95, 4 to 87) years were identified. The median (P5-P95) of the continuity indicators, UPC and COC, was 0.66 (0.25 to 1) and 0.33 (0.04 to 1), respectively. A significant inverse association was observed between the CoC indicators and the number of ER visits, evidenced by adecreasing incidence rate of consultations versus increasing quintiles of CoC (taking the lowest quintile of continuity as a reference). This association was not observed for hospitalizations. Conclusions. The levels of CoC reached and their impact on the use of health services reflect similar values to those of other studies published outside our region and could provide useful elements for outlining strategies aimed at improvingthe quality of medical care. (AU)


Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Calidad de la Atención de Salud/estadística & datos numéricos , Continuidad de la Atención al Paciente/estadística & datos numéricos , Argentina , Relaciones Médico-Paciente , Atención Primaria de Salud/estadística & datos numéricos , Estudios Retrospectivos , Atención Dirigida al Paciente , Medicina Familiar y Comunitaria , Servicios de Salud/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos
11.
AIDS Patient Care STDS ; 35(1): 9-14, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33347344

RESUMEN

Young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) face multiple psychosocial stressors, and are disproportionately impacted by HIV. Mental health care engagement is a promising avenue for addressing these disparities. To date, rates of mental health service utilization have not been examined specifically in this population. We conducted a retrospective cohort study among YB-GBMSM receiving care in a Ryan White-funded HIV care center that includes co-located HIV and mental health services. Of 435 unique YB-GBMSM patients, mental health concerns were identified in n = 191 (43.9%). Depressive symptoms were the most common concerns identified, followed by substance use, anxiety, and trauma. Among patients with identified mental health concerns who were not previously in mental health care, 79.1% were referred to mental health care, 56.3% set an appointment with a mental health provider, 40.5% were linked to mental health care (attended an initial visit), and 19.6% remained engaged in mental health care. Younger YB-GBMSM (age 18-24 years), who received care in a more integrated pediatric/adolescent part of the center, were more likely to have an appointment set once a concern was identified (χ2 = 7.17; p = 0.007). Even in a setting with co-located HIV and mental health care services, we found significant gaps in engagement at each stage of a newly described mental health care continuum. Implications for intervention at the provider and systems levels are discussed.


Asunto(s)
Grupo de Ascendencia Continental Africana/estadística & datos numéricos , Bisexualidad/psicología , Infecciones por VIH/tratamiento farmacológico , Homosexualidad Masculina/psicología , Seguro de Salud/estadística & datos numéricos , Servicios de Salud Mental/estadística & datos numéricos , Adolescente , Adulto , Afroamericanos/psicología , Afroamericanos/estadística & datos numéricos , Grupo de Ascendencia Continental Africana/psicología , Anciano , Bisexualidad/etnología , Niño , Infecciones por VIH/etnología , Homosexualidad Masculina/etnología , Humanos , Masculino , Estudios Retrospectivos , Minorías Sexuales y de Género , Estados Unidos , Adulto Joven
12.
Ann Intern Med ; 174(2): 200-208, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33347769

RESUMEN

BACKGROUND: Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries. OBJECTIVE: To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA). DESIGN: Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016. SETTING: LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals. PATIENTS: 184 922 patients with MA or commercial insurance. MEASUREMENTS: Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers. RESULTS: Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; P = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; P = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status. LIMITATION: Nonrandomized studies are subject to residual confounding and selection. CONCLUSION: Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage. PRIMARY FUNDING SOURCE: Leonard Davis Institute of Health Economics at the University of Pennsylvania.


Asunto(s)
Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Rodilla/economía , Seguro de Salud/estadística & datos numéricos , Medicare/estadística & datos numéricos , Mecanismo de Reembolso/estadística & datos numéricos , Anciano , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Episodio de Atención , Planes de Aranceles por Servicios , Femenino , Gastos en Salud/estadística & datos numéricos , Humanos , Seguro de Salud/economía , Seguro de Salud/organización & administración , Tiempo de Internación/estadística & datos numéricos , Masculino , Medicare/economía , Medicare/organización & administración , Mecanismo de Reembolso/organización & administración , Resultado del Tratamiento , Estados Unidos , Programas Voluntarios/economía , Programas Voluntarios/organización & administración , Programas Voluntarios/estadística & datos numéricos
13.
J Urol ; 205(1): 115-121, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32658588

RESUMEN

PURPOSE: Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer. MATERIALS AND METHODS: This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020. RESULTS: In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p <0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p <0.05). Race and comorbidities were not associated with active surveillance. CONCLUSIONS: Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.


Asunto(s)
Disparidades en el Estado de Salud , Disparidades en Atención de Salud/estadística & datos numéricos , Neoplasias de la Próstata/terapia , Espera Vigilante/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Disparidades en Atención de Salud/economía , Humanos , Cobertura del Seguro/economía , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/economía , Seguro de Salud/estadística & datos numéricos , Calicreínas/sangre , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Estadificación de Neoplasias , Próstata/patología , Antígeno Prostático Específico/sangre , Prostatectomía/economía , Prostatectomía/estadística & datos numéricos , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/diagnóstico , Neoplasias de la Próstata/patología , Radioterapia/economía , Radioterapia/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Factores Socioeconómicos , Espera Vigilante/economía
14.
J Urol ; 205(1): 257-263, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32716676

RESUMEN

PURPOSE: Among some populations access to neonatal circumcision has become increasingly limited despite evidence of its benefits. This study examines national neonatal circumcision trends before and after the 2012 American Academy of Pediatrics recommendation for neonatal circumcision reimbursement. MATERIALS AND METHODS: A retrospective cohort study of boys aged 28 days or less was conducted using data from the Kids' Inpatient Database (2003 to 2016). Boys who underwent neonatal circumcision prior to discharge were compared to boys who did not. Boys with coagulopathies, penile anomalies or a history of prematurity were excluded. RESULTS: An estimated 8,038,289 boys comprised the final cohort. Boys were primarily White (53.7%), privately insured (49.1%) and cared for at large (60.8%) teaching (49.4%) hospitals in metropolitan areas (84.1%). While 55.0% underwent circumcision prior to discharge, neonatal circumcision rates decreased significantly over time (p <0.0001). Black (68.0%) or White (66.0%) boys, boys in the highest income quartile (60.7%) and Midwestern boys (75.0%) were most likely to be circumcised. Neonatal circumcision was significantly more common among privately (64.9%) than publicly (44.6%) insured boys after controlling for demographics, region, hospital characteristics and year (p <0.0001). The odds of circumcision over time were not significantly different in the years before vs after 2012 (p=0.28). CONCLUSIONS: Among approximately 8 million boys sampled over a 13-year period 55.0% underwent neonatal circumcision. The rate of neonatal circumcision varied widely by region, race and socioeconomic status. The finding that boys with public insurance have lower circumcision rates in all years may be related to lack of circumcision access for boys with public insurance.


Asunto(s)
Circuncisión Masculina/tendencias , Accesibilidad a los Servicios de Salud/economía , Disparidades en Atención de Salud/economía , Afroamericanos/estadística & datos numéricos , Circuncisión Masculina/economía , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Geografía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/tendencias , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/tendencias , Humanos , Recién Nacido , Cobertura del Seguro/economía , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/economía , Seguro de Salud/estadística & datos numéricos , Masculino , Estudios Retrospectivos , Clase Social , Estados Unidos
15.
J Urol ; 205(1): 213-218, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32856985

RESUMEN

PURPOSE: Neurogenic lower urinary tract dysfunction is a significant source of morbidity for individuals with spinal cord injury and is managed with a range of treatment options that differ in efficacy, tolerability and cost. The effect of insurance coverage on bladder management, symptoms and quality of life is not known. We hypothesized that private insurance is associated with fewer bladder symptoms and better quality of life. MATERIALS AND METHODS: This is a cross-sectional, retrospective analysis of 1,226 surveys collected as part of the prospective Neurogenic Bladder Research Group SCI Registry. We included patients with complete insurance information, which was classified as private or public insurance. The relationship between insurance and bladder management, bladder symptoms and quality of life was modeled using multinomial logistic regression analysis. Spinal cord injury quality of life was measured by the Neurogenic Bladder Symptom Score. RESULTS: We identified 654 privately insured and 572 publicly insured individuals. The demographics of these groups differed by race, education, prevalence of chronic pain and bladder management. Publicly insured patients were more likely to be treated with indwelling catheters or spontaneous voiding and less likely to take bladder medication compared to those with private insurance. On multivariate analysis insurance type was not associated with differences in bladder symptoms (total Neurogenic Bladder Symptom Score) or in urinary quality of life. CONCLUSIONS: There is an association between insurance coverage and the type of bladder management used following spinal cord injury, as publicly insured patients are more likely to be treated with indwelling catheters. However, insurance status, controlling for bladder management, did not impact bladder symptoms or quality of life.


Asunto(s)
Disparidades en Atención de Salud/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Satisfacción del Paciente/estadística & datos numéricos , Traumatismos de la Médula Espinal/complicaciones , Vejiga Urinaria Neurogénica/terapia , Adulto , Catéteres de Permanencia/economía , Catéteres de Permanencia/estadística & datos numéricos , Estudios Transversales , Femenino , Disparidades en Atención de Salud/economía , Humanos , Cobertura del Seguro/economía , Seguro de Salud/economía , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente/economía , Estudios Prospectivos , Calidad de Vida , Estudios Retrospectivos , Traumatismos de la Médula Espinal/economía , Traumatismos de la Médula Espinal/terapia , Resultado del Tratamiento , Vejiga Urinaria/inervación , Vejiga Urinaria/fisiopatología , Vejiga Urinaria Neurogénica/diagnóstico , Vejiga Urinaria Neurogénica/economía , Vejiga Urinaria Neurogénica/etiología , Cateterismo Urinario/economía , Cateterismo Urinario/estadística & datos numéricos
16.
JAMA Netw Open ; 3(12): e2030214, 2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-33337495

RESUMEN

Importance: Sexual and reproductive health services are a primary reason for care seeking by female young adults, but the association of the 2010 Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE) with insurance use for these services has not been studied to our knowledge. Insurer billing practices may compromise dependent confidentiality, potentially discouraging dependents from using insurance or obtaining care. Objective: To evaluate the association between implementation of ACA-DCE and insurance use for confidential sexual and reproductive health services by female young adults newly eligible for parental coverage. Design, Setting, and Participants: For this cross-sectional study, a difference-in-differences analysis of a US national sample of commercial claims from January 1, 2007, to December 31, 2009, and January 1, 2011, to December 31, 2016, captured insurance use before and after policy implementation among female young adults aged 23 to 25 years (treatment group) who were eligible for dependent coverage compared with those aged 27 to 29 years (comparison group) who were ineligible for dependent coverage. Data were analyzed from January 2019 to February 2020. Exposures: Eligibility for parental coverage under the ACA-DCE as of 2010. Main Outcomes and Measures: Probability of insurance use for contraception and Papanicolaou testing. Emergency department and well visits were included as control outcomes not sensitive to confidentiality concerns. Linear probability models adjusted for age, plan type, annual deductible, comorbidities, and state and year fixed effects, with SEs clustered at the state level. Results: The study sample included 4 690 699 individuals (7 268 372 person-years), with 2 898 275 in the treatment group (mean [SD] age, 23.7 [0.8] years) and 1 792 424 in the comparison group (mean [SD] age; 27.9 [0.8] years). Enrollees in the treatment group were less likely to have a comorbidity (77.3% vs 72.9%) and more likely to have a high deductible plan (14.6% vs 10.1%) than enrollees in the comparison group. Implementation of the ACA-DCE was associated with a -2.9 (95% CI, -3.4 to -2.4) percentage point relative reduction in insurance use for contraception and a -3.4 (95% CI, -3.9 to -3.0) percentage point relative reduction in Papanicolaou testing in the treatment vs comparison groups. Emergency department and well visits increased 0.4 (95% CI, 0.2-0.7) and 1.7 (95% CI, 1.3-2.1) percentage points, respectively. Conclusions and Relevance: The findings suggest that implementation of the ACA-DCE was associated with a reduction in insurance use for sexual and reproductive health services and an increase in emergency department and well health visits by female young adults newly eligible for parental coverage. Some young people who gained coverage under the expansion may not be using essential, confidential services.


Asunto(s)
Cobertura del Seguro/tendencias , Seguro de Salud , Servicios de Salud Reproductiva , Salud Sexual , Servicios de Salud para Mujeres , Anticoncepción/estadística & datos numéricos , Estudios Transversales , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Revisión de Utilización de Seguros , Seguro de Salud/organización & administración , Seguro de Salud/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Prueba de Papanicolaou/estadística & datos numéricos , Patient Protection and Affordable Care Act , Servicios de Salud Reproductiva/economía , Servicios de Salud Reproductiva/estadística & datos numéricos , Salud Sexual/economía , Salud Sexual/estadística & datos numéricos , Estados Unidos , Servicios de Salud para Mujeres/economía , Servicios de Salud para Mujeres/estadística & datos numéricos , Adulto Joven
17.
PLoS One ; 15(12): e0243810, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33338071

RESUMEN

BACKGROUND: There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: To assess the influence of insurance status on STEMI outcomes. METHODS: Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000-2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition. RESULTS: Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53-57 years), more often female (46% vs. 20-36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1-6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11-1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94-0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72-0.75]) and other insurance (aOR 0.91 [95% CI 0.88-0.94]); all p<0.001. Coronary angiography (60% vs. 77-82%) and PCI (45% vs. 63-70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home. CONCLUSIONS: Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.


Asunto(s)
Seguro de Salud/estadística & datos numéricos , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/economía , Anciano , Femenino , Humanos , Masculino , Medicaid/estadística & datos numéricos , Persona de Mediana Edad , Pronóstico , Estados Unidos
18.
Medicine (Baltimore) ; 99(46): e22410, 2020 Nov 13.
Artículo en Inglés | MEDLINE | ID: mdl-33181639

RESUMEN

Despite the enormous burden on patients with severe psoriasis, their utilization of medical care is not well understood in Korea.To compare the characteristics and treatment patterns of psoriasis patients by economic status as well as to examine the factors influencing systemic treatments of psoriasis.We conducted a descriptive cross-sectional study using National Health Insurance sample cohort data in 2015. Psoriasis patients were classified as either the "topical treatment only" or the "systemic treatment" group based on the types of treatment. Patients' economic status was defined by the deciles of health insurance premium, which was determined based on income and assets. Multivariate logistic regression analysis was performed to examine the factors influencing systemic treatments of psoriasis.We identified 6041 psoriasis patients; 39.5% were in the bottom 5 deciles of health insurance premium and 60.5% were in the top 5 deciles. Only 1.9% of the low economic status group and 4.0% of the high economic status group were treated with expensive biologics, although the difference was not statistically significant.Overall, psoriasis patients with higher economic status had a lower likelihood of receiving systemic treatments but had a higher probability of being treated with expensive biologics.


Asunto(s)
Psoriasis/terapia , Factores Socioeconómicos , Adulto , Estudios Transversales , Femenino , Accesibilidad a los Servicios de Salud/normas , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Seguro de Salud/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Psoriasis/epidemiología , Calidad de la Atención de Salud/normas , Calidad de la Atención de Salud/estadística & datos numéricos , República de Corea/epidemiología
19.
N C Med J ; 81(6): 370-376, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33139466

RESUMEN

Prior to the passage of the Affordable Care Act, many individuals across the state and country faced numerous barriers to accessing affordable and quality health care. This paper provides a review of health coverage in North Carolina before the ACA, the impact the ACA has had on access to health care, and how North Carolina could continue to benefit from "complete" implementation of the ACA.


Asunto(s)
Patient Protection and Affordable Care Act , Humanos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , North Carolina , Estados Unidos
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