Health Care Access and Utilization and the Latino Health Paradox.

BACKGROUND: The Latino health paradox is the phenomenon whereby recent Latino immigrants have, on average, better health outcomes on some indicators than Latino immigrants who have lived in the United States longer and US-born Latinos and non-Latino Whites. This study examined whether the paradox holds after accounting for health care access and utilization. METHODS: The 2019-2020 National Health Interview Survey data were used. The main predictors included population groups of foreign-born and US-born Latinos (Mexican or non-Mexican) versus US-born non-Latino Whites. Predicted probabilities of health outcomes (self-reported poor/fair health, overweight/obesity, hypertension, coronary heart disease, diabetes, cancer, and depression) were calculated and stratified by length of residence in the United States (<15 or ≥15 years) among foreign-born Latinos and sex (female or male). Multivariable analyses adjusted for having a usual source of care other than the emergency department, health insurance, a doctor visit in the past 12 months, predisposing and enabling factors, and survey year. RESULTS: After adjusting for health care access, utilization, and predisposing and enabling factors, foreign-born Latinos, including those living in the United States ≥15 years, had lower predicted probabilities for most health outcomes than US-born non-Latino Whites, except overweight/obesity and diabetes. US-born Latinos had higher predicted probabilities of overweight/obesity and diabetes and a lower predicted probability of depression than US-born non-Latino Whites. CONCLUSIONS: In this national survey, the Latino health paradox was observed after adjusting for health care access and utilization and predisposing and enabling factors, suggesting that, although these are important factors for good health, they do not necessarily explain the paradox.

Racial Differences in Treatment Intensity at the End of Life Among Older Adults with Heart Failure: Evidence from the Health and Retirement Study.

Background: Black Americans experience the highest prevalence of heart failure (HF) and the worst clinical outcomes of any racial or ethnic group, but little is known about end-of-life care for this population. Objective: Compare treatment intensity between Black and White older adults with HF near the end of life. Design: Negative binomial and logistic regression analyses of pooled, cross-sectional data from the Health and Retirement Study (HRS). Setting/Subjects: A total of 1607 U.S. adults aged 65 years and older with HF who identify as Black or White, and whose proxy informant participated in an HRS exit interview between 2002 and 2016. Measurements: We compared four common measures of treatment intensity at the end of life (number of hospital admissions, receipt of care in an intensive care unit (ICU), utilization of life support, and whether the decedent died in a hospital) between Black and White HF patients, controlling for demographic, social, and health characteristics. Results: Racial identity was not significantly associated with the number of hospital admissions or admission to an ICU in the last 24 months of life. However, Black HF patients were more likely to spend time on life support (odds ratio [OR] = 2.16, confidence interval [CI] = 1.35-3.44, p = 0.00) and more likely to die in a hospital (OR = 1.53, CI = 1.03-2.28, p = 0.04) than White HF patients. Conclusion: Black HF patients were more likely to die in a hospital and to spend time on life support than White HF patients. Thoughtful and consistent engagement with HF patients regarding treatment preferences is an important step in addressing inequities.

Differences in use of high- and low-value health care between immigrant and US-born adults.

OBJECTIVE: To examine differences in the use of high- and low-value health care between immigrant and US-born adults. DATA SOURCE: The 2007-2019 Medical Expenditure Panel Survey. STUDY DESIGN: We split the sample into younger (ages 18-64 years) and older adults (ages 65 years and over). Our outcome measures included the use of high-value care (eight services) and low-value care (seven services). Our key independent variable was immigration status. For each outcome, we ran regressions with and without individual-level characteristics. DATA COLLECTION/EXTRACTION METHODS: N/A. PRINCIPAL FINDINGS: Before accounting for individual-level characteristics, the use of high- and low-value care was lower among immigrant adults than US-born adults. After accounting for individual-level characteristics, this difference decreased in both groups of younger and older adults. For high-value care, significant differences were observed in five services and the direction of the differences was mixed. The use of breast cancer screening was lower among immigrant than US-born younger and older adults (-5.7 [95% CI: -7.4 to -3.9] and -2.9 percentage points [95% CI: -5.6 to -0.2]) while the use of colorectal cancer screening was higher among immigrant than US-born younger and older adults (2.6 [95% CI: 0.5 to 4.8] and 3.6 [95% CI: 0.2 to 7.0] percentage points). For low-value care, we did not identify significant differences except for antibiotics for acute upper respiratory infection among younger adults and opioids for back pain among older adults (-3.5 [95% CI: -5.5 to -1.5] and -3.8[95% CI: -7.3 to -0.2] percentage points). Particularly, differences in socioeconomic status, health insurance, and care access between immigrant and US-born adults played a key role in accounting for differences in the use of high- and low-value health care. The use of high-value care among immigrant and US-born adults increased over time, but the use of low-value care did not decrease. CONCLUSION: Differential use of high- and low-value care between immigrant and US-born adults may be partly attributable to differences in individual-level characteristics, especially socioeconomic status, health insurance, and access to care.

A Systematic Literature Review of Hispanic Adults' Experiences With the Emergency Medical Services System in the United States Between 2000 and 2021.

OBJECTIVE: This systematic literature review presents an overview of studies that assess the experiences of Hispanic adults with (1) activation of emergency medical services (EMS); (2) on-scene care provided by EMS personnel; (3) mode of transport (EMS vs. non-EMS) to an emergency department (ED); and (4) experiences with EMS before and during the COVID-19 pandemic. METHODS: A bibliographic database search was conducted to identify relevant studies on Ovid MEDLINE (PubMed), Web of Science, EMBASE, and CINAHL. Quantitative, mixed methods, and qualitative studies published in English or Spanish were included if they discussed Hispanic adults' experiences with EMS in the US between January 1, 2000 and December 31, 2021. The Hawker and colleagues quality assessment instrument was used to evaluate the quality of studies. RESULTS: Of the 43 included studies, 13 examined EMS activation, 13 assessed on-scene care, 22 discussed the mode of transport to an ED, and 4 described Hispanic adults' experiences with EMS during the COVID-19 pandemic. Hispanics were less likely to activate EMS (N=7), less likely to receive certain types of on-scene care (N=6), and less likely to use EMS as the mode of transport to an ED (N=13), compared with non-Hispanic Whites. During the early COVID-19 pandemic period (March to May 2020), EMS use decreased by 26.5% compared with the same months during the previous 4 years. CONCLUSIONS: The contribution of this study is its attention to Hispanic adults' experiences with the different phases of the US EMS system.

Injury-Related Emergency Medical Service Calls, Traffic Accidents, and Crime in Mexico City Before and During the COVID-19 Pandemic.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic had detrimental impacts across multiple sectors of the Mexican health care system. The prehospital care system, however, remains largely under-studied. The first objective of this study was to calculate the monthly per capita rates of injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) during the early pandemic period (January 1 through June 30, 2020), while the second objective was to conduct these calculations at the borough-level for the same outcomes and time period. The third objective was to compare monthly per capita rates of injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) during the pre-pandemic (January 1 through June 30, 2019), early pandemic (January 1 through June 30, 2020), and later pandemic periods (January 1 through June 30, 2021). METHODS: A retrospective analysis was conducted to examine injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) and borough-levels. Monthly per capita rates were calculated using four datasets, including Mexico City's Public Release 9-1-1 Emergency Calls, National Institute of Statistics and Geography's (INEGI) Traffic Accidents Micro-Dataset, Mexico City's Attorney General's Office Crime Dataset, and Projections of the Population of the Municipalities of Mexico, 2015 to 2030. All statistical analyses were conducted using STATA 17.0. RESULTS: During the early pandemic period, injury-related 9-1-1 emergency calls, traffic accidents, and crime experienced similar trends in monthly per capita rates at the state-level and borough-levels. While the monthly per capita rates remained constant from January to March 2020, starting in March, there was a precipitous decrease across all three outcomes, although decline rates varied across boroughs. The monthly per capita rates across the three outcomes were higher during the pre-pandemic period compared to the early pandemic period. As the COVID-19 pandemic progressed, the monthly per capita rates during the later pandemic period increased across the three outcomes compared to the early pandemic period, although they did not reach pre-pandemic levels during the study period. CONCLUSION: The precipitous decline in injury-related 9-1-1 calls, traffic accidents, and crime in Mexico City occurred at the same time as the issuance of the first wave of public health orders in March 2020. The largest decrease across the three outcomes occurred one to two months post-issuance of the orders.

The Affordable Care Act and Health Care Access and Utilization Among White, Asian, and Latino Immigrants in California.

OBJECTIVE: The objective of this study was to examine changes in health care access and utilization for White, Asian, and Latino immigrants associated with the implementation of the Patient Protection and Affordable Care Act (ACA) in California. STUDY DESIGN: Using the 2011-2013 and 2015-2017 California Health Interview Survey, we examined changes in 2 health care access and 2 utilization measures among 3 immigrant racial/ethnic groups. We estimated the unadjusted and adjusted percentage point changes in the pre-ACA and post-ACA periods. Adjusted estimates were obtained using linear probability models controlling for predisposing, enabling, and need factors. RESULTS: After the ACA was nationally implemented in 2014, rates of insurance increased for non-Latino (NL) White, NL Asian, and Latino immigrant groups in California. Latino immigrants had the largest increase in insurance coverage (14.3 percentage points), followed by NL Asian immigrants (9.9 percentage points) and NL White immigrants (9.2 percentage points). Despite benefitting from the largest increase in insurance coverage, the proportion of insured Latino immigrants was still lower than that of NL White and NL Asian immigrants. Latino immigrants reported a small but significant decrease in the usual source of care (-2.8 percentage points) and an increase in emergency department utilization (2.9 percentage points) after the ACA. No significant changes were found after the ACA in health care access and utilization among NL White and NL Asian immigrants. CONCLUSIONS: Insurance coverage increased significantly for these 3 immigrant groups after the ACA. While Latino immigrants had the largest gain in insurance coverage, the proportion of Latino immigrants with insurance remained the lowest among the 3 immigrant racial/ethnic groups.

Changing Hearts and Plates: The Effect of Animal-Advocacy Pamphlets on Meat Consumption.

Social movements have driven large shifts in public attitudes and values, from anti-slavery to marriage equality. A central component of these movements is moral persuasion. We conduct a randomized-controlled trial of pro-vegan animal-welfare pamphlets at a college campus. We observe the effect on meat consumption using an individual-level panel data set of approximately 200,000 meals. Our baseline regression results, spanning two academic years, indicate that the pamphlet had no statistically significant long-term aggregate effects. However, as we disaggregate by gender and time, we find small statistically significant effects within the semester of the intervention: a 2.4 percentage-point reduction in poultry and fish for men and a 1.6 percentage-point reduction in beef for women. The effects disappear after 2 months. We merge food purchase data with survey responses to examine mechanisms. Those participants who (i) self-identified as vegetarian, (ii) reported thinking more about the treatment of animals or (iii) expressed a willingness to make big lifestyle changes reduced meat consumption during the semester of the intervention. Though we find significant effects on some subsamples in the short term, we can reject all but small treatment effects in the aggregate.

Preferences of adults with spinal cord injury for widely used health-related quality of life and subjective well-being measures.

OBJECTIVE: To describe preferences for survey instruments on health-related quality of life (HRQOL) and subjective well-being (SWB) among adults with spinal cord injury (SCI), and compare perspectives on the instruments between the United States and the United Kingdom. DESIGN: We conducted 20 in-depth interviews. SETTING: Participants were interviewed in their homes, some in person and some via Skype. PARTICIPANTS: A convenience sample of 20 adults with SCI (10 in the US and 10 in the UK) were recruited via print and on-line advertisements. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Interviewees reviewed six instruments and rated how important it was for their medical providers to know answers to each survey. Two coders analyzed verbatim transcriptions independently using an inductive approach. Keyword-in-context (KWIC) analysis identified the most frequently used words by interviewees to discuss the merits of each instrument. RESULTS: Participants in both samples identified the Fatigue Severity Scale (FSS) as "vital" that their medical providers know about it. This was followed by the Spinal Cord Injury Independence Measure III, and a stand-alone Eudaimonic Well-Being question. The KWIC analysis showed that the most distinctive words used to discuss FSS were "fatigue" and "pain." CONCLUSIONS: Understanding what HRQOL and SWB measures are valued by adults living with SCI can lead to selection of informative instruments, which could help clinicians to complement and tailor established care and rehabilitation protocols for individual needs. Participants identified fatigue as a significant issue, and the FSS as a vitally important instrument to share with medical providers.

The impact of integrating medical assistants and community health workers on diabetes care management in community health centers.

OBJECTIVE: To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients' experiences of chronic care. DATA SOURCES: Clinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation. STUDY DESIGN: A three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects. PRINCIPAL FINDINGS: Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (ß=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs. CONCLUSIONS: Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.

Health Care Access and Physical and Behavioral Health Among Undocumented Latinos in California.

BACKGROUND: This paper provides statewide estimates on health care access and utilization patterns and physical and behavioral health by citizenship and documentation status among Latinos in California. METHODS: This study used data from the 2011-2015 California Health Interview Survey to examine health care access and utilization and physical and behavioral health among a representative sample of all nonelderly Latino and US-born non-Latino white adults (N=51,386). Multivariable regressions estimated the associations between the dependent measures and citizenship/documentation status among Latinos (US-born, naturalized citizen, green card holder, and undocumented). RESULTS: Adjusted results from multivariable analyses observed worse access and utilization patterns among immigrant Latinos compared with US-born Latinos, with undocumented immigrants using significantly less health care. Undocumented Latinos had lower odds of self-reporting excellent/very good health status compared with US-born Latinos, despite them having lower odds of having several physical and behavioral health outcomes (overweight/obesity, physician-diagnosed hypertension, asthma, self-reported psychological distress, and need for behavioral health services). Among those reporting a need for behavioral health services, access was also worse for undocumented Latinos when compared with US-born Latinos. CONCLUSIONS: Patterns of poor health care access and utilization and better physical and behavioral health are observed across the continuum of documentation status, with undocumented immigrants having the worst access and utilization patterns and less disease. Despite fewer reported diagnoses and better mental health, undocumented Latinos reported poorer health status than their US-born counterparts.

Lower barriers to primary care after the implementation of the Affordable Care Act in the United States of America

[ABSTRACT]. Objective. To examine short-term changes in perceived barriers to access to primary care before and after implementation of the Affordable Care Act (ACA) among adults in the United States of America. Methods. The ACA was approved in 2010. We used the National Health Interview Survey (NHIS) for the years 2011-2014 to compare the main reported problems in accessing primary care among adult respondents in 2011-2013 (before implementation of mandatory ACA health insurance for individuals) and in 2014 (after that implementation). A multivariate logistic stepwise regression analysis was used to identify trends with primary care barriers. Results. We found that from 2010 through 2014, individuals were progressively less likely to report challenges to accessing care, such as having trouble finding a provider, getting accepted as new patients, and health care providers not accepting their health insurance. In addition, adults were less likely to report inconveniences linked to waiting times for an appointment and with provider’s office hours. Conclusions. Informing policymakers, providers, and system administrators about the short-term changes in perceived barriers to care offers a baseline for evaluating policies and programs linked to implementing the ACA, as well as assessing how prepared primary care networks were for the influx of newly insured patients. Nevertheless, the abolition of the ACA health insurance mandate through legislation approved in December 2017 has put into question whether patients’ perceptions of improved access to care will be sustained in the future.

[RESUMEN]. Objetivo. Analizar los cambios a corto plazo en las barreras percibidas al acceso a la atención primaria en los adultos en los Estados Unidos de América antes y después de la entrada en vigor de la Ley de Atención Asequible (ACA por su sigla en inglés). Métodos. La ley ACA se aprobó en el 2010. Usamos la Encuesta Nacional de Salud por Entrevistas (NHIS) de los años 2011 al 2014 a fin de comparar los principales problemas mencionados para obtener acceso a la atención primaria por los adultos entrevistados del 2011 al 2013 (antes de la entrada en vigor del seguro de salud obligatorio para las personas de conformidad con la ACA) y en el 2014 (después de que entrase en vigor). Se usó un análisis de regresión logística por pasos con múltiples variables para determinar las tendencias en las barreras a la atención primaria. Resultados. Encontramos que, del 2010 al 2014, fue progresivamente menos probable que las personas notificaran obstáculos para obtener acceso a la atención, como dificultades para encontrar un prestador o ser aceptados como nuevos pacientes, y que los prestadores de atención de salud no aceptaran su seguro de salud. Además, fue menos probable que los adultos notificaran problemas por los períodos de espera para una cita y las horas de oficina de los prestadores. Conclusiones. Informar a los responsables de las políticas, a los prestadores y a los administradores de los sistemas acerca de los cambios a corto plazo en las barreras percibidas a la atención ofrece un punto de referencia para evaluar las políticas y programas vinculados a la aplicación de la ACA, así como para evaluar cuán preparadas estaban las redes de atención primaria para la afluencia de pacientes recién asegurados. No obstante, la abolición del mandato del seguro de salud de la ACA por la legislación aprobada en diciembre del 2017 ha puesto en entredicho si las percepciones de los pacientes de un mejor acceso a la atención se mantendrán en el futuro.

[RESUMO]. Objetivo. Examinar as mudanças a curto prazo nas barreiras percebidas entre adultos ao acesso à atenção primária antes e depois da execução da Lei de Serviços de Saúde Acessíveis (Affordable Care Act, ACA) nos Estados Unidos. Métodos. A ACA foi aprovada em 2010. Este estudo se baseou em dados obtidos da pesquisa nacional de saúde (National Health Interview Survey, NHIS) para os anos 2011–2014 para comparar os principais problemas referidos pelos participantes adultos para obter acesso à atenção primária em 2011–2013 (antes da execução do seguro de saúde obrigatório exigido pela ACA) e em 2014 (depois da execução da lei). Foi realizada uma análise de regressão logística multivariada com o método stepwise para identificar as tendências nas barreiras à atenção primária. Resultados. Verificou-se que, de 2010 a 2014, os participantes tenderam gradativamente a informar menos ter dificuldades de acesso à atenção, como ter dificuldade em encontrar um prestador de serviço, ser aceito como novo paciente e prestadores de serviços de saúde que não aceitam o seguro de saúde do paciente. Além disso, eles tenderam a informar menos os inconvenientes relacionados ao tempo de espera para consultas e ao horário de atendimento dos serviços. Conclusões. Informar os responsáveis por políticas, prestadores de serviços e administradores do sistema sobre as mudanças a curto prazo nas barreiras percebidas à atenção serve de referência para avaliar as políticas e programas vinculados à execução da ACA e determinar se as redes de atenção primária têm condições adequadas para atender os novos usuários segurados. Contudo, a extinção do mandato de seguro de saúde da ACA, com a legislação aprovada em dezembro de 2017, põe em dúvida se a percepção de melhora no acesso à atenção por parte dos pacientes persistirá futuramente.

Development and Psychometric Evaluation of a Fatigability Index for Full-Time Wheelchair Users With Spinal Cord Injury.

OBJECTIVE: To develop and evaluate psychometrically a self-reported instrument assessing physical fatigability (PF) and mental fatigability (MF) in adults with spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Peer-support groups at rehabilitation centers, online support groups. PARTICIPANTS: Adults with SCI (N=464) in the United States. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The dimensional structure was assessed by confirmatory factor analysis. The relationship between item responses and fatigability was measured with item response theory (graded response model). Reliability was measured with test information functions. Differential item functioning was evaluated with Wald chi-square tests and the weighted area between the curves. Construct validity was assessed using the known groups method. RESULTS: An 82-item pool was developed from prior qualitative research and consultations with rehabilitation experts. A non-probability sample (N=464) was used to evaluate the psychometric properties of the PF and MF scales. The item pool was reduced to 75 based on factor loadings and R2. Both scales are primarily unidimensional, despite moderate multidimensionality. There is good discrimination overall: 18 PF items and 26 MF items have high or very high discrimination power (slopes > 1.35). The measurement precision in the theta range -2.0 to 2.5 is the equivalent of 0.94 reliability for PF and 0.91 for MF. For both measures, F statistics P values were significant at P<.01, and means were higher for those with paraplegia vs quadriplegia, and for those with incomplete paraplegia. CONCLUSIONS: The Fatigability Index is the first instrument designed to assess physical and mental fatigability in adults with SCI. The index highlights causes of fatigue and areas requiring immediate intervention. Development of short-forms and further research on representative samples are necessary.

Comparing the Income Elasticity of Health Spending in Middle-Income and High-Income Countries: The Role of Financial Protection.

BACKGROUND: As middle-income countries become more affluent, economically sophisticated and productive, health expenditure patterns are likely to change. Other socio-demographic and political changes that accompany rapid economic growth are also likely to influence health spending and financial protection. METHODS: This study investigates the relationship between growth on per-capita healthcare expenditure and gross domestic product (GDP) in a group of 27 large middle-income economies and compares findings with those of 24 high-income economies from the Organization for Economic Cooperation and Development (OECD) group. This comparison uses national accounts data from 1995-2014. We hypothesize that the aggregated income elasticity of health expenditure in middle-income countries would be less than one (meaning healthcare is a normal good). An initial exploratory analysis tests between fixed-effects and random-effects model specifications. A fixed-effects model with time-fixed effects is implemented to assess the relationship between the two measures. Unit root, Hausman and serial correlation tests are conducted to determine model fit. Additional explanatory variables are introduced in different model specifications to test the robustness of our regression results. We include the out-of-pocket (OOP) share of health spending in each model to study the potential role of financial protection in our sample of high- and middle-income countries. The first-difference of study variables is implemented to address non-stationarity and cointegration properties. RESULTS: The elasticity of per-capita health expenditure and GDP growth is positive and statistically significant among sampled middle-income countries (51 per unit-growth in GDP) and high-income countries (50 per unit-growth in GDP). In contrast with previous research that has found that income elasticity of health spending in middle-income countries is larger than in high-income countries, our findings show that elasticity estimates can change if different criteria are used to assemble a more homogenous group of middle-income countries. Financial protection differences between middle- and high-income countries, however, are not associated with their respective income elasticity of health spending. CONCLUSION: The study findings show that in spite of the rapid economic growth experienced by the sampled middleincome countries, the aggregated income elasticity of health expenditure in them is less than one, and equals that of high-income countries.

Validation Study of the Abbreviated Version of the Lubben Social Network Scale Spanish Translation among Mexican and Mexican-American Older Adults.

PURPOSE: To perform a face validity study of the Spanish version of the Lubben Social Network Scale (LSNS-6) among Mexican and Mexican-American older adults. DESIGN AND METHODS: A cross-national qualitative descriptive approach, based on cognitive survey testing and cross-cultural equivalence analysis, was followed to assess the face validity of the Spanish version of the LSNS-6. Data were collected through 2 focus groups in Los Angeles (LA) and 4 in Mexico City (CDMX). Focus groups followed a semi-structured guide. Eligibility criteria included being 60 years and older, native Spanish speaking, and not suffering from significant cognitive impairments. Four initial focus groups were targeted at conducting a face validity assessment of the initial scale, which led to some modifications. The two remaining focus groups reassessed the face validity of the modified version of the Spanish LSNS-6. RESULTS: 56 older adults participated in the focus groups yielding 152 pages of verbatim transcripts. Analysis of the transcripts identified relevant themes affecting how Mexican and Mexican American older adults understood the items from the LSNS-6 Spanish version, among them: labelling of family members and friends, notions of neighborhood, identifying and counting people, and understanding of "private matters". This led to propose a modified Spanish version of the LSNS-6 following a name generating approach, as well as some language and instruction modifications. The face validity of the modified version suggested a better understanding. IMPLICATIONS: The study proposes that the LSNS-6 Spanish version needs to be adapted for its use among Mexican and Mexican American older adults, and we suggest a modified version. This potentially implies that social isolation may be more accurately measured in a vulnerable group of older adults. Further research is needed to ascertain the construct validity and psychometric properties of the modified version.

Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers.

OBJECTIVE: To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference. STUDY SETTING/DATA COLLECTION: Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053). STUDY DESIGN: We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups. PRINCIPAL FINDINGS: After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients. CONCLUSIONS: Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.

A comparison of perceptions of quality of life among adults with spinal cord injury in the United States versus the United Kingdom.

PURPOSE: To identify which aspects of life are most important to adults with spinal cord injury (SCI) and compare perspectives in the United States and the United Kingdom. METHODS: We conducted 20 in-depth interviews with adults with SCI (ten in the US and ten in the UK). Verbatim transcriptions were independently analyzed line-by-line by two coders using an inductive approach. Codes were grouped into themes about factors that constitute and affect quality of life (QOL). RESULTS: Five overarching themes emerged: describing QOL in the context of SCI; functional adjustment; medical care; financial resources; and socio-political issues. Twenty subthemes emerged on factors that affect QOL. Participants in both samples identified medical care as a key influence on QOL. The US group talked about a predominantly negative influence (e.g., fragmented primary and specialist care, insurance constraints, bureaucracy), whereas UK interviewees mentioned a predominantly positive influence (e.g., universal provision, including free and continuous care, free wheelchairs and home care, and length of rehabilitation commensurate with level of injury). Functional adjustment, such as physical and mental adjustment post-discharge and aging with SCI, was another important contributor to QOL, and varied by country. Most US interviewees reported poor knowledge about self-care post-discharge and poor quality of home adaptations compared to the UK group. CONCLUSIONS: For adults living with SCI, good QOL is essential for successful rehabilitation. Differences between interviewees from the two countries in perceived medical care and functional adjustment suggest that factors affecting QOL may relate to broader health system characteristics.

Reducing Young Adults' Health Care Spending through the ACA Expansion of Dependent Coverage.

OBJECTIVE: To estimate health care expenditure trends among young adults ages 19-25 before and after the 2010 implementation of the Affordable Care Act (ACA) provision that extended eligibility for dependent private health insurance coverage. DATA SOURCES: Nationally representative Medical Expenditure Panel Survey data from 2008 to 2012. STUDY DESIGN: We conducted repeated cross-sectional analyses and employed a difference-in-differences quantile regression model to estimate health care expenditure trends among young adults ages 19-25 (the treatment group) and ages 27-29 (the control group). PRINCIPAL FINDINGS: Our results show that the treatment group had 14 percent lower overall health care expenditures and 21 percent lower out-of-pocket payments compared with the control group in 2011-2012. The overall reduction in health care expenditures among young adults ages 19-25 in years 2011-2012 was more significant at the higher end of the health care expenditure distribution. Young adults ages 19-25 had significantly higher emergency department costs at the 10th percentile in 2011-2012. Differences in the trends of costs of private health insurance and doctor visits are not statistically significant. CONCLUSIONS: Increased health insurance enrollment as a consequence of the ACA provision for dependent coverage has successfully reduced spending and catastrophic expenditures, providing financial protections for young adults.

Clinic Workload, the Quality of Staff Relationships and Diabetes Management in Community Health Centers Catering to Latino and Chinese Patients.

We examine whether workplace climate-quality of staff relationships (QSR) and manageable clinic workload (MCW) are related to better patient care experiences and diabetes care in community health centers (CHCs) catering to Latino and Chinese patients. Patient experience surveys of adult patients with type 2 diabetes and workplace climate surveys of clinicians and staff from CHCs were included in an analytic sample. Comparisons of means analyses examine patient and provider characteristics. The associations of QSR, MCW and the diabetes care management were examined using regression analyses. Diabetes care process were more consistently provided in CHCs with high quality staff relations and more manageable clinic workload, but HbA1c, LDL cholesterol, and blood pressure outcomes were no different between clinics with high vs. low QSR and MCW. Focusing efforts on improvements in practice climate may lead to more consistent provision of important processes of diabetes care for these patients.

Regulating self-selection into private health insurance in Chile and the United States.

In the 1980s, Chile adopted a mixed (public and private) model for health insurance coverage similar to the one recently outlined by the Affordable Care Act in the United States (US). In such a system, a mix of public and private health plans offer nearly universal coverage using a combined approach of managed competition and subsidies for low-income individuals. This paper uses a "most different" case study design to compare policies implemented in Chile and the US to address self-selection into private insurance. We argue that the implementation of a mixed health insurance system in Chile without the appropriate regulations was complex, and it generated a series of inequities and perverse incentives. The comparison of Chile and the US healthcare reforms examines the different approaches that both countries have used to manage economic competition, address health insurance self-selection and promote solidarity. Copyright © 2015 John Wiley & Sons, Ltd.

Measuring Workplace Climate in Community Clinics and Health Centers.

BACKGROUND: The effectiveness of community clinics and health centers' efforts to improve the quality of care might be modified by clinics' workplace climates. Several surveys to measure workplace climate exist, but their relationships to each other and to distinguishable dimensions of workplace climate are unknown. OBJECTIVE: To assess the psychometric properties of a survey instrument combining items from several existing surveys of workplace climate and to generate a shorter instrument for future use. MATERIALS AND METHODS: We fielded a 106-item survey, which included items from 9 existing instruments, to all clinicians and staff members (n=781) working in 30 California community clinics and health centers, receiving 628 responses (80% response rate). We performed exploratory factor analysis of survey responses, followed by confirmatory factor analysis of 200 reserved survey responses. We generated a new, shorter survey instrument of items with strong factor loadings. RESULTS: Six factors, including 44 survey items, emerged from the exploratory analysis. Two factors (Clinic Workload and Teamwork) were independent from the others. The remaining 4 factors (staff relationships, quality improvement orientation, managerial readiness for change, and staff readiness for change) were highly correlated, indicating that these represented dimensions of a higher-order factor we called "Clinic Functionality." This 2-level, 6-factor model fit the data well in the exploratory and confirmatory samples. For all but 1 factor, fewer than 20 survey responses were needed to achieve clinic-level reliability >0.7. CONCLUSIONS: Survey instruments designed to measure workplace climate have substantial overlap. The relatively parsimonious item set we identified might help target and tailor clinics' quality improvement efforts.