Geographical differences in mortality of severely injured patients in Italy

Background In Italy there are no accepted standards for trauma care nor dedicated programs for quality assessment on a national scale, like trauma registries. At the same time there seems to be a north–south gradient in the quality of health care. We hypothesized that geographical inequalities of health-care quality may affect trauma mortality. Methods Retrospective comparison of hospital mortality by Cox regression in three main areas of Italy adjusted for age, Glasgow Coma Scale and source of admission. A leading national database on patients admitted to intensive care units (ICU) in the years 2002–2005 was used. 9162 adult trauma cases admitted to the ICU from the emergency department were included. Results There is a significant north–south gradient of risk. Compared to the north, the risk of death is about 60% higher in the south and about 30% higher in the central region. These figures are similar in both referral centres and other hospitals and both in the head-injured only and total injured cases. Conclusion Despite the limitations of this study, mainly related to sampling issues, risk-adjustment and incomplete follow-up, the large geographic differences in mortality that we found highlight likely deficiencies in the quality of trauma care that deserve further accurate assessment.     

A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates

OBJECTIVES: We investigated socioeconomic disparities in injury hospitalization rates and severity-adjusted mortality for pediatric trauma. METHODS: We used 10 years of pediatric trauma data from Sacramento County, Calif, to compare trauma hospitalization rates, trauma mechanism and severity, and standardized hospital mortality across socioeconomic strata (median household income, proportion of households in poverty, insurance). RESULTS: Children from lower-socioeconomic status (SES) communities had higher injury hospitalization and mortality rates, and presented more frequently with more lethal mechanisms of injury (pedestrian, firearm), but did not have higher severity-adjusted mortality. CONCLUSIONS: Higher injury mortality rates among children of lower SES in Sacramento County are explained by a higher incidence of trauma and more fatal mechanisms of injury, not by greater injury severity or poorer inpatient care.     

Family planning clinic patients: their usual health care providers, insurance status, and implications for managed care.

PURPOSE: To understand the extent to which family planning clinic patients have health insurance or access to other health care providers, as well as their preferences for clinic versus private reproductive medical care. METHOD: An anonymous self-report questionnaire was administered at three Planned Parenthood clinics in Los Angeles County to 780 female patients aged 12-49 years. Dependent variables included insurance status, usual source of care, and a battery of questions regarding the importance of confidentiality. RESULTS: A total of 356 adolescents (aged 12-19 years) and 424 adults (aged 20-49 years) completed the survey in 1994. Fifty-nine percent of adolescents and 53% of adults had a usual source of care other than the clinic. The majority of each group reported some degree of continuity of care in their usual provider setting. Nearly half (49%) of all adolescents had health insurance compared with 27% of adults. Adolescents cited not wanting to involve family members as the primary reason for not using their usual providers, whereas adults were more likely to cite being uninsured. The majority of both adult and adolescent patients indicate they would prefer the clinic over private health care if guaranteed health care that was free, confidential, or both. CONCLUSION: Despite many patients' having health insurance and other sources of health care, family planning clinics were primarily chosen because of cost and confidentiality. Their reasons for preferring clinics may continue despite changes in access to insurance or efforts to incorporate similar reproductive services into mainstream health care provider systems. Making public or private health care funds available to family planning clinics through contracts or other mechanisms may facilitate patients' access to essential services and reduce potential service duplication.     

Evaluating potential spatial access to trauma center care by severely injured patients

Injuries are a major public health problem around the world. Previous research has suggested that providing prompt access to specialized trauma center care may greatly improve the health outcomes of trauma patients. In this paper, a geographic information system (GIS) method is used to examine potential spatial access to trauma centers by individuals who were either hospitalized or died as a result of a major trauma. Overall, it was determined that 68.5% of individuals who suffered from a major trauma lived within one hour travel time of a Level I or II trauma center. In addition, major traumas resulting in death were found to have poorer potential spatial access to trauma center care than those that were admitted to hospital.     

Prenatal care use and health insurance status.

Many observers explain the prevalence of inadequate prenatal care in the United States by citing demographic or psychosocial factors. But few have evaluated the barriers faced by women with different health insurance status and socioeconomic backgrounds. In this study of 149 women at six hospitals in Minneapolis, insurance status was significantly related to the source of prenatal care (p less than .0001). Private physicians cared for 52 percent of privately insured, 23 percent of Medicaid-insured, and two percent of uninsured women. Public clinics were the primary source of care for Medicaid and uninsured women, who, compared to privately insured women, experienced longer waiting times (p less than .001) during prenatal visits and were more likely (p less than .01) to lack continuity of care with a provider. Multiple measures, including expanding Medicaid eligibility, may help correct these problems.     

Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status

PURPOSE Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness.METHODS Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases.RESULTS Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%–50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%–32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%–18.6%) to 30.1% (95% CI, 18.8%–41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types.CONCLUSIONS: Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave considerable gaps in US health care equity. Health care workforce policy should reflect this important population-level function of primary care.     

Economic status differences in infant mortality by cause of death

Infant mortality differentials in a metropolitan aggregate of eight Ohio cities were examined for the years 1979-81. The primary analytical unit was the census tract of mother's usual residence. The independent variable was defined as the percentage of low-income families in each tract at the 1980 census. Results of the analysis revealed that in spite of some very substantial declines in the overall level of infant mortality in recent decades, there continues to be a pronounced inverse association between the aggregate economic status of an area and the probability that a newborn infant will not survive the first year of life. This inverse association characterizes both males and females, whites as well as nonwhites, and it is observed during both the neonatal and postneonatal age intervals. Moreover, it is apparent that the adverse influence of a low economic status is reflected in the incidence of mortality from all major exogenous and endogenous causes. Since these two cause groups have such different underlying determinants, this finding has important implications for the development and implementation of specific maternal and child health care policies and programs.     

Relationships between welfare status,health insurance status,and health and medical care among children with asthma

OBJECTIVES: This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma. METHODS: Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices. RESULTS: Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured. CONCLUSIONS: Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.     

Medical care and mortality: racial differences in preventable deaths

We analyzed deaths of blacks and whites in Alameda County, California where previous studies have documented consistent racial inequalities in health services. We classified each death during 1978 as due to preventable and manageable conditions or as "non-preventable" according to lists compiled by the Working Group on Preventable and Manageable Diseases chaired by Dr. David Rutstein. The total death rate for blacks 0-65 years of age exceeded that of whites by 58 percent (p less than .01). Rates of death due to preventable and manageable conditions for persons aged 0-65 years were 77 percent higher for blacks than for whites (p less than .01). More than one-third of the excess total death rate of blacks relative to whites could be explained by the excess of potentially preventable deaths. Our findings suggest that inequalities in health services reinforce broader social inequalities and are in part responsible for disparities in health status. Improvements in the health and longevity of blacks and other oppressed groups might be achieved by improved access to existing medical, public health, and other preventive measures.     

Factors associated with hospital mortality in traumatic injuries: incentive for trauma care integration

OBJECTIVES: The main aim of this study was to contrast the variation in mortality between trauma centres (TCs) and non-trauma hospitals (NTHs) in Texas, and among TCs by sociodemographic and economic factors of trauma cases. STUDY DESIGN: Difference in fatality due to trauma by hospital type was studied for all injured cases hospitalized over a 2-year period. METHODS: The outcome measure was mortality following an injury for cases that survived the impact and were treated in any hospital. Logistic regressions were employed to compare the risk factors associated with trauma fatalities between TCs and NTHs, and among TCs. RESULTS: The risk of dying at a TC in contrast to an NTH was higher among young adult males and cases admitted through the emergency department/room. In rural areas, fatality was higher among 25-44 year olds, Hispanics, uninsured patients, and cases admitted through transfer. In urban settings, fatality was higher among 18-24 year olds, patients covered by 'other' insurance, and cases admitted as severe emergencies. Increased mortality at Level I TCs occurred due to the transfer of patients from rural areas. Blacks and Hispanics in rural areas were more likely to die, while Hispanics had lower fatality in Level I TCs in urban areas. Survival time was longer for patients treated in urban TCs compared with rural TCs. CONCLUSION: In the absence of validated data about severity of cases and type of injury, and details about the treatment provided to trauma cases in this study, more investigation is needed into the case-mix of trauma patients admitted to TCs and NTHs. Further exploration is necessary for better co-ordination of the emergency care response to integrate NTHs within the trauma system and alleviate the stress placed on Level I TCs. Revisiting the transfer algorithms could improve clinical outcomes, particularly when TCs are closed due to diversion protocols.     

Switching Swiss enrollees from indemnity health insurance to managed care: the effect on health status and stisfaction with care.

OBJECTIVES. In 1992, most members of a Swiss indemnity health insurance plan were automatically transferred into a newly created managed care organization. This study examined whether this semivoluntary change affected enrollees' health status and satisfaction with care. METHODS. Three groups of enrollees were compared: 332 plan members who accepted the switch (managed care joiners); 186 plan members who opted to maintain indemnity coverage (non-joiners); and 296 persons continuosly enrolled in another indemnity plan (indemnity plan members). Health status, health related behaviors, and satisfaction with care received in the previous year were surveyed at baseline and 1 year later. RESULTS. Health status remained unchanged in all three groups. Smoking prevalence decreased among managed care joiners but remained constant in the other groups. Satisfaction with insurance coverage increased between baseline and follow-up in managed care joiners, but decreased in nonjoiners and indemnity plan members. The latter groups had higher satisfaction with health care, particularly with continuity of care. CONCLUSIONS. A semivoluntary switch from indemnity health insurance to managed care reduced satisfaction with health care but increased satisfaction with insurance coverage. There were no changes in self-perceived health status.     

Impact of long-term home care on mortality, functional status, and unmet needs.

This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.     

Regional differences in perinatal mortality: the relationship with various aspects of perinatal care

Regional differences in perinatal mortality in the period 1980-1984 were studied, and the associations with a number of aspects of perinatal care were investigated: percentage of home deliveries, percentage of deliveries supervised by a gynaecologist, and the presence of a 'level 2' or 'level 3' hospital. The analysis controlled for a number of possible confounding variables. For total perinatal mortality, the stillbirth rate and first-week mortality due to birth injury a negative association was found with the presence of a level 2 hospital. For the stillbirth rate a positive association was found with the percentage of home deliveries. The first-week mortality due to a group of 'other' causes of death was positively associated with the percentage of deliveries supervised by a gynaecologist.     

Changes in insurance status and access to care for persons with AIDS in the Boston Health Study.

The purpose of this study was to measure unmet needs and changes in insurance status for persons with acquired immunodeficiency syndrome (AIDS). Thirty-six percent of the study's Boston-area respondents (n = 305) had a change in insurance coverage between AIDS diagnosis and interview. Medicaid coverage increased from 14% to 41%. Pneumocystis carinii pneumonia prophylaxis was nearly universal. Only 5% did not receive zidovudine, and intravenous drug users were at higher risk. Approximately 14% to 15% of patients reported problems in obtaining medical and dental services; Blacks, homeless persons, and those who were not high school graduates were at higher risk. Use of selected treatments for which there were clear clinical guidelines was adequate, yet disadvantaged groups were more likely than other persons with AIDS to face obstacles to other services.     

Racial differences in colorectal cancer mortality. The importance of stage and socioeconomic status

This investigation studies racial and socioeconomic differences in mortality from colorectal cancer, and how they vary by stage and age at diagnosis. Cox proportional hazards models were used to estimate the hazard ratio of dying from colorectal cancer, controlling for tumor characteristics and sociodemographic factors. Black adults had a greater risk of death from colorectal cancer, especially in early stages. The gender gap in mortality is wider among blacks than whites. Differences in tumor characteristics and socioeconomic factors each accounted for approximately one third of the excess risk of death among blacks. Effects of socioeconomic factors and race varied significantly by age. Higher stage-specific mortality rates and more advanced stage at diagnosis both contribute to the higher case-fatality rates from colorectal cancer among black adults, only some of which is due to socioeconomic differences. Socioeconomic and racial factors have their most significant effects in different age groups.     

Health insurance coverage of immigrants living in the United States: differences by citizenship status and country of origin

OBJECTIVES: This study examined health insurance coverage among immigrants who are not US citizens and among individuals from the 16 countries with the largest number of immigrants living in the United States. METHODS: We analyzed data from the 1998 Current Population Survey, using logistic regression to standardize rates of employer-sponsored coverage by country of origin. RESULTS: In 1997, 16.7 million immigrants were not US citizens. Among non-citizens, 43% of children and 12% of elders lacked health insurance, compared with 14% of non-immigrant children and 1% of non-immigrant elders. Approximately 50% of non-citizen full-time workers had employer-sponsored coverage, compared with 81% of non-immigrant full-time workers. Immigrants from Guatemala, Mexico, El Salvador, Haiti, Korea, and Vietnam were the most likely to be uninsured. Among immigrants who worked full-time, sociodemographic and employment characteristics accounted for most of the variation in employer health insurance. For Central American immigrants, legal status may play a role in high un-insurance rates. CONCLUSIONS: Immigrants who are not US citizens are much less likely to receive employer-sponsored health insurance or government coverage; 44% are uninsured. Ongoing debates on health insurance reform and efforts to improve coverage will need to focus attention on this group.