The relationship between use of NHS Direct and deprivation in southeast London: an ecological analysis

BACKGROUND: Little is known about the utilization of NHS Direct by disadvantaged groups, in spite of the service aiming to be 'accessible to all'. This study investigates the relationship between use of NHS Direct and deprivation in one predominantly disadvantaged area. METHODS: Ward-level call rates to NHS Direct South East London over a 6 month period were calculated using postcode data. Jarman and Townsend scores were used as a proxy of deprivation in each ward. We performed negative binomial regression to investigate the relationship between deprivation score and rate of calls to NHS Direct. RESULTS: There was a significant, non-linear (quadratic) effect of deprivation score on call rates; call rates were lower in both the most affluent and most deprived wards. CONCLUSION: Calls to NHS Direct rise with increasing deprivation until, at extreme levels of deprivation, they subsequently decline. This challenges assumptions that NHS Direct is not utilized in deprived areas.     

Pathways to the hospital for the geriatric psychiatric patient in New York and London.

This communication examines the pathways of geriatric psychiatric patients in New York and London from the time of onset of a psychiatric episode to hospitalization. Informants of 50 patients in each city were interviewed with a semi-structured interview covering the events and the patient's activities prior to hospitalization. The results show that the time from the onset of the episode to hospitalization is significantly shorter in London than it is in New York. The major portion of this difference is accounted for by the longer time spent London the doctor is significantly more involved in New York between episode onset and initial medical contact. In the decision to hospitalize. In New York the main reason for hospitalization is harmful behavior, while in London it is psychiatric symptoms.     

Estimating ecological social capital using multi-level regression with post-stratification: A spatial analysis of psychiatric admission rates in wales

Although ecological cognitive social capital is an important predictor of mental health, measurement remains crude. Multi-level regression with post-stratification (MRP) is a technique for computing small area estimates of survey responses, used in political science but hitherto not for estimating ecological protective factors in epidemiology.National Survey for Wales 2016-17 data (N = 10,486) were used to produce MRP estimates of belonging and generalised trust for 410 middle super output areas covering Wales. These estimates were used to predict psychiatric admission rates in 2017 (N = 9978 cases).Low belonging and trust are ecological risk factors for psychiatric admissions, with a 29% (25–33%) and 25% (22–29%) increase in admissions per standard deviation decrease respectively. Equivalent results for using standard simple aggregation of survey data by area suggest 8% (4–12%) and 10% (6–14%) increases in risk per standard deviation.MRP has potential for studying ecological risk factors based on self-report measures, with greater predictive validity for incidence of psychiatric admissions than current methods.     

The health care workforce in Los Angeles County and New York City: a comparison and analysis.

New York City and Los Angeles County have the largest health systems in the United States, but they differ significantly in structure. This study compares and analyzes the structural and workforce differences between the two. The health system in New York City is centered around its large hospitals, and as a result New York employs many more health workers than Los Angeles County, where the health system is centered around physician groups. Health care is a significant contributor to the economy of both areas, but a larger contributor to the economy in New York City.     

Waiting for coronary revascularization: a comparison between New York State, The Netherlands and Sweden

OBJECTIVE: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. METHODS: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. RESULTS: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P < 0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P < 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. CONCLUSIONS: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved.     

The impact of membership in a health maintenance organization on hospital admission rates for acute chest pain.

OBJECTIVE. We evaluate the impact of membership in a staff-model health maintenance organization (HMO) on hospital admission rates for patients presenting to an emergency department with acute chest pain. DATA SOURCES AND STUDY SETTING. Primary prospective data were gathered from all 3,006 patients presenting with a chief complaint of chest pain to the emergency department (ED) of a university teaching hospital from October 1987 to November 1989. STUDY DESIGN. Prospective cohort analysis used clinical data to stratify patients into groups at high (> or = 25%), medium (8-24%), and low risk (< or = 7%) of acute myocardial infarction (AMI). Insurance status was determined as either HMO, Medicare, commercial, Medicaid, or self-pay. Triage decisions were recorded, and patient outcomes of AMI and other final diagnoses were determined for all patients. DATA COLLECTION METHODS. Clinical data were recorded by the physicians in the ED as part of a detailed protocol. Insurance data were recorded separately by the ED staff as part of the hospital administrative database. Patient outcomes were recorded daily by research nurses for hospitalized patients; for patients who were discharged from the ED, telephone or physician follow-up was accomplished within seven days after discharge. PRINCIPAL FINDINGS. HMO patients were more likely to be admitted to the hospital than patients in other insurance groups in both the medium- and low-risk patient categories. Within the low-risk category, after controlling for clinical differences in a multiple logistic model, HMO membership retained an independent positive association with hospital admission compared to all other insurance groups except Medicaid. CONCLUSIONS. For patients with acute chest pain who were at medium and low risk of acute myocardial infarction, HMO membership was associated with higher rates of hospital admission. These findings suggest that organizational factors beyond financial incentives may exercise an important influence on hospitalization rates for HMO patients.     

Marginal costs in general acute care hospitals: A comparison among California,New York and Canada

In the present paper we offer a detailed comparison of hospital costs between California and New York and two Canadian provinces (Ontario and British Columbia) in 1981 and 1985. We find that production technologies differ significantly between the two countries and between California and New York. Marginal costs and their distributions also differ across jurisdictions and across different size hospitals. Marginal cost levels were the lowest in Canadian hospitals for almost all outputs in both years and their distribution was also the tightest. Some very mild scale effects were also present in the acute care production. Hospitals in California experienced for the most part increasing marginal costs for acute care, whereas Canadian hospitals showed the reverse pattern. In New York we find a weak negative scale effect in acute care production. Density estimates conditional on hospital output reinforce these results.     

The relationship between hospital characteristics and the cost of hospital care.

This article examines the relationship between hospital characteristics and costs of hospital care, using the 1991 American Hospital Association Annual Survey of Hospitals. The results discussed herein have implications for hospital executives, researchers and policymakers.     

The relationship between social capital, social support and the adequate use of prenatal care

This study investigated the relationship between social capital and social support and the adequate use of prenatal care. A follow-up study involving 1,485 pregnant women was conducted in two cities in the Rio de Janeiro State, Brazil. Demographic and socioeconomic characteristics, social support and social capital data were collected during the first trimester of pregnancy. The post-partum period included information on levels of prenatal care utilization, social networks, parity, obstetric and gestational risk and prenatal care attendance. Hierarchized multinomial logistic regression was used in the statistical analysis. Prenatal care use above adequate levels was associated with high social capital at the city level (aggregated social capital), socioeconomic status and working during pregnancy. Lower non-aggregated contextual and compositional social capital, gestational risk and pattern of prenatal care were associated with inadequate prenatal care utilization. Contextual social capital and social support were found to be social determinants for the appropriate use of prenatal care.     

The relationship between language spoken and smoking among Hispanic-Latino youth in New York City.

This study was designed to examine the relationship between language spoken and smoking (at least once a month) among New York City Hispanic-Latino adolescents, using a large sample of specific Hispanic-Latino subgroups (Puerto Rican, Dominican, Colombian, and Ecuadorian youth) and controlling for social and environmental factors. The sample included 3,129 Hispanic-Latino students in 47 New York City public and parochial schools. Of the total sample, 43 percent were Puerto Rican, 20 percent Dominican, 7 percent Colombian, and 7 percent Ecuadorian. The students completed questionnaires that were designed to assess social and environmental influences on their smoking and determine what languages they spoke (English and Spanish) with parents and friends. Self-reported smoking data were collected by means of the bogus pipeline to enhance the veracity of self-reports. In the logistic regression model, including background, social influence, and language use variables, 101 students were smokers. Logistic regression analysis indicated that being bicultural (speaking both English and Spanish) at home and with friends appeared to increase the odds of currently smoking. Separate logistic regression analyses for girls and boys revealed that being bicultural at home increased the odds of currently smoking for boys but not girls. Results are discussed in terms of their implications for prevention.     

COVID-19 testing,case, and death rates and spatial socio-demographics in New York City: An ecological analysis as of June 2020

We assessed the geographic variation in socio-demographics, mobility, and built environmental factors in relation to COVID-19 testing, case, and death rates in New York City (NYC). COVID-19 rates (as of June 10, 2020), relevant socio-demographic information, and built environment characteristics were aggregated by ZIP Code Tabulation Area (ZCTA). Spatially adjusted multivariable regression models were fitted to account for spatial autocorrelation. The results show that different sets of neighborhood characteristics were independently associated with COVID-19 testing, case, and death rates. For example, the proportions of Blacks and Hispanics in a ZCTA were positively associated with COVID-19 case rate. Contrary to the conventional hypothesis, neighborhoods with low-density housing experienced higher COVID-19 case rates. In addition, demographic changes (e.g. out-migration) during the pandemic may bias the estimates of COVID-19 rates. Future research should further investigate these neighborhood-level factors and their interactions over time to better understand the mechanisms by which they affect COVID-19.     

The impact of a proactive chronic care management program on hospital admission rates in a German health insurance society

Hospital admissions are the source of significant health care expenses, although a large proportion of these admissions can be avoided through proper management of chronic disease. In the present study, we evaluate the impact of a proactive chronic care management program for members of a German insurance society who suffer from chronic disease. Specifically, we tested the impact of nurse-delivered care calls on hospital admission rates. Study participants were insured individuals with coronary artery disease, heart failure, diabetes, or chronic obstructive pulmonary disease who consented to participate in the chronic care management program. Intervention (n = 17,319) and Comparison (n = 5668) groups were defined based on records of participating (or not participating) in telephonic interactions. Changes in admission rates were calculated from the year prior to (Base) and year after program commencement. Comparative analyses were adjusted for age, sex, region of residence, and disease severity (stratification of 3 [least severe] to 1 [most severe]). Overall, the admission rate in the Intervention group decreased by 6.2% compared with a 14.9% increase in the Comparison group (P < 0.001). The overall decrease in admissions for the Intervention group was driven by risk stratification levels 2 and 1, for which admissions decreased by 8.2% and 14.2% compared to Comparison group increases of 12.1% and 7.9%, respectively. Additionally, Intervention group admissions decreased as the number of calls increased (P = 0.004), indicating a dose-response relationship. These findings indicate that proactive chronic care management care calls can help reduce hospital admissions among German health insurance members with chronic disease.     

Effectiveness of a community coalition for improving child vaccination rates in New York City

We used a retrospective, matching, birth cohort design to evaluate a comprehensive, coalition-led childhood immunization program of outreach, education, and reminders in a Latino, urban community. After we controlled for Latino ethnicity and Medicaid, we found that children enrolled in the program were 53% more likely to be up-to-date (adjusted odds ratio = 1.53; 95% confidence interval = 1.33, 1.75) and to receive timely immunizations than were children in the control group (t = 3.91). The coalition-led, community-based immunization program was effective in improving on-time childhood immunization coverage.     

The New York City shared aide program (cluster care): a model for the future

In order to combat rapidly escalating home health care costs, New York City and State have inaugurated a "shared aide" program in which home attendant "teams," as opposed to individual aides, serve large groups of elderly clients who live in close proximity (e.g., at senior housing sites), thus reducing the aide-to-client ratio. Using New York City as a model, this paper examines the premises underlying the shared aide concept--the program's objectives, methodology, advantages/disadvantages to home care workers and clients, and, most importantly, its potential, if implemented nationwide, for cost containment and a corresponding substantial reduction in the Medicaid budget.     

A comparison of acute psychiatric care under Medicaid carve-outs, HMOs, and fee-for-service

This study compares the use of acute psychiatric hospitalization; selected outcomes, including rehospitalization; as well as costs associated with the health maintenance organization (HMO), carve-out, and fee-for-service models as implemented in the Massachusetts Medicaid program between FY1994 and FY2000. This is a longitudinal analysis that primarily uses unduplicated individual data from the Massachusetts Case Mix database. Analyses focus on 56,518 individuals who were psychiatrically hospitalized on acute units within 57 hospitals. They employ Cox regression to compare rehospitalization among the three programs. The hypotheses were strongly supported: HMOs have the most substantial impacts in minimizing service provision, with the carve-out program having an impact intermediate between the HMO and fee-for-service programs. Lower utilization rates were associated with lower overall rates of hospitalization, shorter lengths of stay, fewer repeated stays, and less geographic access and greater displacement of psychiatric patients to medical units. The final model of rehospitalization has an overall predictive accuracy of 59.6%.     

Prenatal care utilization in New York City: comparison of measures and assessment of their significance for urban health.

This paper considers policy and programmatic consequences of shifting measurement of prenatal care utilization from the Kessner Index (KI) to the Adequacy of Prenatal Care Utilization Index (APNCUI). In gauging the adequacy of prenatal care utilization, the KI considers the timing of prenatal care initiation and the number of prenatal visits. The APNCUI also considers both timing of initiation and number of visits, but the approach taken to conceptualizing and measuring these two aspects of prenatal care utilization is more refined. We used birth certificates to calculate the KI and the APNGUI for 217,183 New York City (NYC) births in 1991-1992. We used cross-tabulations and bivariate odds ratios to compare the classifications resulting from the respective indexes. The APNCUI detected some important dimensions of the problem of inadequate prenatal care use that are not evident when using the KI. The proportion of births with inadequate use increases from 18% with the KI to 35% with the APNGUI. Groups of women at elevated risk for inadequate use are the same, but the KI understates significantly the risk for Hispanic women, teens, women who are less well educated, and those on WIC and Medicaid. The APNGUI yields a fuller picture of the degree to which some urban women are at risk for inadequate prenatal care use. Use of the APNGUI in quality assurance, monitoring, and research is recommended.     

Hepatitis C incidence—a comparison between injection and noninjection drug users in New York City

Hepatitis C virus (HCV) burdens injection drug users (IDUs) with prevalence estimated from 60–100% compared to around 5% among noninjection drug users (non-IDUs). We present preliminary data comparing the risk for HCV among IDUs and non-IDUs to inform new avenues of HCV prevention and intervention planning. Two cohorts, new IDUs (injecting ≤3 years) and non-IDUs (smoke/sniff heroine, crack or cocaine ≤10 years) ages 15–40, were street-recruited in New York City. Participants underwent risk surveys and HCV serology at baseline and 6-month follow-up visits. Person-time analysis was used to estimate annual HCV incidence. Of 683 non-IDUs, 653 were HCV seronegative, 422 returned for at least 1 follow-up visit, and 1 became HCV seropositive. Non-IDUs contributed 246.3 person-years (PY) yielding an annual incident rate of 0.4/100 PY (95% Confidence Interval [CI]=0.0–1.2). Of 260 IDUs, 114 were HCV seronegative, 62 returned for at least 1 follow-up visit, and 13 became HCV seropositive. IDUs contributed 36.3 PY yielding an annual incidence rate of 35.9/100 PY (95% CI=19.1–61.2). Among IDUs, HCV seroconverters tended to be younger (median age 25 vs. 28, respectively), and inject more frequently (61.5% vs. 34.7%, respectively) than nonseroconverters. These interim data suggest that IDUs may have engaged in high-risk practices prior to being identified for prevention services. Preventing or at least delaying transition into injection could increase opportunity to intervene. Identifying risk factors for transition into injection could inform early prevention to reduce onset of injection and risk of HCV. All research was approved by the New York Academy of Medicine’s Institutional Review Board and conforms to the principles embodied in the Declaration of Helsinki.