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Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach.

ABSTRACT: BACKGROUND:Social disparities in healthcare persist in the US despite the expansion of Medicaid under the Affordable Care Act. We investigated the causal impact of socioeconomic status on the quality of care in a setting with minimal confounding bias from race, insurance type, and access to care. METHODS:We designed a retrospective population-based study with a random 25% sample of adult Taiwan population enrolled in Taiwan's National Health Insurance system from 2000 to 2016. Patient's income levels were categorized into low-income group (<25th percentile) and high-income group (?25th percentile). We used marginal structural modeling analysis to calculate the odds of hospital admissions for 11 ambulatory care sensitive conditions identified by the Agency for Healthcare Research and Quality and the odds of having an Elixhauser comorbidity index greater than zero for low-income patients. RESULTS:Among 2,844,334 patients, those in lower-income group had 1.28 greater odds (95% CI 1.24-1.33) of experiencing preventable hospitalizations, and 1.04 greater odds (95% CI 1.03-1.05) of having a comorbid condition in comparison to high-income group. CONCLUSIONS:Income was shown to be a causal factor in a patient's health and a determinant of the quality of care received even with equitable access to care under a universal health insurance system. Policies focusing on addressing income as an important upstream causal determinant of health to provide support to patients in lower socioeconomic status will be effective in improving health outcomes for this vulnerable social stratum.

SUBMITTER: Cho HE

PROVIDER: S-EPMC6929314 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach.

Cho Hoyune E HE Wang Lu L Chen Jung-Sheng JS Liu Mochuan M Kuo Chang-Fu CF Chung Kevin C KC

BMC health services research 20191223 1

<h4>Background</h4>Social disparities in healthcare persist in the US despite the expansion of Medicaid under the Affordable Care Act. We investigated the causal impact of socioeconomic status on the quality of care in a setting with minimal confounding bias from race, insurance type, and access to care.<h4>Methods</h4>We designed a retrospective population-based study with a random 25% sample of adult Taiwan population enrolled in Taiwan's National Health Insurance system from 2000 to 2016. Pat ...[more]

PMID: 31870361

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Project description:ObjectiveThis study aimed to determine the association between adolescent socioeconomic status (father's education and adolescent subjective socioeconomic status) and adult quality of life and the mediation roles of adult socioeconomic status, social capital and lifestyle (physical activity and exposure to smoke) among the "Tehran University of Medical Sciences Employees Cohort (TEC) Study" participants.MethodData of 4455 participants were derived from the Tehran University of Medical Sciences Employees Cohort (TEC) Study. In this study, the World Health Organization quality of life-BREF, the World Bank's Integrated and the International Physical Activity Questionnaire were used. Data were analyzed with structural equation modeling using SPSS Amos 24.0 program.ResultsThe mean age of the participants was 42.31 years (SD: 8.37) and most of the subjects were female (60.7%). Correlation analysis results revealed that, quality of life had a significant and positive association with adolescent subjective socioeconomic status (r = 0.169, p < 0.01) and father's education (r = 0.091, p < 0.01). A mediation model testing the direct relationship between adolescent socioeconomic status and adult socioeconomic status and quality of life, showed a positive relationship between adolescent subjective socioeconomic status (β = 0.229, p < 0.001) and father's education (β = 0.443, p < 0.001) with adult socioeconomic status. Adult socioeconomic status was positively related to quality of life (β = 0.205, p < 0.001). Adult socioeconomic status mediated the relationship between adolescent subjective socioeconomic status (β = 0.047, p < 0.01) and father's education (β = 0.091, p < 0.01) with quality of life. While adult socioeconomic status fully mediated the relationship between the father's education and quality of life, it partially mediated the adolescent subjective socioeconomic status-quality of life association. Other variables such as social capital and lifestyle did not have mediator role in a mediation model.ConclusionThis study provides the evidence for the role of adult socioeconomic status as a partial mediator between adolescent subjective socioeconomic status and quality of life. Therefore, there are several unknown mediators other than adult socioeconomic status that need to be explored in future studies.

Project description:Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.ContextDisparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations.MethodsWe conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors.Measurements5-year and median survival.FindingsLSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls.ConclusionsIn Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Project description:Introduction:Hospital utilization varies across socioeconomic and demographic strata in Canada, a country with a universal health care system. Rates of adverse birth outcomes are known to differ among women of high and low socioeconomic status (SES), but less is known of the excess hospital burden related to SES over the course of childbirth across Canadian provinces. Objective:To examine length of stay and risk of hospitalization surrounding delivery, relative to women's socio-demographic characteristics. Methods:A population-based record linkage between the Canadian Community Health Survey (CCHS) years 2005-2011 and the Discharge Abstract Database (DAD) allowed the tracking of hospital utilization for linked survey respondents between 2005 and 2011. Hourly length of stay for delivery, risk of readmission, and risk of admission prior to delivery was modeled by socio-demographic factors, controlling for other clinical and individual-level characteristics. Results:There were 21,914 complete delivery records from 15,458 female CCHS respondents who agreed to link and share their information. Average length of stay (for both vaginal and Caesarian deliveries) dropped over the study period from 67.86 hours in 2005 to 59.37 hours in 2011. In multivariate analyses, women with the lowest income had on average, two-hour longer stays for vaginal delivery as compared to high-income women (IRR 1.04, 95% CI 1.00-1.08) and higher risk of admission prior to delivery (OR 1.43, CI 1.13-1.81). Low-income women, Aboriginal women and women living in rural areas were also at elevated risk for longer hospital stays and for hospital admission prior to delivery. There was no consistent socioeconomic patterning of hospital burden for Caesarian deliveries. Conclusion:The length of hospital stays for childbirth has declined in Canada. Length of stay remains modestly longer, and risk of hospitalization in the perinatal period higher, for low income women, Aboriginal women and rural women. The absence of egregious income-related differences in hospital burden related to childbirth is reassuring for the equity goals of the Canadian health care system. The persistence of marginally longer, and in turn, costlier visits for low-income and Aboriginal women before and during delivery is, however, suggestive that resources targeted to the prenatal period might be highly cost-effective if they achieve population-wide reductions in length of stay and hospitalization in the perinatal period.

Project description:This study's objective is to provide an alternative explanation for the low enrolment in health insurance in Ghana by analysing differences in perceptions between the insured and uninsured of the non-technical quality of healthcare. It further explores the association between insurance status and perception of healthcare quality to ascertain whether insurance status matters in the perception of healthcare quality. Data from a survey of 1,903 households living in the catchment area of 64 health centres were used for the analysis. Two sample independent t-tests were employed to compare the average perceptions of the insured and uninsured on seven indicators of non-technical quality of healthcare. A generalised ordered logit regression, controlling for socio-economic characteristics and clustering at the health facility level, tested the association between insurance status and perceived quality of healthcare. The perceptions of the insured were found to be significantly more negative than the uninsured and those of the previously insured were significantly more negative than the never insured. Being insured was associated with a significantly lower perception of healthcare quality. Thus, once people are insured, they tend to perceive the quality of healthcare they receive as poor compared to those without insurance. This study demonstrated that health insurance status matters in the perceptions of healthcare quality. The findings also imply that perceptions of healthcare quality may be shaped by individual experiences at the health facilities, where the insured and uninsured may be treated differently. Health insurance then becomes less attractive due to the poor perception of the healthcare quality provided to individuals with insurance, resulting in low demand for health insurance in Ghana. Policy makers in Ghana should consider redesigning, reorganizing, and reengineering the National Healthcare Insurance Scheme to ensure the provision of better quality healthcare for both the insured and uninsured.

Project description:Rational & objectiveNeighborhood socioeconomic status (SES) and health insurance status may be important upstream social determinants of chronic kidney disease (CKD), but their relationship remains unclear. The aim of this study was to determine whether neighborhood SES and individual-level health insurance status were independently associated with CKD prevalence.Study designObservational study using electronic health records (EHRs).Setting & participantsEHRs of patients (n = 185,269) seen at a health care system in the 7-county Minneapolis/St Paul area (2017-2018).ExposuresCensus tract neighborhood SES measures (median value of owner-occupied housing units [wealth], percentage of residents aged >25 years with bachelor's degree or higher [education]) and individual-level health insurance status (aged <65 years: Medicaid vs other insurance; ≥65 years: Medicare vs Medicare and supplemental insurance plan) were obtained from the American Community Survey and EHR data. Neighborhood SES was operationalized into quartiles, comparing low (first quartile) versus high (fourth quartile) neighborhood SES.OutcomesCKD prevalence: estimated glomerular filtration rate < 60 mL/min/1.73 m2 or proteinuria.Analytic approachMultilevel Poisson regression with robust error variance with a random intercept at the census-tract level, adjusted for demographic and clinical covariates, was used to estimate the association between neighborhood SES, insurance, and CKD.ResultsNeighborhood SES and insurance were independently associated with CKD prevalence. In covariate-adjusted models, patients living in low versus high neighborhood SES had a higher CKD prevalence among both younger and older patients. For example, the prevalence ratios of CKD in low versus high neighborhood SES as defined by education among patients younger than 65 and 65 years and older were 1.11 (95% CI, 1.05-1.18) and 1.08 (95% CI, 1.04-1.12), respectively. Patients younger than 65 years receiving Medicaid had higher CKD prevalence versus those with other insurance (1.51 [95% CI, 1.43-1.6]). For patients 65 years and older, insurance was not associated with prevalence of CKD in the fully adjusted model.LimitationsOne health care system and selection bias.ConclusionsLiving in low neighborhood SES as defined by wealth and education and having Medicaid for patients younger than 65 years were associated with higher CKD prevalence.

Project description:BACKGROUND This study aimed to assess whether there are disparities in incidence rates, care, and outcomes for patients with chest pain attended by emergency medical services according to socioeconomic status (SES) in a universal health coverage setting. METHODS AND RESULTS This was a population-based cohort study of individually linked ambulance, emergency, hospital admission, and mortality data in the state of Victoria, Australia, from January 2015 to June 2019 that included 183 232 consecutive emergency medical services attendances for adults with nontraumatic chest pain (mean age 62 [SD 18] years; 51% women) and excluded out-of-hospital cardiac arrest and ST-segment-elevation myocardial infarction. Age-standardized incidence of chest pain was higher for patients residing in lower SES areas (lowest SES quintile 1595 versus highest SES quintile 760 per 100 000 person-years; P<0.001). Patients of lower SES were less likely to attend metropolitan, private, or revascularization-capable hospitals and had greater comorbidities. In multivariable models adjusted for clinical characteristics and final diagnosis, lower SES quintiles were associated with increased risks of 30-day and long-term mortality, readmission for chest pain and acute coronary syndrome, lower acuity emergency department triage categorization, emergency department length of stay >4 hours, and emergency department or emergency medical services discharge without hospital admission and were inversely associated with use of prehospital ECGs and transfer to a revascularization-capable hospital for patients presenting to non-percutaneous coronary intervention centers. CONCLUSIONS In this study, lower SES was associated with a higher incidence of chest pain presentations to emergency medical services and differences in care and outcomes. These findings suggest that substantial disparities for socioeconomically disadvantaged chest pain cohorts exist, even in the setting of universal health care access.

Dataset Information

Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach.

Publications

Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach.

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