SummaryBackground and objectives Many factors have been shown to be associated with ESRD patient placement on the waiting list and receipt of kidney transplantation. Our study aim was to evaluate factors and assess the interplay of patient characteristics associated with progression to transplantation in a large cohort of referred patients from a single institution.Design, setting, participants, & measurements We examined 3029 consecutive adult patients referred for transplantation from 2003 to 2008. Uni-and multivariable logistic models were used to assess factors associated with progress to transplantation including receipt of evaluations, waiting list placement, and receipt of a transplant.Results A total of 56%, 27%, and 17% of referred patients were evaluated, were placed on the waiting list, and received a transplant over the study period, respectively. Older age, lower median income, and noncommercial insurance were associated with decreased likelihood to ascend steps to receive a transplant. There was no difference in the proportion of evaluations between African Americans (57%) and Caucasians (56%). Age-adjusted differences in waiting list placement by race were attenuated with further adjustment for income and insurance. There was no difference in the likelihood of waiting list placement between African Americans and Caucasians with commercial insurance.Conclusions Race/ethnicity, age, insurance status, and income are predominant factors associated with patient progress to transplantation. Disparities by race/ethnicity may be largely explained by insurance status and income, potentially suggesting that variable insurance coverage exacerbates disparities in access to transplantation in the ESRD population, despite Medicare entitlement.

Background Cultural competency has been espoused as an organizational strategy to reduce health disparities in care. Objective To examine the relationship between hospital cultural competency and inpatient experiences with care. Research Design The first model predicted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospital random effects, plus fixed effects for hospital cultural competency, individual race/ethnicity/language, and case-mix variables. The second model tested if the association between a hospital’s cultural competency and HCAHPS scores differed for minority and non-Hispanic white patients. Subjects The National CAHPS® Benchmarking Database’s (NCBD) HCAHPS Surveys and the Cultural Competency Assessment Tool of Hospitals (CCATH) Surveys for California hospitals were merged, resulting in 66 hospitals and 19,583 HCAHPS respondents in 2006. Measures Dependent variables include ten HCAHPS measures: six composites (communication with doctors, communication with nurses, staff responsiveness, pain control, communication about medications, and discharge information), two individual items (cleanliness, and quietness of patient rooms), and two global items (overall hospital rating, and whether patient would recommend hospital). Results Hospitals with greater cultural competency have better HCAHPS scores for doctor communication, hospital rating, and hospital recommendation. Furthermore, HCAHPS scores for minorities were higher at hospitals with greater cultural competency on four other dimensions: nurse communication, staff responsiveness, quiet room, and pain control. Conclusions Greater hospital cultural competency may improve overall patient experiences, but may particularly benefit minorities in their interactions with nurses and hospital staff. Such effort may not only serve longstanding goals of reducing racial/ethnic disparities in inpatient experience, but may also contribute to general quality improvement.

Lifetime experience of and response to discrimination may contribute to race and sex differences in access to care and should be included in research on health care disparities.

Objective. To investigate the financial burdens attributed to overweight and obesity on the U.S. health care system among elderly Americans. Data Source. Longitudinal Cost and Use files of the Medicare Current Beneficiary Survey from 1992 to 2001. Study Design. We constructed a simultaneous equation system to model the dynamic relationship between changes in body weight, chronic diseases, functional status, longevity, and health care expenditures using maximum likelihood estimation. Based on the estimation, we conducted a simulation of one cohort with different baseline weights at age 65 and followed to death or up to age 100 of their health outcomes and lifetime health care expenditures. Principal Findings. The elderly men who were overweight or obese at age 65 had 6-13 percent more lifetime health care expenditures than the same age cohort within normal weight range at age 65. Elderly women who were overweight or obese at age 65 spent 11-17 percent more than those in a normal weight range. Both elderly men and women who were overweight or obese at age 65 had worse health outcomes than the normal weight cohorts. The average body mass index among survivors decreased by age. Conclusion. Overweight and obesity could place significant financial burdens on the U.S. health care system.

Background Limited health literacy is a barrier to understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored. Objective To examine the relationship between health literacy, access to primary care and reasons for ED use among adults presenting for emergency care. Methods Structured interviews that included health literacy assessment were performed with 492 ED patients at one Southern academic medical center. Unadjusted and multivariable logistic regression models assessed the relationship between health literacy and 1) access to a personal physician, 2) doctor office visits, 3) ED visits, 4) hospitalizations, and 5) potentially preventable hospital admissions. Results After adjusting for sociodemographic and health status, those with limited health literacy reported fewer doctor office visits (OR=0.6, 95% CI=0.4-1.0), greater ED use (OR=1.6, 95% CI 1.0-2.4) and had more potentially preventable hospital admissions (OR=1.7, 95% CI=1.0-2.7) than those with adequate health literacy. After further controlling for insurance and employment status, fewer doctor office visits remained significantly associated with patient health literacy. (OR=0.5, 95% CI=0.3-0.9). Patients with limited health literacy reported a preference for emergency care, as the services were perceived as better. Conclusions Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes towards primary care services.

Background Prior studies have shown that racial/ethnic minorities have lower Consumer Assessments of Healthcare Providers and Systems (CAHPS®) scores. Perceived discrimination may mediate the relationship between race/ethnicity and patient experiences with care. Objective To examine the relationship between perceived discrimination based on race/ethnicity and Medicaid insurance and CAHPS® reports and ratings of care. Methods The study analyzed 2007 survey data from 1,509 Florida Medicaid beneficiaries. CAHPS® reports (getting needed care, timeliness of care, communication with doctor, and health plan customer service) and ratings (personal doctor, specialist care, overall health care, and health plan) of care were the primary outcome variables. Patient perceptions of discrimination based on their race/ethnicity and having Medicaid insurance were the primary independent variables. Regression analysis modeled the effect of perceptions of discrimination on CAHPS® reports and ratings controlling for age, gender, education, self-rated health status, race/ethnicity, survey language, and fee-for-service enrollment. Standard errors were corrected for correlation within plans. Results Medicaid beneficiaries reporting discrimination based on race/ethnicity had lower CAHPS® scores, ranging from 15 points lower (on a 0–100 scale) for getting needed care to 6 points lower for specialist rating, compared to those who never experienced discrimination. Similar results were obtained for perceived discrimination based on Medicaid insurance. Conclusions Perceptions of discrimination based on race/ethnicity and Medicaid insurance are prevalent and are associated with substantially lower CAHPS® reports and ratings of care. Practices must develop and implement strategies to reduce perceived discrimination among patients.

Health outcomes among women receiving TANF can be improved with public health interventions. Additional strategies are needed to further reduce health disparities in this population.

Purpose The purpose of this study was to qualitatively explore perceptions related to COVID-19 vaccination intention among African American and Latinx participants and suggest intervention strategies. Approach Ninety minute virtual focus groups (N = 8), segmented by county, race and ethnicity were conducted with stakeholders from 3 vulnerable Alabama counties. Participants Participants (N = 67) were primarily African American and Latinx, at least 19 years, and residents or stakeholders in Jefferson, Mobile, and Dallas counties. Setting Focus groups took place virtually over Zoom. Methods The semi-structured guide explored perceptions of COVID-19, with an emphasis on barriers and facilitators to vaccine uptake. Focus groups lasted approximately 90 minutes and were audio recorded, transcribed, and analyzed by a team of 3 investigators, according to the guidelines of Thematic Analysis using NVivo 12. To provide guidance in the development of interventions to decrease vaccine hesitancy, we examined how themes fit with the constructs of the Health Belief Model. Results We found that primary themes driving COVID-19 vaccine hesitancy, ordered from most to least discussed, are mistrust, fear, and lack of information. Additionally, interventions to decrease vaccine hesitancy should be multi-modal, community engaged, and provide consistent, comprehensive messages delivered by trusted sources.