The Content of a Low-income, Uninsured Primary Care Population: Including the Patient Agenda

Mauksch, Larry B.; Katon, Wayne; Russo, Joan; Tucker, Suzanne; Walker, Edward A.; Cameron, Janet

doi:10.3122/jabfm.16.4.278

Cited by 17 publications

(15 citation statements)

References 75 publications

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“…21,24 Friedman et al 13 found that as many as 42% of patients with LBP in the ER of 1 hospital were unemployed, many of whom were likely uninsured. This same study found that insurance status was associated with decisions to order advanced imaging and that uninsured patients in particular were less likely to undergo such studies.…”

Section: Discussionmentioning

confidence: 99%

Emergency room resource utilization by patients with low-back pain

Drazin

Nuño

Patil

et al. 2016

SPI

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OBJECTIVE The objective of this study was to determine factors associated with admission to the hospital through the emergency room (ER) for patients with a primary diagnosis of low-back pain (LBP). The authors further evaluated the impact of ER admission and patient characteristics on mortality, discharge disposition, and hospital length of stay. METHODS The authors conducted a retrospective analysis of patients with LBP discharged from hospitals according to the Nationwide Inpatient Sample (NIS) between 1998 and 2007. Univariate comparisons of patient characteristics according to the type of admission (ER versus non-ER) were conducted. Multivariate analysis evaluated factors associated with an ER admission, risk of mortality, and nonroutine discharge. RESULTS According to the NIS, approximately 183,151 patients with a primary diagnosis of LBP were discharged from US hospitals between 1998 and 2007. During this period, an average of 65% of these patients were admitted through the ER, with a significant increase from 1998 (54%) to 2005 (71%). Multivariate analysis revealed that uninsured patients (OR 2.1, 95% CI 1.7–2.6, p < 0.0001) and African American patients (OR 1.5, 95% CI 1.2–1.7, p < 0.0001) were significantly more likely to be admitted through the ER than private insurance patients or Caucasian patients, respectively. Additionally, a moderate but statistically significant increase in the likelihood of ER admission was noted for patients with more preexisting comorbidities (OR 1.1, 95% CI 1.0–1.2, p < 0.001). An 11% incremental increase in the odds of admission through the ER was observed with each year increment (OR 1.1, 95% CI 1.0–1.2, p < 0.001). Highest income patients ($45,000+) were more likely to be admitted through the ER (OR 1.3, 95% CI 1.1–1.6, p = 0.007) than the lowest income cohort. While ER admission did not impact the risk of mortality (OR 0.95, 95% CI 0.60–1.51, p = 0.84), it increased the odds of a nonroutine discharge (OR 1.39, 95% CI 1.26–1.53, p < 0.0001). CONCLUSIONS A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ER, with more patients being admitted via this route each year. These patients were less likely to be discharged directly home compared with patients with LBP who were not admitted through the ER. Uninsured and African American patients with LBP were more likely to be admitted through the ER than their counterparts, as were patients with more preexisting health problems. Interestingly, patients with LBP at the highest income levels were more likely to be admitted through hospital ERs. The findings suggest that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients.

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Section: Discussionmentioning

confidence: 99%

Emergency room resource utilization by patients with low-back pain

Drazin

Nuño

Patil

et al. 2016

SPI

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“…Although associations between mental illness and chronic diseases are well recognized, 17 the possible synergistic infl uence of multimorbidity and poverty on psychological distress is less well documented. 18,19 Almost one-third (30%) of patients in the most deprived areas wanted to discuss psychosocial problems, and almost two-thirds (65%) of these patients expected to discuss more than 1 problem. Interventions aimed at increasing the number of problems voiced by patients 20 need to take account of the substantial increases in physician time that would be likely be required to meet such demands in the most deprived areas.…”

Section: Mean Stressmentioning

confidence: 99%

The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland

Mercer¹,

Watt²

2007

The Annals of Family Medicine

305

311

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PURPOSEThe inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates.METHODS A questionnaire study was carried out on 3,044 National Health Service (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affl uent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health variables, and a range of factors relating to quality of care. RESULTSCompared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more longterm illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was signifi cantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychosocial), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation. CONCLUSIONSThe increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities. 2007;5:503-510. DOI: 10.1370/afm.778. Ann Fam Med INTRODUCTIONS cotland has the lowest life expectancy for women in Western Europe and the second lowest for men, with a widening gap between the health of the rich and the poor.1 Twenty-one percent of the population in poorer areas have limiting long-term illnesses or disabilities, compared with only 8.5% in affl uent areas. 1 The bulk of health care in Scotland, as in the rest of the United Kingdom, is delivered through primary care, with fully trained family physicians-general practitioners (GPs)-practice nurses, and other allied health professionals accounting for almost 90% of the activity of the National Health Service (NHS). Clinical encounters are free at the point of use and accessible by 100% of the population. Since the inception of the NHS in 1948, however, the provision of primary care services has not been closely related to health needs in more socioeconomically deprived areas. The mismatch of need and supply has been termed the inverse care law, 2,3 which states that "the provision of good medical care tends to vary inversely with 504INV ER SE C A R E L AW the need for it in the population served." In Scotland, despite the steep gradient in need, the distribution of GPs remains fl at across socioeconomic indices. 4 Although inequalities in health and health care are well recognized, [5][6][7] there is a...

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“…25 Indigent persons tend to have more medical and mental health problems and decreased psychological, social, and physical functioning. 26 For example, headache, chronic back pain, and arthritis were the most frequent complaints among poor and uninsured patients; and depression and anxiety were associated with a higher prevalence of pain. Pain complaints were inversely related to income; low income also negatively influenced access to care for chronic pain.…”

Section: Pain and Low Incomementioning

confidence: 99%

“…Pain complaints were inversely related to income; low income also negatively influenced access to care for chronic pain. 25,26 Emotional and behavioral responses to chronic pain were determined in part by the patient's appraisal of and strategies for coping with pain problems. 27 Racial and ethnic disparities are often considered with income and influence the pain experience.…”

Section: Pain and Low Incomementioning

confidence: 99%