Elham Mahmoudi

Diverging racial and ethnic disparities in access to physician care: comparing 2000 and 2007.

Objective:To examine recent changes in racial and ethnic disparities in access to physician services in the United States, and investigate the economic factors driving the changes observed. Methods:Using nationally representative data on adults aged 25–64 from the 2000 and 2007 Medical Expenditure Panel Survey, we examine changes in two measures of access: whether the individual reported having a usual source of care, and whether he/she had any doctor visits during the past year. In each year, we calculate disparities in access between African Americans and Whites, and between Hispanics and Whites, applying the Institute of Medicine’s definition of a disparity. Nonlinear regression decomposition techniques are then used to quantify how changes in personal characteristics, comparing 2000 and 2007, helped shape the changes observed. Results:Large disparities in access to physician care were evident for both minority groups in 2000 and 2007. Disparities in no doctor visits during the past year diminished for African Americans, but disparities in both measures worsened sharply for Hispanics. Conclusions:Disparities in access to physician care are improving for African Americans in one dimension, but eroding for Hispanics in multiple dimensions. The most important contributing factors to the growing disparities between Hispanics and Whites are health insurance, education, and income differences.

Chronic Conditions in Adults With Cerebral Palsy

Adults with cerebral palsy (CP) represent a growing population whose health status and healthcare needs are poorly understood.1 Mortality records reveal that death due to ischemic heart disease and cancer is higher among adults with CP;2 however, there have been no national surveillance efforts to track disease risk in this population. We examined estimates of chronic conditions in a population-representative sample of adults with CP.

Disparities in access to health care among adults with physical disabilities: Analysis of a representative national sample for a ten-year period

BACKGROUND People with physical disabilities are the largest underserved subpopulation in the U.S. However, disparities in access to health care and how these have changed over time have not been fully explored. OBJECTIVE To examine national trends in disparities in access to health care and to identify the impact of physical disability and the personal factors that are associated with unmet health care needs, defined as self-reported ability to get medical care, dental care or prescription medications, among working age adults within the United States. METHODS Logistic regression analysis of a nationally representative sample of adults ages 25-64 (n = 163,220) with and without physical disabilities, using pooled data from the 2002-2011 Medical Expenditure Panel Survey. RESULTS Individuals with physical disabilities have 75% (p < 0.0001), 57% (p < 0.0001), and 85% (p < 0.000) higher odds of having unmet medical, dental, and prescription medication needs, respectively. Sociodemographic and health factors were related to unmet needs in all three measures of access to care. In particular, being female, living at or near the poverty level, and lacking health insurance increased the odds of unmet health care needs. Predicted probabilities of unmet health care needs from 2002 to 2011 show persistent gaps between individuals with and without physical disabilities, with a growing gap in unmet dental care (p = 0.004). CONCLUSION Having physical disabilities increase the odds of unmet health care needs. This study has important policy and community program implications. The Affordable Care Act could significantly reduce unmet health care needs, especially among individuals with physical disabilities.

The intersection of disability and healthcare disparities: a conceptual framework

Abstract Purpose: This article provides a conceptual framework for understanding healthcare disparities experienced by individuals with disabilities. While health disparities are the result of factors deeply rooted in culture, life style, socioeconomic status, and accessibility of resources, healthcare disparities are a subset of health disparities that reflect differences in access to and quality of healthcare and can be viewed as the inability of the healthcare system to adequately address the needs of specific population groups. Methods: This article uses a narrative method to identify and critique the main conceptual frameworks that have been used in analyzing disparities in healthcare access and quality, and evaluating those frameworks in the context of healthcare for individuals with disabilities. Specific models that are examined include the Aday and Anderson Model, the Grossman Utility Model, the Institute of Medicine (IOM)’s models of Access to Healthcare Services and Healthcare Disparities, and the Cultural Competency model. Results: While existing frameworks advance understandings of disparities in healthcare access and quality, they fall short when applied to individuals with disabilities. Specific deficits include a lack of attention to cultural and contextual factors (Aday and Andersen framework), unrealistic assumptions regarding equal access to resources (Grossman’s utility model), lack of recognition or inclusion of concepts of structural accessibility (IOM model of Healthcare Disparities) and exclusive emphasis on supply side of the healthcare equation to improve healthcare disparities (Cultural Competency model). In response to identified gaps in the literature and short-comings of current conceptualizations, an integrated model of disability and healthcare disparities is put forth. Conclusion: We analyzed models of access to care and disparities in healthcare to be able to have an integrated and cohesive conceptual framework that could potentially address issues related to access to healthcare among individuals with disabilities. The Model of Healthcare Disparities and Disability (MHDD) provides a framework for conceptualizing how healthcare disparities impact disability and specifically, how a mismatch between personal and environmental factors may result in reduced healthcare access and quality, which in turn may lead to reduced functioning, activity and participation among individuals with impairments and chronic health conditions. Researchers, health providers, policy makers and community advocate groups who are engaged in devising interventions aimed at reducing healthcare disparities would benefit from the discussions. Implications for Rehabilitation Evaluates the main models of healthcare disparity and disability to create an integrated framework. Provides a comprehensive conceptual model of healthcare disparity that specifically targets issues related to individuals with disabilities. Conceptualizes how personal and environmental factors interact to produce disparities in access to healthcare and healthcare quality. Recognizes and targets modifiable factors to reduce disparities between and within individuals with disabilities.

Has medicare part D reduced racial/ethnic disparities in prescription drug use and spending?

OBJECTIVE To evaluate whether Medicare Part D has reduced racial/ethnic disparities in prescription drug utilization and spending. DATA Nationally representative data on white, African American, and Hispanic Medicare seniors from the 2002-2009 Medical Expenditure Panel Survey are analyzed. Five measures are examined: filling any prescriptions during the year, the number of prescriptions filled, total annual prescription spending, annual out-of-pocket prescription spending, and average copay level. STUDY DESIGN We apply the Institute of Medicines definition of a racial/ethnic disparity and adopt a difference-in-difference-in-differences (DDD) estimator using a multivariate regression framework. The treatment group consists of Medicare seniors, the comparison group, adults without Medicare aged 55-63 years. PRINCIPAL FINDINGS Difference-in-difference-in-differences estimates suggest that for African Americans Part D increased the disparity in annual spending on prescription drugs by

Exploring Disparities in Access to Physician Services Among Older Adults: 2000–2007

258 (p=.011), yet had no effect on other measures of prescription drug disparities. For Hispanics, DDD estimates suggest that the program reduced the disparities in annual number of prescriptions filled, annual total and out-of-pocket spending on prescription drugs by 2.9 (p=.077),

Racial Variation in Treatment of Traumatic Finger/Thumb Amputation: A National Comparative Study of Replantation and Revision Amputation.

282 (p=.019) and

Longitudinal Analysis of Hospitalization After Spinal Cord Injury: Variation Based on Race and Ethnicity

143 (p<.001), respectively. CONCLUSION Medicare Part D had mixed effects. Although it reduced Hispanic/white disparities related to prescription drugs among seniors, it increased the African American/white disparity in total annual spending on prescription drugs.

A 5-Year Cost-Effectiveness Analysis of Silicone Metacarpophalangeal Arthroplasty in Patients with Rheumatoid Arthritis.

OBJECTIVES To compare racial/ethnic disparities in access to physician services among older adults in 2000 and 2007 and to identify potential factors driving the changes observed. METHOD Using 2000 and 2007 Medical Expenditure Panel Survey data, we examine 2 measures of access for adults aged 65 and older: whether the individual reports of having a usual source of care (USC) and whether he/she made any physician visits during the past year. We model the determinants of access using logistic regressions and then calculate disparities in access between older African Americans and older Whites and between older Hispanics and older Whites applying a disparity definition suggested by the Institute of Medicine. RESULTS In both 2000 and 2007, significant racial/ethnic disparities were evident in having no USC and in having no physician visits. Over the period, the disparity in having no physician visits diminished by 6.16% (p = .003) for African Americans, but it worsened by 5.28% (p = .021) for Hispanics. These changes were associated with a positive shift in the distribution of education among older African Americans and an erosion in Medicare among Hispanic seniors. CONCLUSION Among older adults, disparities in access to physician services have diminished for African Americans but have grown worse for Hispanics.

Healthcare Utilization Associated with Obesity and Physical Disabilities

Background: Traumatic finger/thumb amputations are some of the most prevalent traumatic injuries affecting Americans each year. Rates of replantation after traumatic finger/thumb amputation, however, have been declining steadily across U.S. hospitals, which may make these procedures less accessible to minorities and vulnerable populations. The specific aim of this study was to examine racial variation in finger replantation after traumatic finger/thumb amputation. Methods: Using a two-level hierarchical model, the authors retrospectively compared replantation rates for African American patients with those of whites, adjusting for patient and hospital characteristics. Patients younger than 65 years with traumatic finger/thumb amputation injuries who sought care at a U.S. trauma center between 2007 and 2012 were included in the study sample. Results: The authors analyzed 13,129 patients younger than 65 years with traumatic finger/thumb amputation. Replantation rates declined over time from 19 percent to 14 percent (p = 0.004). Adjusting for patient and hospital characteristics, African Americans (OR, 0.81; 95 percent CI, 0.66 to 0.99; p = 0.049) were less likely to undergo replantation procedures than whites, and uninsured patients (OR, 0.73; 95 percent CI, 0.62 to 0.84; p < 0.0001) were less likely than those who were privately insured. Conclusions: Despite advancements in microsurgical techniques and the increasing use of reconstructive surgery in other fields, finger/thumb replantation rates are declining in the United States and vulnerable populations are less likely to undergo replantation after amputation injuries. Regionalization of care for these injuries may not only provide a higher quality care but also reduce variations in treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.