Karen E. Lasser

Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey

OBJECTIVES We compared health status, access to care, and utilization of medical services in the United States and Canada and compared disparities according to race, income, and immigrant status. METHODS We analyzed population-based data on 3505 Canadian and 5183 US adults from the Joint Canada/US Survey of Health. Controlling for gender, age, income, race, and immigrant status, we used logistic regression to analyze country as a predictor of access to care, quality of care, and satisfaction with care and as a predictor of disparities in these measures. RESULTS In multivariate analyses, US respondents (compared with Canadians) were less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines. Disparities on the basis of race, income, and immigrant status were present in both countries but were more extreme in the United States. CONCLUSIONS United States residents are less able to access care than are Canadians. Universal coverage appears to reduce most disparities in access to care.

The Health and Health Care of US Prisoners: Results of a Nationwide Survey

OBJECTIVES We analyzed the prevalence of chronic illnesses, including mental illness, and access to health care among US inmates. METHODS We used the 2002 Survey of Inmates in Local Jails and the 2004 Survey of Inmates in State and Federal Correctional Facilities to analyze disease prevalence and clinical measures of access to health care for inmates. RESULTS Among inmates in federal prisons, state prisons, and local jails, 38.5% (SE = 2.2%), 42.8% (SE = 1.1%), and 38.7% (SE = 0.7%), respectively, suffered a chronic medical condition. Among inmates with a mental condition ever treated with a psychiatric medication, only 25.5% (SE = 7.5%) of federal, 29.6% (SE = 2.8%) of state, and 38.5% (SE = 1.5%) of local jail inmates were taking a psychiatric medication at the time of arrest, whereas 69.1% (SE = 4.8%), 68.6% (SE = 1.9%), and 45.5% (SE = 1.6%) were on a psychiatric medication after admission. CONCLUSIONS Many inmates with a serious chronic physical illness fail to receive care while incarcerated. Among inmates with mental illness, most were off their treatments at the time of arrest. Improvements are needed both in correctional health care and in community mental health services that might prevent crime and incarceration.

Health Insurance and Mortality in US Adults

OBJECTIVES A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data. METHODS We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death. RESULTS Among all participants, 3.1% (95% confidence interval [CI]=2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI=1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance. CONCLUSIONS Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.

Colorectal Cancer Screening Among Ethnically Diverse, Low-Income Patients: A Randomized Controlled Trial

BACKGROUND Patient navigators may increase colorectal cancer (CRC) screening rates among adults in underserved communities, but prior randomized trials have been small or conducted at single sites and have not included substantial numbers of Haitian Creole-speaking or Portuguese-speaking patients. METHODS We identified 465 primary care patients from 4 community health centers and 2 public hospital-based clinics who were not up-to-date with CRC screening and spoke English, Haitian Creole, Portuguese, or Spanish as their primary language. We enrolled participants from September 1, 2008, through March 31, 2009, and followed them up for 1 year after enrollment. We randomly allocated patients to receive a patient navigation-based intervention or usual care. Intervention patients received an introductory letter from their primary care provider with educational material, followed by telephone calls from a language-concordant navigator. The navigators offered patients the option of being screened by fecal occult blood testing or colonoscopy. The primary outcome was completion of any CRC screening within 1 year. Secondary outcomes included the proportions of patients screened by colonoscopy who had adenomas or cancer detected. RESULTS During a 1-year period, intervention patients were more likely to undergo CRC screening than control patients (33.6% vs 20.0%; P < .001), to be screened by colonoscopy (26.4% vs 13.0%; P < .001), and to have adenomas detected (8.1% vs 3.9%; P = .06). In prespecified subgroup analyses, the navigator intervention was particularly beneficial for patients whose primary language was other than English (39.8% vs 18.6%; P < .001) and black patients (39.7% vs 16.7%; P = .004). CONCLUSIONS Patient navigation increased completion of CRC screening among ethnically diverse patients. Targeting patient navigation to black and non-English-speaking patients may be a useful approach to reducing disparities in CRC screening. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01141114.

Do minorities in the united states receive fewer mental health services than whites

Older studies have found that minorities in the United States receive fewer mental health services than whites. This analysis compares rates of outpatient mental health treatment according to race and ethnicity using more recent, population-based data, from the 1997 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. The authors calculated visit rates per 1,000 population to either primary care or psychiatric providers for mental health counseling, psychotherapy, and psychiatric drug therapy. In the primary care setting, Hispanics and blacks had lower visit rates (per 1,000 population) for drug therapy than whites (48.3 and 73.7 vs. 109.0; P < .0001 and P < .01, respectively). Blacks also had a lower visit rate for talk therapy (mental health counseling or psychotherapy) than whites (23.6 vs. 42.5; P < .01). In the psychiatric setting, Hispanics and blacks had lower visit rates than whites for talk therapy (38.4 and 33.6 vs. 85.1; P < .0001 for both comparisons) and drug therapy (38.3 and 29.1 vs. 71.8; P < .0001 for both comparisons). These results indicate that minorities receive about half as much outpatient mental health care as whites.

Characteristics of recipients of free prescription drug samples: a nationally representative analysis

OBJECTIVES Free prescription drug samples are used widely in the United States. We sought to examine characteristics of free drug sample recipients nationwide. METHODS We analyzed data on 32681 US residents from the 2003 Medical Expenditure Panel Survey (MEPS), a nationally representative survey. RESULTS In 2003, 12% of Americans received at least 1 free sample. A higher proportion of persons who had continuous health insurance received a free sample (12.9%) than did persons who were uninsured for part or all of the year (9.9%; P<.001). The poorest third of respondents were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or higher. After we controlled for demographic factors, we found that neither insurance status nor income were predictors of the receipt of drug samples. Persons who were uninsured all or part of the year were no more likely to receive free samples (odds ratio [OR]=0.98; 95% confidence interval [CI]=0.087, 1.11) than those who were continuously insured. CONCLUSIONS Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples. Our findings suggest that free drug samples serve as a marketing tool, not as a safety net.

Drug Withdrawals in the United States: A Systematic Review of the Evidence and Analysis of Trends

There have been a number of highly publicized safety-based drug withdrawals in the United States in recent years. We conducted a review of drugs withdrawn since 1993 and examined trends in drug withdrawals. Our objective was to determine the frequency and characteristics of withdrawn drugs and trends since 1993, and to discuss the implications of the findings. We found that a mean of 1.5 drugs per year have been withdrawn since 1993, and that the number of withdrawals has not increased over time. However, some recent drug withdrawals have impacted large numbers of people. The rate of withdrawals alone is not an adequate measure of the status of drug safety in the US, and there is a serious dearth of data that can be used to examine the impact of drug withdrawals. Although drug withdrawals are an important issue to address, drug safety policies need to be developed within the broader context of drug safety and effectiveness. A comprehensive approach will be needed to address the improvement of drug safety. We propose improvements to the evidence base to increase drug safety and assess how new scientific evidence can be incorporated into drug safety efforts.

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Massachusetts reform and disparities in inpatient care utilization.

Background:The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform’s impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral. Methods:Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006–12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ≥70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40–64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform. Results:Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [−3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [−20%, 30%]), and whites=7% (95% CI [5%, 10%]). Conclusions:Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Breast and cervical cancer screening for women with mental illness: patient and provider perspectives on improving linkages between primary care and mental health

SummaryObjective: Previous research suggests that women with mental illness may be at increased risk for breast and cervical cancer. This qualitative study of patients and primary care and mental health providers explored challenges to accessing and providing breast and cervical cancer screening for women with mental illness. Method: Key informant patient and provider participants were recruited from a community health setting and teaching hospital. Narrative data from 1) interviews with women in a community primary care setting (n = 16); 2) telephone interviews with women with mental illness (n = 16); and 3) focus groups with primary care providers (n = 9) and mental health providers (n = 26) were collected. Results: Patient, provider, and system factors that may contribute to suboptimal cancer screening among women with mental illness were identified. Communication between primary care and mental health providers was noted as a key area for intervention to enhance screening. Barriers to and possibilities for a more proactive role for mental health providers were also considered. Conclusions: Both patient and provider study participants emphasized the need to address communication gaps between primary care and mental health providers and to promote the active collaboration of mental health providers in preventive cancer screening for women with mental illness.