Melissa M. Ahern

Access to health care and community social capital.

OBJECTIVE To test the hypothesis that variation in reported access to health care is positively related to the level of social capital present in a community. DATA SOURCES The 1996 Household Survey of the Community Tracking Study, drawn from 22 metropolitan statistical areas across the United States (n = 19,672). Additional data for the 22 communities are from a 1996 multicity broadcast media marketing database, including key social capital indicators, the 1997 National Profile of Local Health Departments survey, and Interstudy, American Hospital Association, and American Medical Association sources. STUDY DESIGN The design is cross-sectional. Self-reported access to care problems is the dependent variable. Independent variables include individual sociodemographic variables, community-level health sector variables, and social capital variables. DATA COLLECTION/EXTRACTION METHODS Data are merged from the various sources and weighted to be population representative and are analyzed using hierarchical categorical modeling. PRINCIPAL FINDINGS Persons who live in metropolitan statistical areas featuring higher levels of social capital report fewer problems accessing health care. A higher HMO penetration rate in a metropolitan statistical area was also associated with fewer access problems. Other health sector variables were not related to health care access. CONCLUSIONS The results observed for 22 major U.S. cities are consistent with the hypothesis that community social capital enables better access to care, perhaps through improving community accountability mechanisms.

Social capital and trust in providers

Trust in providers has been in decline in recent decades. This study attempts to identify sources of trust in characteristics of health care systems and the wider community. The design is cross-sectional. Data are from (1) the 1996 Household Survey of the Community Tracking Study, drawn from 24 Metropolitan Statistical Areas; (2) a 1996 multi-city broadcast media marketing database including key social capital indicators; (3) Interstudy; (4) the American Hospital Association; and (5) the American Medical Association. Independent variables include individual socio-demographic variables, HMO enrollment, community-level health sector variables, and social capital. The dependent variable is self-reported trust in physicians. Data are merged from the various sources and analyzed using SUDAAN. Subjects include adults in the Household Survey who responded to the items on trust in physicians (N=17,653). Trust in physicians is independently predicted by community social capital (p<0.001). Trust is also negatively related to HMO enrollment and to many individual characteristics. The effect of HMOs is not uniform across all communities. Social capital plays a role in how health care is perceived by citizens, and how health care is delivered by providers. Efforts to build trust and collaboration in a community may improve trust in physicians, health care quality, access, and preserve local health care control.

Access to Mental Health Services and Health Sector Social Capital

Mental health services are underused relative to mental illness rates. We hypothesized a positive correlation between use of mental health services and community-level health care social capital. Community Tracking Study data from 43 cities (N=43,278), merged with the National Profile of Local Health Departments and other sources, show that use of mental health services was greater when public health districts collaborated with managed care organizations and other community groups, independent of individual predictors and health care system variables. Use was also positively associated with community levels of public insurance coverage and with direct public health provision of behavioral health care services. Research is needed to understand the mechanisms by which social capital may improve access to mental health services.

Anesthesia staffing and anesthetic complications during cesarean delivery: a retrospective analysis.

Background: Obstetrical anesthesia services may be provided by Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, or a combination of the two providers. Research is needed to assist hospitals and anesthesia groups in making cost-effective staffing choices. Objectives: To identify differences in the rates of anesthetic complications in hospitals whose obstetrical anesthesia is provided solely by CRNAs compared to hospitals with only anesthesiologists. Methods: Washington State hospital discharge data were obtained from 1993 to 2004 for all cesarean sections, and were merged with a survey of hospital obstetrical anesthesia staffing. Anesthetic complications were identified via International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Resulting rates were risk-adjusted using regression analysis. Results: Hospitals with CRNA-only staffing had a lower rate of anesthetic complications than those with anesthesiologist staffing (0.58% vs. 0.76%, p =.0006). However, after regression analysis, this difference was not significant (odds ratio for CRNA vs. anesthesiologist complications: 1.046 to 1, 95% confidence interval 0.649-1.658, p =.85). Discussion: There is no difference in rates of complications between the two types of staffing models. As a result, hospitals and anesthesiology groups may safely examine other variables, such as provider availability and costs, when staffing for obstetrical anesthesia. Further study is needed to validate the use of ICD-9-CM codes for anesthesia complications as an indicator of quality.

Data Envelopment Analysis to determine efficiencies of health maintenance organizations

We use Data Envelopment Analysis (DEA) to measure the relative technical efficiencies of 164 HMOs licensed to practice in the United States in 1995 with data collected from the American Association of Health Plans. Health care output measures used in the analysis are the number of commercial, Medicare and Medicaid lives covered in each plan. Inputs to the model are health care utilization measures such as the number of medical and surgical inpatient days, number of maternity and newborn stays in days, number of outpatient and emergency room visits and the number of non‐invasive and invasive procedures performed on patients in an ambulatory setting. Mean efficiency of health plans was 40% (of the most efficient). We use multivariate analysis to try and explain variations in efficiency. Enrollment influences efficiency, with larger HMOs being more efficient than those with fewer enrollees. Plans with a more even distribution of Commercial, Medicare and Medicaid patients were more efficient on average than plans with heterogeneous mixes in enrollment. HMOs with Medicare patients are significantly less efficient, with efficiency decreasing with increasing Medicare participation in plan membership. Health plans in operation for longer periods of time had greater outputs with the same inputs. Health plans that had a majority of their enrollees in network or IPA type arrangements were more efficient as were for‐profit plans compared to not‐for‐profits. Policy implications are discussed.

Avoidable Hospitalizations for Diabetes: Comorbidity Risks

This study examined the risk for avoidable diabetes hospitalizations associated with comorbid conditions and other risk variables. A retrospective analysis was conducted of hospitalizations with a primary diagnosis of diabetes in a 2004 sample of short stay general hospitals in the United States (N = 97,526.) Data were drawn from the Health Care Utilization Project National Inpatient Sample. Avoidable hospitalizations were defined using criteria from the Agency for Healthcare Research and Quality to analyze 2 types of ambulatory care sensitive conditions (ACSCs): short-term complications and uncontrolled diabetes. Maternal cases, patients younger than age 18, and transfers from other hospitals were excluded. Avoidable hospitalization was estimated using maximum likelihood logistic regression analysis, where independent variables included patient age, gender, comorbidities, uninsurance status, patients rural-urban residence and income estimate, and hospital variables. Models were identified using multiple runs on 3 random quartiles and validated using the fourth quartile. Costs were estimated from charge data using cost-to-charge ratios. Results indicated that these 2 ACSCs accounted for 35,312 or 36% of all diabetes hospitalizations. Multiple types of comorbid conditions were related to risk for avoidable diabetes hospitalizations. Estimated costs and length of stay were lower among these types of avoidable hospitalizations compared to other diabetes hospitalizations; however, total estimated nationwide costs for 2004 short-term complications and uncontrolled diabetes hospitalizations totaled over

Community Participation and the Emergence of Late-Life Depressive Symptoms: Differences between Women and Men

1.3 billion. Recommendations are made for how disease management programs for diabetes could incorporate treatment for comorbid conditions to reduce hospitalization risk.

THE IMPORTANCE OF SENSE OF COMMUNITY ON PEOPLE'S PERCEPTIONS OF THEIR HEALTH-CARE EXPERIENCES

OBJECTIVE To understand the role of community participation in prevention of first lifetime depressive episode in older women and men. METHODS We used data from the Wisconsin Longitudinal Study to identify variables that predicted risk for the emergence of depressive symptoms and tested a hypothesis that community participation would protect women from depression more than it would protect men. The sample was drawn from Wisconsin high school graduates who were approximately 64-66 years of age in the 2003-2005 data collection period (n = 2546 with complete data meeting inclusion criteria.) The sample consisted of persons who had no evidence of current or prior lifetime depression in the 1993 data collection period. The emergence of high depressive symptoms was examined for women and men as a function of community participation and other covariates, including social support. RESULTS The emergence of depressive symptoms for both sexes was predicted by poorer reported health status and higher levels of subthreshold depressive symptoms during the previous interview. For men, additional risk factors were pain and low income. For women, additional risks were widowhood, lower education, and lower community participation. CONCLUSIONS Community participation, in the form of volunteering, religious attendance, and engagement in community organizations, is related to reduced risk of first-time depressive symptoms among older women.

INPATIENT UTILIZATION BY UNDOCUMENTED IMMIGRANTS WITHOUT INSURANCE

OBJECTIVES The authors study the relationship between peoples sense of community and problems they experience with the health-care system, specifically problems related to cost, access, provider choice, and satisfaction. METHODS Data from a 1993 Florida poll (n = 1202) was used to conduct a multinomial logit analysis to estimate peoples sense of community as a function of 13 characteristics and perceptions of community. Logit analysis was used to estimate the relationship between peoples sense of community and their health-care experiences, controlling for other demographic influences, including insurance coverage and self-reported health status. RESULTS Lower sense of community was significantly associated with higher levels of choice, cost, and satisfaction problems in peoples interactions with the health-care sector. CONCLUSIONS Community quality needs to be considered in efforts to improve the functional capabilities of health-care institutions.

Predictors of HMO efficiency

Data collected from a large county hospital in Miami, Florida were used to study the severity of illness (using the Case Mix Severity Index) and resource use (measured by average length of stay, procedures, and/or diagnostic tests performed) of undocumented persons from Dade County, Florida in an inpatient setting. Compared with native-born populations and those with permanent residency status (insured by Medicaid or of uninsured status) admitted to the same hospital, undocumented immigrants had a higher Case Mix Severity Index but a lower adjusted average length of stay. Undocumented immigrants and uninsured residents of the United States had a similar number of adjusted procedures/tests performed, but less than Medicaid beneficiaries. Policy issues are discussed.