Randy Randolph

Hospitalization rates as indicators of access to primary care.

Variations in hospitalization rates for selected conditions are being used as indicators of the effectiveness of primary care in small areas. Are these rates actually sensitive to problems in local primary care systems? This study examines the relationship between ambulatory care sensitive condition (ACSC) hospital admission rates and primary care resources and the economic conditions in primary care market areas in North Carolina in 1994. The data show a high degree of correlation between the rates and income but not primary care resources. The distribution of rates did agree with expert assessments of the location of places with poor access to health services. The data confirm that access to effective primary care reflected in lower rates of ACSC admissions is a function of more than the professional resources available in a market area. The solution to reducing disparities in health status may not lie within the health system.

The Rising Rate of Rural Hospital Closures.

PURPOSE Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities. METHODS The 2009 financial performance and market characteristics of rural hospitals that closed from 2010 through 2014 were compared to rural hospitals that remained open during the same period, stratified by critical access hospitals (CAHs) and other rural hospitals (ORHs). Differences were tested using Pearsons chi-square (categorical variables) and Wilcoxon rank test of medians. The relationships between negative operating margin and (1) market factors and (2) utilization/staffing factors were explored using logistic regression. FINDINGS In 2009, CAHs that subsequently closed from 2010 through 2014 had, in general, lower levels of profitability, liquidity, equity, patient volume, and staffing. In addition, ORHs that closed had smaller market shares and operated in markets with smaller populations compared to ORHs that remained open. Odds of unprofitability were associated with both market and utilization factors. Although half of the closed hospitals ceased providing health services altogether, the remainder have since converted to an alternative health care delivery model. CONCLUSIONS Financial and market characteristics appear to be associated with closure of rural hospitals from 2010 through 2014, suggesting that it is possible to identify hospitals at risk of closure. As closure rates show no sign of abating, it is important to study the drivers of distress in rural hospitals, as well as the potential for alternative health care delivery models.

Associations of educational attainment, occupation and community poverty with knee osteoarthritis in the Johnston County (North Carolina) osteoarthritis project

IntroductionThe purpose of this study was to examine data from the Johnston County Osteoarthritis (OA) Project for independent associations of educational attainment, occupation and community poverty with tibiofemoral knee OA.MethodsA cross-sectional analysis was conducted on 3,591 individuals (66% Caucasian and 34% African American). Educational attainment (< 12 years or ≥12 years), occupation (non-managerial or not), and Census block group household poverty rate (< 12%, 12 to 25%, > 25%) were examined separately and together in logistic models adjusting for covariates of age, gender, race, body mass index (BMI), smoking, knee injury and occupational activity score. Outcomes were presence of radiographic knee OA (rOA), symptomatic knee OA (sxOA), bilateral rOA and bilateral sxOA.ResultsWhen all three socioeconomic status (SES) variables were analyzed simultaneously, low educational attainment was significantly associated with rOA (odds ratio (OR) = 1.44, 95% confidence interval (CI) 1.20, 1.73), bilateral rOA (OR = 1.43, 95% CI 1.13, 1.81), and sxOA (OR = 1.66, 95% CI 1.34, 2.06), after adjusting for covariates. Independently, living in a community of high household poverty rate was associated with rOA (OR = 1.83, 95% CI 1.43, 2.36), bilateral rOA (OR = 1.56, 95% CI 1.12, 2.16), and sxOA (OR = 1.36, 95% CI 1.00, 1.83). Occupation had no significant independent association beyond educational attainment and community poverty.ConclusionsBoth educational attainment and community SES were independently associated with knee OA after adjusting for primary risk factors for knee OA.

Arthritis in the family practice setting: Associations with education and community poverty

OBJECTIVE To examine associations of self-reported arthritis in 25 urban and rural family practice clinics with education (individual socioeconomic status) and community poverty (community socioeconomic status). METHODS A total of 7,770 patients at 25 family practice sites across North Carolina self-reported whether they had arthritis. Education was measured as less than a high school (HS) degree, a HS degree, and more than a HS degree. The US Census 2000 block group poverty rate (percentage of households in poverty in that block group) was grouped into low, middle, and high tertiles. We assumed heterogeneity by race (non-Hispanic white and African American) for the effects of these sociodemographic variables, and therefore stratified by race. Multilevel analyses were performed using a 2-level mixed logistic model to examine the independent associations and joint effects of education and poverty with self-reported arthritis as the outcome, adjusting for age, sex, and body mass index. RESULTS White participants with less than a HS degree living in block groups with high poverty had 1.55 times the odds (95% confidence interval [95% CI] 1.10-2.17) of reporting arthritis compared with white participants with more than a HS degree and low poverty rates. African American participants with less than a HS degree and high poverty rates had 2.06 times the odds (95% CI 1.16-3.66) of reporting arthritis compared with African American participants with more than a HS degree and low poverty rates. CONCLUSION In the family practice setting, both disadvantaged white and African American participants showed increased odds of self-reported arthritis, with stronger associations in African Americans.

Associations of Educational Attainment, Occupation, and Community Poverty With Hip Osteoarthritis

To examine cross‐sectional baseline data from the Johnston County Osteoarthritis Project for the association between individual and community socioeconomic status (SES) measures with hip osteoarthritis (OA) outcomes.

The Diffusion Of Physicians

Physicians move from place to place over their careers; this is thought to reflect the economic theory that they seek better opportunities to practice. Using national data, this study tracked physician movement between counties classified by physician-to-population ratio and socioeconomic characteristics. Approximately one-quarter of practicing physicians moved in each of two ten-year periods, 1981-1991 and 1991-2001. The overall tendency of movers was to go to places with lower physician-to-population ratios but higher per capita incomes and lower unemployment. These trends, if they continue, may help decrease access to physician care in rural and urban underserved areas.

Health-related quality of life in adults from 17 family practice clinics in North Carolina.

The main objective of this study is to investigate the long-term effects, 3 years after the end of a 2-year pulmonary rehabilitation program with three weekly 1-h exercise sessions and 32 h of education in patients with chronic obstructive pulmonary disease. The method consists of open prospective observational study with 30 patients. Outcome measures were quality of life (QoL) (St Georges Respiratory Questionnaire, SGRQ), physical exercise performance (6-min walking test, 6MWT), self-management abilities, lung function, hospitalization, and self-reported exercise. FEV(1) at baseline was 40.1% of predicted. The participants had statistical and clinical significant decrease in SGRQ (improved QoL) and increase in 6MWT during the program. They maintained the level of health they achieved during the program in the next 3 years, with a stable SGRQ score (-0.5 points, 95% CI -3.8 to 2.6 P=1.000) and 6MWT (+10 m 95% CI 28 to -4, P=0.273). Eighty percent of the participants had exercised at least 30 min three times a week from the end of the program to year 5. In conclusion, the participants had maintained their achieved level of health, improved their lung function slightly, and continued to exercise regularly 3 years after the end of the program.Introduction We examined health-related quality of life (HRQOL) in white and African American patients based on their own and their communitys socioeconomic status. Methods Participants were 4,565 adults recruited from 17 family physician practices in urban and rural areas of North Carolina. Education was used as a proxy for individual socioeconomic status, and the census block-group poverty level was used as a proxy for community socioeconomic status. HRQOL measures were the 12-Item Short Form Survey Instrument, physical component summary (PCS) and mental component summary (MCS), and 3 Centers for Disease Control and Prevention HRQOL healthy days measures. Multilevel analyses examined independent associations of individual and community poverty level with HRQOL, adjusting for demographics and clustering by family practice. Analyses were stratified by race and were conducted on subgroups of arthritis and cardiovascular disease patients. Results Among whites, all 5 HRQOL measures were significantly associated with the lowest individual socioeconomic status, and 4 HRQOL measures were associated with the lowest community socioeconomic status (MCS being the exception). Among African Americans, 4 HRQOL measures were significantly associated with the lowest individual socioeconomic status and the lowest community socioeconomic status (PCS being the exception). Arthritis and cardiovascular disease subgroup analyses showed generally analogous findings. Conclusion Better HRQOL measures generally were associated with low levels of community poverty and high levels of education, emphasizing the need for further exploration of factors that influence health.