Exploring prevention and management of secondary health conditions in people with spinal cord injury in South Africa

Background/Aims Preventative care for people with spinal cord injury is neglected, even though secondary health conditions are prevalent among this group. There is limited information on preventative care for secondary health conditions among people with spinal cord injury. This study aimed to explore how people with spinal cord injury prevent and manage secondary health conditions. Methods A total of 17 individuals with spinal cord injury attending an outpatients clinic at a public rehabilitation hospital were interviewed face to face. All the interviews were transcribed verbatim and analysed using thematic content analysis. Results The participants used different strategies to prevent and manage secondary health conditions, such as medication, assistive devices, self-management, resilience coping strategies and therapeutic approaches. The participants found prevention of secondary health conditions ‘challenging’ and some of the strategies were ineffective. Conclusions Although many strategies are used by people with spinal cord injury to prevent and manage secondary health conditions, the experience is difficult. To minimise the occurrence and the consequence of secondary health conditions among people with spinal cord injury, health professionals must promote and support preventative care for secondary health conditions.

Identification of patients at risk of new onset heart failure: Utilizing a large statewide health information exchange to train and validate a risk prediction model

Background New-onset heart failure (HF) is associated with poor prognosis and high healthcare utilization. Early identification of patients at increased risk incident-HF may allow for focused allocation of preventative care resources. Health information exchange (HIE) data span the entire spectrum of clinical care, but there are no HIE-based clinical decision support tools for diagnosis of incident-HF. We applied machine-learning methods to model the one-year risk of incident-HF from the Maine statewide-HIE. Methods and results We included subjects aged ≥ 40 years without prior HF ICD9/10 codes during a three-year period from 2015 to 2018, and incident-HF defined as assignment of two outpatient or one inpatient code in a year. A tree-boosting algorithm was used to model the probability of incident-HF in year two from data collected in year one, and then validated in year three. 5,668 of 521,347 patients (1.09%) developed incident-HF in the validation cohort. In the validation cohort, the model c-statistic was 0.824 and at a clinically predetermined risk threshold, 10% of patients identified by the model developed incident-HF and 29% of all incident-HF cases in the state of Maine were identified. Conclusions Utilizing machine learning modeling techniques on passively collected clinical HIE data, we developed and validated an incident-HF prediction tool that performs on par with other models that require proactively collected clinical data. Our algorithm could be integrated into other HIEs to leverage the EMR resources to provide individuals, systems, and payors with a risk stratification tool to allow for targeted resource allocation to reduce incident-HF disease burden on individuals and health care systems.

The Impact of Community Health Coalitions On Preventative Health Outcomes: A Systematic Review

Background/Objective: Six out of ten deaths in the United States are caused by chronic diseases. There are multiple approaches to prevention and/or early detection of chronic diseases through screenings, nutrition, physical activity, and more. Unfortunately, a large portion of the US population have low rates of preventative care. Community health coalitions have the potential to improve preventative health outcomes by partnering with key members of communities to design programs that best fit community needs. In this systematic review, we examine evidence that community health coalitions can improve preventative health outcomes. Methods: PubMed, WebofScience, CINAHL, and PsycINFO were searched for (outcome OR health outcome) AND (prevention) AND (diabetes OR hypertension OR cancer OR prenatal) AND (community-based participatory research OR community coalition OR coalition OR health coalition). After screening 490 articles, 30 full-text, peer-reviewed, English articles meeting inclusion criteria of health coalition, prevention, health outcomes reported, and conducted in the United States were reviewed. Results: 27 of the 30 studies showed community health coalitions having a positive impact. Roughly half of the articles were randomized control trials. Community members and academia were represented in 80% and 77%, respectively, of the coalitions described, while other representations included faith-based organizations, health care, public health, industry, and education. Diabetes and cancer represented 74% of the targeted preventions addressed. 90% of the interventions focused on educating the community, and 33% focused on increasing health screening rates. 60% utilized trained community members to deliver interventions. 60% reported health measurements, 33% reported screening rates, and 30% reported knowledge and awareness. Conclusion, Impact, & Implications: While the evidence suggests community health coalitions are effective in improving preventative health outcomes, the quality of the studies remain low. There is a need for increased rigor of study design and assessment in order to determine the true efficacy of community health coalitions. The majority of the randomized-control trials in this review were rated as low-quality, highlighting the difficulty of designing a randomized, controlled study in a community. Inadequate funding, lack of rigorous design, or ethical challenges can limit the quality of the assessment. Further, although prenatal care was included as a search term, there were no coalitions found that addressed this type of preventative care. This points to a future need for the creation of or increased publications from prenatal health coalitions.

Delaying Health Care Due to the COVID-19 Pandemic: Associations With Physical and Mental Health and Preventive Care

Health care is important for maintaining optimal physical and mental health. However, due to the COVID-19 pandemic, many older adults have delayed or postponed care. Data from the special midterm release of the 2020 Health and Retirement Study (HRS) were used to examine the relationship between chronic conditions and delayed care, as well as between delayed care and mental health outcomes and preventative care among Americans aged 50+ (N=3,266). Approximately 30% of respondents said yes when asked “Since March 2020, was there any time when you needed medical or dental care, but delayed getting or did not get it at all?” Of those, 55% said their provider cancelled, closed or suggested rescheduling, 28.5% decided it could wait, and 20.8% were afraid to go. Results from OLS and logistic regression, controlling for sociodemographic characteristics, indicate that those with lung disease and those with a heart condition had significantly higher odds of delaying care. Delaying care was associated with significantly higher odds of poor self-rated health and feeling depressed, as well as significantly higher average hopelessness, loneliness and negative affect and significantly lower average positive affect. Surprisingly, delaying care was not associated with receiving a flu shot, cholesterol test, colonoscopy, mammogram or prostate exam in the previous two years. It is likely that the full effects of delaying health care during the pandemic have yet to be felt and there is a need to study the implications of such delays.

Racial-Ethnic Disparities in Access to Preventive Services Among Privately Insured Adults With Disabilities

Introduction Cerebral palsy (CP) and spina bifida (SB) are congenital disabilities. Due to life-long disability, adults with CP/SB are with greater needs for preventative care. Little is known about racial/ethnic disparities in use of preventative services in this population. Our objective was to examine racial/ethnic disparities in use of preventative care. Methods Using 2007-2017 private claims data, we identified White, Black, and Hispanic adults (18+) with CP/SB [n=11,635; White=8,935; Black=1,457; Hispanic=1,243)]. We quantified the National Institute of Medicine (NAM) definition of disparity by matching health related variables (age, sex, comorbid conditions, and Elixhauser index) between Whites and each minority subpopulation. Generalized estimating equations were used and all models were adjusted for age, sex, comorbidities, income, education, and U.S. Census divisions. Outcomes of interest were: (1) any office visit; (2) any physical therapy/ occupational therapy (PT/OT); (3) annual wellness visit; (4) bone density screening; (5) cholesterol screening; (6) diabetes screening. Results Rate of recommended services for all adults with CP/SB were low and no significant results were found for most preventative services across race/ethnicity. Compared with Whites, Hispanics had lower odds of annual wellness visit (OR: 0.71; 95% CI: 0.53, 0.96) but higher odds of diabetes screening (OR: 1.48; 95% CI: 1.13, 1.93). Blacks had lower odds of bone density screening (OR: 0.54; 95% CI: 0.31-0.95), and annual wellness visit (OR: 0.50; 95% CI: 0.24-1.00). Conclusions There were no substantial racial/ethnic disparities in use of preventive services among privately insured adults with CP/SB who had a higher-than-average income and education level.

Examining area-level variation in service organisation and delivery across the breadth of primary healthcare. Usefulness of measures constructed from routine data

Background Australia has a universal healthcare system, yet organisation and delivery of primary healthcare (PHC) services varies across local areas. Understanding the nature and extent of this variation is essential to improve quality of care and health equity, but this has been hampered by a lack of suitable measures across the breadth of effective PHC systems. Using a suite of measures constructed at the area-level, this study explored their application in assessing area-level variation in PHC organisation and delivery. Methods Routinely collected data from New South Wales, Australia were used to construct 13 small area-level measures of PHC service organisation and delivery that best approximated access (availability, affordability, accommodation) comprehensiveness and coordination. Regression analyses and pairwise Pearson’s correlations were used to examine variation by area, and by remoteness and area disadvantage. Results PHC service delivery varied geographically at the small-area level–within cities and more remote locations. Areas in major cities were more accessible (all measures), while in remote areas, services were more comprehensive and coordinated. In disadvantaged areas of major cities, there were fewer GPs (most disadvantaged quintile 0.9[SD 0.1] vs least 1.0[SD 0.2]), services were more affordable (97.4%[1.6] bulk-billed vs 75.7[11.3]), a greater proportion were after-hours (10.3%[3.0] vs 6.2[2.9]) and for chronic disease care (28%[3.4] vs 17.6[8.0]) but fewer for preventive care (50.7%[3.8] had cervical screening vs 62.5[4.9]). Patterns were similar in regional locations, other than disadvantaged areas had less after-hours care (1.3%[0.7] vs 6.1%[3.9]). Measures were positively correlated, except GP supply and affordability in major cities (-0.41, p < .01). Implications Application of constructed measures revealed inequity in PHC service delivery amenable to policy intervention. Initiatives should consider the maldistribution of GPs not only by remoteness but also by area disadvantage. Avenues for improvement in disadvantaged areas include preventative care across all regions and after-hours care in regional locations.

Examining the Risk of Potentially Preventable Hospitalization in Adults With Congenital and Acquired Disabilities

Introduction Adults with congenital (cerebral palsy/spina bifida (CP/SB)) or acquired disabilities (spinal cord injury (SCI) or multiple sclerosis (MS)) are more likely than those without disability to develop medical complications. Little is known about potentially preventable hospitalizations (PPH) among adults with disabilities. PPHs are preventable if a patient had timely access to care. Our objective was to estimate PPH risk for each of the aforementioned disabilities. Methods We used private payer claims data from 2007-2017 to identify adults (18+) with diagnoses of CP/SB (n=10,617), SCI (n=5,173), and MS (n=6,198). Adults without these disabilities were included as controls. We propensity score matched individuals for age and sex. Logistic regression models with repeated measures were subsequently applied, adjusting for age, sex, race/ethnicity, health indicators, U.S. census divisions, and socioeconomic variables. Odd ratios (OR) were compared over 4-years of follow up. Results Adults with CP/SB, SCI, and MS had higher odds of any PPH compared with adults without disability [CP/SB: (OR=4.10; 95% CI: 2.31-7.31); SCI: (OR=1.67; 95% CI: 1.21-2.32); and MS: (OR=1.48; 95% CI: 1.00-2.25)]. Use of preventative services reduced the PPH risk. For example, wellness visit reduced the odds of PPH by almost half [CP/SB: (OR=0.52; 95% CI: 0.41-0.67); SCI: (OR=0.57; 95% CI: 0.45-0.71); and MS: (OR=0.53; 95% CI: 0.40-0.66)]. Conclusions Adults with disabilities are at greater odds of PPH compared to adults without disabilities. Clinical guidelines for use of preventative care for adults living with disabilities need to be accordingly updated.

Perceptions on Preventative Care During the Covid-19 Pandemic: A Survey Using Clinical Scenarios

One significant side effect of the Covid-19 pandemic is the decline in preventative healthcare services. The reduction in inpatient and outpatient visits has been attributed to fears of contracting the virus. Our study utilized a cross sectional survey of adults to determine patient risk assessment for receiving preventative care during the pandemic, specifically mammography, colonoscopy, and immunizations, through clinical scenarios (ranked high, medium, or low risk). Based on the scenario, the respondent indicated whether they would schedule their appointment for the relevant procedure within the next month. We hypothesized that more people would choose to seek care as their symptomatic severity and risk factors increased including increased age, outweighing their Covid-19 fears against the urgency of their clinical presentation. Consistent with the hypothesis, there were statistically significant differences to increasing scenario intensity for all procedures (mammography, immunization, colonoscopy). Regarding age, low risk immunization respondents 65 years and older were more likely to get their flu shot than those in the 18-49 or 50-64 age brackets, whereas no significant differences were found for colonoscopy and mammography among eligible age groups. These empirical results epidemiologically support proposed projection models stating there will likely be an increased incidence in late-stage cancers and immunization preventable disease due to missed/unscheduled appointments attributed to the pandemic. Thus, physicians should strongly encourage their patients to receive missed preventative care.

Vaso-Occlusive Events in Pediatric Sickle Cell Disease: Quantifying Social Disadvantage and Its Impact on Hospitalizations

Background: Sickle Cell Disease (SCD) has established socioeconomic disadvantage resulting in increased healthcare utilization. Among the pediatric population, the implementation of preventative care measures within the medical home model has improved outcomes and lifespan. Area deprivation index (ADI) is an established method for quantifying socioeconomic disadvantage and has been shown to be associated with increased hospital readmission in adults and pediatric patients with chronic disease (Singh Am J Public Health. 2003, Kind et al. Ann Intern Med. 2014). ADI has been applied to adults with SCD and vaso-occlusive events (VOE) but has not been investigated in pediatric patients. We explored the role of ADI in pediatric patients with SCD admitted with VOE in order to characterize disadvantage and the hospitalization characteristics that impact hospital readmission. Methods: This retrospective review included 675 consecutive emergency department and hospital admissions for VOE among 101 pediatric (≤ 21 years old) patients with SCD from 2016-2019 at a single urban, US-based medical center. One hospital admission for each patient was selected at random. Information extracted included demographics, SCD characteristics, admission complications, entry and discharge pain scores, length of stay, and management characteristics. Variables were compiled in a descriptive table and compared in logistic regression models against a primary outcome of 7-day readmission. The 2018 ADI dataset was used to assign an ADI value based on the census block corresponding to the patient-reported zip-code for the specific hospital admission (https://www.neighborhoodatlas.medicine.wisc.edu). ADI values were grouped by most and least deprived with higher scores (6-10) indicating more deprivation. Summary statistics described patient and disease characteristics in these groups. Results: Within our cohort, the state and national ADI was calculated for 101 patients with a median age of 14 years (50.4% female; 98.0% Black) (Table 1). Most patients were publicly insured (80.2%). The Hb SS genotype was the most common genotype, followed by Hb SC (22.7%). Median ADI rank was 9 with 11 patients (10.9%) classified as less disadvantaged (ADI 1-5) and 90 patients (89.1%) as more disadvantaged (ADI 6-10). We found the less disadvantaged group had even numbers of public and private insurance use while 83.3% of the patients in the more disadvantaged group had public insurance. The Hb SS genotype was more common in the less disadvantaged (90.9%) than the more disadvantaged (74.4%), where Hb SC was overrepresented (24.4%). Greatest prevalence of mental health disease and hospital complications, including acute chest syndrome, avascular necrosis, and pneumonia, were observed in the more disadvantaged. Additionally, the more disadvantaged group included a greater number of patients with scheduled follow-up (61.1%) and shorter time to follow-up (median: 31 days). For treatment and management, both groups had high numbers of prescriptions for hydroxyurea (HU) and opiates, with slightly higher numbers in the less disadvantaged group (82% HU; 100% opioids) compared to the more disadvantaged (61% HU; 81% opioids). Length of hospital-stay and pain scores were similar across groups. The 7-day readmission rate was 9% for the less disadvantaged group and 14% for the more disadvantaged group. Conclusions: We applied a validated measure of socioeconomic disadvantage to a group of pediatric patients with SCD and VOE. Our cohort consists of more disadvantaged patients across ADI scales. Readmission rate was low for both groups and there was no relationship between greater ADI scores and hospital readmission. Within the more disadvantaged group, the higher prevalence of mental health illness as well as associated disease complications may have been countered by protective factors including established follow-up, shorter time to follow-up, and high number of prescriptions for hydroxyurea and opiates. Our results are consistent with the protective effect of ADI on recurrent acute chest syndrome in pediatric SCD patients (Alishlash et al. Pediatr. Blood Cancer. 2021) highlighting the importance of preventative care within the SCD medical home. Further research is warranted on identifying key protective factors that may reduce acute care utilization and social disparity in this population. Figure 1 Figure 1. Disclosures Novelli: Novartis Pharmaceuticals: Consultancy.