Association of Home Based Primary Care Enrollment with Social Determinants of Health for Older Veterans

The Veterans Administration (VA) Home-based Primary Care (HBPC) program provides comprehensive primary care to older Veterans with multiple chronic conditions who may be at risk of adverse health outcomes due to their social determinants of health. Area Deprivation Index (ADI) can be used as a surrogate measure of a Veteran’s social needs. The objective of this study was to estimate the effect of neighborhood disadvantage, as measured by ADI, on HBPC enrollment for a sample of older Veterans. We estimated a linear multivariate model in which the exposure was ADI and the outcome was enrollment in HBPC. Controls included clinical and demographic characteristics. In a final sample of 12,005,453 observations (total Veteran months) on 353,485 individual Veterans, 18.4% lived in high-deprivation neighborhoods (ADI greater than or equal to 80). Mean monthly probability of new HBPC enrollment was 0.0061. Controlling for clinical characteristics, housing instability, and distance from the medical center, Veterans residing in high-deprivation neighborhoods were 1.4% to 14.8% less likely to enroll in HBPC, though the association was not statistically significant. The VA HBPC program provides beneficial comprehensive, primary care services to Veterans at risk of poor health outcomes. However, a Veteran’s social determinants of health could prevent enrollment. More research is needed to determine the relationship between Veterans’ social needs and HBPC enrollment.

Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol

ABSTRACT Background We evaluated whether a comprehensive STEMI protocol (CSP) focusing on guideline‐directed medical therapy, trans‐radial percutaneous coronary intervention (PCI), and rapid door to balloon time (D2BT) improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with STEMI treated with PCI at a single hospital before (1/1/2011‐7/14/2014) and after (7/15/2014‐7/15/2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤ 50 th percentile; 29.0%), moderate (51‐90 th percentile; 40.8%), and high (>90 th percentile; 30.2%). The primary process outcome was D2BT. Achievement of guideline‐recommend D2BT goals improved in all deprivation groups pre‐ vs. post‐CSP (low: 67.8% vs. 88.5%; moderate: 50.7% vs. 77.6%; high: 65.5% vs. 85.6%; all p<0.001). Median D2BT among ED/in‐hospital patients was significantly non‐inferior in higher vs. lower deprivation groups post‐CSP (non‐inferiority limit = 5 minutes, p non‐inferiority high vs. moderate 0.002, high vs. low <0.001, moderate vs. low 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower post‐CSP in patients with moderate / high deprivation in unadjusted (pre‐CSP 7.0% vs. post‐CSP 3.1%, OR 0.42 [95% CI 0.25, 0.72], p=0.002) and risk‐adjusted (OR 0.42 [0.23, 0.77], p=0.005) models. Conclusions A CSP was associated with improved STEMI care across all deprivation groups and reduced mortality in those with moderate or high deprivation. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as STEMI.

Deprivation Index and Lifestyle: Baseline Cross-Sectional Analysis of the PREDIMED-Plus Catalonia Study

This baseline cross-sectional analysis from data acquired in a sub-sample of the PREDIMED-Plus study participants aimed to evaluate the relation between the Composite Socioeconomic Index (CSI) and lifestyle (diet and physical activity). This study involved 1512 participants (759 (52.2%) women) between 55 and 80 years with overweight/obesity and metabolic syndrome assigned to 137 primary healthcare centers in Catalonia, Spain. CSI and lifestyle (diet and physical activity) were assessed. Multiple linear regression or multinomial regression were applied to the data. Cluster analysis was performed to identify dietary patterns. The multiple linear regression model showed that a high deprivation index was related to a higher consumption of refined cereals (11.98 g/d, p-value = 0.001) and potatoes (6.68 g/d, p-value = 0.001), and to a lower consumption of fruits (−17.52 g/d, p-value = 0.036), and coffee and tea (−8.03 g/d, p-value = 0.013). Two a posteriori dietary patterns were identified by cluster analysis and labeled as “healthy” and “unhealthy”. In addition, the multinomial regression model showed that a high deprivation index was related to an unhealthy dietary pattern and low physical activity (OR 1.42 [95% CI 1.06–1.89]; p-value < 0.05). In conclusion, a high deprivation index was related to an unhealthy lifestyle (diet and physical activity) in PREDIMED-Plus study participants.

A Trauma-Informed Transition Model for New Entrants with Dysregulated Behaviours

The Riroriro programme was a response to the needs of children with extremely dysregulated classroom behaviours, resulting from sustained exposure to traumatic high-stress and high-deprivation environments from pre-birth to school age. Evaluation of the accounts of key individuals involved in the pilot found that participants had improved emotional regulation abilities and interpersonal skills during and up to 1 year after the intervention. Academic performance was not improved significantly, but the interviewees’ accounts suggested that “academic readiness” had been achieved. In line with previous studies, the results indicate preliminary support for the effectiveness of the Riroriro programme in supporting children who have experienced trauma to become mainstream classroom ready. These results suggest that a whole-school, multi-tiered approach providing support at the student, school personnel and system levels can help mitigate the effects of trauma.

Diet quality and risk and severity of COVID-19: a prospective cohort study

ObjectivePoor metabolic health and unhealthy lifestyle factors have been associated with risk and severity of COVID-19, but data for diet are lacking. We aimed to investigate the association of diet quality with risk and severity of COVID-19 and its interaction with socioeconomic deprivation.DesignWe used data from 592 571 participants of the smartphone-based COVID-19 Symptom Study. Diet information was collected for the prepandemic period using a short food frequency questionnaire, and diet quality was assessed using a healthful Plant-Based Diet Score, which emphasises healthy plant foods such as fruits or vegetables. Multivariable Cox models were fitted to calculate HRs and 95% CIs for COVID-19 risk and severity defined using a validated symptom-based algorithm or hospitalisation with oxygen support, respectively.ResultsOver 3 886 274 person-months of follow-up, 31 815 COVID-19 cases were documented. Compared with individuals in the lowest quartile of the diet score, high diet quality was associated with lower risk of COVID-19 (HR 0.91; 95% CI 0.88 to 0.94) and severe COVID-19 (HR 0.59; 95% CI 0.47 to 0.74). The joint association of low diet quality and increased deprivation on COVID-19 risk was higher than the sum of the risk associated with each factor alone (Pinteraction=0.005). The corresponding absolute excess rate per 10 000 person/months for lowest vs highest quartile of diet score was 22.5 (95% CI 18.8 to 26.3) among persons living in areas with low deprivation and 40.8 (95% CI 31.7 to 49.8) among persons living in areas with high deprivation.ConclusionsA diet characterised by healthy plant-based foods was associated with lower risk and severity of COVID-19. This association may be particularly evident among individuals living in areas with higher socioeconomic deprivation.

Mobility and social deprivation on primary care utilisation among paediatric patients with asthma

ObjectiveAsthma care is negatively impacted by neighbourhood social and environmental factors, and moving is associated with undesirable asthma outcomes. However, little is known about how movement into and living in areas of high deprivation relate to primary care use. We examined associations between neighbourhood characteristics, mobility and primary care utilisation of children with asthma to explore the relevance of these social factors in a primary care setting.DesignIn this cohort study, we conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.SettingWe used data from community health centres in 15 OCHIN states.ParticipantsThe sample included 23 773 children with asthma aged 3–17 across neighbourhoods with different levels of social deprivation from 2012 to 2017. We conducted negative binomial regression to examine the rates of primary care visits and annual influenza vaccination and logistic regression to study receipt of pneumococcal vaccination. All models were adjusted for patient-level covariates.ResultsClinic visit rates were higher among children living in or moving to areas with higher deprivation than those living in areas with low deprivation (rate ratio (RR) 1.09, 95% CI 1.02 to 1.17; RR 1.05, 95% CI 1.00 to 1.11). Children moving across neighbourhoods with similarly high levels of deprivation had increased RRs of influenza vaccination (RR 1.13, 95% CI 1.03 to 1.23) than those who moved but stayed in neighbourhoods of low deprivation.ConclusionsMovement into and living within areas of high deprivation is associated with more primary care use, and presumably greater opportunity to reduce undesirable asthma outcomes. These results highlight the need to attend to patient movement in primary care visits, and increase neighbourhood-targeted population management to improve equity and care for children with asthma.

Diet quality and risk and severity of COVID-19: a prospective cohort study

Objective: Poor metabolic health and certain lifestyle factors have been associated with risk and severity of coronavirus disease 2019 (COVID-19), but data for diet are lacking. We aimed to investigate the association of diet quality with risk and severity of COVID-19 and its intersection with socioeconomic deprivation. Design: We used data from 592,571 participants of the smartphone-based COVID Symptom Study. Diet quality was assessed using a healthful plant-based diet score, which emphasizes healthy plant foods such as fruits or vegetables. Multivariable Cox models were fitted to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) for COVID-19 risk and severity defined using a validated symptom-based algorithm or hospitalization with oxygen support, respectively. Results: Over 3,886,274 person-months of follow-up, 31,815 COVID-19 cases were documented. Compared with individuals in the lowest quartile of the diet score, high diet quality was associated with lower risk of COVID-19 (HR, 0.91; 95% CI, 0.88-0.94) and severe COVID-19 (HR, 0.59; 95% CI, 0.47-0.74). The joint association of low diet quality and increased deprivation on COVID-19 risk was higher than the sum of the risk associated with each factor alone (Pinteraction=0.005). The corresponding absolute excess rate for lowest vs highest quartile of diet score was 22.5 (95% CI, 18.8-26.3) and 40.8 (95% CI, 31.7-49.8; 10,000 person-months) among persons living in areas with low and high deprivation, respectively. Conclusions: A dietary pattern characterized by healthy plant-based foods was associated with lower risk and severity of COVID-19. These association may be particularly evident among individuals living in areas with higher socioeconomic deprivation.

"Healthy Eating - Healthy Action": evaluating New Zealand's obesity prevention strategy

Background. New Zealand rates of obesity and overweight have increased since the 1980s, particularly among indigenous Mori people, Pacific people and those living in areas of high deprivation. New Zealand's response to the obesity epidemic has been The Healthy Eating-Healthy Action: Oranga Kai - Oranga Pumau (HEHA) Strategy ('the Strategy'), launched in 2003. Because the HEHA Strategy explicitly recognises the importance of evaluation and the need to create an evidence base to support future initiatives, the Ministry of Health has commissioned a Consortium of researchers to evaluate the Strategy as a whole. Methods. This paper discusses the Consortium's approach to evaluating the HEHA Strategy. It includes an outline of the conceptual framework underpinning the evaluation, and describes the critical components of the evaluation which are: judging to what extent stakeholders were engaged in the process of the strategy implementation and to what extent their feedback was incorporated in to future iterations of the Strategy (continuous improvement), to what extent the programmes, policies, and initiatives implemented span the target populations and priority areas, whether there have been any population changes in nutrition and/or physical activity outcomes or behaviours relating to those outcomes, and to what extent HEHA Strategy and spending can be considered value for money. Discussion. This paper outlines our approach to evaluating a complex national health promotion strategy. Not only does the Evaluation have the potential to identify interventions that could be adopted internationally, but also the development of the Evaluation design can inform other complex evaluations. © 2009 McLean et al; licensee BioMed Central Ltd.

"Healthy Eating - Healthy Action": evaluating New Zealand's obesity prevention strategy

Background. New Zealand rates of obesity and overweight have increased since the 1980s, particularly among indigenous Mori people, Pacific people and those living in areas of high deprivation. New Zealand's response to the obesity epidemic has been The Healthy Eating-Healthy Action: Oranga Kai - Oranga Pumau (HEHA) Strategy ('the Strategy'), launched in 2003. Because the HEHA Strategy explicitly recognises the importance of evaluation and the need to create an evidence base to support future initiatives, the Ministry of Health has commissioned a Consortium of researchers to evaluate the Strategy as a whole. Methods. This paper discusses the Consortium's approach to evaluating the HEHA Strategy. It includes an outline of the conceptual framework underpinning the evaluation, and describes the critical components of the evaluation which are: judging to what extent stakeholders were engaged in the process of the strategy implementation and to what extent their feedback was incorporated in to future iterations of the Strategy (continuous improvement), to what extent the programmes, policies, and initiatives implemented span the target populations and priority areas, whether there have been any population changes in nutrition and/or physical activity outcomes or behaviours relating to those outcomes, and to what extent HEHA Strategy and spending can be considered value for money. Discussion. This paper outlines our approach to evaluating a complex national health promotion strategy. Not only does the Evaluation have the potential to identify interventions that could be adopted internationally, but also the development of the Evaluation design can inform other complex evaluations. © 2009 McLean et al; licensee BioMed Central Ltd.