Built Environment and Health Care Use: Disparities Among Chronically Ill Elders

描述(由申请人提供)：老年人居住的社区特征与慢性病晚年生活差异之间的联系一直是一个快速增长的研究领域的主题。对于患有慢性病的低收入和少数族裔老年人来说，在获得和护理质量方面的差距造成了疾病负担方面的差距。对慢性病的研究也强调了医生监督不足、可能可以预防的住院治疗和糟糕的健康结果之间的联系。然而，除了当地的医疗服务供应之外，人们对社区环境因素如何影响患有慢性病的城市老年人如何利用医生服务来管理他们的健康知之甚少。这项研究通过考察居住在纽约市的老年、慢性病联邦医疗保险受益人之间的社区建筑环境(例如步行能力、公共交通)、医生服务的使用以及可预防的住院和急诊科就诊之间的关系来解决这一差距。具体地说，这项研究的目的是：1)检查城市慢性病老年人社区建筑环境和医生服务使用之间的关联；2)确定建筑环境的变化是否以及在多大程度上影响潜在的可预防的住院和急诊科就诊；以及3)通过应用：(I)替代建模技术；以及(Ii)内生性测试，以解决基于服务使用和结果将患者分类到具有不同特征的社区的可能性，从而重新评估目标1和2的结果。这项研究将基于对居住在纽约市的65岁及以上联邦医疗保险受益人样本的现有数据的纵向分析，将个人特征和服务使用措施与其他来源的小区域级别数据联系起来。分析将集中在充血性心力衰竭和糖尿病患者--这两个患者是可预防住院的两个主要因素。这项研究将深入了解临床、社会、经济和环境因素之间的相互依存关系，这些因素会影响慢性病护理的质量，并最终影响患有多种疾病的老年人的生活质量。拟议的研究将应用并扩大候选人在整个K01获奖期间的培训，包括流行病学和卫生经济学方面的高级方法学培训。培训和研究活动将为该奖项后几年的R01申请奠定基础。这项研究和未来的研究结果最终将被应用于开发有效的干预措施，以改善生活在服务不足社区的慢性病老年人获得、持续和提高门诊护理的质量，进而缓解晚年健康差距。 与公共卫生有关：老年人慢性病负担方面存在着巨大的社会经济和种族/族裔差异，部分原因是旨在预防慢性病并发症的门诊护理的机会和质量存在差异。尽管先前的研究考察了县等地区在获得医疗保健方面的地理差异，但关于社区一级环境和社会经济因素的差异如何影响弱势群体，特别是低收入和少数族裔老年人在服务使用和结果方面的差异，人们知之甚少。这项研究旨在通过检查居住在纽约市的老年、慢性病联邦医疗保险受益人之间的社区建筑环境、医生服务的使用以及可预防的住院和急诊科就诊之间的关系来解决这一差距。

DESCRIPTION (provided by applicant): Associations between characteristics of the neighborhoods in which older people live and late-life disparities in chronic illness have been the subject of a rapidly growing field of research. For low-income and minority elders with chronic illness, disparities in access to and quality of care contribute to disparities in the burden of illness. Research on chronic illness has also underscored the links between inadequate physician oversight, potentially preventable hospitalizations, and poor health outcomes. However, little is known about the ways in which neighborhood environmental factors - beyond local supply of medical services - inform how urban older adults with chronic illness use physician services to manage their health. This study addresses this gap by examining the relationships between neighborhood built environment (e.g. walk-ability, access to public transit), use of physician services, and preventable hospitalizations and emergency department visits among elderly, chronically ill Medicare beneficiaries who live in New York City. Specifically, the study aims to: 1) Examine associations between neighborhood built environment and physician service use among urban, chronically ill older adults; 2) Determine whether and to what extent variations in the built environment influence potentially preventable hospitalizations and emergency department visits; and 3) Reassess findings from Aims 1 and 2 by applying: (i) alternative modeling techniques; and (ii) tests of endogeneity to address the potential sorting of patients into neighborhoods with different characteristics based on service use and outcomes. The study will be based on longitudinal analysis of existing data on a sample of NYC-dwelling Medicare beneficiaries age 65 and older, linking individual characteristics and service use measures with small area- level data from other sources. Analyses will focus on patients with congestive heart failure and diabetes - two major contributors to preventable hospitalizations. This study will provide insight into the interdependence of clinical, social, economic, and environmental factors that influence quality of chronic illness care and, ultimately, quality of life, for older adults with multiple co-morbidities. The proposed research will apply and expand on the candidate's training throughout the K01 award period, including advanced methodological training in epidemiology and health economics. The training and research activities will lay the foundation for an R01 application in the later years of the award. Findings from this study and future research will ultimately be applied toward developing effective interventions to improve access to, continuity, and quality of ambulatory care for chronically ill elders living in underserved communities and, in turn, mitigate late-life health disparities. PUBLIC HEALTH RELEVANCE: Significant socio-economic and racial/ethnic disparities exist in the burden of chronic illness among older adults, due partly to disparities in access to and quality of ambulatory care aimed at preventing chronic illness complications. Although prior research has examined geographic variations in health care access across areas such as counties, little is known about how variations in environmental and socio-economic factors at the neighborhood level influence disparities in service use and outcomes among vulnerable groups, particularly low-income and minority elders. This study aims to address this gap by examining the relationships between neighborhood built environment, use of physician services, and preventable hospitalizations and emergency department visits among elderly, chronically ill Medicare beneficiaries who live in New York City.