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晚年慢性病差异之间的联系已经成为一个快速发展的研究领域的主题。对于患有慢性疾病的低收入和少数群体老年人来说，获得护理的机会和质量方面的差异造成了疾病负担方面的差异。对慢性病的研究也强调了医生监督不足、本可预防的住院治疗和不良健康结果之间的联系。然而，除了当地医疗服务供应之外，社区环境因素是如何影响患有慢性疾病的城市老年人如何利用医生服务来管理他们的健康的，对此我们知之甚少。本研究通过检查居住在纽约市的老年慢性病医疗保险受益人中社区建筑环境（例如步行性、公共交通）、医生服务的使用以及可预防的住院和急诊就诊之间的关系，解决了这一差距。具体而言，该研究旨在：1)研究城市慢性病老年人社区建筑环境与医生服务使用之间的关系；2)确定建筑环境的变化是否以及在多大程度上影响潜在可预防的住院和急诊就诊；3)通过应用：(i)替代建模技术重新评估目标1和2的发现；（ii）内生性测试，以解决根据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。这项研究将基于对纽约市65岁及以上的医疗保险受益人样本现有数据的纵向分析，将个人特征和服务使用措施与来自其他来源的小区域数据联系起来。分析将集中在充血性心力衰竭和糖尿病患者-两个主要贡献者可预防的住院治疗。本研究将深入了解临床、社会、经济和环境因素对慢性疾病护理质量的影响，并最终影响患有多种合并症的老年人的生活质量。拟议的研究将适用并扩展候选人在整个K01奖励期间的培训，包括流行病学和卫生经济学方面的高级方法培训。培训和研究活动将为该奖项后期的R01申请奠定基础。本研究和未来研究的结果将最终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流动护理的机会、连续性和质量，从而减轻晚年健康差距。

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.