Journal of Women & Aging, 27:273–289, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0895-2841 print/1540-7322 online DOI: 10.1080/08952841.2014.950135
Evaluating Access to Primary Health Care Among Older Women and Men in Barbados Using Preventable Hospitalization JENNIFER H. BUSHELLE-EDGHILL Department of Management, School of Business and Economics, Fayetteville State University, Fayetteville, NC
JAMES N. LADITKA, SARAH B. LADITKA, and LARISSA R. BRUNNER HUBER Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC
We evaluated access to primary health care for older women and men in Barbados, a developing country, using a widely accepted access indicator, hospitalization for ambulatory care sensitive conditions. Using 2003–2008 data, we calculated gender-specific total annual population-based rates of these hospitalizations per 1,000 older women and men and individual rates for the six most prevalent conditions. Across the 6 years, these hospitalizations increased 33.6% for women, 30.6% for men (both P < .0001). However, the average rate for diabetes fell 32% for women, 36% for men. Findings suggest an opportunity to improve access to primary health care, particularly for older women. KEYWORDS aging, ambulatory care sensitive conditions, preventable hospitalization, primary health care, public health, women
INTRODUCTION Hospitalization for ambulatory care sensitive conditions (ACSH), also called preventable hospitalization, has become a widely used measure of Address correspondence to Jennifer H. Bushelle-Edghill, Department of Management, Fayetteville State University, 1200 Murchison Road, Fayetteville, NC 28301. E-mail: jbushell@ uncfsu.edu 273
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population health and the accessibility of primary health care in developed countries (Ansari, Laditka, & Laditka, 2006; Chen, Laditka, Laditka, & Xirasagar, 2007; J. N. Laditka, 2003, 2004; J. N. Laditka & Laditka, 2006b, S. B. Laditka & Laditka 1999; J. N. Laditka, Laditka, & Mastanduno, 2003; J. N. Laditka, Laditka, & Probst, 2009; Pappas, Hadden, Kozak, & Fisher, 1997). Much less research has used the ACSH indicator in developing countries, largely due to data limitations. This study is the first to use hospitalization for ambulatory care sensitive conditions with data from Barbados, a developing country with a universal health-care system. We examined ACSH among older women and men in Barbados. We also describe how the findings can be used to monitor population health in a developing country such as Barbados to evaluate effects of health policy initiatives intended to improve access to primary health care and promote public health. Extending the study of preventable hospitalization to older adults in developing countries is especially useful for older women in several ways. Consistent with findings in developed countries (Crimmins, Hayward, Ueda, Saito, & Kim, 2008; Crimmins, Kim, & Hagedorn, 2002; S. B. Laditka & Laditka, 2002, 2009; S. B. Laditka & Wolf, 1998), women in developing countries face a greater burden of disease for many conditions than men (Lim et al., 2012). In most developing countries, women are much less likely than men to participate in the labor market, in paid or unpaid positions (World Bank, 2012). Much lower labor force participation is associated with lower income and more poverty for women than men (UNICEF, 2007). Economic disadvantage is strongly associated with disability (S. B. Laditka & Laditka, 2009; Martikainen, Makela, Koskinen, & Valkonen, 2001; Matthews, Jagger, & Hancock, 2006). Thus, older women in developing countries are much more likely than men to face multiple disadvantages associated with aging, including poorer health and substantially worse economic status. Given these demographic and economic findings from developing counties, it is useful to develop ways to monitor public health and access to primary care for older populations and particularly for older women.
OVERVIEW OF HEALTH-CARE DELIVERY AND ACSH IN BARBADOS Barbados is the most easterly of the Caribbean Islands, with a population of 287,700 in 2012 (Index Mundi, 2013). Life expectancy at birth increased from 1990 to 2010 for women (74.7 to 77) and men (69 to 74.3) (Salomon et al., 2012). Much of that increase is attributed to improved medical care and enhanced public health efforts (Salomon et al., 2012). Barbados has so substantially reduced infectious and parasitic diseases, as well as nutritional deficiencies, that its epidemiological profile is similar to that of developed countries (Barbados Ministry of Health, 2003a). However, chronic diseases have become a major concern. Consistent with the global epidemic of diabetes, morbidity associated with diabetes is a major challenge in Barbados
Preventable Hospitalization in Barbados
275
(Murray et al., 2012; Vos et al., 2012; Wild, Roglic, Green, Sicree, & King, 2004). Responding to this challenge, during the past 10 years Barbados has increased health-promotion and disease-prevention efforts and has worked to improve primary health care. The national goal was to reduce the prevalence of chronic conditions, manage existing cases more effectively, and avoid exacerbations of those conditions that result in costly hospitalizations (Barbados Ministry of Health, 2003a; Pan American Health Organization [PAHO], 2008). The Health Services Act of 1969 provided a framework for universal health care for all residents regardless of income (Barbados Ministry of Health, 2003a; PAHO, 2008). Health care is funded by taxes and is free at all public facilities. Primary health care is available through a national system that combines public health and medical care. It covers most costs of hospitalization, outpatient services, imaging, and other services (PAHO, 2008). The 600-bed Queen Elizabeth Hospital provides most hospital services (Barbados Ministry of Health, 2003a). One small privately owned hospital, Bayview, typically accepts patients for planned surgical and obstetric services and has only 4% of Barbados’ acute care bed capacity; thus, its services are not highly relevant to the country’s ACSH rates, and all further references to hospitalization refer to the Queen Elizabeth Hospital. The Ministry of Health runs eight polyclinics and four satellite clinics (Barbados Ministry of Health, 2003a, 2003b), which provide public health services such as health education, nutrition counseling, and free primary care to about 110,000 individuals annually for major chronic illnesses (PAHO, 2005). The polyclinics are located to ensure accessible care, in catchment areas with populations ranging from 17,000 to 50,000 (Barbados Ministry of Health, 2003a, 2003b). Despite the availability of free public health care, about one-quarter of Barbados’ residents have private health insurance (Barbados Ministry of Health, 2003a). In 2005, about 36% of health-care spending was private (Barbados Ministry of Health, 2003a). Private care is financed through out-of-pocket payments on a fee-for-service basis, typically reimbursed by employers or individual health insurance (Barbados Ministry of Health, 2003a). One reason why the private sector attracts patients is a common belief that the public system provides less-adequate care (Husbands, 2011). The factual basis for this belief has not been studied. Twenty-five percent of the population is age 50 and over (Barbados Ministry of Health, 2003a). Chronic diseases associated with aging are increasingly common. Chronic ambulatory care sensitive conditions are among these, including congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. Those conditions are among the five leading causes of death in Barbados (Barbados Ministry of Health, 2003a). Diabetes mortality and amputation rates in Barbados are among the highest globally. The mortality rate for diabetes in 2000 was 81.8 per 10,000 (PAHO, Health Analysis and Statistics Unit, Regional Core Health
276
J. H. Bushelle-Edghill et al.
Data Initiative, 2007). Analogous rates in the Unites States and Canada were 22.2 and 24.7 respectively (PAHO, Health Analysis, 2007). Research in the 1990s suggested that 80% of female admissions and 50% of male admissions to general surgical wards were for diabetic foot problems (Walrond & Ramesh, 1998). Only 58% of these patients had regular foot care; 40% reported lack of care continuity (Walrond & Ramesh, 1998). The Caribbean Health Research Council has developed guidelines for clinicians to add foot inspections to routine health-care visits for people with diabetes every three months (Caribbean Health Research Council & Pan American Health Organization/World Health Organization [CHRC & PAHO/WHO], 2006). Preventable hospitalization risk may also be influenced by the availability and use of prescription drugs, which help to control many chronic ambulatory care sensitive conditions. Under the Barbados Drug Service, medications in the Barbados National Drug Formulary are free at all public health-care facilities, including the hospital and the polyclinics (Barbados Ministry of Health, 2003a). They are also free at participating private pharmacies to residents age 16 or younger; those age 65 or older; and anyone diagnosed with hypertension, diabetes, or asthma, as well as cancer or epilepsy (Barbados Ministry of Health, 2003a). In 2002, stakeholders met to develop the Barbados Strategic Plan for Health (Barbados Ministry of Health, 2003a). The Plan identified goals for 10 priorities to improve health and health care. One priority is to reduce mortality and morbidity associated with chronic diseases. The plan emphasizes health promotion, nutrition, and physical activity. Clinical guidelines for treating diabetes, hypertension, and cardiovascular disease were developed in 2002 (Barbados Ministry of Health, 2003a). Public health diabetes education programs began in 2005 (Barbados Ministry of Health, 2003a).
STUDY OBJECTIVES AND CONTRIBUTIONS The main purpose of our study is to use hospitalization for ambulatory care sensitive conditions to identify potential problems of access to primary care for older women and men in Barbados. Rates of disease, disease severity, and hospitalization for several of the conditions that comprise the ACSH indicator also provide a measure of public health and may be influenced by public health interventions (Chen et al., 2007; J. N. Laditka & Laditka, 2006b; Pappas et al., 1997). Such conditions include asthma, influenza, diabetes, and hypertension. Appropriate primary health care and effective public health efforts should limit hospitalizations for ambulatory care sensitive conditions (U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality [USDHHS, AHRQ], 2001; Bindman, Chattopadhyay, Osmond, Huen, & Bacchetti, 2005; DeLia, 2003; Institute of Medicine, 1993; J. N. Laditka, 2003; J. N. Laditka & Laditka, 2006b; J. N. Laditka et al., 2009;
Preventable Hospitalization in Barbados
277
Pappas et al., 1997). It is not clear whether universal health care affects these hospitalizations (Ansari, Barbetti, Carson, Auckland, & Cicuttini, 2003; Ansari et al., 2006; Chen et al., 2007; J. N. Laditka, 2003, 2004; J. N. Laditka & Laditka, 2004; J. N. Laditka et al., 2003), although governments with publicly supported health care have economic incentives to limit these costly events (Chen et al., 2007). Consistent with most research in this area, we examined total ACSH rates, combining all potentially preventable hospitalizations. We defined older adults as age 50 and over. Using age 50 and over is consistent with established approaches to defining older populations, particularly in the context of disease prevention and chronic diseases (Centers for Disease Control and Prevention, 2007). We calculated total ACSH rates for women and men ages 50 and over separately. We also examined disease-specific ACSH rates for each of the six most prevalent ambulatory care sensitive conditions. Focusing on the public health and health-care system in Barbados, we also describe how the findings of the present study help monitor population health among older women and men and evaluate effects of recent health policy initiatives to improve access to primary health care and promote public health.
METHODS Data Sources We used data representing admissions through the emergency department (ED) from 2003 through 2008. Most admissions begin in the ED, other than routine surgery and psychiatric conditions. Hospitalization for ambulatory care sensitive conditions is usually measured using hospital discharge information. Barbados is a developing country with limited health information resources. We used diagnosis information from the ED record because there is no electronic database representing discharges. There is evidence that ED data are useful for understanding ACSH (Oster & Bindman, 2003). The ED data also had narrative discharge notes that included diagnoses. We scanned the narratives electronically to identify ACSH. In rare instances (
Evaluating Access to Primary Health Care Among Older Women and Men in Barbados Using Preventable Hospitalization JENNIFER H. BUSHELLE-EDGHILL Department of Management, School of Business and Economics, Fayetteville State University, Fayetteville, NC
JAMES N. LADITKA, SARAH B. LADITKA, and LARISSA R. BRUNNER HUBER Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC
We evaluated access to primary health care for older women and men in Barbados, a developing country, using a widely accepted access indicator, hospitalization for ambulatory care sensitive conditions. Using 2003–2008 data, we calculated gender-specific total annual population-based rates of these hospitalizations per 1,000 older women and men and individual rates for the six most prevalent conditions. Across the 6 years, these hospitalizations increased 33.6% for women, 30.6% for men (both P < .0001). However, the average rate for diabetes fell 32% for women, 36% for men. Findings suggest an opportunity to improve access to primary health care, particularly for older women. KEYWORDS aging, ambulatory care sensitive conditions, preventable hospitalization, primary health care, public health, women
INTRODUCTION Hospitalization for ambulatory care sensitive conditions (ACSH), also called preventable hospitalization, has become a widely used measure of Address correspondence to Jennifer H. Bushelle-Edghill, Department of Management, Fayetteville State University, 1200 Murchison Road, Fayetteville, NC 28301. E-mail: jbushell@ uncfsu.edu 273
274
J. H. Bushelle-Edghill et al.
population health and the accessibility of primary health care in developed countries (Ansari, Laditka, & Laditka, 2006; Chen, Laditka, Laditka, & Xirasagar, 2007; J. N. Laditka, 2003, 2004; J. N. Laditka & Laditka, 2006b, S. B. Laditka & Laditka 1999; J. N. Laditka, Laditka, & Mastanduno, 2003; J. N. Laditka, Laditka, & Probst, 2009; Pappas, Hadden, Kozak, & Fisher, 1997). Much less research has used the ACSH indicator in developing countries, largely due to data limitations. This study is the first to use hospitalization for ambulatory care sensitive conditions with data from Barbados, a developing country with a universal health-care system. We examined ACSH among older women and men in Barbados. We also describe how the findings can be used to monitor population health in a developing country such as Barbados to evaluate effects of health policy initiatives intended to improve access to primary health care and promote public health. Extending the study of preventable hospitalization to older adults in developing countries is especially useful for older women in several ways. Consistent with findings in developed countries (Crimmins, Hayward, Ueda, Saito, & Kim, 2008; Crimmins, Kim, & Hagedorn, 2002; S. B. Laditka & Laditka, 2002, 2009; S. B. Laditka & Wolf, 1998), women in developing countries face a greater burden of disease for many conditions than men (Lim et al., 2012). In most developing countries, women are much less likely than men to participate in the labor market, in paid or unpaid positions (World Bank, 2012). Much lower labor force participation is associated with lower income and more poverty for women than men (UNICEF, 2007). Economic disadvantage is strongly associated with disability (S. B. Laditka & Laditka, 2009; Martikainen, Makela, Koskinen, & Valkonen, 2001; Matthews, Jagger, & Hancock, 2006). Thus, older women in developing countries are much more likely than men to face multiple disadvantages associated with aging, including poorer health and substantially worse economic status. Given these demographic and economic findings from developing counties, it is useful to develop ways to monitor public health and access to primary care for older populations and particularly for older women.
OVERVIEW OF HEALTH-CARE DELIVERY AND ACSH IN BARBADOS Barbados is the most easterly of the Caribbean Islands, with a population of 287,700 in 2012 (Index Mundi, 2013). Life expectancy at birth increased from 1990 to 2010 for women (74.7 to 77) and men (69 to 74.3) (Salomon et al., 2012). Much of that increase is attributed to improved medical care and enhanced public health efforts (Salomon et al., 2012). Barbados has so substantially reduced infectious and parasitic diseases, as well as nutritional deficiencies, that its epidemiological profile is similar to that of developed countries (Barbados Ministry of Health, 2003a). However, chronic diseases have become a major concern. Consistent with the global epidemic of diabetes, morbidity associated with diabetes is a major challenge in Barbados
Preventable Hospitalization in Barbados
275
(Murray et al., 2012; Vos et al., 2012; Wild, Roglic, Green, Sicree, & King, 2004). Responding to this challenge, during the past 10 years Barbados has increased health-promotion and disease-prevention efforts and has worked to improve primary health care. The national goal was to reduce the prevalence of chronic conditions, manage existing cases more effectively, and avoid exacerbations of those conditions that result in costly hospitalizations (Barbados Ministry of Health, 2003a; Pan American Health Organization [PAHO], 2008). The Health Services Act of 1969 provided a framework for universal health care for all residents regardless of income (Barbados Ministry of Health, 2003a; PAHO, 2008). Health care is funded by taxes and is free at all public facilities. Primary health care is available through a national system that combines public health and medical care. It covers most costs of hospitalization, outpatient services, imaging, and other services (PAHO, 2008). The 600-bed Queen Elizabeth Hospital provides most hospital services (Barbados Ministry of Health, 2003a). One small privately owned hospital, Bayview, typically accepts patients for planned surgical and obstetric services and has only 4% of Barbados’ acute care bed capacity; thus, its services are not highly relevant to the country’s ACSH rates, and all further references to hospitalization refer to the Queen Elizabeth Hospital. The Ministry of Health runs eight polyclinics and four satellite clinics (Barbados Ministry of Health, 2003a, 2003b), which provide public health services such as health education, nutrition counseling, and free primary care to about 110,000 individuals annually for major chronic illnesses (PAHO, 2005). The polyclinics are located to ensure accessible care, in catchment areas with populations ranging from 17,000 to 50,000 (Barbados Ministry of Health, 2003a, 2003b). Despite the availability of free public health care, about one-quarter of Barbados’ residents have private health insurance (Barbados Ministry of Health, 2003a). In 2005, about 36% of health-care spending was private (Barbados Ministry of Health, 2003a). Private care is financed through out-of-pocket payments on a fee-for-service basis, typically reimbursed by employers or individual health insurance (Barbados Ministry of Health, 2003a). One reason why the private sector attracts patients is a common belief that the public system provides less-adequate care (Husbands, 2011). The factual basis for this belief has not been studied. Twenty-five percent of the population is age 50 and over (Barbados Ministry of Health, 2003a). Chronic diseases associated with aging are increasingly common. Chronic ambulatory care sensitive conditions are among these, including congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. Those conditions are among the five leading causes of death in Barbados (Barbados Ministry of Health, 2003a). Diabetes mortality and amputation rates in Barbados are among the highest globally. The mortality rate for diabetes in 2000 was 81.8 per 10,000 (PAHO, Health Analysis and Statistics Unit, Regional Core Health
276
J. H. Bushelle-Edghill et al.
Data Initiative, 2007). Analogous rates in the Unites States and Canada were 22.2 and 24.7 respectively (PAHO, Health Analysis, 2007). Research in the 1990s suggested that 80% of female admissions and 50% of male admissions to general surgical wards were for diabetic foot problems (Walrond & Ramesh, 1998). Only 58% of these patients had regular foot care; 40% reported lack of care continuity (Walrond & Ramesh, 1998). The Caribbean Health Research Council has developed guidelines for clinicians to add foot inspections to routine health-care visits for people with diabetes every three months (Caribbean Health Research Council & Pan American Health Organization/World Health Organization [CHRC & PAHO/WHO], 2006). Preventable hospitalization risk may also be influenced by the availability and use of prescription drugs, which help to control many chronic ambulatory care sensitive conditions. Under the Barbados Drug Service, medications in the Barbados National Drug Formulary are free at all public health-care facilities, including the hospital and the polyclinics (Barbados Ministry of Health, 2003a). They are also free at participating private pharmacies to residents age 16 or younger; those age 65 or older; and anyone diagnosed with hypertension, diabetes, or asthma, as well as cancer or epilepsy (Barbados Ministry of Health, 2003a). In 2002, stakeholders met to develop the Barbados Strategic Plan for Health (Barbados Ministry of Health, 2003a). The Plan identified goals for 10 priorities to improve health and health care. One priority is to reduce mortality and morbidity associated with chronic diseases. The plan emphasizes health promotion, nutrition, and physical activity. Clinical guidelines for treating diabetes, hypertension, and cardiovascular disease were developed in 2002 (Barbados Ministry of Health, 2003a). Public health diabetes education programs began in 2005 (Barbados Ministry of Health, 2003a).
STUDY OBJECTIVES AND CONTRIBUTIONS The main purpose of our study is to use hospitalization for ambulatory care sensitive conditions to identify potential problems of access to primary care for older women and men in Barbados. Rates of disease, disease severity, and hospitalization for several of the conditions that comprise the ACSH indicator also provide a measure of public health and may be influenced by public health interventions (Chen et al., 2007; J. N. Laditka & Laditka, 2006b; Pappas et al., 1997). Such conditions include asthma, influenza, diabetes, and hypertension. Appropriate primary health care and effective public health efforts should limit hospitalizations for ambulatory care sensitive conditions (U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality [USDHHS, AHRQ], 2001; Bindman, Chattopadhyay, Osmond, Huen, & Bacchetti, 2005; DeLia, 2003; Institute of Medicine, 1993; J. N. Laditka, 2003; J. N. Laditka & Laditka, 2006b; J. N. Laditka et al., 2009;
Preventable Hospitalization in Barbados
277
Pappas et al., 1997). It is not clear whether universal health care affects these hospitalizations (Ansari, Barbetti, Carson, Auckland, & Cicuttini, 2003; Ansari et al., 2006; Chen et al., 2007; J. N. Laditka, 2003, 2004; J. N. Laditka & Laditka, 2004; J. N. Laditka et al., 2003), although governments with publicly supported health care have economic incentives to limit these costly events (Chen et al., 2007). Consistent with most research in this area, we examined total ACSH rates, combining all potentially preventable hospitalizations. We defined older adults as age 50 and over. Using age 50 and over is consistent with established approaches to defining older populations, particularly in the context of disease prevention and chronic diseases (Centers for Disease Control and Prevention, 2007). We calculated total ACSH rates for women and men ages 50 and over separately. We also examined disease-specific ACSH rates for each of the six most prevalent ambulatory care sensitive conditions. Focusing on the public health and health-care system in Barbados, we also describe how the findings of the present study help monitor population health among older women and men and evaluate effects of recent health policy initiatives to improve access to primary health care and promote public health.
METHODS Data Sources We used data representing admissions through the emergency department (ED) from 2003 through 2008. Most admissions begin in the ED, other than routine surgery and psychiatric conditions. Hospitalization for ambulatory care sensitive conditions is usually measured using hospital discharge information. Barbados is a developing country with limited health information resources. We used diagnosis information from the ED record because there is no electronic database representing discharges. There is evidence that ED data are useful for understanding ACSH (Oster & Bindman, 2003). The ED data also had narrative discharge notes that included diagnoses. We scanned the narratives electronically to identify ACSH. In rare instances (
