RESUMO
Importance: On September 20, 2017, one of the most destructive hurricanes in US history made landfall in Puerto Rico. Anecdotal reports suggest that many persons with kidney failure left Puerto Rico after Hurricane Maria; however, empirical estimates of migration and health outcomes for this population are scarce. Objective: To assess the changes in migration and mortality among patients with kidney failure in need of dialysis treatment in Puerto Rico after Hurricane Maria. Design, Setting, and Participants: This cross-sectional study used an interrupted time-series design of 6-month mortality rates and migration of 11â¯652 patients who received hemodialysis or peritoneal dialysis care in Puerto Rico before Hurricane Maria (before October 1, 2017) and/or during and after Hurricane Maria (on/after October 1, 2017). Data analyses were performed from February 12, 2019, to June 16, 2022.. Main Outcomes and Measures: Number of unique persons dialyzed in Puerto Rico per quarter; receipt of dialysis treatment outside Puerto Rico per quarter; and 6-month mortality rate per person-quarter for all persons undergoing dialysis. Exposures: Hurricane Maria. Results: The entire study sample comprised 11 652 unique persons (mean [SD] age, 59 [14.7] years; 7157 [61.6%] men and 4465 [38.4%] women; 10 675 [91.9%] Hispanic individuals). There were 9022 patients with kidney failure and dialysis treatment before and 5397 patients after Hurricane Maria. Before the hurricane, the mean quarterly number of unique persons dialyzed in Puerto Rico was 2834 per quarter (95% CI, 2771-2897); afterwards it dropped to 261 (95% CI, -348 to -175; relative change, 9.2%). The percentage of persons who had 1 or more dialysis sessions outside of Puerto Rico in the next quarter following a previous dialysis in Puerto Rico was 7.1% before Hurricane Maria (95% CI, 4.8 to 9.3). There was a significant increase of 5.8 percentage points immediately after the hurricane (95% CI, 2.7 to 9.0). The 6-month mortality rate per person-quarter was 0.08 (95% CI, 0.08 to 0.09), and there was a nonsignificant increase in level of mortality rates and a nonsignificant decreasing trend in mortality rates. Conclusions and Relevance: The findings of this cross-sectional study suggest there was a significant increase in the number of people receiving dialysis outside of Puerto Rico after Hurricane Maria. However, no significant differences in mortality rates before and after the hurricane were found, which may reflect disaster emergency preparedness among dialysis facilities and the population with kidney failure, as well as efforts from other stakeholders.
Assuntos
Tempestades Ciclônicas , Insuficiência Renal , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Porto Rico/epidemiologia , Diálise Renal , Insuficiência Renal/terapiaRESUMO
OBJECTIVES: To examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization. METHODS: Retrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use. RESULTS: Participants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48-3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35-10.25), nursing home care utilization 11.32 (95% CI, 3.88-33.02), hospitalizations 4.12 (95% CI, 2.88-5.90) and emergency room admissions 4.24 (95% CI, 3.04-5.91). DISCUSSION: Our findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.
Assuntos
Americanos MexicanosRESUMO
OBJECTIVES: Mexico is among the countries in Latin America hit hardest by coronavirus disease 2019 (COVID-19). A large proportion of older adults in Mexico have high prevalence of multimorbidity and live in poverty with limited access to health care services. These statistics are even higher among adults living in rural areas, which suggest that older adults in rural communities may be more susceptible to COVID-19. The objectives of the article were to compare clinical and demographic characteristics for people diagnosed with COVID-19 by age group, and to describe cases and mortality in rural and urban communities. METHOD: We linked publicly available data from the Mexican Ministry of Health and the Census. Municipalities were classified based on population as rural (<2,500), semirural (≥2,500 and <15,000), semiurban (≥15,000 and <100,000), and urban (≥100,000). Zero-inflated negative binomial models were performed to calculate the total number of COVID-19 cases, and deaths per 1,000,000 persons using the population of each municipality as a denominator. RESULTS: Older adults were more likely to be hospitalized and reported severe cases, with higher mortality rates. In addition, rural municipalities reported a higher number of COVID-19 cases and mortality related to COVID-19 per million than urban municipalities. The adjusted absolute difference in COVID-19 cases was 912.7 per million (95% confidence interval [CI]: 79.0-1746.4) and mortality related to COVID-19 was 390.6 per million (95% CI: 204.5-576.7). DISCUSSION: Urgent policy efforts are needed to mandate the use of face masks, encourage handwashing, and improve specialty care for Mexicans in rural areas.
Assuntos
COVID-19/epidemiologia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Pobreza/estatística & dados numéricos , População Rural/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Fatores Etários , Idoso , COVID-19/terapia , Feminino , Humanos , Masculino , México/epidemiologia , Serviços de Saúde Rural/organização & administração , Serviços Urbanos de Saúde/organização & administraçãoRESUMO
OBJECTIVES: The purpose of the study is to contribute to the literature regarding post-acute nursing home utilization and quality indicators among Medicare beneficiaries in Puerto Rico compared with the US mainland. DESIGN: Medicare data from 2015 to 2017 was used to identify new discharges to skilled nursing facilities (SNFs) using the Minimum Data Set and the Medicare Provider Analysis and Review. SETTING AND PARTICIPANTS: Post-acute care patients admitted to SNFs in Puerto Rico and the United States. METHODS: Our final cohort included 4,732,222 beneficiaries from Puerto Rico and the United States enrolled in Medicare fee-for-service or Medicare Advantage programs admitted to an SNF (N = 15,197) following an acute hospital stay. We compared demographic, clinical, and facility-level characteristics among patients in Puerto Rico and the United States. We also described 2 quality indicators among these groups: (1) 30-day rehospitalization rates and (2) successful discharge from the facility to the community. RESULTS: Medicare patients in Puerto Rico were physically and cognitively healthier than patients in the United States. Puerto Ricans were also more likely to be admitted to lower quality nursing homes than US patients (2.5 vs 3.4). Finally, Puerto Ricans had higher rates of successful discharge to the community [17.6, 95% confidence interval (CI) 13.0-22.3], but higher 30-day rehospitalization rates compared with US patients (11.2, 95% CI 6.2-16.3). These differences were consistent even when comparing these quality outcomes among Puerto Ricans to US Hispanics only. CONCLUSIONS AND IMPLICATIONS: SNFs in the United States and Puerto Rico are now receiving financial penalties for high readmission rates. Currently, Medicare does not measure readmission rates for Medicare Advantage patients-even though some states, including Puerto Rico, have a high proportion of Medicare Advantage beneficiaries. As Medicare Advantage enrollment continues to increase, our results highlight the importance of measuring performance among Medicare Advantage patients and assessing disparities in quality of post-acute care among patients in Puerto Rico and the United States.
Assuntos
Indicadores de Qualidade em Assistência à Saúde , Instituições de Cuidados Especializados de Enfermagem , Idoso , Planos de Pagamento por Serviço Prestado , Humanos , Porto Rico , Cuidados Semi-Intensivos , Estados UnidosRESUMO
OBJECTIVE: Determine the effect of Seguro Popular (SP) on preventive care utilization among low-income SP beneficiaries and uninsured elders in Mexico. MATERIALS AND METHODS: Fixed-effects instrumental-variable (FE-IV) pseudo-panel estimation from three rounds of the Mexican National Health and Nutrition Survey (2000, 2006 and 2012). RESULTS: Our findings suggest that SP has no significant effect on the use of preventive services, including screening for diabetes, hypertension, breast cancer and cervical cancer, by adults aged 50 to 75 years. CONCLUSIONS: Despite the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in healthcare access and utilization still exist in Mexico. The Mexican government must keep working on extending health insurance coverage to vulnerable adults. Additional efforts to increase health care coverage and to support preventive care are needed to reduce persistent disparities in healthcare utilization.
OBJETIVO: Determinar el efecto del Seguro Popular (SP) en la utilización de la atención preventiva entre beneficiarios de SP de bajos ingresos y ancianos sin seguro en México. MATERIAL Y MÉTODOS: Estimación de pseudopanel de variables instrumentales de efectos fijos (FE-IV) en tres rondas de la Encuesta Nacional de Salud y Nutrición de México (2000, 2006 y 2012). RESULTADOS: El SP no tiene un efecto significativo en el uso de los servicios preventivos, incluida la detección de diabetes, hipertensión, cáncer de mama y cáncer de cuello uterino en adultos de 50 años o más. CONCLUSIONES: Aún existen desigualdades en el acceso a la asistencia médica en México. El gobierno mexicano debe seguir trabajando para extender la cobertura del seguro de salud a la población más vulnerable. Se necesitan esfuerzos adicionales para aumentar la cobertura de atención médica y apoyar la atención preventiva para reducir las disparidades persistentes.
Assuntos
Cobertura do Seguro/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Serviços Preventivos de Saúde/estatística & dados numéricos , Idoso , Redução de Custos , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Feminino , Inquéritos Epidemiológicos , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/terapia , Masculino , Programas de Rastreamento/estatística & dados numéricos , México/epidemiologia , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Pobreza , Utilização de Procedimentos e Técnicas , Estudos de Amostragem , Fatores SocioeconômicosRESUMO
Abstract: Objective: Determine the effect of Seguro Popular (SP) on preventive care utilization among low-income SP beneficiaries and uninsured elders in Mexico. Materials and methods: Fixed-effects instrumental-variable (FE-IV) pseudo-panel estimation from three rounds of the Mexican National Health and Nutrition Survey (2000, 2006 and 2012). Results: Our findings suggest that SP has no significant effect on the use of preventive services, including screening for diabetes, hypertension, breast cancer and cervical cancer, by adults aged 50 to 75 years. Conclusions: Despite the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in healthcare access and utilization still exist in Mexico. The Mexican government must keep working on extending health insurance coverage to vulnerable adults. Additional efforts to increase health care coverage and to support preventive care are needed to reduce persistent disparities in healthcare utilization.
Resumen: Objetivo: Determinar el efecto del Seguro Popular (SP) en la utilización de la atención preventiva entre beneficiarios de SP de bajos ingresos y ancianos sin seguro en México. Material y métodos: Estimación de pseudopanel de variables instrumentales de efectos fijos (FE-IV) en tres rondas de la Encuesta Nacional de Salud y Nutrición de México (2000, 2006 y 2012). Resultados: El SP no tiene un efecto significativo en el uso de los servicios preventivos, incluida la detección de diabetes, hipertensión, cáncer de mama y cáncer de cuello uterino en adultos de 50 años o más. Conclusiones: Aún existen desigualdades en el acceso a la asistencia médica en México. El gobierno mexicano debe seguir trabajando para extender la cobertura del seguro de salud a la población más vulnerable. Se necesitan esfuerzos adicionales para aumentar la cobertura de atención médica y apoyar la atención preventiva para reducir las disparidades persistentes.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Serviços Preventivos de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Pobreza , Fatores Socioeconômicos , Estudos de Amostragem , Inquéritos Epidemiológicos , Redução de Custos , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/terapia , Diabetes Mellitus/epidemiologia , Hospitalização/estatística & dados numéricos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , México/epidemiologia , Neoplasias/diagnósticoRESUMO
Life expectancy is increasing in Mexico, creating new opportunities and challenges in different areas, including gerontology and geriatric education and research. Although in the European Union there are more than 3,000 institutions that focus on aging research, in Latin America there are only 250 programs where theoretical and practical knowledge is taught. In Mexico, the number of institutions that offer gerontology and geriatric education is relatively small. One of the major concerns is that Mexico is not adequately prepared to optimally deal with the aging of its population. Thus, the main challenge that Mexico faces is to train practitioners, researchers, and policy makers to be able to respond to the aging priorities of this country. The goal of this review is to investigate the literature regarding 60 years in the fields of gerontology and geriatrics in Mexico. Even when programs have evolved within the past decades, there are some challenges to gerontological and geriatric education and aging research in Mexico. The implications for Mexico are discussed, as well as opportunities for moving these fields forward.
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Geriatria/educação , Geriatria/tendências , Pesquisa/organização & administração , Currículo , Humanos , Medicina/organização & administração , México , Cuidados Paliativos/organização & administração , Recursos HumanosRESUMO
OBJECTIVE: To examine the impact of Seguro Popular (Mexican social health insurance for the poor; SP) on diabetes and hypertension care, intermediate process indicators for older adults (>50 years): pharmacological treatment, blood glucose tests, the use of complementary and alternative medicine (CAM), and adherence to their nutrition and exercise program. (CAM was defined as products or practices that were not part of the medical standard of care.) DATA SOURCES/STUDY SETTING: Repeated cross-sectional surveys from Encuesta Nacional de Salud y Nutrición (Mexican Health and Nutrition Survey, ENSANUT), a nationally representative health and nutrition survey sampling N = 45,294 older adults in 2000, N = 45,241 older adults in 2005-2006, and N = 46,277 older adults in 2011-2012. STUDY DESIGN: Fixed-effects instrumental variable (FE-IV) repeated cross-sectional at the individual level with municipality fixed-effects estimation was performed. PRINCIPAL FINDINGS: We found a marginally significant effect of SP on the use of insulin and oral agents (40 percentage points). Contrary to that expected, no other significant differences were found for diabetes or hypertension treatment and care indicators. CONCLUSIONS: Social health insurance for the poor improved some but not all health care process indicators among diabetic and hypertensive older people in Mexico.
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Diabetes Mellitus/tratamento farmacológico , Acessibilidade aos Serviços de Saúde/economia , Hipertensão/tratamento farmacológico , Seguro Saúde/economia , Idoso , Estudos Transversais , Feminino , Financiamento Governamental , Inquéritos Epidemiológicos , Humanos , Cobertura do Seguro , Masculino , México , Pessoa de Meia-Idade , PobrezaRESUMO
IMPORTANCE: Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA). OBJECTIVE: To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6â¯289â¯374), Hispanic enrollees in the United States (n = 795â¯039), and Hispanic enrollees in Puerto Rico (n = 267â¯016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016. MAIN OUTCOMES AND MEASURES: Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a ß-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs). RESULTS: Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P < .01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]). CONCLUSIONS AND RELEVANCE: We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.
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Hispânico ou Latino/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , População Branca/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Porto Rico/epidemiologia , Estados Unidos/epidemiologiaRESUMO
The main purpose of this study was to examine the relationships between religiosity, social support, diabetes care and control and self-rated health of people living in Mexico who have been diagnosed with diabetes. Structural equation modeling was used to examine these associations using the Mexican Health and Aging Study, a national representative survey of older Mexicans. Findings indicate that emotional support from one's spouse/partner directly affects diabetes care and control and health. Although there is no direct relationship between religiosity and health, religiosity was positively associated with diabetes care and control, but not significantly related to health.
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Diabetes Mellitus/psicologia , Diabetes Mellitus/terapia , Religião , Apoio Social , Feminino , Humanos , Masculino , México , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico. METHOD: Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012. RESULTS: After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears. DISCUSSION: Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.
Assuntos
Planos de Assistência de Saúde para Empregados/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Programas Nacionais de Saúde/estatística & dados numéricos , Serviços Preventivos de Saúde/estatística & dados numéricos , Idoso , Estudos Transversais , Diabetes Mellitus/diagnóstico , Feminino , Reforma dos Serviços de Saúde , Pesquisas sobre Atenção à Saúde , Disparidades em Assistência à Saúde , Humanos , Hipercolesterolemia/diagnóstico , Hipertensão/diagnóstico , Modelos Logísticos , Masculino , México , Pessoa de Meia-Idade , Neoplasias do Colo do Útero/diagnósticoRESUMO
Clergy in the Mexico play a major role in addressing the health care needs of their congregants. With qualitative semi-structured key-informant interviews, this study explored the views of ten male Mexican religious leaders (mostly Catholic) about their understanding of their role in diabetes health promotion. The major themes from the qualitative interviews emphasized the importance of open communication between church leaders and their parishioners, the role of the church in diabetes programs, and the unique position of religious institutions as a link between physical and spiritual aspects of health. Implications for diabetes interventions are discussed.
Assuntos
Clero , Diabetes Mellitus/psicologia , Diabetes Mellitus/terapia , Promoção da Saúde , Necessidades e Demandas de Serviços de Saúde , Liderança , Religião e Medicina , Adulto , Comunicação , Diabetes Mellitus/etnologia , Humanos , Entrevista Psicológica , Masculino , México , Pessoa de Meia-Idade , Religião , Religião e Psicologia , Autocuidado/psicologia , EspiritualidadeRESUMO
AIMS: Examine the associations of depression and self-esteem on self-care activities and care received among Mexicans with diabetes. METHODS: Using data from the Mexican Nutrition and Health Survey 2012, logistic regression models were fit to test the associations between each self-care activity and diabetes care, and self-esteem and depression. RESULTS: People with low self-esteem were less likely to follow a diet, but no other associations were found. Contrary to what was expected, there were no relationships between depression and quality of care received or self-care behaviors. CONCLUSION: Current findings support the importance of looking at mental health and emotional state among older adults with diabetes. Future studies should explore the relationship between different psychological barriers to proper diabetes management.