Dissertations and Theses
Date of Degree
9-1-2018
Document Type
Dissertation
Degree Name
Doctor of Public Health (DPH)
Department
Health Policy and Management
Advisor(s)
William Gallo
Committee Members
William Gallo
Betsy Eastwood
Mimi Fahs
Subject Categories
Medicine and Health Sciences | Public Health
Keywords
Health Care Desert, Food Desert, SPARCS, Prevention Quality Indicators, Potentially Preventable Emergency Department Visits
Abstract
Introduction: A “health care desert” is a part of the country where needed medical, behavioral, mental, dental, and/or pharmaceutical health care services are extremely limited or altogether unavailable. This terminology is based on the concept of a “food desert,” which describes an area where people have limited access to affordable and healthy foods, and which, together with the negative health consequences of eating lower-quality foods, is well described in public health literature. The application of this terminology to an urban environment with ready access to transportation has been limited and is controversial. However, the recent increase in urban hospital closures in certain communities is clearly impacting health care and the overall health of the people who live there. This study applies economic theory and fundamental cause theory to explore what establishes and maintains an urban health care desert. Additionally, the impact of this condition on health care and overall health is examined by comparing selected health care desert communities to robust (non-desert) health care communities in Brooklyn, New York.
Objectives: The three overarching objectives of this study are to characterize an urban health care desert and describe the theoretical foundations that result in the creation and persistence of urban health care deserts; to examine the effects of living in Northern and Central Brooklyn health care desert communities on medical health care access and quality; and to examine the effects of living in Northern and Central Brooklyn health care desert communities on mental and behavioral health care access and quality.
Methods: The outcomes of interest in this study are poor access to and quality of health care and resulting poor health. The risk factors for this outcome include: 1) preventable hospitalizations as defined using the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) and selected high-risk mental/behavioral health diagnoses; 2) increased hospitalization length of stay (LOS); and 3) potentially preventable emergency department (ED) visits. Preventable hospitalizations and ED visits will be used to assess access and LOS will be used as a proxy for quality. The exposure for this study is living in a Brooklyn urban health care desert community. The health care desert communities are compared to nearby non-desert communities. This study also characterizes desert and non-desert community demographics.
Results: Using the food desert framework, several health care desert communities were identified in Brooklyn, New York. These communities were compared to non-desert (robust) health care communities, also in Brooklyn. For medical hospitalizations, significant differences between desert and non-desert communities for PQI 1, PQI 3, PQI 14, and PQI 15 were seen across all three study years. These differences showed higher admission rates for health care desert community patients with several diabetes diagnoses as well as asthma. PQI 90, the composite, also showed higher hospitalization rates for health care desert communities from 2010 to 2012. For PQI 92, the chronic illness composite, health care desert communities again showed higher rates of hospitalization. ED utilization was greater in the health care desert communities for 11 of the 12 PQIs, and for each of the composite measures. For mental and behavioral hospitalizations, health care desert communities had higher rates for drug abuse, major depression, and schizophrenia for all three study years. For mental and behavioral emergency department utilization, desert communities showed higher rates. Additionally, the composite score, which included all diagnoses, also found higher overall utilization in desert communities. LOS data was only significant for PQI 2, perforated appendix; hospitalizations in health care desert communities and the Heckman correction were also significant. No difference was found in LOS for mental/behavioral conditions.
Conclusion: Health care desert communities face challenges with accessing health care. This difference of access for desert communities, versus non-desert communities, results in increased hospitalization rates for several chronic diseases including diabetes and asthma. Additionally, hospitalizations for severe mental health and behavioral illness, including schizophrenia and drug abuse, were greater in the health care desert communities. In general LOS findings for both medical and mental/behavioral hospitalizations did not support a difference in quality of care between desert and non-desert communities. Emergency department utilization was also greater in health care desert communities for the vast majority of medical, mental, and behavioral illnesses. It is clear from this study that health care desert communities face health disparities, especially when considering chronic illness. The approach to addressing these disparities should include identifying health care desert communities and applying a focused population health approach.
Recommended Citation
Garcia, Estevan A., "THE URBAN FOOD DESERT AS A MODEL FOR THE URBAN HEALTH CARE DESERT: FUNDAMENTAL CAUSES AND ECONOMIC CONSIDERATIONS" (2018). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/25