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Open Access Publications from the University of California

Scholarly Works (30 results)

  • Thesis
  • Peer Reviewed
UCLA Electronic Theses and Dissertations (2012)

Social inequalities can produce disparities in healthcare access and quality. This dissertation explores relationships between two social stratification processes- community residential segregation and social capital- on the supply of U.S. urban safety net providers.

The first paper, "Community residential segregation and the local supply of Federally Qualified Health Centers," used data from the Area Resource File and the U.S. Census to examine growth in FQHCs in urban counties from 2000 to 2007. Residential segregation by poverty and race/ethnicity were measured using the dissimilarity index. Logistic and negative binomial regression models were used for dichotomous and count outcomes, respectively. Residential segregation measures were associated with both county FQHC supply at baseline and the addition of new FQHCs over time. Residential segregation may produce geographic segregation of health services, such that FQHCs may be required to fill the gaps arising from provider maldistribution.

The second paper, "Residential segregation and the survival of U.S. urban public hospitals," used data from the American Hospital Association Annual Survey from 1987 to 2007. Cox proportional hazards models were used to estimate competing risks of hospital closure versus privatization. Poverty rates, intermediate poverty segregation, a low proportion of black residents, and low black residential segregation were associated with closure. Poverty associations suggest that areas with a high need for safety net services may be at risk to lose them, but segregated black communities may successfully advocate for maintenance of public hospitals. In contrast, Hispanic residential segregation was associated with privatization. Areas with segregated Hispanic communities may be less inclined to support public provision of services and have reduced opposition to privatization.

The third paper analyzed the same sample of urban public hospitals in relation to measures of community social capital. Voting rates were associated with closure, whereas bridging social capital among elites was associated with privatization. The findings suggest that social capital among privileged groups bears more influence on public hospital outcomes than vertical connections between the disadvantaged and those in power.

Taken together, the three papers suggest that social determinants may dictate both the need and societal response for the safety net.

    Cover page: Social stratification and the healthcare safety net
    • Article
    • Peer Reviewed
    UCLA Previously Published Works (2024)
      Cover page: Short and Clear: YouTube Shorts Recommendations for RosaceaCreative Commons 'BY-NC-ND' version 4.0 license
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2014)
        Cover page: No man is an island: disentangling multilevel effects in health services research
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2015)
        Policymakers have increasingly promoted health services integration to improve quality and efficiency. The US health care safety net, which comprises providers of health care to uninsured, Medicaid, and other vulnerable patients, remains a largely fragmented collection of providers. We interviewed leadership from safety net hospitals and community health centers in 5 US cities (Boston, MA; Denver, CO; Los Angeles, CA; Minneapolis, MN; and San Francisco, CA) throughout 2013 on their experiences with service integration. We identify conflicts in organizational mission, identity, and consumer orientation that have fostered reluctance to enter into collaborative arrangements. We describe how smaller scale initiatives, such as capitated model for targeted populations, health information exchange, and quality improvements led by health plans, can help bridge cultural differences to lay the groundwork for developing integrated care programs.
          Cover page: Integrating Health Care for the Most Vulnerable: Bridging the Differences in Organizational Cultures Between US Hospitals and Community Health Centers
          • Article
          • Peer Reviewed
          UC Davis Previously Published Works (2016)
          Previous research has associated declines in health care resources such as hospitals and trauma centers with communities' racial composition. However, little is known about changes in the substance use disorder treatment infrastructure in recent years and the implications for black communities. We used data for the period 2002-10 from the National Survey of Substance Abuse Treatment Services to describe changes in the supply of public and private outpatient facilities for substance use disorder treatment, and to determine whether these trends had implications for the geographical availability of these facilities in counties with high percentages of black residents. During the study period the number of publicly owned facilities declined 17.2 percent, whereas the number of private for-profit facilities grew 19.1 percent. At baseline, counties with very high percentages of black residents (that is, more than one standard deviation above the mean) were more likely than counties with less than the mean percentage of black residents to be served by public facilities and were thus disproportionately affected by the overall decline in public facilities. Future research should examine the effect of expanding eligibility for Medicaid on the supply of substance use disorder treatment facilities across diverse communities.
            Cover page: Decline In Public Substance Use Disorder Treatment Centers Most Serious In Counties With High Shares Of Black Residents
            • Thesis
            • Peer Reviewed
            UC Davis Electronic Theses and Dissertations (2023)

            Government endorsed redlining practices carried out by the Home Owners’ Loan Corporation (HOLC) beginning in the mid-1930s have garnered attention in the population health literature over the last few years, with increased recognition of structural racism and de jure residential segregation as fundamental causes of racial/ethnic health disparities. HOLC’s appraisal process was carried out in cities with at least 40,000 residents and entailed the assignment of color-coded “risk grades” to residential properties in urban neighborhoods based on perceived risk for foreclosure. Neighborhoods with concentrations of Black and/or immigrant residents were systematically graded in the highest risk category and experienced subsequent declines in property values, private investment, and lending opportunities associated with the “hazardous” designation. Digitization of HOLC’s infamous “residential security maps” by the University of Richmond’s Mapping Inequality Project has enabled researchers to link historical redlining patterns to a range of contemporary social, economic and health outcomes, from birth outcomes to chronic disease. The connection between historical redlining practices and contemporary health outcomes may highlight an important pathway by which structural racism produces and reproduces racialized and place-based health inequities across generations.

            Despite the recent profusion of evidence associating historical redlining and contemporary health outcomes, few studies have probed these relationships for heterogeneity across population groups or geographic areas, and few have examined the mechanisms by which historical redlining practices may impact contemporary neighborhood conditions and health. This dissertation links data from the Centers for Disease Control and Prevention (CDC) PLACES Project (2020 release), Historic Redlining Scores Project, American Community Survey 5-year estimates (2013-2017), and the Home Mortgage Disclosure Act database (2013-2017) to examine historical and contemporary forms of institutionalized racism in housing markets as drivers of neighborhood health inequities. In the first empirical chapter (Chapter 2), I examine whether and how associations between historical redlining patterns and neighborhood health – specifically, prevalence of poor mental health and diagnosed diabetes – are moderated by contemporary neighborhood racial/ethnic composition. The findings of this study may point to differential impacts of historical to contemporary structural racism across racial/ethnic groups. In the second empirical chapter (Chapter 3), I examine whether and to what extent features of contemporary housing markets explain the documented association between historical redlining patterns and neighborhood prevalence of poor mental health. As inequities within local housing markets have particularly affected Black communities, I also examine whether the effects of historical redlining patterns through features of contemporary housing markets are dependent on the relative size of the Black population within a neighborhood. The findings of this study suggest neighborhood property values, homeownership rates, and loan denial rates for home purchase explain a large share of the association between redlining patterns and poor mental health. Finally, in the third empirical chapter (Chapter 4), I examine whether and how associations between historical redlining patterns and neighborhood diabetes prevalence vary across metropolitan areas. Specifically, I examine a novel composite measure of institutionalized anti-Black racism in housing markets as a possible metropolitan/micropolitan area-level modifier of the relationship between historical redlining and neighborhood diabetes prevalence. This study suggests contemporary institutionalized racism in local housing markets may be perpetuating legacies of historical redlining practices and other exclusionary policies. Overall, these studies contribute to a burgeoning body of literature examining the roles of historical to contemporary forms of institutionalized racism in housing markets in the (re)production of racial/ethnic and place-based health inequities. This work is particularly timely as policymakers have garnered stronger interest in pursuing reparations for historical injustices imposed on Black communities, including use of the HOLC maps to prioritize neighborhoods for place-based investments.

              Cover page: Connecting Past to Present: Institutionalized Racism in Housing Markets and Neighborhood Health Inequities
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2018)
              Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes' implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.
                Cover page: Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training.
                • Article
                • Peer Reviewed
                UC Davis Previously Published Works (2014)

                Importance

                Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees.

                Objective

                To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure.

                Design, setting, and participants

                We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population.

                Main outcomes and measures

                Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid.

                Results

                Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME],  -3.1; 95% CI,  -5.2% to -0.9%), rural (-9.2%; -11.1% to -7.4%), and/or uninsured (-9.5%; -13.0% to -5.9%) residents are less likely to have one of these facilities.

                Conclusions and relevance

                The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.
                  Cover page: Race/Ethnicity and Geographic Access to Medicaid Substance Use Disorder Treatment Facilities in the United States
                  • Article
                  • Peer Reviewed
                  UC Davis Previously Published Works (2015)
                  With the expansion of coverage as a result of federal health care reform, safety net providers are confronting a challenge to care for the underserved while also competing as a provider of choice for the newly insured. Safety net institutions may be able to achieve these goals by pursuing greater delivery system integration. We interviewed safety net hospital and community health center (CHCs) leaders in five US cities to determine what strategies these organizations are employing to promote care integration in the safety net. Although there is some experimentation with payment reform and health information exchange, safety net providers identify significant policy and structural barriers to integrating service delivery. The enhanced Medicaid payments for CHCs and the federal requirement that CHCs retain independent boards discourage these organizations from integrating with other safety net providers. Current policies are not mobilizing safety net providers to pursue integration as a way to deliver more efficient and effective care. Medicaid and other policies at the federal and state level could be revised to overcome known fragmentation in the health care safety net. This includes addressing the conflicts in financing and governance arrangements that are encouraging providers to resist integration to preserve their independence.
                    Cover page: Safety Net Integration: A Shared Strategy for Becoming Providers of Choice
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2007)

                    Background

                    The University of California, Los Angeles (UCLA)/Charles R. Drew University Medical Education Program was developed to train physicians for practice in underserved areas. The UCLA/Drew Medical Education Program students receive basic science instruction at UCLA and complete their required clinical rotations in South Los Angeles, an impoverished urban community. We have previously shown that, in comparison to their UCLA counterparts, students in the Drew program had greater odds of maintaining their commitment to medically disadvantaged populations over the course of medical education.

                    Objective

                    To examine the independent association of graduation from the UCLA/Drew program with subsequent choice of physician practice location. We hypothesized that participation in the UCLA/Drew program predicts future practice in medically disadvantaged areas, controlling for student demographics such as race/ethnicity and gender, indicators of socioeconomic status, and specialty choice.

                    Design

                    Retrospective cohort study.

                    Participants

                    Graduates (1,071) of the UCLA School of Medicine and the UCLA/Drew Medical Education Program from 1985-1995, practicing in California in 2003 based on the address listed in the American Medical Association (AMA) Physician Masterfile.

                    Measurements

                    Physician address was geocoded to a California Medical Service Study Area (MSSA). A medically disadvantaged community was defined as meeting any one of the following criteria: (a) federally designated HPSA or MUA; (b) rural area; (c) high minority area; or (d) high poverty area.

                    Results

                    Fifty-three percent of UCLA/Drew graduates are located in medically disadvantaged areas, in contrast to 26.1% of UCLA graduates. In multivariate analyses, underrepresented minority race/ethnicity (OR: 1.57; 95% CI: 1.10-2.25) and participation in the Drew program (OR: 2.47; 95% CI: 1.59-3.83) were independent predictors of future practice in disadvantaged areas.

                    Conclusions

                    Physicians who graduated from the UCLA/Drew Medical Education Program have higher odds of practicing in underserved areas than those who completed the traditional UCLA curriculum, even after controlling for other factors such as race/ethnicity. The association between participation in the UCLA/Drew Medical Education Program and physician practice location suggests that medical education programs may reinforce student goals to practice in disadvantaged communities.
                      Cover page: The Role of Medical Education in Reducing Health Care Disparities: The First Ten Years of the UCLA/Drew Medical Education Program
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