Vulnerable Populations

Access to primary care in Hong Kong, Greater London and New York City

Access to primary care in Hong Kong, Greater London and New York City
Cambridge University Press 2013. Health Economics, Policy and Law / Volume 8 / Issue 01 / January 2013, pp 95 109, Published online.

Pui Hing Chau, Jean Woo, Michael K. Gusmano, Daniel Weisz, Victor G. Rodwin and Kam Che Chan
01/01/2013

We investigate avoidable hospital conditions (AHC) in three world cities as a way to assess access to primary care. Residents of Hong Kong are healthier than their counterparts in Greater London or New York City. In contrast to their counterparts in New York City, residents of both Greater London and Hong Kong face no financial barriers to an extensive public hospital system. We compare residence-based hospital discharge rates for AHC, by age cohorts, in these cities and find that New York City has higher rates than Hong Kong and Greater London. Hong Kong has the lowest hospital discharge rates for AHC among the population 15–64, but its rates are nearly as high as those in New York City among the population 65 and over. Our findings suggest that in contrast to Greater London, older residents in Hong Kong and New York face significant barriers in accessing primary care. In all three cities, people living in lower socioeconomic status neighborhoods are more likely to be hospitalized for an AHC, but neighborhood inequalities are greater in Hong Kong and New York than in Greater London.

How Microfinance Really Works

How Microfinance Really Works
The Milken Institute Review

Morduch, Jonathan
01/01/2013

About half of the world’s adults lack bank accounts. Most of these “unbanked” are deemed too expensive to serve, or not worth the hassle created by banking regulations. But what may be good business from a banker’s perspective isn’t necessarily what’s best for society. The inequalities that persist in financial access reinforce broader inequalities in the distribution of income and wealth. This is the opening for microfinance and also its challenge. Microlending has been sold as a practical means to get capital into the hands of small-scale entrepreneurs who can then earn their way out of poverty. The idea appeals to our impulse to help people help themselves and to our conviction that bottom-up development depends on the embrace of the market. By eschewing governments and traditional charities, the sector promises to sidestep the bureaucracy and inertia that have hobbled other attempts to expand the opportunities of the poor.

Beyond Black: Diversity among Black Immigrant Students in New York City Public Schools

Beyond Black: Diversity among Black Immigrant Students in New York City Public Schools
Randy Capps and Michael Fix, editors, Young Children of Black Immigrants in America: Changing Flows, Changing Faces. Washington, DC: Migration Policy Institute: 299-331

Doucet, F., Schwartz, A. E., & Debraggio, E.
12/14/2012

The child population in the United States is rapidly changing and diversifying — in large part because of immigration. Today, nearly one in four US children under the age of 18 is the child of an immigrant. While research has focused on the largest of these groups (Latinos and Asians), far less academic attention has been paid to the changing Black child population, with the children of Black immigrants representing an increasing share of the US Black child population.

To better understand a unique segment of the child population, chapters in this interdisciplinary volume examine the health, well-being, school readiness, and academic achievement of children in Black immigrant families (most with parents from Africa and the Caribbean).

The volume explores the migration and settlement experiences of Black immigrants to the United States, focusing on contextual factors such as family circumstances, parenting behaviors, social supports, and school climate that influence outcomes during early childhood and the elementary and middle-school years.  Many of its findings hold important policy implications for education, health care, child care, early childhood development, immigrant integration, and refugee assistance.

Banking The World

Banking The World
The MIT Press

(eds.) Cull, Robert, Asli Demirgüç-Kunt and Jonathan Morduch
12/01/2012

About 2.5 billion adults, just over half the world’s adult population, lack bank accounts. If we are to realize the goal of extending banking and other financial services to this vast “unbanked” population, we need to consider not only such product innovations as microfinance and mobile banking but also issues of data accuracy, impact assessment, risk mitigation, technology adaptation, financial literacy, and local context. In Banking the World, experts take up these topics, reporting on new research that will guide both policy makers and scholars in a broader push to extend financial markets.

The contributors consider such topics as the complexity of surveying people about their use of financial services; evidence of the impact of financial services on income; the occasional negative effects of financial services on poor households, including disincentives to work and overindebtedness; and tools for improving access such as nontraditional credit scores, financial incentives for banking, and identification technologies that can dramatically reduce loan default rates.

Asthma Hospital Admissions and Ambient Air Pollutant Concentrations in New York City

Asthma Hospital Admissions and Ambient Air Pollutant Concentrations in New York City
Journal of Environmental Protection, Vol. 3 No. 29, 2012, pp. 1102-1116. doi: 10.4236/jep.2012.329129.

C. Restrepo, J. Simonoff, G. Thurston and R. Zimmerman
09/01/2012

Air pollution is considered a risk factor for asthma. In this paper, we analyze the association between daily hospital admissions for asthma and ambient air pollution concentrations in four New York City counties. Negative binomial regression is used to model the association between daily asthma hospital admissions and ambient air pollution concentrations. Potential confounding factors such as heat index, day of week, holidays, yearly population changes, and seasonal and long-term trends are controlled for in the models. Nitrogen dioxide (NO2), sulfur dioxide (SO2) and carbon monoxide (CO) show the most consistent statistically significant associations with daily hospitalizations for asthma during the entire period (1996-2000). The associations are stronger for children (0 - 17 years) than for adults (18 - 64 years). Relative risks (RR) for the inter-quartile range (IQR) of same day 24-hour average pollutant concentration and asthma hospitalizations for children for the four county hospitalization totals were: NO2 (IQR = 0.011 ppm, RR = 1.017, 95% CI = 1.001, 1.034), SO2 (IQR = 0.008 ppm, RR = 1.023, 95% CI = 1.004, 1.042), CO (IQR = 0.232 ppm, RR = 1.014, 95% CI = 1.003, 1.025). In the case of ozone (O3) and particulate matter (PM2.5) statistically significant associations were found for daily one-hour maxima values and children’s asthma hospitalization in models that used lagged values for air pollution concentrations. Five-day weighted average lag models resulted in these estimates: O3 (one-hour maxima) (IQR = 0.025 ppm, RR = 1.049, 95% CI = 1.002, 1.098), PM2.5 (one-hour maxima) (IQR = 16.679 μg/m3, RR = 1.055, 95% CI = 1.008, 1.103). In addition, seasonal variations were also explored for PM2.5 and statistically significant associations with daily hospital admissions for asthma were found during the colder months (November-March) of the year. Important differences in pollution effects were found across pollutants, counties, and age groups. The results for PM2.5 suggest that the composition of PM is important to this health outcome, since the major sources of NYC PM differ between winter and summer months.

Infant Antibiotic Exposures and Early-Life Body Mass

Infant Antibiotic Exposures and Early-Life Body Mass
International Journal of Obesity , (21 August 2012) | doi:10.1038/ijo.2012.132

Trasande, Leonardo, Jan Blustein, Mengling Liu, Elise Corwin, Laura M Cox, Martin J Blaser
08/21/2012

Objectives:

To examine the associations of antibiotic exposures during the first 2 years of life and the development of body mass over the first 7 years of life.

Design:

Longitudinal birth cohort study.

Subjects:
A total of 11 532 children born at greater than or equal to2500 g in the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based study of children born in Avon, UK in 1991–1992.

Measurements:

Exposures to antibiotics during three different early-life time windows (

Results:

Antibiotic exposure during the earliest time window (

Conclusions:

Exposure to antibiotics during the first 6 months of life is associated with consistent increases in body mass from 10 to 38 months. Exposures later in infancy (6–14 months, 15–23 months) are not consistently associated with increased body mass. Although effects of early exposures are modest at the individual level, they could have substantial consequences for population health. Given the prevalence of antibiotic exposures in infants, and in light of the growing concerns about childhood obesity, further studies are needed to isolate effects and define life-course implications for body mass and cardiovascular risks.

Low Cognitive Ability and Poor Skill with Numbers May Prevent Many from Enrolling in Medicare Supplemental Coverage

Low Cognitive Ability and Poor Skill with Numbers May Prevent Many from Enrolling in Medicare Supplemental Coverage
Health Affairs. 2012; 31(8): 1847-1854. doi: 10.1377/hlthaff.2011.1000

Chan, Sewin and Brian Elbel
08/01/2012

Because traditional Medicare leaves substantial gaps in coverage, many people obtain supplemental coverage to limit their exposure to out-of-pocket costs. However, some Medicare beneficiaries may not be well equipped to navigate the complex supplemental coverage landscape successfully because of their lower cognitive ability or numeracy—that is, the ability to work with numbers. We found that people in the lower third of the cognitive ability and numeracy distributions were at least eleven percentage points less likely than those in the upper third to enroll in a supplemental Medicare insurance plan. This result means that many Medicare beneficiaries do not have the financial protections and other benefits that would be available to them if they were enrolled in a supplemental insurance plan. Our findings suggest that policy makers may want to consider alternatives tailored to these high-need groups, such as enhanced education and enrollment programs, simpler sets of plan choices, or even some type of automatic enrollment with an option to decline coverage.

Use of community-level data in the National Children's Study to establish the representativeness of segment selection in the Queens Vanguard Site.

Use of community-level data in the National Children's Study to establish the representativeness of segment selection in the Queens Vanguard Site.
Int J Health Geogr. 2012 Jun 5;11:18.

Rundle A, Rauh VA, Quinn J, Lovasi G, Trasande L, Susser E and Andrews HF.
06/05/2012

BACKGROUND:

The WHO Multiple Exposures Multiple Effects (MEME) framework identifies community contextual variables as central to the study of childhood health. Here we identify multiple domains of neighborhood context, and key variables describing the dimensions of these domains, for use in the National Children's Study (NCS) site in Queens. We test whether the neighborhoods selected for NCS recruitment, are representative of the whole of Queens County, and whether there is sufficient variability across neighborhoods for meaningful studies of contextual variables.

METHODS:

Nine domains (demographic, socioeconomic, households, birth rated, transit, playground/greenspace, safety and social disorder, land use, and pollution sources) and 53 indicator measures of the domains were identified. Geographic information systems were used to create community-level indicators for US Census tracts containing the 18 study neighborhoods in Queens selected for recruitment, using US Census, New York City Vital Statistics, and other sources of community-level information. Mean and inter-quartile range values for each indicator were compared for Tracts in recruitment and non-recruitment neighborhoods in Queens.

RESULTS:

Across the nine domains, except in a very few instances, the NCS segment-containing tracts (N = 43) were not statistically different from those 597 populated tracts in Queens not containing portions of NCS segments; variability in most indicators was comparable in tracts containing and not containing segments.

CONCLUSIONS:

In a diverse urban setting, the NCS segment selection process succeeded in identifying recruitment areas that are, as a whole, representative of Queens County, for a broad range of community-level variables.

Growing Older in Hong Kong, New York and London

Growing Older in Hong Kong, New York and London
The Hong Kong Jockey Club Charities Trust. Hong Kong, 2012.

P. Chau, J. Woo, M. Gusmano, D. Weisz, and Rodwin, V.
05/08/2012

Declining birth rates, increasing longevity and urbanization have created a new challenge for cities: how to respond to an ageing population. Although population ageing and urbanization are not new concerns for national governments around the world, the consequences of these trends for quality of life in cities has only recently started to receive attention from policy makers and researchers. Few comparative studies of world cities examine their health or long-term care systems; nor have comparisons of national systems for the provision of long-term care focused on cities, let alone world cities.

By extending the work of the CADENZA and World Cities Projects , this report investigates how three world cities -- Hong Kong, New York and London -- are coping with this challenge. These world cities are centers of finance, information, media, arts, education, specialized legal services and advanced business services, and contribute disproportionate shares of GDP to their national economies. But are these influential centers prepared to meet the challenge posed by the “revolution of longevity?” How will these world cities accommodate this revolutionary demographic change? Are they prepared to implement the health and social policy innovations that may be required to serve their residents, both old and young? Will they be able to identify the new opportunities that increased longevity may offer? Can they learn from one another as they seek to develop creative solutions to the myriad issues that arise? Finally, can other cities learn from the experience of these three cities as they confront this challenge?

To address these questions, we examine comparable data on the economic and health status of older persons, as well as the availability and use of health, social and long-term care across and within these cities. In the report “How Well Are Seniors in Hong Kong Doing? An International Comparison”, a first attempt was made to compare the situation in Hong Kong with five economically developed countries. This report extends this study by comparing the situation in Hong Kong with two other world cities—New York City and London, which are more comparable in terms of population size and economic characteristics.

Medicare’s Flagship Test Of Pay-For-Performance Did Not Spur More Rapid Quality Improvement Among Low-Performing Hospitals

Medicare’s Flagship Test Of Pay-For-Performance Did Not Spur More Rapid Quality Improvement Among Low-Performing Hospitals
Health Affairs; 31(4):797-805.

Ryan, Andrew M., Jan Blustein, Lawrence P. Casalino.
04/01/2012

Medicare’s flagship hospital pay-for-performance program, the Premier Hospital Quality Incentive Demonstration, began in 2003 but changed its incentive design in late 2006. The goals were to encourage greater quality improvement, particularly among lower-performing hospitals. However, we found no evidence that the change achieved these goals. Although the program changes were intended to provide strong incentives for improvement to the lowest-performing hospitals, we found that in practice the new incentive design resulted in the strongest incentives for hospitals that had already achieved quality performance ratings just above the median for the entire group of participating hospitals. Yet during the course of the program, these hospitals improved no more than others. Our findings raise questions about whether pay-for-performance strategies that reward improvement can generate greater improvement among lower performing providers. They also cast some doubt on the extent to which hospitals respond to the specific structure of economic incentives in pay-for-performance programs.

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