Using electronic health record data to evaluate preventive service utilization among uninsured safety net patients
Introduction
In the United States, people without continuous health insurance coverage have worse access to important health care services, report lower satisfaction with their health care, and are less likely to be up-to-date on recommended preventive health services, compared to those with continuous coverage (Ayanian et al., 2001, Bandi et al., 2012, Bednarek and Schone, 2003, Berenson et al., 2012, Casillas et al., 2011, DeVoe et al., 2003, Fretts et al., 2000, Halterman et al., 2008, Mainous et al., 1999, McWilliams et al., 2003, Nelson et al., 2005, Nickel et al., 1998, Powell-Griner et al., 1999, Sudano and Baker, 2003, Walker et al., 2012). The association between continuous insurance coverage and the increased likelihood of preventive care receipt has been demonstrated across genders, age, race/ethnicity, and socioeconomic strata (Ayanian et al., 2001, Bandi et al., 2012, Bednarek and Schone, 2003, Berenson et al., 2012, Casillas et al., 2011, DeVoe et al., 2003, Fretts et al., 2000, Halterman et al., 2008, Mainous et al., 1999, McWilliams et al., 2003, Nelson et al., 2005, Nickel et al., 1998, Powell-Griner et al., 1999, Sudano and Baker, 2003, Walker et al., 2012).
Even in populations with a usual source of primary care, prevention disparities persist between uninsured and insured patients. For example, patients with insurance and a usual source of care have a greater likelihood of receiving lipid screenings, blood pressure checks, breast cancer screenings, and pap smears than those with a usual source of care but no insurance (DeVoe et al., 2003, Mainous et al., 1999). However, little is known about which specific preventive services uninsured patients are more or less likely to receive when they access primary care at community health centers (CHCs), where care is delivered regardless of insurance status (National Association of Community Health Centers, 2011, Shi et al., 2012). In part, this uncertainty is due to limitations in data typically used in these types of analyses. For example, claim datasets do not capture uninsured patients, and surveys are vulnerable to recall bias and health literacy limitations. To address these past limitations, and simultaneously address the paucity of data regarding preventive care received by uninsured patients compared to insured patients in the same clinics, this retrospective cohort study used electronic health record (EHR) data to compare preventive service utilization of uninsured CHC patients with that of continuously insured CHC patients.
Section snippets
Data sources
We utilized two data sources for this analysis. First, we used EHR data from OCHIN (originally the Oregon Community Health Information Network but shortened to OCHIN as other states joined). OCHIN's centrally hosted and linked Epic© EHR contains data on > 1 million patients served at > 300 CHCs in several states (OCHIN, 2014). An estimated 80–90% of CHC patients in Oregon seek care at an OCHIN clinic and have relevant ambulatory care data in OCHIN's EHR; from 4/1/2013 through 3/31/2014,
Population characteristics
The total study population was 18,044 patients (Table 1). Uninsured CHC patients were less likely than the continuously insured to be female, non-white Hispanic, English-speaking, from households earning ≤ 100% of the federal poverty level (FPL), and to have ˃4 visits in the 4 year study period. Uninsured patients were more likely to be Hispanic, Spanish-speaking, and have household earnings > 100% FPL.
Multivariable regression
After adjustment for covariates, there were no significant differences between the insured and
Discussion
This evaluation of the association between insurance status and preventive service receipt is novel in that it uses an EHR dataset and follows patients for 4 years. The results show that Oregon CHCs provide many recommended preventive services to uninsured patients: odds of receipt were not significantly different between uninsured and continuously insured patients for most services routinely provided during a CHC visit (e.g., blood pressure screening, BMI, smoking assessment). These are
Limitations
Our study had several limitations. Results were limited to CHCs in Oregon, so may not generalize to other settings. We could not confirm that services provided at other settings during the study period were documented in the EHR; patients may have migrated in or out of the clinic during the study period, affecting our results. However, the likelihood that we missed many services is low: CHCs provide more care to uninsured and low-income populations than private facilities do (Sadowski et al.,
Conclusion
Uninsured patients receive many recommended preventive services at their primary care CHCs, often at rates equivalent to those among patients with continuous insurance. There were some recommended services that uninsured patients had lower odds of receiving, even when they had primary care visits with some frequency. These missed services were those that usually require an order or a referral. Policymakers should consider the future health and societal implications of reduced access to
Funding sources
This study was supported by grant R01HL107647 from the National Heart, Lung, and Blood Institute and grant 1K08HS021522 from the Agency for Healthcare Research and Quality.
Conflict of interest statement
The authors report no conflicts of interest.
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