RESEARCH OBJECTIVE: Adults with Cerebral Palsy (CP) or Spina Bifida (SB) are at elevated risk of age-related chronic disease. In addition to comprehensive management of these conditions, they require visits to healthcare providers for their primary disability, management of secondary conditions and preventive services. Prior studies demonstrate that persons with disabilities encounter physical barriers in their environment to access healthcare. Their complexity of care needs and challenges accessing facilities and providers can increase likelihood of care fragmentation. This highlights the need to examine continuity of care (COC) in this population. There is limited evidence examining which features of the environment are important for continuous care for this population. To address this important gap, we examined the individual and contextual features associated with continuous care.
STUDY DESIGN: In this cross-sectional study, geocoded information for adults with CP/SB were linked to the following neighborhood-level data from the National Neighborhood Data Archive (NaNDA): 1) Healthcare resources (e.g., hospitals), 2) Transit, 3) Broadband connections, and 4) Affluence and disadvantage. We also included data on spatial accessibility of healthcare providers. The Bice-Boxerman COC index was computed using number of outpatient visits with providers. COC reflects the degree to which patient visits are concentrated among providers. A higher COC score is assigned to visit patterns where greater shares of the visits are with fewer providers. Multilevel logistic regression was used to examine neighborhood-level factors associated with odds of high COC, considering geographic clustering.
POPULATION STUDIED: We leveraged claims data from Optum Clinformatics. Individuals 18+ with an ICD-9 diagnostic code for CP/SB were selected. To calculate a stable COC score, we restricted our sample to those with at least 4 outpatient visits in a year.
PRINCIPAL FINDINGS: Amongst 8,596 individuals, the mean score was 0.52 and 0.14 for those with high and low continuity, respectively. Individuals with high continuity were more likely to be older and male and their total visits were less dispersed across different physician specialty types, compared to those with low continuity. In adjusted models, more comorbid conditions were associated with lower odds of high continuity (Odds Ratio [OR]: 0.83, 95% Confidence Interval [CI]: 0.76-0.92). Additionally, features of the neighborhood were significant predictors of continuity. Individuals residing in areas with a lower density of residential care facilities (Q1 vs Q3: OR 0.72, 95% CI: 0.59-0.88) and hospitals (Q2 vs Q3: OR 0.84, 95% CI: 0.72-0.98) had lower odds of high continuity. Less spatial availability to primary care physicians/nurse practitioners (PCPs/NPs) was associated with more continuous care. In addition to built features, neighborhood affluence and disadvantage were independently associated with care continuity.
CONCLUSIONS: For adults with CP/SB who had private health insurance, features of their neighborhood, namely affluence, availability of healthcare facilities and spatial accessibility of PCPs/NPs were significantly associated with continuous care.
