Neighborhood disadvantage and chronic disease management

Abstract

Objective: To assess the relationship between a composite measure of neighborhood disadvantage, the Area Deprivation Index (ADI), and control of blood pressure, diabetes, and cholesterol in the Medicare Advantage (MA) population.

Data sources: Secondary analysis of 2013 Medicare Healthcare Effectiveness Data and Information Set, Medicare enrollment data, and a neighborhood disadvantage indicator.

Study design: We tested the association of neighborhood disadvantage with intermediate health outcomes. Generalized estimating equations were used to adjust for geographic and individual factors including region, sex, race/ethnicity, dual eligibility, disability, and rurality.

Data collection: Data were linked by ZIP+4, representing compact geographic areas that can be linked to Census block groups.

Principal findings: Compared with enrollees residing in the least disadvantaged neighborhoods, enrollees in the most disadvantaged neighborhoods were 5 percentage points (P < 0.05) less likely to have controlled blood pressure, 6.9 percentage points (P < 0.05) less likely to have controlled diabetes, and 9.9 percentage points (P < 0.05) less likely to have controlled cholesterol. Adjustment attenuated this relationship, but the association remained.

Conclusions: The ADI is a strong, independent predictor of diabetes and cholesterol control, a moderate predictor of blood pressure control, and could be used to track neighborhood-level disparities and to target disparities-focused interventions in the MA population.

Keywords: Medicare; geographic/spatial factors/small area variations; social determinants of health.

Figure 1

Map of the most disadvantaged neighborhoods of residence for medicare advantage enrollees eligible for control measures in 2013^† [Color figure can be viewed at http://www.wileyonlinelibrary.com/]

1. Notes. ^†Neighborhood deprivation is derived from the Area Deprivation Index score, which was split into five equally sized quintiles. The most (5th) disadvantaged quintile is presented here. This map includes neighborhoods of residence for the entire study population of enrollees eligible for blood pressure, diabetes, and/or cholesterol control in 2013.

Figure 2

Number of white, black, hispanic, and asian enrollees in each ventile of neighborhood deprivation for blood pressure control^† [Color figure can be viewed at http://www.wileyonlinelibrary.com/]

1. Notes. ^†Neighborhood deprivation is derived from the Area Deprivation Index score, which was split into 20 equally sized ventiles, representing increasing (worsening) neighborhood deprivation in 5 percent increments. Results not shown for diabetes and cholesterol control cohorts.

Figure 3

Proportion of enrollees achieving control of blood pressure, diabetes, and cholesterol with increasing neighborhood deprivation^† [Color figure can be viewed at http://www.wileyonlinelibrary.com/]

1. Notes. ^†Neighborhood deprivation is derived from the Area Deprivation Index score, which was split into 20 equally sized ventiles, representing increasing (worsening) neighborhood deprivation in 5 percent increments. Each point plots the mean outcome control for either the entire population, or one racial/ethnic group in the population, over equally sized Area Deprivation Index ventiles that were created from the full population.