Neighborhood Disadvantage, Healthcare Utilization, Costs, and Outcomes among U.S. Veterans with COPD

Abstract

Among individuals with chronic obstructive pulmonary disease (COPD), neighborhood-level poverty is associated with increased disease rates and poorer outcomes. The purpose of this study was to determine whether neighborhood socioeconomic disadvantage is associated with outpatient healthcare utilization and costs among U.S. veterans with COPD. We used the 2018 Area Deprivation Index (ADI) to represent neighborhood disadvantage. Our primary outcomes were total outpatient utilization and total outpatient costs in the year following index date. Secondary outcomes included total primary care, pulmonary, cardiology, urgent care, and emergency department visits; total outpatient visit costs and total outpatient medication costs; and binary outcomes of death, any COPD exacerbation, and hospitalization for COPD exacerbation during one-year follow-up. In adjusted multivariable analyses, there was no significant association between ADI and total outpatient utilization, however, residence in a neighborhood in the highest ADI quartile compared to the lowest quartile was associated with lower 1-year outpatient costs (Average Marginal Effects [AME] = -$192.49; 95% CI: -$314.29, -$70.70). In adjusted secondary analyses, residence in a neighborhood in the highest ADI quartile was associated with fewer pulmonary visits (AME = -0.14; 95% CI: -0.21, -0.07), lower outpatient encounter costs (AME = -$175.83; 95% CI: -$278.14, -$73.52), higher odds of death (OR = 1.07; 95% CI: 1.002, 1.13), higher odds of COPD exacerbation or death (OR = 1.13; 95% CI: 1.06, 1.20), and higher odds of hospitalization for COPD exacerbation or death (OR = 1.09; 95% CI: 1.02, 1.16). These results indicate that individuals from more disadvantaged neighborhoods may be underserved by the healthcare system.