Elizabeth K. Rasch

The Complex Web of Health: Relationships Among Chronic Conditions, Disability, and Health Services

Objectives. A critical issue in health-care reform concerns how to realign health-care delivery systems to manage medical care services for people with ongoing and costly needs for care. We examined the overlapping health-care needs of two such population groups among the U.S. working-age population (those aged 18–64 years): people with chronic medical conditions and people with disabilities. Methods. Using the Medical Expenditure Panel Survey (2002–2004), we examined differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. We also analyzed people with three key chronic conditions: arthritis, diabetes, and depression. Results. More than half of working-age people with disabilities reported having more than one chronic condition. Among those with activities of daily living or instrumental activities of daily living limitations, 35% reported four or more chronic conditions at a time. We found considerable variability in access problems and service use depending on how we accounted for the overlap of multiple conditions among people with arthritis, diabetes, and depression. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems. Conclusions. The overall prevalence of chronic conditions among the U.S. working-age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health-care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diagnosis are required to track the ongoing needs for health services that these populations present.

Health of Community-Dwelling Adults With Mobility Limitations in the United States: Incidence of Secondary Health Conditions. Part II

OBJECTIVE To compare incident health conditions that occurred over a 2-year period in nationally representative groups of adults with mobility, nonmobility, and no limitations. DESIGN Data were collected prospectively from a probability subsample of households that represent the civilian, noninstitutionalized U.S. population. SETTING Five rounds of household interviews were conducted over 2 years. PARTICIPANTS Data were analyzed on the same respondents from the 1996-1997 Medical Expenditure Panel Survey (MEPS) and the 1995 National Health Interview Survey Disability Supplement. Respondents were categorized into 3 groups for analysis; those with mobility limitations, nonmobility limitations, and no limitations. The analytic sample included 12,302 MEPS adults (>/=18y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Number, types, and 2-year incidence of self-reported health conditions compared across groups. RESULTS The mean number of incident conditions (95% confidence intervals [CIs]) over the 2-year period was greatest in adults with mobility limitations (mean, 4.7; 95% CI, 4.4-4.9) compared with those with nonmobility limitations (mean, 3.9; 95% CI, 3.7-4.2) or no limitations (mean, 2.6; 95% CI, 2.5-2.7). Incident conditions affected most major body systems. CONCLUSIONS Because secondary conditions are potentially preventable, determining factors that influence their occurrence is an important public health issue requiring specific action.

Health of Community-Dwelling Adults With Mobility Limitations in the United States: Prevalent Health Conditions. Part I

OBJECTIVE To characterize the extent and types of prevalent health conditions among nationally representative groups of adults with mobility, nonmobility, and no limitations. DESIGN Data were collected during 5 rounds of household interviews from a probability subsample of households that represent the civilian, noninstitutionalized U.S. population. With some exceptions, round 1 variables were used for this analysis. SETTING Community. PARTICIPANTS Data were analyzed on the same respondents from the 1996 to 1997 Medical Expenditure Panel Survey (MEPS) and the 1995 National Health Interview Survey Disability Supplement. Respondents were categorized into 3 groups for analysis: those with mobility limitations, nonmobility limitations; and no limitations. The analytic sample included 13,897 MEPS adults (> or =18y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Number, types, and prevalence of self-reported health conditions compared across groups. RESULTS On average, adults with mobility limitations had significantly more prevalent conditions (3.6) than those with nonmobility limitations (2.4), or no limitations (1.3). Greater comorbidity existed in the context of fewer personal resources and more than half of adults with mobility limitations were working age. CONCLUSIONS Determining factors that influence the health of adults with mobility limitations is a critical public health issue.

If We Build It, Who Will Come?: Working-Age Adults With Chronic Health Care Needs and the Medical Home

Background:Currently, there is a call to implement and test the patient-centered medical home in adult populations, particularly among those with chronic conditions. However, the size, composition, and service use of the population who might require this coordinated care model need to be assessed, as does the way they are defined and identified. Objectives:Using nationally representative data from the 2002 to 2004 Medical Expenditure Panel Survey, we provide a preliminary profile of the population of working-age adults with chronic health care needs (ACHCN), including those with chronic health conditions and disabilities. Results:ACHCN comprised the majority (52%) of the working-aged population. Relative to persons without chronic health care needs, they had significantly more service use, access problems, and 4 times more health care expenditures. Of the 2 disability groups within the larger population of ACHCN, those reporting need for help or supervision with activities of daily livings (ADLs) or instrumental ADLs (IADLs) had the highest rates/percentages of the following: mean chronic (3.5) and acute (4.4) conditions during the year, service use (all services), and access problems. The ADL/IADL-limited group reported annual medical expenditures totaling 100 billion dollars, more than what was spent on the entire working-age population without chronic health care needs. Conclusions:These data reveal the drawbacks of selecting the potential population targeted for a medical home on the basis of diagnosis alone. New measurement approaches on the basis of shared need for ongoing health and related services are required to bridge the division between disability and chronic health conditions.

Ongoing Coverage for Ongoing Care: Access, Utilization, and Out-of-Pocket Spending Among Uninsured Working-Aged Adults with Chronic Health Care Needs

OBJECTIVES We sought to determine how part-year and full-year gaps in health insurance coverage affected working-aged persons with chronic health care needs. METHODS We conducted multivariate analyses of the 2002-2004 Medical Expenditure Panel Survey to compare access, utilization, and out-of-pocket spending burden among key groups of persons with chronic conditions and disabilities. The results are generalizable to the US community-dwelling population aged 18 to 64 years. RESULTS Among 92 million adults with chronic conditions, 21% experienced at least 1 month uninsured during the average year (2002-2004). Among the 25 million persons reporting both chronic conditions and disabilities, 23% were uninsured during the average year. These gaps in coverage were associated with significantly higher levels of access problems, lower rates of ambulatory visits and prescription drug use, and higher levels of out-of-pocket spending. CONCLUSIONS Implementation of health care reform must focus not only on the prevention of chronic conditions and the expansion of insurance coverage but also on the long-term stability of the coverage to be offered.

Connecting contemporary paradigms to the Social Security Administration’s disability evaluation process

From 1998 to 2008, the Social Security Administration’s (SSA) disability insurance program (DI) applications rose from 1.2 million to 2.3 million and exceeded 3 million in 2009. Given these large and growing numbers, even small changes in processing disability applications may reduce processing time, lower program costs, and improve performance of SSA’s disability programs. A literature review examining current conceptual models of disability and SSA’s disability evaluation process for adults was conducted. A gap exists between contemporary models of disability and how SSA defines and operationalizes disability. This is complicated by substantial variation in the timing, quantity, and quality of applicant functional information and workplace demands. A focus on impairment marginalizes more comprehensive assessment of function necessary to assess capacity for work. Novel assessment methodologies, such as computer adaptive testing to measure human functioning may hold promise for SSA’s data collection methods and disability assessment.

Conceptual Foundation for Measures of Physical Function and Behavioral Health Function for Social Security Work Disability Evaluation

Physical and mental impairments represent the 2 largest health condition categories for which workers receive Social Security disability benefits. Comprehensive assessment of physical and mental impairments should include aspects beyond medical conditions such as a persons underlying capabilities as well as activity demands relevant to the context of work. The objective of this article is to describe the initial conceptual stages of developing new measurement instruments of behavioral health and physical functioning relevant for Social Security work disability evaluation purposes. To outline a clear conceptualization of the constructs to be measured, 2 content models were developed using structured and informal qualitative approaches. We performed a structured literature review focusing on work disability and incorporating aspects of the International Classification of Functioning, Disability and Health as a unifying taxonomy for framework development. Expert interviews provided advice and consultation to enhance face validity of the resulting content models. The content model for work-related behavioral health function identifies 5 major domains: (1) behavior control, (2) basic interactions, (3) temperament and personality, (4) adaptability, and (5) workplace behaviors. The content model describing physical functioning includes 3 domains: (1) changing and maintaining body position, (2) whole-body mobility, and (3) carrying, moving, and handling objects. These content models informed subsequent measurement properties including item development and measurement scale construction, and provided conceptual coherence guiding future empirical inquiry. The proposed measurement approaches show promise to comprehensively and systematically assess physical and behavioral health functioning relevant to work.

Development of a computer-adaptive physical function instrument for Social Security Administration disability determination.

OBJECTIVES To develop and test an instrument to assess physical function for Social Security Administration (SSA) disability programs, the SSA-Physical Function (SSA-PF) instrument. Item response theory (IRT) analyses were used to (1) create a calibrated item bank for each of the factors identified in prior factor analyses, (2) assess the fit of the items within each scale, (3) develop separate computer-adaptive testing (CAT) instruments for each scale, and (4) conduct initial psychometric testing. DESIGN Cross-sectional data collection; IRT analyses; CAT simulation. SETTING Telephone and Internet survey. PARTICIPANTS Two samples: SSA claimants (n=1017) and adults from the U.S. general population (n=999). INTERVENTIONS None. MAIN OUTCOME MEASURES Model fit statistics, correlation, and reliability coefficients. RESULTS IRT analyses resulted in 5 unidimensional SSA-PF scales: Changing & Maintaining Body Position, Whole Body Mobility, Upper Body Function, Upper Extremity Fine Motor, and Wheelchair Mobility for a total of 102 items. High CAT accuracy was demonstrated by strong correlations between simulated CAT scores and those from the full item banks. On comparing the simulated CATs with the full item banks, very little loss of reliability or precision was noted, except at the lower and upper ranges of each scale. No difference in response patterns by age or sex was noted. The distributions of claimant scores were shifted to the lower end of each scale compared with those of a sample of U.S. adults. CONCLUSIONS The SSA-PF instrument contributes important new methodology for measuring the physical function of adults applying to the SSA disability programs. Initial evaluation revealed that the SSA-PF instrument achieved considerable breadth of coverage in each content domain and demonstrated noteworthy psychometric properties.

Disability Measurement Matrix: A Tool for the Coordination of Measurement Purpose and Instrument Development

The multidimensionality of the concept of disability makes the development of questions to measure the concept very complicated. In addition, the purposes of data collection can require a variety of different dimensions of the concept of disability to meet the variety of data uses. This paper proposes a data matrix for use in focusing the methodologist on the issues related to the multidimensionality of the concept and the variety of data needs when planning surveys. Discussions of the three components of the matrix, purpose, conceptual domains and question characteristics, provides the reader with an understanding of the elements of this tool. Multiple tables provide examples of the possible uses of the matrix.

Development of an Instrument to Measure Behavioral Health Function for Work Disability: Item Pool Construction and Factor Analysis

OBJECTIVES To develop a broad set of claimant-reported items to assess behavioral health functioning relevant to the Social Security disability determination processes, and to evaluate the underlying structure of behavioral health functioning for use in development of a new functional assessment instrument. DESIGN Cross-sectional. SETTING Community. PARTICIPANTS Item pools of behavioral health functioning were developed, refined, and field tested in a sample of persons applying for Social Security disability benefits (N=1015) who reported difficulties working because of mental or both mental and physical conditions. INTERVENTIONS None. MAIN OUTCOME MEASURE Social Security Administration Behavioral Health (SSA-BH) measurement instrument. RESULTS Confirmatory factor analysis (CFA) specified that a 4-factor model (self-efficacy, mood and emotions, behavioral control, social interactions) had the optimal fit with the data and was also consistent with our hypothesized conceptual framework for characterizing behavioral health functioning. When the items within each of the 4 scales were tested in CFA, the fit statistics indicated adequate support for characterizing behavioral health as a unidimensional construct along these 4 distinct scales of function. CONCLUSIONS This work represents a significant advance both conceptually and psychometrically in assessment methodologies for work-related behavioral health. The measurement of behavioral health functioning relevant to the context of work requires the assessment of multiple dimensions of behavioral health functioning. Specifically, we identified a 4-factor model solution that represented key domains of work-related behavioral health functioning. These results guided the development and scale formation of a new SSA-BH instrument.