Ellen Meara

The Gap Gets Bigger: Changes In Mortality And Life Expectancy, By Education, 1981–2000

In this paper we examine educational disparities in mortality and life expectancy among non-Hispanic blacks and whites in the 1980s and 1990s. Despite increased attention and substantial dollars directed to groups with low socioeconomic status, within race and gender groups, the educational gap in life expectancy is rising, mainly because of rising differentials among the elderly. With the exception of black males, all recent gains in life expectancy at age twenty-five have occurred among better-educated groups, raising educational differentials in life expectancy by 30 percent. Differential trends in smoking-related diseases explain at least 20 percent of this trend.

Health and economic impact of surgical site infections diagnosed after hospital discharge.

Although surgical site infections (SSIs) are known to cause substantial illness and costs during the index hospitalization, little information exists about the impact of infections diagnosed after discharge, which constitute the majority of SSIs. In this study, using patient questionnaire and administrative databases, we assessed the clinical outcomes and resource utilization in the 8-week postoperative period associated with SSIs recognized after discharge. SSI recognized after discharge was confirmed in 89 (1.9%) of 4,571 procedures from May 1997 to October 1998. Patients with SSI, but not controls, had a significant decline in SF-12 (Medical Outcomes Study 12-Item Short-Form Health Survey) mental health component scores after surgery (p=0.004). Patients required significantly more outpatient visits, emergency room visits, radiology services, readmissions, and home health aide services than did controls. Average total costs during the 8 weeks after discharge were US

Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage.

5,155 for patients with SSI and

Physical and mental health status of older long-term cancer survivors

1,773 for controls (p<0.001).

Spending Differences Associated With the Medicare Physician Group Practice Demonstration

Context Acquiring health insurance and getting better quality of care could reduce health care disparities. The relative importance of these 2 factors is unknown. Contribution To measure changes in chronic disease control, the authors used blood pressure, hemoglobin A1c, and total cholesterol measurements that were obtained from participants in the 1999 to 2006 National Health and Nutrition Examination Survey. Disease control improved over 8 years, but gaps between white and nonwhite patients did not change. The gaps were smaller after age 65 years, when universal Medicare insurance begins. Caution Each annual National Health and Nutrition Examination Survey enrolled different persons. Implication Access to care through universal health insurance reduced disparities in chronic disease control; improved quality of care did not affect sociodemographic differences. The Editors In 3 comprehensive reports since 2001, the Institute of Medicine has advanced recommendations to expand access (1), improve quality (2), and eliminate disparities in health care (3). Although widespread deficits in the quality of care have been reported in the United States (4), some evidence suggests that quality of care has improved in the past decade (58). More consistent efforts to provide high-quality care may also reduce racial, ethnic, and socioeconomic differences in health (9). However, quality improvement may not necessarily lead to more equitable care (5, 10, 11), especially if improvements occur among providers who serve fewer disadvantaged patients (1218) or if new financial incentives to improve quality have unintended, detrimental consequences (1820). Furthermore, better performance and smaller racial differences in processes of care for cardiovascular disease and diabetes have not been consistently associated with reduced racial differences in clinical outcomes, such as control of cholesterol or glucose levels (8, 21, 22). Although overall disease control in the United States may be improving for some measures (2325), recent national trends in sociodemographic differences in control have not been comprehensively assessed. Insurance coverage may be an important mediator of sociodemographic differences in control of cardiovascular disease and diabetes (3, 26). Racial and ethnic minorities and adults of lower socioeconomic status are much more likely to be uninsured (27), and uninsured adults are much less likely to receive basic clinical services for these conditions (28). Near-universal Medicare coverage after age 65 years has been associated with decreased racial and socioeconomic differences in self-reported general health status and receipt of mammography (29, 30). Recent longitudinal studies also suggest that acquiring Medicare coverage increases use of health services and improves self-reported health outcomes for previously uninsured adults with cardiovascular disease or diabetes (3133). However, previous studies have not assessed the effects of increases in insurance coverage on racial, ethnic, and socioeconomic differences in clinical measures of disease control. Our primary objectives were to assess national trends from 1999 to 2006 in blood pressure control (for adults with hypertension), glycemic control (for adults with diabetes), and cholesterol level control (for adults with coronary heart disease, stroke, or diabetes); to analyze concomitant changes in differences by race, ethnicity, and education for each of these measures; and to evaluate whether these differences narrow after age 65 years with Medicare coverage. Methods Study Sample We analyzed serial cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative study designed to assess population health through interviews, physical examinations, and clinical testing (34). From 1999 to 2006, 41474 noninstitutionalized adults and children were enrolled (average response rate, 81.4%), including oversamples of black adults, Mexican Americans, and adults age 60 years or older. Data have been released in four 2-year increments. Among participants who completed a standardized interview in English or Spanish, 39352 (94.9%) had clinical examinations and testing, including 12079 participants age 40 to 85 years. We studied adults age 40 to 85 years who had at least 1 of the following conditions: diabetes, hypertension, coronary heart disease, or stroke (Table 1). If we assessed disease control only among those with self-reported diagnoses, improved diagnosis of less severe disease might bias estimates of time trends in disease control in a positive direction. Therefore, on the basis of relevant clinical testing, we identified and included adults with undiagnosed hypertension and diabetes so that disease control was consistently assessed among all prevalent cases (a detailed classification of conditions is in the Appendix). Table 1. Demographic Characteristics of Adults Age 40 to 85 Years With Cardiovascular Disease or Diabetes Because the proportion of immigrant Hispanic adults varies by age and has increased over time (35) and because Hispanic immigrants experience different patterns of chronic disease care and outcomes from those of U.S.-born Hispanic adults (36), we excluded 743 Hispanic adults (53.1%) who were born outside the United States, restricting all analyses to the U.S.-born Hispanic group (hereafter referred to as Hispanic). This restriction improved comparability of Hispanic samples over time and ensured that age-related differences in outcomes were not confounded by health differences between immigrant and U.S.-born Hispanic adults. In contrast, only 5.2% of white participants and 12.7% of black participants were born outside the United States. Results were similar when we excluded white and black immigrants in a sensitivity analysis. Finally, we excluded 202 participants who were not white, black, or Hispanic because samples for other groups were too small for statistical comparisons. The Human Studies Committee of Harvard Medical School approved our study protocol. Study Variables We used dichotomous and continuous measures of disease control to compare rates of control and mean levels, respectively, across groups. We assessed blood pressure control (average systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) (37) and average systolic blood pressure readings among participants with hypertension; glycemic control (hemoglobin A1c levels <7.0%) (38) and hemoglobin A1c levels among participants with diabetes; and cholesterol level control (total cholesterol level <200 mg/dL [<5.2 mmol/L]) (39) and total cholesterol levels among participants with coronary heart disease, stroke, or diabetes. We defined comparison groups by race or ethnicity (non-Hispanic black and Hispanic each vs. non-Hispanic white) or education (high school graduates vs. nonhigh school graduates). We also determined age, sex, ratio of family income to poverty threshold, body mass index (BMI), current smoking status, and insurance coverage from NHANES data. Statistical Analysis We compared trends in disease control for each measure by using a linear model (E[Yi] = 0 + 1timei + 2groupi + 3timeigroupi), in which Yi is a dichotomous or continuous indicator of disease control for the ith individual; time is a chronologic index of the four 2-year survey periods ranging from 1 (1999 to 2000) to 4 (2005 to 2006); and group is an indicator of membership in a particular racial, ethnic, or educational comparison group. Thus, coefficients for the time-by-group interaction terms represent biennial trends (average change over 2-year periods between survey waves) in racial, ethnic, and educational differences in disease control from 1999 to 2006. We estimated overall trends by using simpler models without group variables. We also calculated rates of control and mean values for each of the four 2-year periods for reporting purposes. We adjusted all reported estimates of rates and trends for age and sex. To determine whether trends in disease control were related to changes in other population characteristics, we also estimated overall trends that were further adjusted for race, ethnicity, education, income, BMI, smoking status, and insurance coverage. We did not adjust analyses of racial, ethnic, or educational differences in disease control for factors other than age and sex, because we were interested in overall differences that could result from many individual and health care system factors, rather than attributing differences to specific mediators, such as discrimination (40). To estimate effects of near-universal Medicare coverage on sociodemographic differences, we compared racial, ethnic, and educational differences in systolic blood pressure, hemoglobin A1c levels, and total cholesterol levels before and after age 65 years. For example, to identify changes in racial differences in systolic blood pressure associated with Medicare eligibility, we fitted a linear model predicting mean systolic blood pressure as a function of black race, an indicator of age 65 years or older, and an interaction between these 2 predictors, with white adults serving as the reference group. We fitted similar models for each racial, ethnic, and educational comparison and for each outcome. We used measured values rather than dichotomous outcomes in these analyses to identify clinically important changes with greater sensitivity. In our study, differences in mortality rates, time-varying characteristics, and use of cross-sectional data posed several challenges to interpreting age-related changes in sociodemographic differences in disease control. Older groups may have differed from younger groups in predictors of disease control other than age or insurance coverage, and these differences between age groups may have differed by sociodemographic characteristics. Therefore, to estimate effects of Medicare coverage more robustly, we made several p

Does Housing Mobility Policy Improve Health

Objectives: To assess the physical and mental health status of older long‐term cancer survivors.

The Technology of Birth: Is it Worth it?

CONTEXTnThe Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs.nnnOBJECTIVEnTo estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid.nnnDESIGNnQuasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix.nnnSETTINGnTen physician groups from across the United States.nnnPATIENTS AND PARTICIPANTSnThe intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid.nnnMAIN OUTCOME MEASUREnAnnual spending per Medicare fee-for-service beneficiary.nnnRESULTSnAnnual savings per beneficiary were modest overall (adjusted mean

Is Spending More Always Wasteful? The Appropriateness Of Care And Outcomes Among Colorectal Cancer Patients

114, 95% CI,

State Legal Restrictions and Prescription-Opioid Use among Disabled Adults

12-

Few ACOs Pursue Innovative Models That Integrate Care For Mental Illness And Substance Abuse With Primary Care

216). Annual savings were significant in dually eligible beneficiaries (adjusted mean