Heather F. de Vries McClintock

Health care experiences and perceptions among people with and without disabilities

BACKGROUND Little is known about health care experiences among people with and without disabilities. OBJECTIVE We sought to explore perceptions of people with and without disabilities related to their health care experiences. METHODS Nineteen persons with and without disabilities participated in one of four focus groups. Focus groups were conducted in the physical world in Milwaukee, WI and in the virtual world in Second Life(®) with Virtual Ability, a well-established community designed by and for people with a wide range of disabilities. A grounded theory methodology was employed to analyze focus group data. Inclusion of physical and virtual world focus groups enabled people with a wide range of disabilities to participate. RESULTS While some participants described instances of receiving good care, many discussed numerous barriers. The main themes that emerged in focus groups among both persons with and without disabilities related to their health care experiences including poor coordination among providers; difficulties with insurance, finances, transportation and facilities; short duration of visits with physicians; inadequate information provision; feelings of being diminished and deflated; and self-advocacy as a tool. Transportation was a major concern for persons with disabilities influencing mobility. Persons with disabilities described particularly poignant experiences wherein they felt invisible or were viewed as incompetent. CONCLUSIONS Both persons with and without disabilities experienced challenges in obtaining high quality health care. However, persons with disabilities experienced specific challenges often related to their type of disability. Participants stressed the need for improving health care coordination and the importance of self-advocacy.

Neighborhood social environment and patterns of adherence to oral hypoglycemic agents among patients with type 2 diabetes mellitus.

This study examined whether neighborhood social environment was related to patterns of adherence to oral hypoglycemic agents among primary care patients with type 2 diabetes mellitus. Residents in neighborhoods with high social affluence, high residential stability, and high neighborhood advantage, compared to residents in neighborhoods with one or no high features present, were significantly more likely to have an adherent pattern compared to a nonadherent pattern. Neighborhood social environment may influence patterns of adherence. Reliance on a multilevel contextual framework, extending beyond the individual, to promote diabetic self-management activities may be essential for notable public health improvements.

Health care access and quality for persons with disability: Patient and provider recommendations

BACKGROUND Significant disparities in health care access and quality persist between persons with disabilities (PWD) and persons without disabilities (PWOD). Little research has examined recommendations of patients and providers to improve health care for PWD. OBJECTIVE We sought to explore patient and health care provider recommendations to improve health care access and quality for PWD through focus groups in the physical world in a community center and in the virtual world in an online community. METHODS In all, 17 PWD, 4 PWOD, and 6 health care providers participated in 1 of 5 focus groups. Focus groups were conducted in the virtual world in Second Life® with Virtual Ability, an online community, and in the physical world at Agape Community Center in Milwaukee, WI. Focus group data were analyzed using a grounded theory methodology. RESULTS Themes that emerged in focus groups among PWD and PWOD as well as health care providers to improve health care access and quality for PWD were: promoting advocacy, increasing awareness and knowledge, improving communication, addressing assumptions, as well as modifying and creating policy. Many participants discussed political empowerment and engagement as central to health care reform. CONCLUSIONS Both PWD and PWOD as well as health care providers identified common themes potentially important for improving health care for PWD. Patient and health care provider recommendations highlight a need for modification of current paradigms, practices, and approaches to improve the quality of health care provision for PWD. Participants emphasized the need for greater advocacy and political engagement.

Patterns of Adherence to Oral Hypoglycemic Agents and Glucose Control among Primary Care Patients with Type 2 Diabetes

Researchers sought to examine whether there are patterns of oral hypoglycemic-agent adherence among primary-care patients with type 2 diabetes that are related to patient characteristics and clinical outcomes. Longitudinal analysis via growth curve mixture modeling was carried out to classify 180 patients who participated in an adherence intervention according to patterns of adherence to oral hypoglycemic agents across 12 weeks. Three patterns of change in adherence were identified: adherent, increasing adherence, and nonadherent. Global cognition and intervention condition were associated with pattern of change in adherence (p < .05). Patients with an increasing adherence pattern were more likely to have an Hemoglobin A1c (HbA1c) < 7%; adjusted odds ratio = 14.52, 95% CI (2.54, 82.99) at 12 weeks, in comparison with patients with the nonadherent pattern. Identification of patients with type 2 diabetes at risk of nonadherence is important for clinical prognosis and the development and delivery of interventions.

Disability Stages and Trouble Getting Needed Health Care Among Medicare Beneficiaries.

Objective The aim of this study was to examine whether activity limitation stages were associated with patient-reported trouble getting needed health care among Medicare beneficiaries. Design This was a population-based study (n = 35,912) of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey for years 2001–2010. Beneficiaries were classified into an activity limitation stage from 0 (no limitation) to IV (complete) derived from self-reported or proxy-reported difficulty performing activities of daily living and instrumental activities of daily living. Beneficiaries reported whether they had trouble getting health care in the subsequent year. A multivariable logistic regression model examined the association between activity limitation stages and trouble getting needed care. Results Compared with beneficiaries with no limitations (activities of daily living stage 0), the adjusted odds ratios (ORs) (95% confidence intervals [CIs]) for stage I (mild) to stage IV (complete) for trouble getting needed health care ranged from OR = 1.53 (95% CI, 1.32–1.76) to OR = 2.86 (95% CI, 1.97–4.14). High costs (31.7%), not having enough money (31.2%), and supplies/services not covered (24.2%) were the most common reasons for reporting trouble getting needed health care. Conclusion Medicare beneficiaries at higher stages of activity limitations reported trouble getting needed health care, which was commonly attributed to financial barriers.

Costs of Coexisting Depression and Diabetes

A ccording to the Global Burden of Disease Study 2010 and the World Health Organization, diabetes and depression are leading causes of disability. In the United States, approximately 25.6 million adults have diabetes mellitus (11.3% of the population). The burden of diabetes is anticipated to grow, with estimates suggesting that the proportion of the population affected by diabetes and related costs will at least double in the next 25 years, yet the proportion of adults whose diabetes is controlled is decreasing over time and is particularly low among older adults and ethnic minorities. Depression is a risk factor for diabetes and risk of depression is increased by a factor of two in patients with diabetes. Depressive symptoms contribute to poor patient engagement, poor adherence to medication and dietary regimens, poor glycemic control, reduced quality of life, and increased health expenditures. The influence of depression on outcomes for diabetes includes both biological mechanisms such as increased inflammation, poor self-care, and decreased adherence to treatment regimens. For patients with diabetes, depression has been specifically linked to prognostic variables such as microvascular and macrovascular complications. Depression has been found to increase all-cause mortality even in the context of good glucose control. For diabetes, increasing attention has been given to the principle that day-to-day management should be in the hands of patients themselves. Self-care activities (e.g., checking one’s own finger-stick blood sugar), health behaviors (e.g., smoking, alcohol use, diet, physical activity), and patient choice (e.g., whether to start a new medication or undergo a procedure) all profoundly affect outcomes in diabetes and all are strongly influenced by depression. The biological, social, psychological, and behavioral links between depression and diabetes provide a strong incentive to examine the healthcare costs of depression in adults with diabetes. Moreover, national estimates of the healthcare costs of comorbid depression and diabetes are essential for providing decision makers with needed information to inform policy and practice changes. In this issue of JGIM, Egede et al. investigate the trends in healthcare costs over 8 years in patients aged 18 years and older with diabetes. Based on International Classification of Diseases, Clinical Modification (ICD-9-CM) codes to measure the presence or absence of a depression diagnosis and the two-item Patient Health Questionnaire (PHQ-2) to measure the presence or absence of depressive symptoms, patients with diabetes were classified as no depression, unrecognized depression, asymptomatic depression, or symptomatic depression. The authors report that patients with unrecognized and asymptomatic depression had healthcare expenditures that were

Patient Satisfaction and Perceived Quality of Care among Younger Medicare Beneficiaries According to Activity Limitation Stages

2000–

Incorporating Patients’ Social Determinants of Health into Hypertension and Depression Care: A Pilot Randomized Controlled Trial

3000 higher compared to patients with no depression, and patients with symptomatic depression had healthcare expenditures that were

Patient Satisfaction and Perceived Quality of Care Among Older Adults According to Activity Limitation Stages

5000 higher compared to patients with no depression after adjustment for potentially influential covariates. The authors adjusted for sociodemographic factors, comorbidities, and time trend covariates. No depression was associated with the lowest total, inpatient, outpatient, prescription, office-based, and emergency room costs, and symptomatic depression was associated with the highest costs of all types. The authors found the higher medical expenditures associated with depression persisted over time. This study used data from the 2004–2011 Medical Expenditure Panel Survey (MEPS), a nationally representative estimate of healthcare expenditures maintained and cosponsored by the Agency for Healthcare Research and Quality (AHRQ). The MEPS data spanned 8 years and involved 15,548 adults with diabetes. The large ethnically diverse and nationally representative sample and the pooled data set over 8 years are significant strengths. Because of the focus on costs due to medical expenditures, other nonmedical costs related to caregiving, community services, short-term sick leave, and social services are not included and are an important area of future inquiry. The overall mean medical expenditures for patients with diabetes and no depression was

Patient Satisfaction and Prognosis for Functional Improvement and Deterioration, Institutionalization, and Death Among Medicare Beneficiaries Over 2 Years.

10,016 (95 % CI 9589– 10,442), with unrecognized depression was