Howard R. Kelman

The emergence of depressive symptoms in late life: The importance of declining health and increasing disability

Despite considerable progress in the epidemiology of late life depressive disorders, the determinants and course of late life depressive symptoms remain unclear. The apparent reciprocal relationship between depression and disability, a consistent finding in cross-sectional studies further confounds efforts to estimate the importance of depressive symptoms in the elderly. In a longitudinal study of 1457 aged community residents who completed the Center for Epidemiologic Studies Depression scale at baseline and 24 months later, a significant level of depressive symptoms emerged in 163 respondents (11%), while 1080 (74%) remained symptom free. Unlike other studies, we found that the number of medical conditions, social support, life events, and demographic characteristics contributed little to distinguish those with emerging symptoms from those who remained symptom free. However, increasing disability and declining health preceded the emergence of depressive symptoms and accounted for seventy percent of the variance explained by discriminant analysis. These findings have etiologic implications for both the course and determinants of depression in late life.

Controlled study of the impact of educational home visits by pharmacists to high-risk older patients

Lack of information about medications coupled with high rates of utilization complicates compliance with medication regimens and increases the risk of adverse effects among older adults. We undertook a study of the efficacy of community-based interventions by pharmacists in a randomly-allocated one-half of a sample of 284 older adults considered to be at high risk for medication-related problems. Information and attitudes towards prescription and over-the-counter medications did not differ significantly between the intervention and comparison groups, either before or after the pharmacist interventions. However, visits to physicians were significantly less in the intervention group, suggesting an important if unexpected impact on health-related behavior.

Longitudinal patterns of formal and informal social support in an urban elderly population

Stability and change in the use of formal and informal social support was assessed over a three year period among a representative sample of 1855 elderly urban participants in a longitudinal study of aging and health. Whether people received informal, formal, both types of support or no support was determined in baseline, 12 and 24 month personal interviews. Most respondents retained the same form of support across all three interviews. The extent of stability or change varied according to the form of support reported at baseline. Two-thirds of those with no social support continued without support and 40% of those using both informal and formal support continued to do so at subsequent assessments. The substitution of formal for informal support was infrequent and not statistically significant. Pair wise discriminant function analyses of groups of respondents with the most frequent longitudinal support patterns were performed to identify baseline health and social characteristics associated with stable use, the addition of another form of support or change to nonuse, over time. Changes in the use of support were influenced more by initial levels of health and functional status than by social and economic circumstances. Larger proportions of respondents dropped use of support then added an additional form of support. Respondents using both formal and informal support at baseline died across time in higher proportions than those in other support categories. The extent of stability in support use and nonuse, the character of changes in support use across time and greater attrition among those who were the heaviest users of support, serve to create a relative balance in the use of informal and formal support in this aging cohort, at least over the time frame over which respondents were followed in this study.

Hospital and ambulatory service use by the urban elderly under different health care delivery systems.

For a sample of elderly persons living in an urban community, patterns of use of health-care services varied according to whether or not respondents identified one of three fee-for-service delivery systems as their primary source of care: a hospital, a private physician, or a medical group practice. Differences in utilization patterns persisted even when population health and socioeconomic characteristics were controlled, and are attributable either to differences in system structure or to the populations behavioral response to these systems of care. As expected, the health variables, as well as whether or not persons had a source of care, were the most important factors in explaining aggregate inpatient and ambulatory care visits. In addition, particular sources of care and socioeconomic variables were significant in explaining duration of time spent in hospital and types of ambulatory care visits. Policy implications of these and related findings are discussed.

Health services use among the elderly under alternative health service delivery systems

This article compares patterns of health care utilization for hospitalizations and ambulatory care in a sample of 1855 urban, elderly, community residents who report obtaining their health care from one of four types of arrangements: a fee-for-service (FFS) physician, a hospital-based health maintenance organization, a network model HMO, or a preferred provider organization (PPO). Utilization rates reported by respondents at six month intervals over three years were adjusted for health and socioeconomic characteristics of enrollees. PPO plan members consistently have mean and total lengths of hospital stay one-third to one-half those of the others. Although rates of use of particular categories of ambulatory care vary across systems of care, total ambulatory care rates are highest for network model HMO plan members. Specific features of alternative delivery systems, rather than general model types, may have an impact on utilization rates and the costs of care.This article compares patterns of health care utilization for hospitalizations and ambulatory care in a sample of 1855 urban, elderly, community residents who report obtaining their health care from one of four types of arrangements: a fee-for-service (FFS) physician, a hospital-based health maintenance organization, a network model HMO, or a preferred provider organization (PPO). Utilization rates reported by respondents at six month intervals over three years were adjusted for health and socioeconomic characteristics of enrollees. PPO plan members consistently have mean and total lengths of hospital stay one-third to one-half those of the others. Although rates of use of particular categories of ambulatory care vary across systems of care, total ambulatory care rates are highest for network model HMO plan members. Specific features of alternative delivery systems, rather than general model types, may have an impact on utilization rates and the costs of care.

Aging, health and health care

The articles which make up this issue of the Journal are all based on data collected and analyzed as part of the Norwood-Montefiore Aging Study (NMAS). Funded by the National Institute on Aging in 1983, this longitudinal study of aging, health and health care was uniquely designed to investigate little understood factors--including the use of health services--contributing to the health and well-being of persons in the later years of their lives. The NMAS sought to investigate the impact of depression and cognitive impairment, sleep disorders, and medication misuse on the health and functioning of older people, and how the type, amount or mix of health services provided by various providers, including group practice programs, private physicians or local hospitals contributed to the well being of older people living in their own homes in the community. The study was conducted in Norwood, a neighborhood in the North Central Bronx, a borough of New York City. This area was chosen for its high concentration of elderly people of diverse income and ethnic backgrounds, and for the variety of available health and health related services, including a long established hospital-based group practice program. In addition, the Montefiore Medical Center, a teaching and research center affiliated with the Albert Einstein College of Medicine, is within its boundaries. This institution, with a history of pioneering efforts in developing both long-term care programs and research, greatly facilitated the work of the NMAS in the community and provided necessary logistical and administrative support through its Department of Epidemiology and Social Medicine. The research structure of the NMAS has consisted of five subprojects. All have utilized a common study population and shared other support and analytic services. The specific projects are:

Unreimbursed expenses for medical care among urban elderly people

Out-of-pocket medical expenditures were examined among a sample of 400 low-to-moderate income Medicare recipients living in the Bronx for a twelve month period in 1986–87. Using three different measures of magnitude, the most significant expenses were for Medicare and private insurance premiums, medications, and dental care. The mean percent of per capita income spent out-of-pocket for medical care (including health care premiums) was 11.0%. Elderly people who spend over 12% of their own income on medical care include those in the poorest health, those with annual incomes under

Patterns of Stability and Change in Health Service Use among Elderly People Do Service Systems Leave an Imprint on Behavior

15,000, people living with spouses or others, and those using a private physician as a primary source of medical care.

Persistence and remission of depressive symptoms in late life

Stability and change in patterns of health service use over a 3-year period were determined for a sample of elderly people in an urban area who claimed one of five types of health service provider as a primary source of health care—a hospital, a private physician, a network model health maintenance organization (HMO), a hospital-based group practice program (G-HMO), or a preferred provider organization (PPO). Despite certain differences in use rates for individual services, the total volume of ambulatory service use was equivalent for all five groups as was the relative rank order of use of specific ambulatory services for four of the five groups. People who claimed a hospital as their primary care source had the most unique use patterns over a full range of health care services, characterized by extremely low rates of physician visits and the highest rates of visits to hospital outpatient clinics across three time periods. G-HMO members used health-related services more frequently than did all others. PPO members, at baseline, had lower rates of total and mean hospital days than other source group members except hospital users. People who changed principal source of care during the study period were most likely to report a hospital as their care source initially. Although there is much consistency in hospital and ambulatory use across groups, the persistence of certain use patterns for members of some groups suggests that health care systems can leave an imprint on the health service use of people for whom they provide regular care.