James N. Laditka

Access to health care and hospitalization for ambulatory care sensitive conditions.

Hospitalization for Ambulatory Care Sensitive Conditions (ACSH) is an accepted indicator of access to health care and avoidable morbidity. Accessible care of reasonable quality should reduce ACSH. Little research has examined the indicator’s external validity. We calculated standardized ACSH rates for 32 areas of Victoria, Australia (population 4.4 million). A representative survey measured access, disease prevalence, propensity to seek care, disease burden, social determinants of health services use, and behavioral risk factors. Regression analyses compared self-rated access with ACSH rates. Independent of prevalence, propensity to seek care, disease burden, and physician supply, better access was associated with lower ACSH rates. Results provide support for the ACSH indicator. When rural residence was considered, the covariate measuring access was not significant. However, rural residence also may contribute importantly to access. Results suggest both the complexity of the meaning of access and the desirability of further research to validate the ACSH indicator.

Effect of Exercise on Cognitive Performance in Community‐Dwelling Older Adults: Review of Intervention Trials and Recommendations for Public Health Practice and Research

There is evidence from observational studies that increasing physical activity may reduce the risk of cognitive decline in older adults. Exercise intervention trials have found conflicting results. A systematic review of physical activity and exercise intervention trials on cognition in older adults was conducted. Six scientific databases and reference lists of previous reviews were searched. Thirty studies were eligible for inclusion. Articles were grouped into intervention–outcome pairings. Interventions were grouped as cardiorespiratory, strength, and multicomponent exercises. Cognitive outcomes were general cognition, executive function, memory, reaction time, attention, cognitive processing, visuospatial, and language. An eight‐member multidisciplinary panel rated the quality and effectiveness of each pairing. Although there were some positive studies, the panel did not find sufficient evidence that physical activity or exercise improved cognition in older adults. Future research should report exercise adherence, use longer study durations, and determine the clinical relevance of measures used.

Health care access in rural areas: evidence that hospitalization for ambulatory care-sensitive conditions in the United States may increase with the level of rurality.

UNLABELLED We examined whether levels of rurality are associated with hospitalization for ambulatory care-sensitive conditions (ACSH) in eight states of the United States. ACSH is an indicator of access to reasonably effective primary health care. ACSH for children did not vary systematically with rurality. Compared to the most urban counties, the adjusted rate in the most rural was 90% greater for ages 18-64 and 45% greater for ages 65+ (both p<.001). Adjusted adult rates generally increased with the level of rurality. CONCLUSIONS Increasing levels of rurality may be positively associated with ACSH, suggesting rural disparities in access to primary health care.

Race, Ethnicity and Hospitalization for Six Chronic Ambulatory Care Sensitive Conditions in the USA

Objectives. Hospitalization for ambulatory care sensitive conditions, also called preventable hospitalization, has been widely accepted as an indicator of access to primary health care, and of the overall success of the primary health care system. Our objective is to examine associations between preventable hospitalization and race and ethnicity in the USA, separately for six major chronic diseases: angina, asthma, chronic obstructive pulmonary disease, congestive heart failure, diabetes and hypertension. Design. We used the 1997 Nationwide Inpatient Sample, 1997 Current Population Survey and 1997 National Health Interview Survey, to calculate rates of preventable hospitalization, and the prevalence of ambulatory care sensitive conditions, for African Americans, Hispanics and non-Hispanic whites. Rates were calculated for ages 19–64, and 65 and over. Preventable hospitalization rates that accounted for underlying hospitalization patterns were also estimated. A final set of estimations adjusted the preventable hospitalization rates for disease prevalence. Results. Preventable hospitalization rates were notably higher for African Americans and Hispanics than for non-Hispanic whites for almost all of the conditions, both for women and men and for both age groups. Rates adjusted for underlying hospitalization patterns showed a similar pattern. Adjusted for disease prevalence, rate differences remained notably large for both women and men, and for both age groups. Particularly great, for both African Americans and Hispanics of both sexes, are the risks of preventable hospitalization for asthma, diabetes and hypertension. Conclusion. African Americans and Hispanics have high preventable hospitalization rates for major chronic conditions, even after disease prevalence and underlying hospital utilization patterns are considered. These rates are particularly high for asthma, diabetes and hypertension, which are amenable to prevention and management interventions. Our results suggest a need to improve access to quality primary health care for African Americans and Hispanics in the USA, and for enhanced support of targeted prevention efforts.

Prospective study of cardiorespiratory fitness and depressive symptoms in women and men.

Most studies of the relationship between cardiorespiratory fitness (CRF) and depression have been limited to cross-sectional designs. The objective of this study was to follow individuals over time to examine whether those with higher levels of CRF have lower risk of developing depressive symptoms. Participants were 11,258 men and 3085 women enrolled in the Aerobics Center Longitudinal Study in Dallas, TX. All participants completed a maximal treadmill exercise test at baseline (1970-1995) and a follow-up health survey in 1990 and/or 1995. Individuals with a history of a mental disorder, cardiovascular disease, or cancer were excluded. CRF was quantified by exercise test duration, and categorized into age and sex-stratified groups as low (lowest 20%), moderate (middle 40%), or high (upper 40%). Depressive symptoms were assessed using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Those who scored 16 or more on the CES-D were considered to have depressive symptoms. After an average of 12 years of follow-up, 282 women and 740 men reported depressive symptoms. After adjusting for age, baseline examination year, and survey response year, the odds of reporting depressive symptoms were 31% lower for men with moderate CRF (odds ratio, OR 0.69; 95% confidence interval, CI 0.56-0.85) and 51% lower for men with high CRF (OR 0.49, CI 0.39-0.60), compared to men with low CRF. Corresponding ORs for women were 0.56 (CI 0.40-0.80) and 0.46 (CI 0.32-0.65). Higher CRF is associated with lower risk of incident depressive symptoms independent of other clinical risk predictors.

Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states

BackgroundFederally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions.MethodsWe conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties). Counties were categorized by facility availability: CHC(s) only, RHC(s) only, both (CHC and RHC), and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individuals county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios.ResultsAmong working age adults, rate ratio (RR) comparing ACS hospitalization rates for CHC-only counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78–0.95). Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81–0.87); for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84–0.92). No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations.ConclusionOur results suggest that CHCs and RHCs may play a useful role in providing access to primary health care. Their presence in a county may help to limit the countys rate of hospitalization for ACS diagnoses, particularly among older people.

Nonoccupational physical activity by degree of urbanization and U.S. geographic region

PURPOSE To estimate levels of nonoccupational leisure-time physical activity (LTPA) by degree of urbanization and geographic region of the United States. METHODS Participants were respondents to the Behavioral Risk Factor Surveillance System (BRFSS) in 2001 (N = 137,359). Moderate- and vigorous-intensity LTPA was categorized as meeting recommended levels, insufficient, or inactive. The U.S. Department of Agriculture rural-urban continuum codes were used to describe degrees of urbanization (metro, large urban, small urban, and rural). Geographic regions were defined by the U.S. Bureau of the Census (Northeast, Midwest, South, and West). Prevalence estimates were calculated using sample weights to account for the design of the BRFSS. Multivariate logistic regression analyses examined regional differences in the odds of physical inactivity (physically inactive vs insufficient or meets) by degree of urbanization after adjustment for sex, age, race, BMI, education, and occupational physical activity. RESULTS Large urban areas (49.0%) and the western United States (49.0%) had the highest prevalence of recommended levels of LTPA. Rural areas (24.1%) and the southern United States (17.4%) had the highest prevalence of inactivity. Adults living in the four urbanization categories of the midwestern (metro (OR = 1.47, 95% CI = 1.31, 1.65), large urban (OR = 1.83, 95% CI = 1.51, 2.23), small urban (OR = 1.99, 95% CI = 1.65, 2.40), and rural (OR = 2.59, 95% CI = 1.35, 4.97)); and southern (metro (OR = 1.70, 95% CI = 1.53, 1.88), large urban (OR = 2.04, 95% CI = 1.72, 2.41), small urban (OR = 2.32, 95% CI = 2.02, 2.67), and rural (OR = 5.49, 95% CI = 2.82, 10.68)) U.S. regions were more likely to be inactive than adults living in similar areas of the western United States. Adults in northeast metro and large urban areas (OR = 1.62, 95% CI = 1.45, 1.81; and OR = 1.37, 95% CI = 1.08, 1.74, respectively) were more likely to be inactive than those residing in western metro and large urban areas. CONCLUSION The prevalence of physical inactivity varies by degree of urbanization and geographic region of the United States.

Cardiorespiratory Fitness as a Predictor of Fatal and Nonfatal Stroke in Asymptomatic Women and Men

Background and Purpose— Prospective data on the association between cardiorespiratory fitness (CRF) and stroke are largely limited to studies in men or do not separately examine risks for fatal and nonfatal stroke. This study examined the association between CRF and fatal and nonfatal stroke in a large cohort of asymptomatic women and men. Methods— A total of 46 405 men and 15 282 women without known myocardial infarction or stroke at baseline completed a maximal treadmill exercise test between 1970 and 2001. CRF was grouped as quartiles of the sex-specific distribution of maximal metabolic equivalents achieved. Mortality follow-up was through December 31, 2003, using the National Death Index. Nonfatal stroke, defined as physician-diagnosed stroke, was ascertained from surveys during 1982 to 2004. Cox regression models quantified the pattern and magnitude of association between CRF and stroke. Results— There were 692 strokes during 813 944 man-years of exposure and 171 strokes during 248 902 woman-years of exposure. Significant inverse associations between CRF and age-adjusted fatal, nonfatal, and total stroke rates were observed for women and men (Ptrend≤0.05 each). After adjusting for several cardiovascular disease risk factors, the inverse association between CRF and each stroke outcome remained significant (Ptrend<0.05 each) in men. In women, the multivariable-adjusted relationship between CRF and nonfatal and total stroke remained significant (Ptrend≤0.01 each), but not between CRF and fatal stroke (Ptrend=0.18). A CRF threshold of 7 to 8 maximal metabolic equivalents was associated with a substantially reduced rate of total stroke in both men and women. Conclusions— These findings suggest that CRF is an independent determinant of stroke incidence in initially asymptomatic and cardiovascular disease-free adults, and the strength and pattern of the association is similar for men and women.

Adult Children Helping Older Parents: Variations in Likelihood and Hours by Gender, Race, and Family Role

Using the 1993 Panel Study of Income Dynamics, the authors examine help given to older parents in typical American families. Daughters and sons not in couples were more likely to help than those in couples, and gave substantially more hours. In couples, daughters were less likely to help than sons, but they helped for considerably more hours. Black daughters helped at least as commonly as White daughters, and did so for substantially more hours than either White daughters or sons of either race. Results suggest that Black sons may help less commonly than White sons. Black sons who help, however, do so for at least as many hours as White sons. Findings suggest that changes in the Black American family have not produced the notable intergenerational relations breakdown anticipated by some researchers. Results also illuminate the important role of sons in family help and suggest that changing marriage patterns may not reduce help to older parents.

Estimated Functional Capacity Predicts Mortality in Older Adults

OBJECTIVES: To examine associations between functional capacity estimated from cardiorespiratory fitness (CRF) and mortality risks in adults aged 60 and older.