Jennifer Perloff

Homelessness in female-headed families : Childhood and adult risk and protective factors

OBJECTIVES To identify risk and protective factors for family homelessness, a case-control study of homeless and low-income, never-homeless families, all female-headed, was conducted. METHODS Homeless mothers (n = 220) were enrolled from family shelters in Worcester, Mass. Low-income housed mothers receiving welfare (n = 216) formed the comparison group. The women completed an interview covering socioeconomic, social support, victimization, mental health, substance use, and health domains. RESULTS Childhood predictors of family homelessness included foster care placement and respondents mothers use of drugs. Independent risk factors in adulthood included minority status, recent move to Worcester, recent eviction, interpersonal conflict, frequent alcohol or heroin use, and recent hospitalization for a mental health problem. Protective factors included being a primary tenant, receiving cash assistance or a housing subsidy, graduating from high school, and having a larger social network. CONCLUSIONS Factors that compromise an individuals economic and social resources are associated with greater risk of losing ones home.

The Sonya Slifka Longitudinal Multiple Sclerosis Study: methods and sample characteristics:

The Sonya Slifka Longitudinal Multiple Sclerosis Study follows a population-based cohort of approximately 2000 people with multiple sclerosis (MS) to study demographic and clinical characteristics, course of illness, utilization and cost of health services, provider characteristics, use of MS specialists and disease modifying agents, and neurologic, economic and psychosocial outcomes. This report describes the study methodology, presents baseline demographic and clinical data, and evaluates the representativeness of the sample. A stratified random sample of persons with established and recently-diagnosed MS selected from the National Multiple Sclerosis Society (NMSS) mailing lists was supplemented with recently-diagnosed patients recruited through systematic nationwide outreach. Baseline data were collected by computer-assisted telephone interviews derived from standardized instruments; data collection continues at six-month intervals. The cohort was comparable to population-based and clinical samples with respect to demographics, course, relapse rate, symptoms, and severity of disability. Almost two-thirds of the cohort needed help with activities of daily living, three-quarters were limited in work or other activities, and half had emotional problems that compromised quality of life. The Slifka Study cohort is broadly representative of the MS population and the database can be used to address questions not answered by natural history studies, clinical databases, or population-based surveys.

Multiply homeless families: The insidious impact of violence

Abstract Little is known about the dynamics of homelessness among families that have been homeless more than once. Using longitudinal data from the Worcester Family Research Project, this article describes the duration of family homelessness, compares the characteristics of mothers who had been homeless only once with those who had been homeless multiple times, and identifies factors that contribute to repeated episodes of family homelessness. Certain factors such as interpersonal violence, especially during childhood, were highly associated with residential instability. At baseline, multiply homeless mothers had higher rates of childhood sexual abuse and stranger violence than their first‐time homeless counterparts. Sexual molestation during childhood was also an important predictor of recidivism. When the sample was followed prospectively, first‐time homeless mothers who experienced partner violence after being rehoused were more than three times as likely to experience a second homeless episode. Although homelessness is primarily a structural problem, national housing policy for poor people must be combined with supportive programs.

Access to and utilization of neurologists by people with multiple sclerosis

Objective: This study examined access to and use of neurologists among a broad, national sample of people with multiple sclerosis (MS); identified demographic, economic, and clinical factors associated with access and use; and examined differences in treatment and management of MS. Methods: We used computer-assisted telephone interviews to collect data from 2,156 people with MS on demographics, disease characteristics, and use of neurologists, other specialists, and disease-modifying agents (DMAs). We used χ2 tests and logistic regressions to compare patients of neurologists and other providers and identify predictor variables and treatment factors associated with seeing neurologists. Results: For their usual MS care, 72.2% of participants saw a neurologist. The probability of seeing a neurologist was significantly lower for people who lacked health insurance, were poor, lived in rural areas, or were African American; had been ill for more than 15 years; had difficulty walking but did not use an assistive device; or required a wheelchair/scooter or were confined to bed. People who reported one to two relapses in the preceding year and women were significantly more likely to see neurologists. Patients of neurologists were significantly more likely to take a DMA, attend an outpatient rehabilitation program, or see an occupational therapist, urologist, or physical therapist. Conclusions: People with multiple sclerosis who see neurologists are more likely than people who see other providers to receive treatment with disease-modifying agents and see rehabilitation specialists and urologists. While some people may choose other providers, economic, insurance, racial, and geographic factors appear to limit access to neurologists. GLOSSARY: AMA = American Medical Association; DMA = disease-modifying agent; MEPS = Medical Expenditure Panel Survey; MS = multiple sclerosis; NHIS = National Health Interview Survey; NMSS = National Multiple Sclerosis Society.

Role of Kin and Nonkin Support in the Mental Health of Low‐Income Women

Data from the Worcester Family Research Project were analyzed to determine whether social support processes are altered by poverty and whether kin and nonkin support are differentially related to mental health in low-income mothers. The authors found that conflict with family and friends predicted adverse mental health and more strongly predicted these outcomes than emotional and instrumental support. Moreover, sibling conflict was a stronger predictor of mental health than parent conflict. Finally, only instrumental support from professionals predicted mental health.

Using Medicare data to assess nurse practitioner–provided care

BACKGROUND To mitigate shortages of primary care physicians and ensure access to health care services for a growing number of Medicare beneficiaries, some policy makers have recommended expanding the supply and roles of nurse practitioners (NPs). Little is known about the number of NPs billing Medicare or their practice patterns. PURPOSE This study examines the geographic distribution and county characteristics of NPs billing Medicare, compares the types and quantities of primary care services provided to Medicare beneficiaries by NPs and primary care physicians, and analyzes the characteristics of beneficiaries receiving primary care from each type of clinician. METHODS We performed a cross-sectional analysis of 2008 Medicare administrative data from 959,848 aged and/or disabled beneficiaries continuously enrolled in fee-for-service Medicare during the study period. Outcome measures included geographic distribution of NPs measured by the rate of NPs per 1,000 Medicare beneficiaries by state, average utilization, and patient characteristics. DISCUSSION States with the highest rate of NPs billing were rural. Over 80% of the payments received by both NPs and primary care physicians were for evaluation and management services. Beneficiaries assigned to an NP were more likely to be female, to be dually eligible for Medicare and Medicaid, and to have qualified for Medicare because of a disability. NPs with assigned beneficiaries were significantly more likely than similar primary care physicians to practice in federally designated primary care shortage areas. CONCLUSIONS Approximately 45,000 NPs were providing services to beneficiaries and billing under their own provider numbers in 2008. Aspects of NP practice patterns were different from primary care physicians, and NPs appeared more likely to provide services to disadvantaged Medicare beneficiaries.

Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity: Health Reform and the Primary Care Workforce.

Background:Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians—particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. Objective:We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. Research Design:An observational study. Subjects:2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. Measures:The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. Results:We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. Conclusions:Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.

Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians

OBJECTIVE This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs). DATA SOURCE Medicare Part A (inpatient) and Part B (office visit) claims for 2009-2010. STUDY DESIGN Retrospective cohort design using propensity score weighted regression. DATA EXTRACTION METHODS Beneficiaries cared for by a random sample of NPs and primary care physicians. PRINCIPAL FINDINGS After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were

Association of military deployment of a parent or spouse and changes in dependent use of health care services.

207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well. CONCLUSIONS This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.

The plight of extremely poor Puerto Rican and Non-Hispanic White single mothers

Background:U.S. Armed Forces members and spouses report increased stress associated with combat deployment. It is unknown, however, whether these deployment stressors lead to increased dependent medication use and health care utilization. Objective:To determine whether the deployment of Army active duty members (sponsors) is associated with changes in dependent health care utilization. Design:A quasi-experimental, pre-post study of health care patterns of more than 55,000 nonpregnant spouses and 137,000 children of deployed sponsors and a comparison group of dependents. Measures:Changes in dependent total utilization in the military health system, and separately in military-provided and purchased care services in the year following the sponsors’ deployment month for office visit services (generalist, specialist); emergency department visits; institutional stays; psychotropic medication (any, antidepressant, antianxiety, antistimulant classes). Results:Sponsor deployment was associated with net increased use of specialist office visits (relative percent change 4.2% spouses; 8.8% children), antidepressants (6.7% spouses; 17.2% children), and antianxiety medications (14.2% spouses; 10.0% children; P<0.01) adjusting for group differences. Deployment was consistently associated with increased use of purchased care services, partially, or fully offset by decreased use of military treatment facilities. Conclusions:These results suggest that emotional or behavioral issues are contributing to increased specialist visits and reliance on medications during sponsors’ deployments. A shift to receipt of services from civilian settings raises questions about coordination of care when families temporarily relocate, family preferences, and military provider capacity during deployment phases. Findings have important implications for the military health system and community providers who serve military families, especially those with children.