Joseph J. Sudano

Intermittent Lack of Health Insurance Coverage and Use of Preventive Services

OBJECTIVESnThis study examined the association between intermittent lack of health insurance coverage and use of preventive health services.nnnMETHODSnAnalyses focused on longitudinal data on insurance status and preventive service use among a national sample of US adults who participated in the Health and Retirement Study.nnnRESULTSnFindings showed that, among individuals who obtain insurance coverage after histories of intermittent coverage, relatively long periods may be necessary to reestablish clinically appropriate care patterns. Increasing periods of noncoverage led to successively lower rates of use of most preventive services.nnnCONCLUSIONSnIntermittent lack of insurance coverage-even across a relatively long period-results in less use of preventive services. Studies that examine only current insurance status may underestimate the population at risk from being uninsured.

Loss of health insurance and the risk for a decline in self-reported health and physical functioning.

Background. Millions of Americans are intermittently uninsured. The health consequences of this are not known. Setting. National survey. Participants. Six thousand seventy-two participants in the Health and Retirement Study (HRS) age 51 to 61 years old with private insurance in 1992. Measurements. Loss of insurance coverage between 1992 and 1992 and development of a major decline in overall health or a new physical difficulty between 1994 and 1996. Results. In 1994, 5768 (95.0%) people continued to have private insurance, 229 (3.8%) reported having lost all insurance, and 75 (1.2%) converted to having only public insurance. Over the subsequent 2 years (1994–1996), the risk for a major decline in overall health was 15.6% for those who lost all insurance versus 7.2% for those with continuous private insurance (P <0.001). After adjusting for baseline sociodemographics, health behaviors, and health status, the adjusted relative risk for a major decline in health for those who lost coverage was 1.82 (95% CI, 1.25–2.59) compared with those with continuous private insurance. Those who lost insurance also had a higher risk for developing a new mobility difficulty compared with those with continuous private insurance (28.5% vs. 20.4%, respectively;P = 0.02), but this was not significant in multivariate analysis (adjusted RR, 1.26; 95% CI, 0.90–1.68). Conclusions. Loss of insurance has adverse health consequences even within 2 years after becoming uninsured. Studies of insurance coverage should routinely measure the number of Americans uninsured at any time over the preceding 2 years as a more accurate measure of the population at risk from being uninsured.

Health insurance coverage and the risk of decline in overall health and death among the near elderly, 1992-2002.

Background:Although individuals’ health insurance coverage changes frequently, previous analyses have not accounted for changes in insurance coverage over time. Objective:We sought to determine the independent association between lack of insurance and the risk of a decline in self-reported overall health and death from 1992 to 2002, accounting for changes in self-reported overall health and insurance coverage. Methods:We analyzed data from the Health and Retirement study, a prospective cohort study of a national sample of community-dwelling adults age 51–61 years old at baseline. Major decline in self-reported overall health and mortality was determined at 2-year intervals. Results:People who were uninsured at baseline had a 35% (95% confidence interval [CI] 12–62%) higher risk-adjusted mortality from 1992 to 2002 compared with those with private insurance. However, when we analyzed outcomes over 2-year intervals, individuals who were uninsured at the start of each interval were more likely to have a major decline in their overall health (pooled adjusted relative risk 1.43, 95% CI 1.28–1.63), but they were equally likely to die (pooled adjusted relative risk 0.96, 95% CI 0.73–1.27). Of the 1512 people who were uninsured at baseline, 220 (14.6%) died; of those who died, only 70 (31.8%) were still uninsured at the HRS interview prior to death. Conclusions:Death does not appear to be a short-term consequence of being uninsured. Instead, higher long-term mortality among the uninsured results from erosion in this populations health status over time and the attendant higher mortality associated with this. Most deaths among the uninsured occur after individuals have gained either public or private health insurance.

Health literacy and performance on the Mini-Mental State Examination.

The objectives of the study were to determine the relationship between functional health literacy and performance on the Mini-Mental State Examination (MMSE). New Medicare managed-care enrollees aged 65 years and older, living independently in the community in four US cities (Cleveland, Houston, Tampa, and Fort Lauderdale/Miami), were eligible to participate. In-home interviews were conducted to determine demographics and health status, and interviewers then administered the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the MMSE. We then determined the relationship between functional health literacy and the MMSE, including total scores, subscale scores (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction), and individual items. Functional health literacy was linearly related to the total MMSE score across the entire range of S-TOFHLA scores (R 2 = 0.39, p < 0.001). This relationship between health literacy and MMSE was consistent across all MMSE subscales and individual items. Adjustment for chronic conditions and self-reported overall health did not change the relationship between health literacy and MMSE score. Health literacy was related to MMSE performance even for subscales of the MMSE that were not postulated to be directly dependent on reading ability or education (e.g. delayed recall). These results suggest that the lower MMSE scores for patients with low health literacy are only partly due to test bias and also result from true differences in cognitive functioning. Adjusting MMSE scores for an individuals functional health literacy may be inappropriate because it may mask true differences in cognitive functioning.

Antihypertensive Medication Use in Hispanic Adults: A Comparison With Black Adults and White Adults

Background.Variations in awareness, treatment, and control of hypertension among different racial/ethnic groups have been widely reported. It is unclear whether these differences are explained fully by differences in socioeconomic status, insurance coverage, health status, and health behaviors, or whether these differences indicate that racial/ethnic subgroups have unique barriers to hypertension control. Objectives.Determine whether there are significant differences between racial/ethnic groups in medication use for hypertension after adjusting for potentially confounding variables. Research Design. Cross-sectional analysis of the 1992 Health and Retirement Study. Subjects.2450 non-Hispanic white, 939 non-Hispanic black, and 345 Hispanic participants, ages 51 to 61, reporting a history of hypertension. Measures.Self-reported current antihypertensive medication use. We used logistic regression to adjust for demographics, socioeconomic status, health status, insurance, and health risk behaviors. Results.63.6% of white adults, 72.6% of black adults, and 52.5% of Hispanic adults reported current medication use to control hypertension (P <0.001 across all three groups). In stratified analysis, the lower rate of use for Hispanic adults was consistent regardless of gender, insurance coverage, or health status. After controlling for all variables, the adjusted prevalence for Hispanic adults was 50.8% and 73.3% for black adults. Conclusions.The differences in antihypertensive medication use between white adults, black adults, and Hispanic adults, particularly the markedly lower rates among Hispanic adults, are not explained by differences in demographics, socioeconomic status, health insurance coverage, health status, or health risk behaviors. Alternative explanations for these results and areas for future research and intervention are explored.

Changes in health for the uninsured after reaching age-eligibility for medicare

BACKGROUND: Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance.OBJECTIVE: To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare.DESIGN: Prospective cohort study.PARTICIPANTS: Participants (N=3.419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview.MEASUREMENTS: We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t−2 to t0) and the following 2 years (t0 to t2).RESULTS: Between the interview before age 65 (t−2) and the first interview after reaching age 65 (t0), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t0 to t2), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare.CONCLUSIONS: Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.

Measuring disparities: bias in the Short Form-36v2 among Spanish-speaking medical patients.

BackgroundMany national surveys have found substantial differences in self-reported overall health between Spanish-speaking Hispanics and other racial/ethnic groups. However, because cultural and language differences may create measurement bias, it is unclear whether observed differences in self-reported overall health reflect true differences in health. ObjectivesThis study uses a cross-sectional survey to investigate psychometric properties of the Short Form-36v2 for subjects across 4 racial/ethnic and language groups. Multigroup latent variable modeling was used to test increasingly stringent criteria for measurement equivalence. SubjectsOur sample (N=1281) included 383 non-Hispanic whites, 368 non-Hispanic blacks, 206 Hispanics interviewed in English, and 324 Hispanics interviewed in Spanish recruited from outpatient medical clinics in 2 large urban areas. ResultsWe found weak factorial invariance across the 4 groups. However, there was no evidence for strong factorial invariance. The overall fit of the model was substantially worse (change in Comparative Fit Index >0.02, root mean square error of approximation change >0.003) after requiring equal intercepts across all groups. Further comparisons established that the equality constraints on the intercepts for Spanish-speaking Hispanics were responsible for the decrement to model fit. ConclusionsObserved differences between SF-36v2 scores for Spanish-speaking Hispanics are systematically biased relative to the other 3 groups. The lack of strong invariance suggests the need for caution when comparing SF-36v2 mean scores of Spanish-speaking Hispanics with those of other groups. However, measurement equivalence testing for this study supports correlational or multivariate latent variable analyses of SF-36v2 responses across all the 4 subgroups, as these analyses require only weak factorial invariance.

Patients With Worse Mental Health Report More Physical Limitations After Adjustment for Physical Performance

Objective: To determine whether mental health scores are associated with self-reported physical limitations after adjustment for physical performance. Patient-reported physical limitations are widely used to assess health status or the impact of disease. However, patients’ mental health may influence their reports of their physical limitations. Methods: Mental health and physical limitations were measured using the SF-36v2 mental health and physical functioning subscales in a cross-sectional study of 1024 participants. Physical performance was measured using tests of strength, endurance, dexterity, and flexibility. Multivariable linear regression was performed to examine the relationship between self-reported mental health and physical limitations adjusting for age, gender, race/ethnicity, education, body mass index, and measured physical performance. Results: The score distributions for mental health and physical functioning were similar to that of the United States population in this age range. In unadjusted analyses, every 10-point decline in mental health scores was associated with a 4.8-point decline in physical functioning scores (95% Confidence Interval (CI) = −4.2 to −5.3; p < .001). After adjusting for covariables including measured physical performance, every 10-point decline in mental health scores was associated with a 3.0-point decline in physical functioning scores (95% CI = −2.5 to −3.6; p < .001). Conclusions: People with poor mental health scores seem to report more physical limitations than would be expected based on physical performance. When comparing self-reported physical limitations between groups, it is important to consider differences in mental health. BMI = body mass index; CI = Confidence Interval; SD = standard deviation; SF-36v2 = SF-36v2 Health Survey.

Neighborhood racial residential segregation and changes in health or death among older adults

We assessed relationships between neighborhood racial residential segregation (RRS), individual-level health declines and mortality using Health and Retirement Study data. We calculated the census-tract level Location Quotient for Racial Residential Segregation (LQRRS), and estimated adjusted relative risks (ARR) of LQRRS for declines in self-reported health or death 1992-2000, controlling for individual-level characteristics. Of 6653 adults, 3333 lived in minimal, 2242 in low, 562 in moderate, and 516 in high LQRRS tracts in 1992. Major decline/death rates were: 18.6%, 25.2%, 33.8% and 30.4% in minimal, low, moderate and high tracts, respectively. Adjusting for demographic characteristics, residence in low, moderate and high LQRRS census tracts was associated with greater likelihood of major decline/death compared to minimal LQRRS. Controlling for all variables, only moderate LQRRS predicted major decline/death, ARR=1.31 (95% CI 1.07, 1.59; p<.05).

A multimethod investigation including direct observation of 3751 patient visits to 120 dental offices.

This report defines verbal interactions between practitioners and patients as core activities of dental practice. Trained teams spent four days in 120 Ohio dental practices observing 3751 patient encounters with dentists and hygienists. Direct observation of practice characteristics, procedures performed, and how procedure and nonprocedure time was utilized during patient visits was recorded using a modified Davis Observation Code that classified patient contact time into 24 behavioral categories. Dentist, hygienist, and patient characteristics were gathered by questionnaire. The most common nonprocedure behaviors observed for dentists were chatting, evaluation feedback, history taking, and answering patient questions. Hygienists added preventive counseling. We distinguish between preventive procedures and counseling in actual dental offices that are members of a practice-based research network. Almost a third of the dentist’s and half of the hygienist’s patient contact time is utilized for nonprocedure behaviors during patient encounters. These interactions may be linked to patient and practitioner satisfaction and effectiveness of self-care instruction.