Julia Hecht

Self-Efficacy and Health Behavior Among Older Adults*

Self-efficacy has a well-established, beneficial effect on health behavior and health status in young and middle-aged adults, but little is known about these relationships in older populations. We examined this issue as part of a randomized trial to determine the cost savings and changes in health-related quality of life associated with the provision and reimbursement of a preventive services package to 2,524 Medicare beneficiaries enrolled in Group Health Cooperative of Puget Sound. Baseline self-efficacy data were collected for all participants in five behavioral areas: exercise, dietary fat intake, weight control, alcohol intake, and smoking. Results reveal that efficacy and outcome expectations for these health behaviors are not independent. Correlational and factor analyses indicate two dimensions of efficacy expectations, one consisting of exercise, dietary fat, and weight control, and another consisting of smoking and alcohol consumption. Outcome expectations of the five behaviors form a single dimension. Older adults with high self-efficacy had lower health risk in all behaviors and better health. Regression analyses detected a positive association between socioeconomic status and health-related quality of life (p < .02), but the strength of the association declined (p < .11) after the self-efficacy measures entered the model, indicating that self-efficacy explains part of the association between socioeconomic status and health status. Interventions aimed at improving self-efficacy also may improve health status.

Preventing disability and falls in older adults: a population-based randomized trial

OBJECTIVES Because preventing disability and falls in older adults is a national priority, a randomized controlled trial was conducted to test a multicomponent intervention program. METHODS From a random sample of health maintenance organization (HMO) enrollees 65 years and older, 1559 ambulatory seniors were randomized to one of three groups: a nurse assessment visit and follow-up interventions targeting risk factors for disability and falls (group 1, n = 635); a general health promotion nurse visit (group 2, n = 317); and usual care (group 3, n = 607). Data collection consisted of a baseline and two annual follow-up surveys. RESULTS After 1 year, group 1 subjects reported a significantly lower incidence of declining functional status and a significantly lower incidence of falls than group 3 subjects. Group 2 subjects had intermediate levels of most outcomes. After 2 years of follow-up, the differences narrowed. CONCLUSIONS The results suggest that a modest, one-time prevention program appeared to confer short-term health benefits on ambulatory HMO enrollees, although benefits diminished by the second year of follow-up. The mechanisms by which the intervention may have improved outcomes require further investigation.

Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults

OBJECTIVES: The purpose of this study was to determine whether walking is associated with a reduced risk of cardiovascular disease hospitalization and death in community‐dwelling older men and women.

Has Asthma Medication Use in Children Become More Frequent, More Appropriate, or Both?

Objective. Despite national initiatives to improve asthma medical treatment, the appropriateness of physician prescribing for children with asthma remains unknown. This study measures trends and recent patterns in the pediatric use of medications approved for reversible obstructive airway disease (asthma medications). Design. Population-based longitudinal and cross-sectional analyses. Setting. A nonprofit staff model health maintenance organization located in the Puget Sound area of Washington state. Participants. Children 0 to 17 years of age enrolled continuously during any one of the years from 1984 to 1993 (N = 83 232 in 1993). Primary Outcome Measures. Percent of enrollees filling prescriptions for asthma medications and fill rates by medication class and estimated duration of inhaled antiinflammatory medication use. Results. Between 1984 and 1993, the frequency of asthma medication use increased: the percent of children filling any asthma medication prescription increased from 4.0% to 8.1%, whereas the percent filling an inhaled antiinflammatory inhaler rose from 0.4% to 2.4%. In contrast, the intensity of inhaled antiinflammatory use decreased among users; 37% of users filled more than two inhalers during the year in 1984, and 29% in 1993. In high β-agonist users (filling more than two β-agonist inhalers each quarter per year), the estimated duration of inhaled antiinflammatory use increased slightly from a mean of 4.1 months per year in 1984–1986 to 5.0 months in 1991–1993; estimated duration of use in adolescents 10 to 17 years of age was approximately half that of children 5 to 9 years of age. Conclusions. The proportion of children using asthma medications increased substantially during the study period, but the use of inhaled antiinflammatory medication per patient remained low even for those using large amounts of inhaled β-agonists. These findings suggest that most asthma medications were used by children with mild lower airway symptoms and that inhaled antiinflammatory medication use in children with more severe disease fell short of national guidelines.

Five-year prospective study of the effects of anxiety and depression in patients with coronary artery disease☆

Anxiety and depression have significant and widespread effects on daily function and symptoms of patients with coronary artery disease over a 5-year period. This may partially explain why results of treadmill stress testing and angiography poorly predict the daily functioning of patients with coronary artery disease.

Predicting Hospitalization and Functional Decline in Older Health Plan Enrollees: Are Administrative Data as Accurate as Self-Report?

OBJECTIVE: To compare the predictive accuracy of two validated indices, one that uses self‐reported variables and a second that uses variables derived from administrative data sources, to predict future hospitalization. To compare the predictive accuracy of these same two indices for predicting future functional decline.

Responsiveness of Health Status Measures to Change among Older Adults

Objective: This study examines the ability of commonly used self‐reported health status measures to detect important changes in health (responsiveness) in older adults.

Tracking progress toward national health objectives in the elderly: what do restricted activity days signify?

Restricted activity days is the measure by which the 1990 health objectives for prevention of functional disability in older adults will be evaluated. Yet its significance in older populations is poorly understood. We evaluated its use as an outcome measure for a randomized trial designed to impact upon physical function in elderly HMO enrollees. As predicted, restricted activity days was more correlated with physical disability measures than with other health status measures. Distributional properties and rates of missing data were shortcomings.

Tubal sterilization and risk of subsequent hospital admission for menstrual disorders

OBJECTIVE Our objective was to investigate tubal sterilization and subsequent hospitalization for menstrual disorders. STUDY DESIGN Automated discharge data were used in a population-based cohort study of 7253 women aged 20 to 49 years with tubal sterilization (1968 through 1983) at Group Health Cooperative of Puget Sound. Comparisons were with an age-matched cohort of 25,448 nonsterilized women and a nonmatched cohort of 5283 spouses of men with vasectomies. RESULTS In the sterilization cohort, 282 had hospitalization for menstrual disorders (curettage, n = 191; hysterectomy, n = 66; nonsurgical, n = 25). Risk of hospitalization for menstrual disorders was 2.4 times greater after tubal sterilization (95% confidence interval 2.0 to 2.9). This risk was 6.1 times greater for sterilized women aged 20 to 24 years (95% confidence interval 0.72 to 3.2). Compared with the risk for nonsterilized women whose spouses had a vasectomy, the risk was 1.6 times greater (95% confidence interval 1.3 to 2.1). Hospitalization for menstrual disorders was not more common after unipolar sterilization than after other methods, as might have been expected if the menstrual disorder was related to impaired uteroovarian circulation. CONCLUSIONS Tubal sterilization is associated with a greater risk of hospitalization for menstrual disorders. A biologic association is not supported by these results.

Depression predicts revascularization procedures for 5 years after coronary angiography

Objective Depression has been reported to increase cardiac event rates and functional impairment in patients with coronary disease. This article describes the impact of depression on subsequent healthcare utilization for such patients. Methods One hundred ninety-eight health maintenance organization patients with stable coronary disease were interviewed after elective angiography using a structured psychiatric diagnostic scale. Cardiac events, hospitalizations, procedures, and costs were monitored for the next 5 years through automated data. Subjects were classified at the time of angiography by modified DSM-IV criteria into those with major, minor, and no depression. Results In univariate analyses, the no depression group (N = 136) was most likely to receive coronary artery bypass grafting (CABG) (61% vs. 36% in the major depression group vs. 27% in the minor depression group, p = .001), and the major depression group (N = 25) was most likely to receive percutaneous transluminal coronary angioplasty (PTCA) (44% vs. 14% in the minor depression group vs. 24% in the no depression group). The minor depression group (N = 37) was least likely to be hospitalized for cardiac reasons during follow-up (54% vs. 80% in the major depression group vs. 80% in the no depression group, p = .005). Five-year rates of myocardial infarction and death did not differ significantly between groups. Proportional hazard models showed that those in the depression groups differed in time from catheterization to CABG (&khgr;2(2) = 11.9, p = .003) and time to PCTA (&khgr;2(2) = 7.74, p = .02) after controlling for relevant covariates. Median regression showed that patients with no depression had higher costs during the first year but tended to have lower costs in years 2 through 5 than patients with minor or major depression. Conclusions Depression status at angiography is associated with the need for revascularization and total healthcare costs for the following year.