Konrad Dobbertin

Disparities in Health Care Access and Receipt of Preventive Services by Disability Type: Analysis of the Medical Expenditure Panel Survey

OBJECTIVE To examine differences in access to health care and receipt of clinical preventive services by type of disability among working-age adults with disabilities. DATA SOURCE Secondary analysis of Medical Expenditure Panel Survey (MEPS) data from 2002 to 2008. STUDY DESIGN We conducted cross-sectional logistic regression analyses comparing people with different types of disabilities on health insurance status and type; presence of a usual source of health care; delayed or forgone care; and receipt of dental checkups and cancer screening. DATA COLLECTION We pooled annualized MEPS data files across years. Our analytic sample consisted of adults (18-64 years) with physical, sensory, or cognitive disabilities and nonmissing data for all variables of interest. PRINCIPAL FINDINGS Individuals with hearing impairment had better health care access and receipt than people with other disability types. People with multiple types of limitations were especially likely to have health care access problems and unmet health care needs. CONCLUSIONS There are differences in health care access and receipt of preventive care depending on what type of disability people have. More in-depth research is needed to identify specific causes of these disparities and assess interventions to address health care barriers for particular disability groups.

Health outcome disparities among subgroups of people with disabilities: A scoping review

BACKGROUND A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences. OBJECTIVES To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities. METHODS We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article. RESULTS For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender. CONCLUSIONS There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

The relationship between vehicle roof crush and head, neck and spine injury in rollover crashes

BACKGROUND It is well established that rollover crashes are associated with a higher risk of serious injury and death than other types of crashes. Some of the most serious injuries that can result from a rollover crash are those to the head, neck and spine. The mechanism of injury to these body parts in a rollover is a matter of dispute in the literature. Some authors have concluded that the magnitude of vehicle roof deformation or vertical roof crush resulting from a rollover crash is not causally associated with head and neck injury severity, while others offer support for a causal association between roof crush and the degree of injury. A better understanding of the cause of serious injuries resulting from rollover crashes is important for improving injury prevention. METHODS This study utilized data from the National Automotive Sampling System--Crashworthiness Data System (NASS-CDS) for the years 1997 through 2007. Both cross-sectional and matched case-control designs along with a new composite injury metric termed the Head, Neck and Spine New Injury Severity Score (HNS-NISS) were used to analyze these data. RESULTS The cross-sectional analysis demonstrated a 64% (95% CI: 26-114%) increase in the odds of a life-threatening injury as estimated by the HNS-NISS with every 10 cm of increased roof crush. The results of the matched case-control analysis demonstrated a 44% (95% CI: 8-91%) increase in the odds of sustaining any injury to the head, neck or spine with every 10 cm increase in roof crush. CONCLUSION These results lend statistical support to a causal association between roof crush and head, neck and spine injury severity. Though they do not constitute definitive proof, they do contradict previously published theories suggesting that roof deformation is unrelated to such injuries.

Serious head and neck injury as a predictor of occupant position in fatal rollover crashes

Serious head and neck injuries are a common finding in fatalities associated with rollover crashes. In some fatal rollover crashes, particularly when ejection occurs, the determination of which occupant was driving at the time of the crash may be uncertain. In the present investigation, we describe the analysis of rollover crash data from the National Automotive Sampling System-Crashworthiness Data System for the years 1997 through 2007 in which we examined the relationship between a serious head and neck injury in an occupant and a specified degree of roof deformation at the occupants seating position. We found 960 occupants who qualified for the analysis, with 142 deaths among the subjects. Using a ranked composite head and neck injury score (the HNISS) we found a strong relationship between HNISS and the degree of roof crush. As a result of the analysis, we arrived at a predictive model, in which each additional unit increase in HNISS equated to an increased odds of roof crush as follows: for ≥8 cm of roof crush compared with <8 cm by 4%, for ≥15 cm of roof crush compared to <8 cm by 6% and for ≥30 cm of roof crush compared to <8 cm by 11%. We describe two hypothetical scenarios in which the model could be applied to the real world investigation of occupant position in a rollover crash-related fatality.

Disparities in receipt of breast and cervical cancer screening for rural women age 18 to 64 with disabilities.

BACKGROUND Previous research has found breast and cervical cancer screening disparities between women with and without disabilities, and between women living in rural versus urban areas. Living in a rural area may add to the barriers women with disabilities experience when attempting to obtain screening for breast and cervical cancer. The purpose of this study was to examine the combination of disability status and rurality in association with receipt of breast and cervical cancer screening among women age 18 to 64 in the United States. METHODS We conducted cross-sectional analyses of data from the Medical Expenditure Panel Survey, using pooled annual data files from 2002 through 2008. We compared recent receipt of breast and cervical cancer screening among four groups: 1) urban women without disabilities, 2) urban women with disabilities, 3) rural women without disabilities, and 4) rural women with disabilities. FINDINGS Overall, women with disabilities were less likely to be up to date with mammograms and Pap tests compared with women with no disabilities. Similarly, women in rural areas were less likely to have received breast or cervical cancer screening within recommended timeframes. Women who both had a disability and lived in a rural area were the least likely to be current with screening. CONCLUSIONS Our findings suggest that living in rural regions compounds disparities in receipt of cancer screening among women with disabilities. Increased attention is needed to improve receipt of cancer screening among rural women with disabilities.

Subgroup differences in having a usual source of health care among working-age adults with and without disabilities

BACKGROUND Having a usual source of health care is positively associated with regular health maintenance visits and receipt of preventive services. People with disabilities are, overall, more likely than those without disabilities to have a usual source of care (USC). However, the population of people with disabilities is quite heterogenous, and some segments of the population may have less access to a USC than others. OBJECTIVE To determine whether there are significant subgroup differences in having a USC within the U.S. population of working-age adults with disabilities, and to compare adults with and without disabilities while controlling for other subgroup differences. METHODS We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We performed both bivariate and multivariate logistic regression analyses to examine the relationship of sociodemographic and disability subgroup variables with having a USC. RESULTS Within the disability population, individuals who were younger; male; Black, Hispanic, or other (non-White) race; less educated; of lower income; or uninsured for part or all of the year were significantly less likely to have a USC. These differences mirrored those among adults without disabilities. When controlling for these differences, people with physical, hearing, or multiple disabilities had greater odds of having a USC than people without disabilities, but those with vision or cognitive limitations did not differ significantly from the non-disabled referent group. CONCLUSIONS Disparities among people with and without disabilities are similar, underscoring the need for attention to disparities within the disability population.

Usual source of care and unmet health care needs interaction of disability with race and ethnicity

Background:Having a usual source of care (USC) and having unmet health care needs have been found to vary in relation to sociodemographic differences in the US population, including race, ethnicity, and disability status. People in underserved racial and ethnic groups who also have a disability may experience a complex mix of health care advantages and disparities. However, little is known about this intersection. Objective:To determine how disability status, combined with membership in an underserved racial or ethnic group, is associated with having a USC and unmet health care needs. Methods:We conducted multivariate regression analyses of 2002–2010 data from the Medical Expenditure Panel Survey, focused on working age adults (18–64 y). Results:Although most racial and ethnic groups were less likely to have a USC than non-Hispanic whites, people with disabilities were more likely to have a USC; Hispanics with basic activity limitations were the only disability group with elevated odds of lacking a USC. Conversely, disability was strongly associated with unmet health care needs, but we did not find inflated impacts of both having a disability and belonging to an underserved racial or ethnic group. Conclusions:We found limited evidence of interaction or additive effects of disability and race/ethnicity but did confirm separate disparities for each. Ongoing research is needed to track both disability-related and racial/ethnic disparities, to determine whether increased insurance coverage, provider training, care coordination, and other efforts under the Affordable Care Act lead to reductions in disparities.

Rural disparities in receipt of colorectal cancer screening among adults ages 50–64 with disabilities

BACKGROUND Colorectal cancer is the third leading cause of cancer deaths in the United States. Early detection can reduce mortality; however, only 59% of U.S. adults age 50 and over meet recommended colorectal cancer screening guidelines. Studies in the general population have observed that rural residents are less likely to have received colorectal cancer screening than residents of urban areas. OBJECTIVE To determine whether urban/rural disparities in colorectal cancer screening exist among people with disabilities, similar to the disparities found in the general population. METHODS We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We conducted logistic regression analyses to examine the relationship between urban/rural residence and ever having received screening for colorectal cancer (via colonoscopy, sigmoidoscopy, or fecal occult blood test). RESULTS Among U.S. adults ages 50-64 with disabilities, those living in rural areas were significantly less likely to have ever received any type of screening for colorectal cancer. The urban/rural difference was statistically significant regardless of whether or not we controlled for demographic, socioeconomic, health, and health care access variables. CONCLUSIONS Disparity in screening for colorectal cancer places rural residents with disabilities at greater risk for late stage diagnosis and mortality relative to people with disabilities in urban areas. Thus, there is a need for strategies to improve screening among people with disabilities in rural areas.

Disparities in dental care associated with disability and race and ethnicity

BACKGROUND Both racial and ethnic and disability-related disparities in dental care exist, yet little is known about the cumulative effect of these 2 characteristics. The purpose of this study was to determine how the combination of disability and race and ethnicity is associated with dental examinations, delays in receiving needed care, and inability to obtain needed care among noninstitutionalized working-age adults in the United States. METHODS The authors conducted cross-sectional analyses of Medical Expenditure Panel Survey data pooled across the years 2002 to 2012, yielding a sample of 208,548. Multivariable logistic regression analyses were used to examine the association of disability (including physical, sensory, and cognitive limitations) and race and ethnicity with each of the dependent variables. RESULTS Compared with non-Hispanic whites, other racial and ethnic groups were less likely to receive annual dental examinations. There were significant disparities for people with disabilities in receipt of examinations, delays in obtaining needed care, and being unable to obtain needed care. The combination of disability status and membership in an underserved racial or ethnic group was associated with a greater magnitude of disparity in all 3 areas, especially for American Indian, Alaska Native, and multiracial people with disabilities. CONCLUSIONS Community-dwelling adults with disabilities in underserved racial and ethnic groups have higher levels of delayed and unmet needs for dental care and lower receipt of routine dental examinations. PRACTICAL IMPLICATIONS As the United States population ages and grows more diverse, the population of people with disabilities in underserved racial and ethnic groups will expand. Dentists need to be aware of, and be prepared to address, the needs of these people.

Food Insecurity, Hunger, and Obesity Among Informal Caregivers

Introduction Increasing numbers of US residents rely on informal caregiving from friends and family members. Caregiving can have substantial health and financial impacts on caregivers. This study addressed whether those impacts include adverse nutritional states. Specifically, we examined household food insecurity, individual hunger, and obesity among caregivers compared with noncaregivers. Methods We analyzed 2012 Behavioral Risk Factor Surveillance System data from Oregon. The Caregiving Module was administered to a random subset of 2,872 respondents. Module respondents included 2,278 noncaregivers and 594 caregivers providing care or assistance to a friend or family member with a health problem or disability. We used multivariable logistic regression to assess associations between caregiving status and each of our dependent variables. Results Caregivers had significantly greater odds of reporting household food insecurity (odds ratio [OR] = 2.10, P = .003) and personal hunger (OR = 2.89, P = .002), even after controlling for income and other correlates of food insecurity. There were no significant differences in obesity between caregivers and noncaregivers. Conclusion Caregiving is associated with increased risk of food insecurity and hunger in Oregon, suggesting that careful attention to the nutritional profile of households with family caregivers is needed in this population.