Melissa M. Farmer

Health Trajectories: Long-Term Dynamics Among Black and White Adults

Disability has long been identified as a predictor of self-assessed health, but some studies suggest the opposite causal direction. The aim of this study is to examine the dynamic relationships between physical disability and assessments of health among Black and White adults while simultaneously considering changing morbidity. Research questions include: Do more negative health assessments lead to greater morbidity and physical disability? Do negative health assessments lead to a cycle of health decline over time? These questions were addressed for Black and White respondents over 15 years using data from three waves of the National Health and Nutrition Examination Survey I: Epidemiologic Follow-Up Study. Results from structural equation modeling reveal that self-assessed health predicts subsequent change in health, suggesting a cycle between health problems and negative health assessments for both White and Black adults. In addition, self-assessed health among African Americans declined at a faster rate than was the case for White adults.

Distress and perceived health: mechanisms of health decline.

Stress is a common experience in modern society, and it can affect both physical and mental health. Recognizing that not all stress is detrimental to health, this research examines the relationship between perceptions of distress and perceived health within a longitudinal framework. Using two waves of a nationally representative panel study, the National Health and Nutrition Examination Survey I (NHANES I), structural equation modeling revealed that distress leads to more negative health perceptions. In addition, perceived health was found to impact distress levels at the following wave suggesting a cycle of decline between distress and perceived health. Finally, perceived health was found to have predictive validity in determining future functional disability even when considering distress.

Double jeopardy to health hypothesis for African Americans : Analysis and critique

Considerable research on minority health has examined whether members of a minority group experience more rapid health declines than the White majority when both groups reach later life. Researchers have sought to determine if being both old and a member of a minority creates a double disadvantage to health. The primary purpose of this research is to test the double jeopardy to health hypothesis among Black and White Americans using data from a 15-year panel study of adults: National Health and Nutrition Examination Survey I: Epidemiological Follow-up Study (NHEFS). African Americans have poorer health at all three times on a variety of health status measures, but no evidence for double jeopardy was uncovered. There were important racial differences for change in health status but Black Americans of all ages -- including Black older adults -- suffered from growing disability and more negative ratings of health. Black adults are more likely to develop serious illness, and their ratings of health decline more rapidly than is the case for White respondents. While there is little support for the double jeopardy hypothesis as originally stated, there is overwhelming evidence to show that the health of Black Americans of all ages declines at a faster rate. The formulation of the double jeopardy hypothesis is critiqued on several points: ontogenetic fallacy, attribution of discrimination, and selective mortality.

Primary care provider perceptions of barriers to and facilitators of colorectal cancer screening in a managed care setting

Colorectal cancer (CRC) screening tests (e.g., fecal occult blood testing [FOBT], flexible sigmoidoscopy [FS], etc.) are underused. Primary care providers (PCPs) play a critical role in screening, but barriers to and facilitators of screening as perceived by PCPs in managed care settings are poorly understood. The objectives of the current study were to describe current CRC screening practices and to explore determinants of test use by PCPs in a managed care setting.

Finding order in heterogeneity: types of quality-improvement intervention publications

Background: Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications. Methods: A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs. Results: By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

Results of a Randomized Controlled Trial to Increase Colorectal Cancer Screening in a Managed Care Health Plan

Colorectal cancer (CRC) is the third most common cause of cancer deaths; however, rates of regular screening for this cancer are low. A quality improvement (QI) program to increase CRC screening was developed for use in a managed care health plan.

Gender Differences in Smoking and Smoking Cessation Treatment: An Examination of the Organizational Features Related to Care

OBJECTIVES Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment. METHODS We merged national organizational-level data focused on primary care (sites = 225) and womens health (sites = 195) with patient-level survey data (n = 15,033 smokers). Organizational measures focused on smoking cessation-specific structure and processes in primary care and womens health. Primary outcomes were patient-reported receipt of smoking cessation treatments-advised to quit, medication recommendation, and other treatment recommendation. We used multi-level, random-intercept logistic regression. RESULTS In 2007, 29% of women and 23% of men were smokers. Overall, 83% of smokers reported they had been advised to quit, 62% recommended medications, and 60% recommended other treatments. Women were more likely to report being advised to quit (odds ratio, 1.33; 95% confidence interval, 1.07-1.64) but equally likely as men to have medications or other treatment recommended. Organizational factors did not eliminate the gender differences in being advised to quit. CONCLUSION Despite having equivalent or higher smoking cessation treatment rates, women Veterans were more likely to smoke than men. With the rapid growth of women entering VA care, the need for effective gender-focused and gender-sensitive smoking cessation care arrangements is critical for the future health of women who have served.

Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies.

BACKGROUND Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial. METHODS Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator. RESULTS Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups. CONCLUSIONS Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.

Assessment of the healthcare needs and barriers to VA use experienced by women veterans: findings from the national survey of women Veterans.

Background:Prior regional studies of women Veterans identified barriers to Veterans Affairs (VA) healthcare use. However, these studies do not reflect the demographic profile of women Veterans nationally, recent advances in VA women’s healthcare, and the national context of expanded healthcare alternatives. Objective:To characterize health, VA perceptions, barriers, healthcare delivery preferences, and reasons for VA or non-VA healthcare use in a national women Veteran sample. Methods:Cross-sectional, population-based 2008–2009 National Survey of Women Veterans (n=3611). Results:VA users had worse physical and mental health than non–VA-only users and healthcare nonusers. Older women Veterans had worse physical health, whereas younger groups had worse mental health. Healthcare use was highest for dual users, followed by VA-only users, but did not differ by age group. Healthcare nonusers were most likely to lack a regular source for healthcare. Perceptions of VA care quality and sex-appropriateness were highest for VA-only, followed by dual, then non–VA-only users. VA perceptions were guided by personal experience for 90% of VA users, versus media or other secondhand sources for 70% of other groups. Non–VA-only users and healthcare nonusers had more knowledge gaps about VA and misperceptions about VA eligibility and services; non–VA-only users more likely encountered VA enrollment barriers. Conclusions:Many nonusers had healthcare needs that were not met. Positive VA perceptions by women with first-hand VA experience, contrasted with VA knowledge gaps by those without such exposure, suggests the need for more education about available VA healthcare services. VA planning should account for mental health needs and healthcare use by younger women Veterans.

Predictors of Colorectal Cancer Screening From Patients Enrolled in a Managed Care Health Plan

Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests.