45 research outputs found
Depression and AllâCause Mortality in Persons with Diabetes Mellitus: Are Older Adults at Higher Risk? Results from the Translating Research Into Action for Diabetes Study
Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107493/1/jgs12833.pd
Physician Compensation from Salary and Quality of Diabetes Care
OBJECTIVE: To examine the association between physician-reported percent of total compensation from salary and quality of diabetes care. DESIGN: Cross-sectional analysis. PARTICIPANTS: Physicians (nâ=â1248) and their patients with diabetes mellitus (nâ=â4200) enrolled in 10 managed care plans. MEASUREMENTS: We examined the associations between physician-reported percent compensation from salary and processes of care including receipt of dilated eye exams and foot exams, advice to take aspirin, influenza immunizations, and assessments of glycemic control, proteinuria, and lipid profile, intermediate outcomes such as adequate control of hemoglobin A1c, lipid levels, and systolic blood pressure levels, and satisfaction with provider communication and perceived difficulty getting needed care. We used hierarchical logistic regression models to adjust for clustering at the health plan and physician levels, as well as for physician and patient covariates. We adjusted for plan as a fixed effect, meaning we estimated variation between physicians using the variance within a particular health plan only, to minimize confounding by other unmeasured health plan variables. RESULTS: In unadjusted analyses, patients of physicians who reported higher percent compensation from salary (>90%) were more likely to receive 5 of 7 diabetes process measures and more intensive lipid management and to have an HbA1c<8.0% than patients of physicians who reported lower percent compensation from salary (<10%). However, these associations did not persist after adjustment. CONCLUSIONS: Our findings suggest that salary, as opposed to fee-for-service compensation, is not independently associated with diabetes processes and intermediate outcomes
Schools, families, and social reproduction
Neoliberal educational discourse across the Global North is marked by an increasing homogeneity, but this masks significant socio-spatial differences in the enactment of policy. The authors focus on four facets of roll-out neoliberalism in English education policy that have expanded the function of primary schools, and redrawn the boundary between state and family responsibilities. Specifically, these are increased state support for: (1) working parenthood through provision of wraparound childcare; (2) parent-child relationships through school-led provision of parenting classes; (3) parental involvement in childrenâs learning; and (4) child development through schoolsâ fostering of extracurricular activities. The politics of policies that both enhance state responsibility for, and influence in, matters that were previously within the purview of families are complex. The collective impact of these developments has been both to reform how the work of daily and generational social reproduction is done, and to reshape the social reproduction of a classed and gendered society
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Development of the 12-item Expectations Regarding Aging Survey.
PurposeThis study describes the development of a short version of the Expectations Regarding Aging Survey (ERA-38), a 38-item survey measuring expectations regarding aging.Design and methodsIn 1999, surveys containing the ERA-38 were mailed to 588 adults aged > or = 65 years who were recruited through physicians; 429 individuals (73%) returned completed surveys. The mean age of participants was 77 years; 76% were White. In 2001, we surveyed 643 adults aged > or = 65 years recruited at 14 senior centers. The mean age of participants was 78 years; 37% were Latino and 16% were African American. With the 1999 data, we selected items for the shorter version of the ERA-38 by using qualitative criteria and by evaluating the items' factor structure, internal consistency reliability of scales, and correlations with age and self-reported measures of health. Then, using the 2001 data, we evaluated the selected items with confirmatory factor analysis, and we reevaluated the internal consistency reliability and associations of the scales with age and self-reported measures of health.ResultsThe factor analyses of the ERA-12 on both samples provided support for three 4-item scales (expectations regarding physical health, expectations regarding mental health, and expectations regarding cognitive function), and one global expectations regarding aging scale combining all 12 items. In both samples, internal consistency reliability estimates for all scales exceeded 0.74, and the 12 items together explained over 88% of the variance in the ERA-38 total score. We found comparable associations of the ERA-12 scales with age and self-reported health measures in both samples.ImplicationsThe ERA-12 demonstrated acceptable reliability and validity to estimate expectations regarding aging
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Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation.
Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems
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Development of the 12-item Expectations Regarding Aging Survey.
PurposeThis study describes the development of a short version of the Expectations Regarding Aging Survey (ERA-38), a 38-item survey measuring expectations regarding aging.Design and methodsIn 1999, surveys containing the ERA-38 were mailed to 588 adults aged > or = 65 years who were recruited through physicians; 429 individuals (73%) returned completed surveys. The mean age of participants was 77 years; 76% were White. In 2001, we surveyed 643 adults aged > or = 65 years recruited at 14 senior centers. The mean age of participants was 78 years; 37% were Latino and 16% were African American. With the 1999 data, we selected items for the shorter version of the ERA-38 by using qualitative criteria and by evaluating the items' factor structure, internal consistency reliability of scales, and correlations with age and self-reported measures of health. Then, using the 2001 data, we evaluated the selected items with confirmatory factor analysis, and we reevaluated the internal consistency reliability and associations of the scales with age and self-reported measures of health.ResultsThe factor analyses of the ERA-12 on both samples provided support for three 4-item scales (expectations regarding physical health, expectations regarding mental health, and expectations regarding cognitive function), and one global expectations regarding aging scale combining all 12 items. In both samples, internal consistency reliability estimates for all scales exceeded 0.74, and the 12 items together explained over 88% of the variance in the ERA-38 total score. We found comparable associations of the ERA-12 scales with age and self-reported health measures in both samples.ImplicationsThe ERA-12 demonstrated acceptable reliability and validity to estimate expectations regarding aging
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Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans-Mediation and moderating effects.
ObjectiveTo examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.Data sourcesElectronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.Study designRacial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.Principal findingsMortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.ConclusionsNeighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention
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Race Differences in Patient Experience by Hispanic Ethnicity Among Veteran Health Administration Users.
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Drug benefit changes under Medicare Advantage Part D: heterogeneous effects on pharmaceutical use and expenditures.
BackgroundAlthough Medicare Part D improved drug benefits for many beneficiaries, its impact on the coverage of Medicare Advantage Part D (MAPD) enrollees depended on their pre-existing benefits and whether they had gap coverage under Part D.ObjectiveTo examine changes in prescription drug utilization and expenditures associated with drug benefit changes resulting from the implementation of Part D.PatientsWe studied 248,773 continuously enrolled MAPD patients in eight states. Patients whose insurance product or Census block could not be identified or who had atypical benefits, low-income subsidies or Medicaid coverage were excluded.Main measuresThe main outcomes were changes in prescription drug days supply and expenditures from 2005 to 2006 and 2005 to 2007.DesignWe linked Census data with 2005-7 MAPD claims, encounter, enrollment, and benefits data and estimated associations of the outcomes with changes in drug benefits, controlling for 2005 comorbidities, demographics, and Census population characteristics.Key resultsMAPD enrollees whose drug benefits became potentially less generous after Part D had the smallest increases in drug utilization and expenditures (e.g., drug expenditures increased by 302). The differences in benefit design changes had a stronger association with drug utilization and outcomes among patients at high risk of gap entry than among the entire sample.ConclusionsAlthough Medicare Part D unambiguously improved drug coverage for many elderly, it led to heterogeneous changes in drug benefits among MAPD enrollees, who already had generic and sometimes branded drug benefits. After 2006, benefits were worse for individuals who had branded drug coverage in 2005 but now had a coverage gap, but benefits may have improved for individuals who acquired branded drug coverage. Commensurate with these differential changes in benefits following Part D, changes in drug utilization and expenditures varied substantially as well
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Cost-lowering strategies used by medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage.
ContextThe majority of Medicare drug benefits in managed care (Medicare + Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year. In the new national Medicare drug benefit, beneficiaries with high medication expenditures will also face a period without drug coverage when their total drug costs exceed annual caps but are not high enough to qualify for catastrophic coverage.ObjectiveTo describe strategies adopted by beneficiaries exceeding annual drug benefit caps to lower prescription costs, the type of medications involved, and their financial burden.Design, setting, and participantsA survey (completed in 2002) of Medicare + Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs (65% response rate). The different caps offered in different counties were used as a natural experiment. Study participants (n = 665) exceeded a 750 dollars or 1200 dollars yearly cap in 2001 and had coverage gaps of 75 to 180 days. Control participants (n = 643) had 2000 dollars caps, which they did not exceed. Study and control participants were matched by average total drug expenditures per month.Main outcome measuresProportion of beneficiaries reporting specific strategies to decrease medication costs, medications affected, and difficulty paying for prescriptions.ResultsIn multivariate analyses adjusting for demographic and health characteristics, a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18% vs 10%, respectively; P<.001), but similar proportions reported stopping medications completely (8% for both, P =.86) and of not starting prescribed medications (6% vs 5%, P =.39). Patients exceeding caps more often called pharmacies to find the best price (46% vs 29%, P<.001), switched medications (15% vs 9%, P =.002), used samples (34% vs 27%, P =.006), and had difficulty paying for prescriptions (62% vs 37%, P<.001). Twelve of the 20 therapeutic classes most often affected by decreases in use of medication were for chronic health problems such as hypertension, hyperlipidemia, and emphysema or asthma.ConclusionsMedicare beneficiaries often decreased use of essential medications and experienced difficulty paying for prescriptions during gaps in coverage. Health professionals need to explore how they can lessen the impact of caps on patients' health and financial burden