Biomedical subjects

D Grembowski

Publications and source records attributed to D Grembowski.

At least 19 recordsLinked to original sources

PubMed2000

Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders.

We used data from a 4-year prospective study of 2,558 primary care patients age 65 and older in a large staff model health maintenance organization to examine the association of clinically significant depressive symptoms and eight other chronic medical conditions with quality adjusted life years (QALYs). We developed linear regression models to examine the association of clinically significant depressive symptoms as defined by a score of 16 or greater on the Center for Epidemiological Studies Depression Scale and eight common chronic medical disorders at baseline with QALYs over the 4-year study period. Estimates of QALYs were derived from Quality of Well-Being Scale scores at baseline, at 2-year follow-up, and at 4-year follow-up. Individuals with clinically significant depressive symptoms at baseline had significantly lower QALYs over the 4-year study period than nondepressed subjects, even after adjusting for differences in age, gender, and the eight other chronic medical conditions. In terms of the entire study population, only arthritis and heart disease were more strongly associated with QALYs than depression.

Aged↗

PubMed2000

Third-party reimbursement and use of fluoride varnish in adults among general dentists in Washington State.

BACKGROUND: Studies have indicated that a minority of dentists regularly use fluoride varnish to control caries. To increase the use of this new technology, Washington Dental Service, or WDS, began reimbursing dentists for providing fluoride varnish in January 1996. The aim of the authors' study was to determine whether reimbursement increased dentists' use of fluoride varnish. METHODS: In the fall of 1995, the authors asked a random sample of 532 general dentists in Washington state to complete a mail questionnaire on their use of caries control services. The survey was conducted before the institution of payment for fluoride varnish use, and dentists were unaware that fluoride varnish use would be a paid service in January 1996. In the fall of 1997 the same dentists were asked to complete a second questionnaire on the same topic. RESULTS: About 32 percent of dentists used fluoride varnish regularly before WDS started reimbursement for the service. Two years after reimbursement began, about 44 percent of dentists regularly used fluoride varnish (P = .004). Dentists' rates of use of other caries-control services (chlorhexidine rinses for caries control and adult pit-and-fissure sealants) did not change. Dentists' reasons for not using fluoride varnish included lack of awareness, lack of convincing evidence of a favorable cost:benefit ratio, patients' rejection of the service and low caries risk among adult patients. CONCLUSIONS: After fluoride varnish became a covered benefit, the use of fluoride varnish among general dentists increased after two years, but a majority of dentists still had not adopted the technology. The increase in use may be due to reimbursement, as well as other factors. PRACTICE IMPLICATIONS: Reimbursement by itself cannot increase dentists' use of caries control services.

Adult↗

PubMed1999

Primary care physicians' participation in managed care networks.

The study described in this article explored the relationships between primary care physician characteristics and patterns of managed care affiliation in a single region. Secondary data sources were used to investigate the affiliations of all primary care physicians in King County, Washington (Seattle and environs) with 29 managed care products in 1996. Descriptive findings indicate that specialty, board certification, and experience all are associated with the managed care affiliations held by physicians. Differences between managed care product provider lists suggest that there are different strategies for the design and management of provider networks.

Case Management↗

PubMed1997

Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study.

OBJECTIVE: To examine whether depressive symptoms in older adults contribute to increased cost of general medical services. DESIGN: A 4-year prospective cohort study. SETTING: Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash. PATIENTS: A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Non-participants were somewhat older and had a higher level of chronic medical illness. MAIN OUTCOME MEASURES: Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO. RESULTS: In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness. CONCLUSIONS: Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness.

Aged↗

PubMed1997

Does fluoridation reduce the use of dental services among adults?

OBJECTIVES: The authors determine whether prevention influences the use of health services. Fluoridation's effect on restorative dental demand among 972 Washington state employees and spouses, aged 20 to 34 years, in two fluoridated communities and a nonfluoridated community was examined. METHODS: At baseline, adults were interviewed by telephone, and oral assessments were conducted to measure personal characteristics, lifetime exposure to fluoridated water, oral disease, and the quality of restorations. Adults were followed for 2 years to measure dental demand from dental claims. Each adult's baseline and claims data were linked with provider and practice variables collected from the dentist who provided treatment. RESULTS: Relative to adults with no lifetime exposure to fluoridated water, adults drinking fluoridated water for half or more of their lives had less disease at baseline and a lower but nonsignificant probability of receiving a restoration in the follow-up period. In the 2-year follow-up period, however, more than half of the restorations were performed to replace fillings of satisfactory or ideal quality at baseline. When only teeth with decay and unsatisfactory fillings at baseline were considered, adults with high fluoridation exposure had a lower probability of receiving a restoration than adults with no exposure. Market effects also were detected in demand equations; relative to adults in the nonfluoridated community, adults residing in the fluoridated community with a large dentist supply received a greater number of restorations, suggesting potential supplier-induced demand from less disease and fewer patients. CONCLUSIONS: Among adults aged 20 to 34 years with private dental insurance, fluoridation reduces oral disease but may or may not reduce use of restorative services, depending on dentists' clinical decisions.

Adult↗

PubMed1997

Factors influencing the appropriateness of restorative dental treatment: an epidemiologic perspective.

OBJECTIVES: An epidemiology analysis was performed to identify patient and dentist factors influencing over- and undertreatment of restorative services in a sample of insured adults. METHODS: At baseline, 681 Washington State employees and their spouses, aged 20 to 34 years and residing in the Olympia or Pullman areas, were interviewed by telephone. Oral assessments were conducted to measure personal characteristics, oral disease, and restoration quality. Adults were followed for two years to measure use of restorative services from dental insurance claims. Each adult's baseline and claims data were linked with provider and practice variables collected from the dentist who provided treatment. RESULTS: For overtreatment, 39 percent of adults received one or more replacement restorations in nondecayed teeth with satisfactory fillings at baseline, while 18 percent of adults had one or more restorations placed in teeth with no decay and fillings. An adult's probability of overtreatment was higher if the adult had more fillings at baseline, or if an adult's dentist was younger, had a busy practice, advertised, charged higher fees, had less continuing education, or had a solo practice. For undertreatment, about 16 percent of adults either received no replacement restorations in teeth with unsatisfactory fillings at baseline, or had decayed teeth at baseline that were not filled or crowned. An adult's probability of undertreatment was higher if an adult had less decayed or more missing surfaces at baseline, or if an adult's dentist believed in sharing information with patients, had a busy practice, or reported not placing fillings when radiographic evidence of new caries was present. CONCLUSIONS: A minority of adults aged 20 to 34 experienced potential over- or undertreatment of restorative services, which are influenced by both patient and dentist factors.

Adult↗

PubMed1997

Making Medicaid child dental services work: a partnership in Washington state.

Eighty-one percent of general dentists and 86 percent of pediatric dentists who are members of the local dental society in Spokane County, Washington, participated in a pilot program to provide dental care in private offices to children up to 5 years of age from low-income families served by the Medicaid program. Outreach staff from the local public health agency recruited and enrolled families in the program. University faculty provided special training in the care of young children to the dentists participating in the program. In the program's first year, 37 percent of the enrolled children had made at least one visit to the dentist, in contrast to 12 percent of children who were not enrolled in the program.

Child, Preschool↗

PubMed1997

Adoption of innovative caries-control services in dental practice: a survey of Washington State dentists.

To assess the adoptability of the medical model for caries control, the authors surveyed general dentists about their use of four caries-control services among adult patients: salivary functioning tests, fluoride varnishes, chlorhexidine rinses, and pit-and-fissure sealants. Responses indicated that leaders in the dental community and those with a wider network of professional colleagues were likely to adopt new services more quickly than other dentists. Earlier adopters also had more correct information about these services than later or nonadopters. Overall, the knowledge base of the services studied in this survey was not uniform, making adoption of the medical model for caries control premature.

Adult↗

PubMed1997

The role of health services research in the renaissance of the dental profession.

Health services research may play a critical role in achieving the recommendations of the IOM study. Toward this end, the field of health services research is defined. Applications of health services research to health outcomes, patient care, and other IOM directives are reviewed. Alternative approaches to building the capacities of dental schools to conduct health services research are presented.

Dental Health Services↗

PubMed1995

Socioeconomic status and exercise self-efficacy in late life.

Self-efficacy, or assessments about one's ability to carry out particular tasks, has been shown to play a central role in the adoption and maintenance of exercise. The relationship between exercise self-efficacy and socioeconomic status (SES), however, has not been formally developed or tested, and the implications of SES for exercise interventions are not known. We hypothesize pathways through which income, education, and occupation affect self-efficacy and capitalize on the availability of responses from 1944 older HMO enrollees to investigate the direct and indirect associations of SES indicators with exercise self-efficacy. Direct associations of age and education are found. Indirect associations of age, income, education, and occupation operate primarily through previous exercise experience, satisfaction with amount of walking, depression, and outcome expectations. The potentially modifiable nature of exercise outcome expectations (i.e., belief in the benefits of exercise) in combination with its strong association with exercise self-efficacy argue in support of greater consideration of its role in attempts to improve exercise self-efficacy.

Aged↗

PubMed1995

Including deaths when measuring health status over time.

Measuring health status over time is problematic when some subjects die, because death does not have a defined value on most health status measures. This situation is different from the usual missing data problem because the health status of the dead is, in a sense, known. We examined eight strategies for incorporating deaths into such analyses using three health status measures taken from two data sets, after which we used computer simulation to explore more fully the effect of deaths. The strategies differed in the amount of influence given to the deaths, varying from none (deaths were discarded) to complete (mortality itself was the health measure). The strategies that gave less influence to deaths tended to show more favorable changes in health over time, and therefore, tended to favor the group that had more deaths. The strategies that were more influenced by death showed more negative changes over time and favored the group with fewer deaths. The choice of strategy should depend on the goals of an intervention. For health promotion studies, we recommend recoding the health variables to estimate the probability that a person will be healthy in 2 years (or in some other period that can be estimated from the data).

Aged↗

PubMed1993

Fluoridation effects on periodontal disease among adults.

Numerous studies report that water fluoridation reduces caries in children, but little current evidence exists about fluoridation's effects on the periodontal health of adults. To address this issue, we estimated fluoridation effects on periodontal disease among 1066 Washington state employees and their spouses, aged 20 to 34, with current residences divided evenly between fluoridated and nonfluoridated communities. Subjects were interviewed by telephone to collect residence histories, personal characteristics and other data. Each subject's lifetime years of fluoridation exposure (YFE) was calculated from the person's residence history and the U.S. Centers for Disease Control's Fluoridation Census. Oral assessments were conducted to measure the extent of periodontal disease. Relative to adults with no exposure, continuous lifetime exposure reduced the probability of attachment loss from 0.87 to 0.72. Similar benefits were obtained for bleeding gingiva and calculus. The estimates of fluoridation's benefits were not influenced by selection bias due to subjects' nonparticipation in the oral assessments.

Adult↗

PubMed1993

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.

Age Factors↗

PubMed1992

How fluoridation affects adult dental caries.

Oral assessments conducted to measure caries experience in adults reveal that, on average, each year of exposure to fluoridated water reduced DFS by 0.29 surfaces. Fluoridation appears to have both pre- and post-eruptive benefits.

Adult↗

PubMed1991

Dental decisionmaking and variation in dentist service rates.

Previous medical and dental studies report wide variations in service rates across small areas, regions and providers. A major source of this variation appears to be the pattern of clinical decisionmaking of the provider. This argument was tested using dentist service rates (the average number of services provided per patient) calculated from 1984-1985 claims data for a population of well-educated, middle-class patients in Washington state, U.S.A. (N = 23,153). Service rates were calculated for each dental procedure in the following pairs of alternative treatments: crown vs amalgam or crown build-up; root canal therapy vs extraction; and fixed bridge vs removable partial denture. For each pair, dentists identified patient (e.g. cost, patient preference) and technical (e.g. periodontal status, tooth damage) factors which they considered to be important in choosing therapy. Regression analysis revealed that the technical factors explained little variation in the rates, while at least one patient factor was significant across services, except prosthetics. Environmental characteristics, structural features of the practice, and the dentists' practice beliefs also explained variation in the rates.

Crowns↗

PubMed1991

Participation of higher users in a randomized trial of Medicare reimbursement for preventive services.

In a study of older enrollees in an HMO, we found that seniors who are higher users of health care services are willing to participate in health promotion programs. Although people aged 85 or older and those with chronic diseases are slightly more reluctant to participate, they are willing to make additional visits for health promotion purposes. Close proximity to the clinic and support from their family physician are important correlates of participation.

Age Factors↗

PubMed1990

Variation in dentist service rates in a homogeneous patient population.

Previous studies in medicine and dentistry document wide variations in service rates across small areas, large regions, and providers. The practice patterns of providers and underlying differences in patient need are thought to be important sources of this variation. To control for variation in patient needs, we calculated service rates of 200 general dentists in Washington state based on a homogeneous, well-educated, upper-middle-class population of patients. Wide variations were found in the rate for many dental services. Dentists' practice beliefs and characteristics of the practice were sources of variation in the rates. The evidence is insufficient to determine whether undertreatment of overtreatment occurred among dentists with the lowest and highest expenditures per patient, respectively. However, the perceived oral health status of adult patients was lower in practices with the lowest total expenditures per patient than in practices with the highest total expenditures per patient, suggesting the undertreatment of adult patients in the lowest-expenditure practices may have occurred.

Adult↗

PubMed1990

Factors influencing variation in dentist service rates.

In the previous article, we calculated dentist service rates for 200 general dentists based on a homogeneous, well-educated, upper-middle-class population of patients. Wide variations in the rates were detected. In this analysis, factors influencing variation in the rates were identified. Variation in rates for categories of dental services was explained by practice characteristics, patient exposure to fluoridated water supplies, and non-price competition in the dental market. Rates were greatest in large, busy practices in markets with high fees. Older practices consistently had lower rates across services. As a whole, these variables explained between 5 and 30 percent of the variation in the rates.

Attitude of Health Personnel↗