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Biomedical subjects

David W Baker

Publications and source records attributed to David W Baker.

At least 19 recordsLinked to original sources
PubMed2006

Health literacy and health risk behaviors among older adults.

BACKGROUND: Limited health literacy is associated with poorer physical and mental health, although the causal pathways are not entirely clear. In this study, the association between health literacy and the prevalence of health risk behaviors was examined among older adults. METHODS: A cross-sectional survey of 2923 new Medicare, managed-care enrollees was conducted in four U.S. metropolitan areas (Cleveland OH; Houston TX; Tampa FL; Fort Lauderdale-Miami FL). Health literacy was measured using the short form of the Test of Functional Health Literacy in Adults. Behaviors investigated included self-reported cigarette smoking, alcohol consumption, physical activity, body mass index, and seat belt use. RESULTS: Individuals with inadequate health literacy were more likely to have never smoked (46.7% vs. 38.6, p =0.01); to completely abstain from alcohol (75.6% vs. 57.9, p <0.001); and to report a sedentary lifestyle (38.2% vs. 21.6%, p <0.001) compared to those with adequate health literacy. No significant differences were noted by mean body mass index or seat belt use. In multinomial logistic regression models that adjusted for relevant covariates, inadequate health literacy was not found to be significantly associated with any of the health risk behaviors investigated. CONCLUSIONS: Among community-dwelling elderly, limited health literacy was not independently associated with health risk behaviors after controlling for relevant covariates.

Aged↗
PubMed2006

Assessing the validity of national quality measures for coronary artery disease using an electronic health record.

BACKGROUND: Nationally endorsed, clinical performance measures are available that allow for quality reporting using electronic health records (EHRs). To our knowledge, how well they reflect actual quality of care has not been studied. We sought to evaluate the validity of performance measures for coronary artery disease (CAD) using an ambulatory EHR. METHODS: We performed a retrospective electronic medical chart review comparing automated measurement with a 2-step process of automated measurement supplemented by review of free-text notes for apparent quality failures for all patients with CAD from a large internal medicine practice using a commercial EHR. The 7 performance measures included the following: antiplatelet drug, lipid-lowering drug, beta-blocker following myocardial infarction, blood pressure measurement, lipid measurement, low-density lipoprotein cholesterol control, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for patients with diabetes mellitus or left ventricular systolic dysfunction. RESULTS: Performance varied from 81.6% for lipid measurement to 97.6% for blood pressure measurement based on automated measurement. A review of free-text notes for cases failing an automated measure revealed that misclassification was common and that 15% to 81% of apparent quality failures either satisfied the performance measure or met valid exclusion criteria. After including free-text data, the adherence rate ranged from 87.5% for lipid measurement and low-density lipoprotein cholesterol control to 99.2% for blood pressure measurement. CONCLUSIONS: Profiling the quality of outpatient CAD care using data from an EHR has significant limitations. Changes in how data are routinely recorded in an EHR are needed to improve the accuracy of this type of quality measurement. Validity testing in different settings is required.

Ambulatory Care↗
PubMed2006

National Cholesterol Education Program risk assessment and potential for risk misclassification.

BACKGROUND: The National Cholesterol Education Program Adult Treatment Panel report from 2001 (ATP III) recommends clinicians calculate 10-year coronary risk using multivariable methods only for adults with 2 or more risk factors. We aimed to determine who would be falsely classified as low risk using this approach. METHODS: We studied 4097 adults aged 20 to 79 years without diagnosed cardiovascular disease or diabetes from the National Health and Nutrition Examination Survey from 1999 to 2002. We determined the proportion with fewer than 2 risk factors who nonetheless had estimated 10-year risk of cardiac death or myocardial infarction > or =10% using multivariable methods. RESULTS: Among persons with fewer than 2 risk factors, 5.3% (95% confidence interval 4.7 to 6.1%), had a 10-year risk > or =10% using the Framingham Risk Score and would be misclassified using the risk factor counting method (this corresponds to approximately 5,640,000 U.S. adults). Compared to individuals whose classification was unchanged, those misclassified as low risk were older (P<0.001) and more likely male (85.5% vs. 41.2%, P<0.001). CONCLUSIONS: Relying on the ATP III risk factor counting method rather than determining risk using multivariable methods in all patients resulted in misclassifiying as low risk over 5 million adults with at least moderately high risk of coronary heart disease, most of whom are middle-aged and older men.

Adult↗
PubMed2006

Changes in health for the uninsured after reaching age-eligibility for Medicare.

BACKGROUND: Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance. OBJECTIVE: To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare. DESIGN: Prospective cohort study. PARTICIPANTS: Participants (N=3,419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview. MEASUREMENTS: We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t(-2) to t(0)) and the following 2 years (t(0) to t(2)). RESULTS: Between the interview before age 65 (t(-2)) and the first interview after reaching age 65 (t(0)), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t(0) to t(2)), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare. CONCLUSIONS: Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.

Age Factors↗
PubMed2006

A system for rapidly and accurately collecting patients' race and ethnicity.

OBJECTIVES: We assessed the feasibility of collecting race/ethnicity data from patients using their own preferred racial/ethnic terms. METHODS: The 424 patients described their race/ethnicity using their own categories, and we compared their descriptions with their responses to the questions (1) "Do you consider yourself Latino or Hispanic?" and (2) "Which category best describes your race?" (7 response options in our computer interview). We also determined patients' preferences between the 2 approaches. RESULTS: The proportions of patients who described themselves with 1, 2, 3, or 4 terms were 46%, 33%, 14%, and 6%, respectively; 2 said only "American" (1%,) and 1 refused to answer (0.5%). The average completion time was 37 +/- 17 seconds. Rates of missing values and categorization as "other" race were lower than with the closed questions. Agreement between racial/ethnic categorization with open-ended and closed responses was 93% (kappa =0.88). Latino/Hispanic and multiracial/multiethnic individuals were more likely to prefer using their own categories to describe their race/ethnicity. CONCLUSIONS: Collecting race/ethnicity data using patients' own racial/ethnic categories is feasible with the use of computerized systems to capture verbatim responses and results in lower rates of missing and unusable data than do standard questions.

Adult↗
PubMed2006

Outpatient physicians' satisfaction with discharge summaries and perceived need for an electronic discharge summary.

BACKGROUND: Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. OBJECTIVE: To evaluate satisfaction with current discharge summaries, perceptions of preventable adverse events related to suboptimal information transfer, and the perceived need for the electronic discharge summary we plan to design. DESIGN AND PARTICIPANTS: : Survey of Department of Medicine physicians with an outpatient practice. MEASUREMENTS: Satisfaction with timeliness and quality of discharge summaries was assessed using a 5-point Likert scale. Respondents estimated the number of patients with preventable adverse events related to suboptimal information transfer at discharge. RESULTS: Of the 416 eligible respondents, 226 completed the survey (54%). Only 19% of the participants were satisfied or very satisfied with timeliness, and only 32% were satisfied or very satisfied with the quality of discharge summaries. Overall, 41% believed that at least 1 of their patients hospitalized in the previous 6 months had experienced a preventable adverse event related to poor transfer of information at discharge. CONCLUSIONS: Physicians were not satisfied with the timeliness or quality of discharge summaries. Physicians indicated that suboptimal transfer of information at hospital discharge contributed to preventable adverse events.

Ambulatory Care↗
PubMed2006

How hospitalists spend their time: insights on efficiency and safety.

BACKGROUND: Despite the dramatic growth of hospitalists, no studies have evaluated the type and frequency of activities that hospitalists perform. To evaluate the types and frequency of activities that hospitalists perform during routine work, we conducted a time-motion study of hospitalist physicians at our institution. DESIGN: A research assistant shadowed hospitalist physicians for 3- to 5-hour periods. Observation periods were distributed in order to sample all parts of a typical day of a hospitalist, including both admitting and nonadmitting periods. Activities were recorded on a standardized data collection form in 1-minute intervals. Incoming pages were recorded as well. RESULTS: Ten hospitalists were shadowed by a single research assistant for a total of 4467 minutes. Hospitalists spent 18% of their time on direct patient care, 69% on indirect patient care, 4% on personal activities, and 3% each on professional development, education, and travel. Communication accounted for 24% of the total minutes. Multitasking, performing more than one activity at the same time, was done 21% of the time. Hospitalists received an average of 3.4 +/- 1.5 pages per hour. CONCLUSIONS: Hospitalists spent most of their time on indirect patient care activities and relatively little time on direct patient care. Hospitalists spent a large amount of time on communication, underscoring the need for hospitalists to have outstanding communication skills and systems that support efficient communication. Multitasking and paging interruptions were common. The inherent distraction caused by interruptions and multitasking is a potential contributor to medical error and warrants further study.

Adult↗
PubMed2006

Health insurance coverage and the risk of decline in overall health and death among the near elderly, 1992-2002.

BACKGROUND: Although individuals' health insurance coverage changes frequently, previous analyses have not accounted for changes in insurance coverage over time. OBJECTIVE: We sought to determine the independent association between lack of insurance and the risk of a decline in self-reported overall health and death from 1992 to 2002, accounting for changes in self-reported overall health and insurance coverage. METHODS: We analyzed data from the Health and Retirement study, a prospective cohort study of a national sample of community-dwelling adults age 51-61 years old at baseline. Major decline in self-reported overall health and mortality was determined at 2-year intervals. RESULTS: People who were uninsured at baseline had a 35% (95% confidence interval [CI] 12-62%) higher risk-adjusted mortality from 1992 to 2002 compared with those with private insurance. However, when we analyzed outcomes over 2-year intervals, individuals who were uninsured at the start of each interval were more likely to have a major decline in their overall health (pooled adjusted relative risk 1.43, 95% CI 1.28-1.63), but they were equally likely to die (pooled adjusted relative risk 0.96, 95% CI 0.73-1.27). Of the 1512 people who were uninsured at baseline, 220 (14.6%) died; of those who died, only 70 (31.8%) were still uninsured at the HRS interview prior to death. CONCLUSIONS: Death does not appear to be a short-term consequence of being uninsured. Instead, higher long-term mortality among the uninsured results from erosion in this population's health status over time and the attendant higher mortality associated with this. Most deaths among the uninsured occur after individuals have gained either public or private health insurance.

Cohort Studies↗
PubMed2006

The effect of private insurance on the health of older, working age adults: evidence from the health and retirement study.

OBJECTIVE: Primarily, to determine if the presence of private insurance leads to improved health status, as measured by a survey-based health score. Secondarily, to explore sensitivity of estimates to adjustments for endogeneity. The study focuses on adults in late middle age who are nearing entry into Medicare. DATA SOURCES: The analysis file is drawn from the Health and Retirement Study, a national survey of relatively older adults in the labor force. The dependent variable, an index of 5 health outcome items, was obtained from the 1996 survey. Independent variables were obtained from the 1992 survey. State-level instrumental variables were obtained from the Area Resources File and the TAXSIM file. The final sample consists of 9,034 individuals of which 1,540 were uninsured. STUDY DESIGN: Estimation addresses endogeneity of the insurance participation decision in health score regressions. In addition to ordinary least squares (OLS), two models are tested: an instrumental variables (IV) model, and a model with endogenous treatment effects due to Heckman (1978). Insurance participation and health behaviors enter with a lag to allow their effects to dissipate over time. Separate regressions were run for groupings of chronic conditions. PRINCIPAL FINDINGS: The OLS model results in statistically significant albeit small effects of insurance on the computed health score, but the results may be downward biased. Adjusting for endogeneity using state-level instrumental variables yields up to a six-fold increase in the insurance effect. Results are consistent across IV and treatment effects models, and for major groupings of medical conditions. The insurance effect appears to be in the range of about 2-11 percent. There appear to be no significant differences in the insurance effect for subgroups with and without major chronic conditions. CONCLUSIONS: Extending insurance coverage to working age adults may result in improved health. By conjecture, policies aimed at expanding coverage to this population may lead to improved health at retirement and entry to Medicare, potentially leading to savings. However, further research is needed to determine whether similar results are found when alternative measures of overall health or health scores are used. Future research should also explore the use of alternative instrumental variables. Preliminary results provide no justification for targeting certain subgroups with susceptibility to certain chronic conditions rather than broad policy interventions.

Chronic Disease↗
PubMed2006

Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions.

OBJECTIVES: To provide an overview of why health care organizations (HCOs) should collect race, ethnicity, and language data, review current practices, discuss the rationale for collecting this information directly from patients, and describe barriers and solutions. PRINCIPAL FINDINGS: Hospitals and HCOs with data from their own institutions may be more likely to look at disparities in care, design targeted programs to improve quality of care, and provide patient-centered care. Yet data collection is fragmented and incomplete within and across organizations. A major factor affecting the quality of data is the lack of understanding about how best to collect this information from patients. CONCLUSIONS: If HCOs make a commitment to systematically collect race/ethnicity and language data from patients, it would be a major step in enhancing the ability of HCOs to monitor health care processes and outcomes for different population groups, target quality initiatives more efficiently and effectively, and provide patient-centered care.

Data Collection↗
PubMed2006

Low literacy impairs comprehension of prescription drug warning labels.

BACKGROUND: Adverse events resulting from medication error are a serious concern. Patients' literacy and their ability to understand medication information are increasingly seen as a safety issue. OBJECTIVE: To examine whether adult patients receiving primary care services at a public hospital clinic were able to correctly interpret commonly used prescription medication warning labels. DESIGN: In-person structured interviews with literacy assessment. SETTING: Public hospital, primary care clinic. PARTICIPANTS: A total of 251 adult patients waiting for an appointment at the Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) Primary Care Clinic. MEASUREMENTS: Correct interpretation, as determined by expert panel review of patients' verbatim responses, for each of 8 commonly used prescription medication warning labels. RESULTS: Approximately one-third of patients (n=74) were reading at or below the 6th-grade level (low literacy). Patient comprehension of warning labels was associated with one's literacy level. Multistep instructions proved difficult for patients across all literacy levels. After controlling for relevant potential confounding variables, patients with low literacy were 3.4 times less likely to interpret prescription medication warning labels correctly (95% confidence interval: 2.3 to 4.9). CONCLUSIONS: Patients with low literacy had difficulty understanding prescription medication warning labels. Patients of all literacy levels had better understanding of warning labels that contained single-step versus multiple-step instructions. Warning labels should be developed with consumer participation, especially with lower literate populations, to ensure comprehension of short, concise messages created with familiar words and recognizable icons.

Adolescent↗
PubMed2005

Implications of changing national cholesterol education program goals for the treatment and control of hypercholesterolemia.

BACKGROUND: Modifications to the National Cholesterol Education Program (NCEP) guidelines lowered optional low-density lipoprotein cholesterol (LDL-C) treatment goals. OBJECTIVE: We evaluated the implications of widely adopting these optional goals in clinical practice. DESIGN AND PARTICIPANTS: We performed a cross-sectional study using 1999 to 2002 data from 3,281 U.S. adults aged 20 to 79 years participating the National Health and Nutrition Examination Survey. MEASUREMENTS: The primary outcomes were the proportions of adults whose fasting LDL-C levels exceeded NCEP recommended and optional targets from 2001 and 2004. We used survey weights to estimate the size of the U.S. population exceeding targets. We examined outcomes for 4 coronary disease risk subgroups described by the NCEP. RESULTS: Low-density lipoprotein cholesterol values exceeded 2001 NCEP goals for 30.0% of adults, and 35.8% had levels above optional 2004 goals. An estimated 24,900,000 individuals (14.2%) exceeded 2001 thresholds for drug therapy, 46,200,000 (26.3%) exceeded optional 2001 thresholds for drug therapy, and 56,500,000 (32.2%) were above the optional 2004 thresholds for drug therapy. For lower, moderate, moderately high, and high-risk groups, 13.4%, 44.2%, 58.8%, and 71.8%, respectively, exceeded 2001 NCEP goals; 13.4%, 15.7%, 87.4%, and 96.0% of these groups exceeded optional 2004 thresholds for drug therapy. CONCLUSIONS: In 1999 to 2002, LDL-C levels commonly exceeded 2001 NCEP goals, especially for moderately high and high-risk individuals, and cholesterol-lowering medications were underused. Optional goals promulgated by the NCEP in 2001 and 2004 moderately increased the number of adults with LDL-C above their goal, and greatly increased the number of low, moderately high, and high-risk adults who exceeded LDL-C thresholds, for cholesterol-lowering medication.

Adult↗
PubMed2005

Effect of physical activity on functional status among older middle-age adults with arthritis.

OBJECTIVE: To determine the effect of leisure time and work-related physical activity on changes in physical functioning among 3,554 nationally representative survey respondents, ages 53-63 years in 1994, with arthritis and joint symptoms, interviewed in the Health and Retirement Study (HRS). METHODS: In 1992-1994, light and vigorous exercise items were empirically categorized into recommended, insufficient, and inactive leisure time physical activity levels using data from the HRS. Leisure and work-related physical activity levels in 1994 were used to predict 1996 functional decline or improvement, controlling for baseline functional difficulties, health status, sociodemographic characteristics, and behavioral risk factors. RESULTS: Whereas 29.7% of respondents reported functional declines in 1996, 38.6% of those with baseline difficulties in 1994 reported improvement. Compared with inactive respondents, recommended and insufficient leisure time physical activity were equally protective against functional decline (odds ratio [OR] 0.59 and 0.62, respectively; P < 0.0001). Higher levels of physical activity were also modestly associated with functional improvement among respondents with baseline functional difficulties (OR 1.47, P = 0.05 and OR 1.45, P = 0.01, respectively). Work-related physical activity was not a significant predictor of decline or improvement. CONCLUSION: Given the high prevalence of arthritis, even modest increases in rates of lifestyle physical activity among older adults could make a substantial contribution to disability-free life expectancy.

Activities of Daily Living↗
PubMed2005

Health literacy and functional health status among older adults.

BACKGROUND: Individuals with limited health literacy have less health knowledge, worse self-management skills, lower use of preventive services, and higher hospitalization rates. We evaluated the association between health literacy, self-reported physical and mental health functioning, and health-related activity limitations among new Medicare managed care enrollees. METHODS: A cross-sectional survey of 2923 enrollees was conducted in Cleveland, Ohio; Houston, Tex; Tampa, Fla; and Fort Lauderdale-Miami, Fla. Health literacy was measured using the short form of the Test of Functional Health Literacy in Adults. We used outcome measures that included scores on the physical and mental health functioning subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey, difficulties with instrumental activities of daily living and activities of daily living, and limitations because of physical health and pain. RESULTS: After adjusting for the prevalence of chronic conditions, health risk behaviors, and sociodemographic characteristics, individuals with inadequate health literacy had worse physical function (67.7 vs 78.0, P<.001) and mental health (76.2 vs 84.0, P<.001) than individuals with adequate health literacy. Individuals with inadequate health literacy were more likely to report difficulties with instrumental activities of daily living (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.74-2.92) and activities of daily living (OR, 2.83; 95% CI, 1.62-4.96), limitations in activity because of physical health (OR, 1.79; 95% CI, 1.39-2.32), fewer accomplishments because of physical health (OR, 1.90; 95% CI, 1.48-2.45), and pain that interferes with normal work activities (OR, 2.01; 95% CI, 1.46-2.77). CONCLUSION: Among community-dwelling older adults, inadequate health literacy was independently associated with poorer physical and mental health.

Activities of Daily Living↗
PubMed2005

Explaining US racial/ethnic disparities in health declines and mortality in late middle age: the roles of socioeconomic status, health behaviors, and health insurance.

Pervasive health disparities continue to exist among racial/ethnic minority groups, but the factors related to these disparities have not been fully elucidated. We undertook this prospective cohort study to determine the independent contributions of socioeconomic status (SES), health behaviors, and health insurance in explaining racial/ethnic disparities in mortality and health declines. Our study period was 1992-1998, and our study population consists of a US nationally representative sample of 6286 non-Hispanic whites (W), 1391 non-Hispanic blacks (B), 405 Hispanics interviewed in English (H/E), and 318 Hispanics interviewed in Spanish (H/S), ages 51-61 in 1992 in the Health and Retirement Study. The main outcome measures were death; major decline in self-reported overall health (SROH); and combined outcome of death or major decline in SROH. Crude mortality rates over the 6-year study period for W, B, H/E and H/S were 5.8%, 10.6%, 5.8%, and 4.4%, respectively. Rates of major decline in SROH were 14.6%, 23.2%, 22.1% and 39.4%, for W, B, H/E and H/S, respectively. Higher mortality rates for B versus W were mostly explained by worse baseline health. For major decline in SROH, education, income, and net worth independently explained more of the disparities for all three minority groups as compared to health behaviors and insurance, reducing the effect for B and H/E to non-significance, while leaving a significant elevated odds ratio for H/S. Without addressing the as-yet undetermined and pernicious effects of lower SES, public health initiatives that promote changing individual health behaviors and increasing rates of insurance coverage among blacks and Hispanics will not eliminate racial/ethnic health disparities.

Black or African American↗
PubMed2005

Health insurance coverage during the years preceding medicare eligibility.

BACKGROUND: Adults in late middle age who lack health insurance are more likely to die or experience a decline in their overall health. Because most estimates of the uninsured are cross-sectional, the true number of individuals whose health is at risk from being uninsured is unclear. METHODS: We analyzed a nationally representative sample of 6065 US adults 51 to 57 years old who were interviewed in 1992, 1994, 1996, 1998, and 2000 as part of the Health and Retirement Study. Insurance coverage was determined at the time of each interview and classified as private, public, or uninsured. Longitudinal data were used to determine the proportion of individuals who were uninsured at any interview during the 8-year study period. RESULTS: The proportion of participants who were uninsured at the time of the 1992, 1994, 1996, 1998, and 2000 interviews was 14.3%, 10.8%, 9.7%, 8.8%, and 8.2%, respectively. People frequently transitioned between having insurance and being uninsured. As a result, despite the declining prevalence of being uninsured, the percentage who were uninsured at least once during the 8-year period rose to 23.3% by 2000; few participants (2.6%) were continuously uninsured. Only 60.1% of participants were continuously enrolled in private insurance across all 5 interviews. CONCLUSIONS: The proportion of US adults in late middle age at risk from being uninsured over a 10-year follow-up period was 2 to 3 times higher than cross-sectional estimates. At least one quarter of older adults will be uninsured at some point during the years preceding eligibility for Medicare.

Black or African American↗