Preventive service delivery for children in a managed care environment: contrasts and lessons from Israel.
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Budgets↗
Biomedical subjects
G H DeFriese
Publications and source records attributed to G H DeFriese.
Self-reported arthritis-related disruptions in sleep and daily life and the use of medical, complementary, and self-care strategies for arthritis: the National Survey of Self-care and Aging.
OBJECTIVE: To assess relations between self-reported arthritis-related disruptions in sleep, physical activity, and social functioning and use of medical care, complementary therapies, and self-care for arthritis in older adults. DESIGN: A survey of self-reported arthritis-related disruptions in sleep and daily life as risk factors for use of 15 medical, complementary, and self-care modalities for relief of arthritis symptoms. SETTING: General community from 38 urban and 12 rural areas in the contiguous United States. PARTICIPANTS: Nine hundred thirty-seven older persons reporting arthritis; of the 1925 in the 1993 to 1994 follow-up of the National Survey of Self-care and Aging, a population-based, stratified, random sample of noninstitutionalized Medicare beneficiaries aged 65 years and older. MAIN OUTCOME MEASURES: Use of 15 medical, self-care, and complementary modalities for relief of arthritis symptoms. RESULTS: Most respondents reported use of at least 1 medical, complementary, or self-care strategy for arthritis. Arthritis was reported to disrupt sleep and leisure in 32.8% and 33.4% of respondents, respectively. Individuals with sleep disruption were more likely than those without sleep disturbance to use medical, complementary, and self-care strategies (adjusted odds ratio [95% confidence interval], 2.31 [1.59-3.37] for seeing a physician; and 2.23 [1.60-3.10] for using physical modalities). Reported disruption in sleep from arthritis was associated with use of more medical, complementary, and self-care strategies than was any other disruption. CONCLUSIONS: Self-reported arthritis-related disruption in sleep is associated with use of a wide range of medical, complementary, and self-care strategies. Physicians, other health care providers, and researchers should not overlook the importance of this common and often-neglected symptom.
Activities of Daily Living↗
Improving immunization surveillance and performance monitoring.
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Centers for Disease Control and Prevention, U.S.↗
Self-care practices used by older men and women to manage urinary incontinence: results from the national follow-up survey on self-care and aging.
OBJECTIVES: To estimate the extent to which self-care practices are employed by older adults with urinary incontinence (UI); to determine how demographic and functional status measures are associated with self-care practice use; and to explore the relationship between contacting a doctor and disposable pad use. DESIGN: A cross-sectional analysis of a national probability sample using multiple logistic regression. SETTING: Responses of subjects with UI (n = 787) from the 1993-1994 National Follow-up Survey on Self-Care and Aging, a follow-up survey of older Medicare beneficiaries living in the community within the contiguous United States drawn in 1990-1991 MEASURES: Subject responses about UI, fecal incontinence, dressing, eating, bathing, Instrumental Activities of Daily Living (IADL), Mobility Activities of Daily Living (MADL), age, gender, place of residence, race, education, proxy response to the survey, and self-reported medical conditions. RESULTS: Self-care practices used by more than 25% of respondents with UI included using disposable pads, limiting trips, and limiting fluids. Among older adults with incontinence, more women used disposable pads (44.5%; 95% CI, 36.9-52.1) and performed exercises (14.2%; 95% CI, 9.7-18.9) than did men (15.1%; 95% CI, 8.1-22.1; and 4.3%; 95% CI, 1.0-7.7, respectively). Bi-variate analysis showed respondents with severe UI or fecal incontinence reported greater use of self-care practices. In multivariate models of the three most commonly used self-care practices, measures of UI severity were not always associated independently with self-care practice use, whereas ADL measures of functional status were. Disposable pad use was positively independently associated (OR 3.36; 95% CI, 2.01-5.63) in multivariate models with contacting a doctor about incontinence, even after controlling for age, gender, demographics, and self-reported medical conditions. CONCLUSIONS: Use by older adults of self-care practices to manage urinary incontinence is predicted independently in multivariate models by measures of functional status such as dressing, eating, bathing, IADLs or MADLs, but not by all UI measures. Disposable pad users had increased odds of contacting a doctor, suggesting that self-care practices and formal medical care are not always inversely related.
Activities of Daily Living↗
The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries.
OBJECTIVES: Self-care includes actions taken by individuals to promote or ensure their health, to recover from diseases or injuries, or to manage their effects. This study measured associations between self-care practices (lifestyle practices, adaptations to functional limitations, and medical self-care) and Medicare expenditures among a national sample of adults 65 years and older. METHODS: Regression models of Medicare use and expenditures were estimated by using the National Survey of Self-Care and Aging and Medicare claims for 4 years following a baseline interview. RESULTS: Lifestyle factors (swimming and walking) and functional adaptations (general home modifications) were associated with reductions in monthly Medicare expenditures over a 12-month follow-up period. Expenditure reductions were found over the 48-month follow-up period for participation in active sports, gardening, and medical self-care. Practices associated with increases in expenditures included smoking, physical exercise (possibly of a more strenuous nature), and specific home modifications. CONCLUSIONS: Certain self-care practices appear to have significant implications for Medicare expenditures and presumptively for the health status of older adults. Such practices should be encouraged among older adults as a matter of national health policy.
Activities of Daily Living↗
The association of urinary incontinence with poor self-rated health.
OBJECTIVES: To assess whether urinary incontinence (UI) and its severity are associated with poor self-rated health in a national sample of community-living older adults and whether this relationship persists after controlling for confounding attributable to functional status, comorbidity, and demographic factors. DESIGN: A cross-sectional analysis using multivariate logistic regression. SETTING: Subjects were from the 1990-1991 National Survey of Self-Care and Aging (N = 3485), a random sampling in geographic clusters of community-dwelling Medicare beneficiaries 65 years of age or older in the contiguous United States. MEASURES: The responses to an interviewer-administered questionnaire regarding urinary incontinence, Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living (IADL), Mobility Activities of Daily Living (MADL), age, gender, place of residence, race, education, need for proxy response to the survey, and number of medical conditions. RESULTS: Unadjusted analysis showed the presence of urinary incontinence to be associated with poor self-rated health (OR 2.7, 2.1-3.3). With gender, number of comorbid conditions, race, IADL impairment, and interaction terms of incontinence/race and incontinence/IADL in the final model, UI was associated with poor self-rated health in certain subgroups. White subjects with no IADL impairment and mild-moderate incontinence had an OR of 2.0 (95% CI 1.5-2.9) and those with severe incontinence had an OR of 4.5 (95% CI 2.4-8.4) of rating their health as poor, whereas those with no IADL impairment and no incontinence were the referent group. For those with a lot of difficulty performing one or more IADL activity, the association of UI and poor self-rated health was weak. For non-white subjects, there was no association, or a very weak association, of UI and poor self-rated health. CONCLUSION: In this national sample, urinary incontinence was independently and positively associated with poor self-rated health after adjustment for age, comorbidity, and frailty for most community-dwelling older adults. This association between UI and poor self-rated health was weaker and statistically insignificant when IADL impairment was present or in non-white subjects. Further research is indicated to better understand the impact of urinary incontinence in specific cultural settings.
Activities of Daily Living↗
Predicting mortality from community surveys of older adults: the importance of self-rated functional ability.
Using data from the 1990 baseline of the National Survey of Self-Care and Aging (NSSCA), and nearly three years of follow-up mortality data, we examined the association between self-rated functional ability, a global measure of perceived ability of function independently, and mortality among a national sample of older adults. The study included 3,485 subjects selected from the Medicare Beneficiary Files according to a stratified random sampling design, with approximately equal numbers of adults by gender in each of three age categories, 65-74, 75-84, and 85 and over. Self-rated functional ability was found to have an independent contribution to the subsequent risk of death among older adults. Using multivariate models that accounted for self-rated health, age, gender, medical conditions, functional status, and assistance from others, poor self-ratings on this single item nearly doubled the risk of death during the follow-up period. These findings suggest the importance, for both researchers and clinicians, of measuring the potential prognostic importance of self-ratings of health and self-ratings of functional ability among older adults.
Activities of Daily Living↗
Metropolitan versus nonmetropolitan differences in functional status and self-care practice: findings from a national sample of community-dwelling older adults.
The objective of this study was to use a recent national probability survey of the noninstitutionalized older adult population to compare the functional status and self-care practices of older adults residing in metropolitan and nonmetropolitan communities and to identify differences associated with residential location. The survey used in this study was the National Survey of Self-care and Aging (NSSCA). A cross-sectional design was employed using weighted bivariate and multivariate logistic regression analyses to examine the relationship between metropolitan and nonmetropolitan residential location and self-reported ability to perform basic, mobility, and instrumental activities of daily living (ADLs), as well as to assess the degree to which the levels and types of functional limitations affect metropolitan versus nonmetropolitan older adults' performance of self-care activities. The bivariate logistic analyses pointed to modest, often insignificant metropolitan versus nonmetropolitan differences in the ability to perform functional tasks. However, larger positive effects of nonmetropolitan residence were generally observed once other factors likely to account for some of these differences were taken into account. Older adults from nonmetropolitan areas were more likely to report being able to perform functional activities but also were more likely to report performing self-care activities both in the presence and absence of disability. This study, therefore, concluded that nonmetropolitan older adults may discount the significance of declining functional status, thus normalizing the trajectory of aging in a different way than do their metropolitan counterparts. If this process occurs, it may affect how nonmetropolitan persons use primary health care and/or long-term care services, challenging the economists' concept of demand, the clinicians' concept of need, and the policy analysts' concept of equity. Additional work is required to assess whether such a normalization process actually occurs and, if so, to explore its distribution, causes, correlates, and consequences.
Activities of Daily Living↗
Knowledge of risk among patients at increased risk for stroke.
BACKGROUND AND PURPOSE: Patients who recognize their increased risk for stroke are more likely to engage in (and comply with) stroke prevention practices than those who do not. We describe perceived risk of stroke among a nationally diverse sample of patients at increased risk for stroke and determine whether patients' knowledge of their stroke risk varied according to patients' demographic and clinical characteristics. METHODS: Respondents were recruited from the Academic Medical Center Consortium (n = 621, five academic medical centers, inpatients of varying age); the Cardiovascular Health Study (n = 321, population-based sample of persons aged 65+ years); and United HealthCare (n = 319, five health plans, inpatients and outpatients typically younger than 65 years). The primary outcome was awareness of being at risk for stroke. RESULTS: Only 41% of respondents were aware of their increased risk for stroke (including less than one half of patients with previous minor stroke). Approximately 74% of patients who recalled being told of their increased stroke risk by a physician acknowledged this risk in comparison with 28% of patients who did not recall being informed by a physician. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. CONCLUSIONS: Over one half of patients at increased risk of stroke are unaware of their risk. Healthcare providers play a crucial role in communicating information about risk, and successful communication encourages adoption of stroke prevention practices. Educational messages should be targeted toward patients least likely to be aware of their risk.
Adult↗
Older adults as a community resource: results from the National Survey of Self-Care and Aging.
Using data collected from the first wave of a longitudinal data set collected in the late fall and winter of 1990-1991, the National Survey of Self-Care and Aging (NSSCA), we examined the extent and type of assistance older people provided to others. Age, gender, and perceived health status were the most consistent predictors of the four types of assistance: personal care, child care, volunteer work, and listening/offering advice and support. Help with instrumental activities of daily living either alone or in combination with other activities of daily living was the most common type of personal care provided.
Activities of Daily Living↗
The effects of having a regular doctor on access to primary care.
The authors assessed the relationship between having a regular doctor and access to care, as measured by a set of preventive and primary care utilization indicators recommended by the Institute of Medicine. The 1987 National Medical Expenditure Survey was used in the analyses (n = 30,012). The results of the regression analyses suggest that individuals with any type of regular source of care had better access than those without a regular source of care. Persons with a regular doctor had better access to primary care than those with a regular site but no regular doctor. However, the apparent advantage of having a regular doctor over a regular site disappeared when only those individuals reporting a physician's office, clinic, or health maintenance organization as their regular source of care were compared. These results suggest that policies that promote the doctor-patient relationship will increase access, although the gains may be negligible for individuals who use mainstream primary care sites (physician's office, clinic, or health maintenance organization) versus sites such as walk-in clinics or emergency rooms.
Adolescent↗
Prospects for childhood immunization registries in public health assessment and assurance: initial observations from the All Kids Count initiative projects.
This article offers an overview of selected evaluation findings from the initial implementation year of the Robert Wood Johnson Foundation's All Kids Count childhood immunization initiative in which demonstration projects were funded to develop community-based immunization registry and follow-up systems in 14 sites throughout the United States. The basic components of these systems, the process through which these registries were developed, efforts to secure the participation of private sector providers, the prospects for system success at the community level, and the potential for these immunization programs to influence other aspects of primary health care for children are addressed.
Health Services Accessibility↗
Requiem or reveille for health services research?
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Career Choice↗
Non-profit conversions: a challenge and an opportunity for health services research with a clear "public benefit".
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Community-Institutional Relations↗
Self-care and assistance from others in coping with functional status limitations among a national sample of older adults.
Using data from the first wave of a new longitudinal data set collected in the late fall and winter of 1990-1991, the National Survey of Self-Care and Aging (NSSCA), we examined older adults' self-care practices in coping with functional status limitations based on in-person interviews with a national probability sample of 3,485 noninstitutionalized adults aged 65 or older selected from Medicare beneficiary files. A composite score of functional status was calculated to reflect the presence and severity of disability in three dimensions: basic, mobility, and instrumental activities of daily living. Three types of self-care coping strategies were defined: use of equipment or devices, changes in behavior, and modifications in one's environment. National estimates of self-care practices, assistance from others, and functional status measures were presented. Data revealed that the likelihood of engaging in self-care coping strategies increased as the severity of disability increased, except among the most severely disabled. Generally, those receiving assistance from others were more likely to engage in self-care activities, suggesting that receiving assistance supplements, rather than supplants, self-care coping strategies.
Activities of Daily Living↗
US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices.
BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.
Aspirin↗
Adoption of a new Haemophilus influenzae type b vaccine recommendation.
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Adult↗
The Stroke Prevention Patient Outcomes Research Team. Goals and methods.
BACKGROUND AND PURPOSE: The aim of the present study, based at Duke University and involving 14 other institutions, is to identify the most appropriate and cost-effective clinical strategies for prevention of ischemic (thrombotic or embolic) stroke in high-risk individuals and to design and test an intervention to disseminate this information to providers and the public. METHODS: The study uses (1) secondary data from literature review, Medicare claims, and population-based data from three epidemiological studies and (2) primary data generated in national physician and patient surveys and in demonstration trials. Phases I through III involve data collection and analysis using a decision/cost-effectiveness model and consensus development methods. Phase IV includes intervention in physicians' practice patterns. Data is collected by literature survey and abstraction, review of medical records, claims analysis, and patient and physician surveys. CONCLUSIONS: A structured decision model and a well-defined clinical focus provide a successful organization for a PORT on stroke prevention.
Cerebrovascular Disorders↗