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Biomedical subjects

Julie A Gazmararian

Publications and source records attributed to Julie A Gazmararian.

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.

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PubMed2006

Interdisciplinary epidemiologic and economic research needed to support a universal childhood influenza vaccination policy.

Recent research indicates that influenza vaccination of children may decrease the influenza disease burden in adults to a greater extent than targeting vaccination to populations at high risk of serious disease. Possible new policies reflecting these results would add groups most likely to transmit disease to existing vaccination recommendations. Interdisciplinary research combining epidemiology with economics is needed to answer critical questions about the desirability and feasibility of potential new policies, such as what additional resources medical providers might need to expand vaccination to larger groups or what opportunity costs parents might incur in vaccinating their children annually. In this paper, the authors provide background for some of the changes in influenza vaccination rates and disease and discuss existing information gaps and research methods capable of closing these gaps. They provide several examples of interdisciplinary studies that have incorporated both economics and epidemiology or health policy issues. These studies are representative of a variety of stakeholder perspectives needed to determine whether community-based, universal childhood vaccination policies would be more efficacious and cost-effective than strategies targeted toward persons at high risk of disease complications.

Child↗
PubMed2006

Differences in self-management behaviors and use of preventive services among diabetes management enrollees by race and ethnicity.

We assessed the degree that managed care organization (MCO) enrollees used preventive services and engaged in diabetes self-management behaviors by race/ethnicity. A 40-item selfadministered survey was mailed to 19,483 diabetic MCO enrollees. The survey measured use of eight preventive services and engagement in four self-management behaviors among enrollees who self-identified as black, white, or Hispanic. Of the 6,035 surveys analyzed, 4,623 respondents (76.6%) were white, 984 (16.3%) were black, and 428 (7.0%) were Hispanic. Black and Hispanic respondents reported more healthcare visits (mean of 7.0 and 6.5, respectively) in the past year compared to whites (mean, 5.7; p < 0.0001). However, compared to whites, blacks had significantly lower utilization of five of the eight preventive services measured, and Hispanics had significantly lower utilization of seven of the eight preventive services (p < 0.005). With regard to self-management behaviors, blacks were significantly less likely than whites to monitor their diet (65.9% vs. 73.7%, p < 0.0001), exercise (46.4% vs. 52.8%; p = 0.0004) and not smoke (85.1% vs. 89.3%; p = 0.0002); while Hispanics were less likely to monitor their diet (67.3% vs. 73.7%, p = 0.0051). All racial/ethnic groups had low levels of selfmanagement behaviors. Further research is warranted to identify why disparities remain in settings where services are universally available, and to find practical ways to eliminate disparities in a group with routine healthcare encounters.

Black or African American↗
PubMed2006

Impact of health literacy on socioeconomic and racial differences in health in an elderly population.

BACKGROUND: Differences in health literacy levels by race and education are widely hypothesized to contribute to health disparities, but there is little direct evidence. OBJECTIVE: To examine the extent to which low health literacy exacerbates differences between racial and socioeconomic groups in terms of health status and receipt of vaccinations. DESIGN: Retrospective cohort study. PARTICIPANTS (OR PATIENTS OR SUBJECTS): Three thousand two hundred and sixty noninstitutionalized elderly persons enrolling in a Medicare managed care plan in 1997 in Cleveland, OH; Houston, TX; South Florida; and Tampa, FL. MEASUREMENTS: Dependent variables were physical health SF-12 score, mental health SF-12 score, self-reported health status, receipt of influenza vaccine, and receipt of pneumococcal vaccine. Independent variables included health literacy, educational attainment, race, income, age, sex, chronic health conditions, and smoking status. RESULTS: After adjusting for demographic and health-related variables, individuals without a high school education had worse physical and mental health and worse self-reported health status than those with a high school degree. Accounting for health literacy reduced these differences by 22% to 41%. Black individuals had worse self-reported health status and lower influenza and pneumococcal vaccination rates. Accounting for health literacy reduced the observed difference in self-reported health by 25% but did not affect differences in vaccination rates. CONCLUSIONS: We found that health literacy explained a small to moderate fraction of the differences in health status and, to a lesser degree, receipt of vaccinations that would normally be attributed to educational attainment and/or race if literacy was not considered.

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PubMed2006

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy.

BACKGROUND: The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence. OBJECTIVES: To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549). MEASURES: Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%. RESULTS: Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64). CONCLUSIONS: The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.

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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

Public health literacy in America: an ethical imperative.

One of public health professionals' major challenges is to provide the public with messages that are understandable and based on science. Traditionally, public health communication efforts have focused on the science behind the message rather than on how the information should be communicated and whether the message is understood. With more than one third of the U.S. population struggling with low health literacy, ensuring that individuals understand critical health messages is an ethical imperative for public health agencies, organizations, and professionals. This paper explores the ethical implications of public health literacy and the steps the public health community needs to take to promote a society that is public health literate.

Communication↗
PubMed2005

The prevalence of limited health literacy.

OBJECTIVE: To systematically review U.S. studies examining the prevalence of limited health literacy and to synthesize these findings by evaluating demographic associations in pooled analyses. DESIGN: We searched the literature for the period 1963 through January 2004 and identified 2,132 references related to a set of specified search terms. Of the 134 articles and published abstracts retrieved, 85 met inclusion criteria, which were 1) conducted in the United States with > or =25 adults, 2) addressed a hypothesis related to health care, 3) identified a measurement instrument, and 4) presented primary data. The authors extracted data to compare studies by population, methods, and results. MAIN RESULTS: The 85 studies reviewed include data on 31,129 subjects, and report a prevalence of low health literacy between 0% and 68%. Pooled analyses of these data reveal that the weighted prevalence of low health literacy was 26% (95% confidence interval [CI], 22% to 29%) and of marginal health literacy was 20% (95% CI, 16% to 23%). Most studies used either the Rapid Estimate of Adult Literacy in Medicine (REALM) or versions of the Test of Functional Health Literacy in Adults (TOFHLA). The prevalence of low health literacy was not associated with gender (P=.38) or measurement instrument (P=.23) but was associated with level of education (P=.02), ethnicity (P=.0003), and age (P=.004). CONCLUSIONS: A pooled analysis of published reports on health literacy cannot provide a nationally representative prevalence estimate. This systematic review exhibits that limited health literacy, as depicted in the medical literature, is prevalent and is consistently associated with education, ethnicity, and age. It is essential to simplify health services and improve health education. Such changes have the potential to improve the health of Americans and address the health disparities that exist today.

Educational Status↗
PubMed2005

Can an algorithm for appropriate prescribing predict adverse drug events?

OBJECTIVE: To evaluate whether a medication-appropriateness algorithm applied to pharmacy claims data can identify ambulatory patients at risk for experiencing adverse drug events (ADEs) from those medications. STUDY DESIGN: Cohort study. METHODS: We surveyed a random sample of 211 community-dwelling Medicare managed care enrollees over age 65 years who were identified by pharmacy claims as taking a potentially contraindicated medication (exposed enrollees) and a random sample of 195 enrollees who were identified as not taking such a medication (unexposed enrollees). The primary outcome of interest was the prevalence of self-reported events in previous 6 months. RESULTS: Ninety-nine (24.4% of total sample) respondents reported a total of 134 ADEs during the previous 6 months. Exposed enrollees had a significantly higher number of chronic conditions and were taking more prescription and nonprescription medications. However, the higher rate of self-reported ADEs among exposed enrollees was not statistically significant from that of unexposed enrollees (prevalence odds ratio = 1.42; 95% confidence interval [CI] = 0.90, 2.25). Only 1.5% (2/134) of the self-reported ADEs were attributed to a medication from the potentially contraindicated list. Instead, most ADEs were attributed to medications that are commonly used in older patients, including cardiovascular agents (21.6%), anti-inflammatory agents (12.2%), and cholesterol-lowering agents (7.9%). CONCLUSIONS: A medication-appropriateness algorithm using pharmacy claims data was not able to identify a subgroup of enrollees at higher risk of experiencing an ADE from those medications. The vast majority of ADEs were attributable to commonly prescribed medications.

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PubMed2004

Health literacy and use of outpatient physician services by Medicare managed care enrollees.

OBJECTIVE: To determine whether inadequate functional health literacy adversely affects use of physician outpatient services. DESIGN: Cohort study. SETTING: Community. PARTICIPANTS: New Medicare managed care enrollees age 65 or older in 4 U.S. cities (N = 3,260). MEASUREMENTS AND MAIN RESULTS: We measured functional health literacy using the Short Test of Functional Health Literacy in Adults. Administrative data were used to determine the time to first physician visit and the total number of visits during the 12 months after enrollment. The time until first visit, the proportion without any visit, and adjusted mean visits during the year after enrollment were unrelated to health literacy in crude and multivariate analyses. Participants with inadequate and marginal health literacy were more likely to have an emergency department (ED) visit than those with adequate health literacy (30.4%, 27.6%, and 21.8%, respectively; P =.01 and P <.001, respectively). In multivariate analysis, the adjusted relative risk of having 2 or more ED visits was 1.44 (95% confidence interval, 1.01 to 2.02) for enrollees with marginal health literacy and 1.34 (1.00 to 1.79) for those with inadequate health literacy compared to participants with adequate health literacy. CONCLUSIONS: Inadequate health literacy was not independently associated with the mean number of visits or the time to a first visit. This suggests that inadequate literacy is not a major barrier to accessing outpatient health care. Nevertheless, the higher rates of ED use by persons with low literacy may be caused by real or perceived barriers to using their usual source of outpatient care.

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PubMed2003

Health literacy and knowledge of chronic disease.

We sought to examine the relationship between health literacy and knowledge of disease among patients with a chronic disease. A total of 653 new Medicare enrollees aged 65 years or older who had at least one chronic disease (115 asthma, 266 diabetes, 166 congestive heart failure, 214 hypertension), completed both the in-person and telephone survey. Health literacy measured by the short test of functional health literacy in adults (S-TOFHLA) and demographic information were collected during the in-person survey. Knowledge of disease was assessed by questions based on key elements in educational materials during a telephone survey. Overall, 24% of patients had inadequate and 12% had marginal health literacy skills. Respondents with inadequate health literacy knew significantly less about their disease than those with adequate literacy. Multivariate analysis indicated that health literacy was independently related to disease knowledge. There are many opportunities to improve patients' knowledge of their chronic disease(s), and efforts need to consider their health literacy skills.

Aged↗
PubMed2002

Hospitalizations during pregnancy among managed care enrollees.

OBJECTIVE: To describe the prevalence of hospitalizations during pregnancy, the reason for hospitalization, the length of stay, and the associated costs. METHODS: We analyzed data from a national managed care organization and determined the occurrence of hospitalizations for 46,179 women who had a live birth or a pregnancy loss in 1997. RESULTS: Overall, 8.7% of women were hospitalized during their pregnancy. Of these, 5.7% were hospitalized and discharged while pregnant, 0.8% experienced extended stays before a live birth or pregnancy loss, and 2.1% experienced pregnancy loss. Hospitalizations were more common among younger women, women with multiple gestations, and women in the northeastern United States. Women who had a live birth were primarily hospitalized for preterm labor (24%), hyperemesis (9%), hypertension (9%), kidney disorders (6%), and prolonged premature rupture of membranes (6%). Charges totaled over $36 million. CONCLUSION: Antenatal hospitalizations are common.

Adolescent↗
PubMed2002

Vaccine storage practices in primary care physician offices: assessment and intervention.

PURPOSE: To assess the proportion of primary care physician (PCP) offices meeting vaccine storage guidelines, identify factors associated with low compliance, and evaluate whether a quality improvement (QI) activity improves compliance. METHODS: We examined compliance with guidelines of 721 PCP offices contracted with a national managed care organization in four cities. A QI activity (educational materials, written feedback, and distribution of thermometers) was conducted at baseline and a follow-up assessment occurred within 3 months. RESULTS: Baseline compliance was relatively high, with >80% adherence to most guidelines. For example, 89% of offices had a thermometer; and 83% of temperatures were appropriate. Most units did not have vaccines stored in the door or food/biological materials in the unit (80% and 96%, respectively). Almost all vaccines had not expired. Multivariate analysis indicated that practice location, type of physician, participation in vaccine programs, and using guidelines were associated with compliance. For most of the compliance measures, pediatric offices had the highest compliance. Adherence to guidelines improved after the QI activity; the net change between pre- and post-intervention ranged from +1% to +19%. Measurements most impacted included temperature log posted (19% improvement in refrigerator; 16% improvement in freezer) and no vaccine stored in refrigerator door (14% improvement). CONCLUSIONS: Despite generally high compliance, there are some opportunities for improvement in how PCPs store vaccines. Incorporating an intervention program in existing practice activities can improve storage practices. Further research is needed to determine the possible benefits of targeting interventions to certain types of providers who may be less knowledgeable about recommended guidelines.

Chi-Square Distribution↗
PubMed2002

Unintended pregnancy in a commercially insured population.

OBJECTIVES: While much attention has been focused on unintended pregnancy in disadvantaged populations, few studies have focused on women in lower risk groups. This study, conducted in a national managed care organization, reports the prevalence of unintended pregnancy resulting in live births and examines associated factors METHODS: Women ages 18-49 who delivered a live infant during a 6-month interval were eligible for the study. Telephone surveys were conducted after delivery. We report the rate of unintended pregnancy resulting in a live birth, and describe its association with sociodemographic and pregnancy-related factors, partner's intention status, and contraceptive use. RESULTS: Of 1173 births, 29% were unintended. Women who reported that the partner did not want the pregnancy were 7.4 times more likely than women whose partner wanted the pregnancy to regard the pregnancy as unintended. Only 40% of the women with an unintended birth used birth control and 64% of those used less effective methods such as condoms and diaphragms. CONCLUSIONS: In a population where the majority of women were married, educated, and with incomes over $40,000, almost 1/3 of the births resulted from unintended pregnancies. Future research is needed to help us better understand contradictions in pregnancy intention and contraceptive behavior. Comprehensive efforts are needed to promote consistent and correct use of contraception by women at risk for unintended pregnancy, and to involve male partners in family planning.

Adolescent↗
PubMed2002

How are patients' specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians?

CONTEXT: Few data are available regarding the consequences of patients' problems with interpersonal aspects of medical care. OBJECTIVE: To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want. DESIGN: Telephone survey during 1997. PARTICIPANTS: Patients (N=2,052; 58% response) insured by a large national health insurer. MEASUREMENTS: Patient trust, overall ratings of physicians, and having considered changing physicians. RESULTS: Most patients (78%) reported at least 1 problem experience. In multivariable analyses, each problem experience was independently associated with lower trust (all P <.001) and 5 of 6 with lower overall ratings (P <.001). Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3 to 3.0), not always taking enough time to answer questions (OR, 3.3; 95% CI, 2.2 to 5.2), and not always giving enough medical information (OR, 4.0; 95% CI, 2.4 to 6.6). CONCLUSIONS: Problem experiences in the ambulatory setting are strongly related to lower trust. Several are also associated with lower overall ratings and with considering changing physicians, particularly problems related to communication of health information. Efforts to improve patients' experiences may promote more trusting relationships and greater continuity and therefore should be a priority for physicians, educators, and health care organizations.

Adult↗
PubMed2002

Health literacy and preventive health care use among Medicare enrollees in a managed care organization.

BACKGROUND: Many older adults in Medicare managed care programs have low health literacy, and this may affect use of preventive services. OBJECTIVES: To determine whether older adults with inadequate health literacy were less likely to report receiving influenza and pneumococcal vaccinations, mammograms, and Papanicolaou smears than individuals with adequate health literacy after adjusting for other covariates. RESEARCH DESIGN: Cross-sectional survey; home interviews with community dwelling enrollees. SUBJECTS: Medicare managed care enrollees 65 to 79 years old in four US cities (n = 2722). MEASURES: Short Test of Functional Health Literacy in Adults and self-reported preventive service use. RESULTS: In bivariate analyses, self-reported lack of preventive services was higher among individuals with inadequate health literacy than those with adequate health literacy: never had an influenza vaccination: 29% versus 19% (P = 0.000); never had a pneumococcal vaccination: 65% versus 54% (P = 0.000); no mammogram in the last 2 years: 24% versus 17% (P = 0.017); never had a Papanicolaou smear: 10% versus 5% (P = 0.002). After adjusting for demographics, years of school completed, income, number of physician visits, and health status, people with inadequate health literacy were more likely to report they had never received the influenza (OR, 1.4; 95% CI, 1.1-1.9) or pneumococcal vaccination (OR, 1.3; 95% CI, 1.1-1.7), and women were less likely to have received a mammogram (OR, 1.5; 95% CI, 1.0-2.2) or Papanicolaou smear (OR, 1.7; 95% CI, 1.0-3.1). CONCLUSIONS: Among Medicare managed care enrollees, inadequate health literacy is independently associated with lower use of preventive health services.

Aged↗
PubMed2002

Functional health literacy and the risk of hospital admission among Medicare managed care enrollees.

OBJECTIVES: This study analyzed whether inadequate functional health literacy is an independent risk factor for hospital admission. METHODS: We studied a prospective cohort of 3260 Medicare managed care enrollees. RESULTS: Of the participants, 29.5% were hospitalized. The crude relative risk (RR) of hospitalization was higher for individuals with inadequate literacy (n = 800; RR = 1.43; 95% confidence interval [CI] = 1.24, 1.65) and marginal literacy (n = 366; RR = 1.33; 95% CI = 1.09, 1.61) than for those with adequate literacy (n = 2094). In multivariate analysis, the adjusted relative risk of hospital admission was 1.29 (95% CI = 1.07, 1.55) for individuals with inadequate literacy and 1.21 (95% CI = 0.97, 1.50) for those with marginal literacy. CONCLUSIONS: Inadequate literacy was an independent risk factor for hospital admission among elderly managed care enrollees.

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