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PubMed2005

Elder financial abuse: an evaluation framework and supporting evidence.

OBJECTIVES: To develop a valid and reliable framework for evaluating cases of alleged elder financial abuse. DESIGN: Experienced experts in elder financial abuse rated a framework with eight elements. SETTING: Professionals attending an advanced training course on elder abuse. PARTICIPANTS: Deputy district attorneys (n=44), senior law enforcement detectives (n=59), Adult Protective Service workers, and public guardians and victim advocates (n=56) who had a combined total of 1,985 years of experience and who had investigated a total of 3,225 cases (mean of 13.1 years and 21.2 cases) were included. MEASUREMENTS: These experienced professionals were asked to rate how well an evaluative framework matched their experience with elder financial abuse using a 5-point rating scale ranging from very little to almost entirely. RESULTS: The mean rating for the model was 4.4 out of 5. About 90% of the sample rated it as almost entirely or very much matching their experience. There were no differences between professions. The reliability measure was 0.85. CONCLUSION: These results suggest a reliable and valid framework for evaluating cases of possible elder financial abuse.

Aged↗
PubMed2006

Flood risk acceptability and economic value of evacuation.

The economic value of evacuation and its relationship with flood risk acceptability in Japan were studied by applying the contingent valuation method (CVM). Flood risk acceptability here refers to the extent to which people accept the occurrence of floods, in terms of scale and frequency. The economic value of evacuation refers to people's willingness to pay (WTP) for avoiding evacuation inconvenience because of its inconvenience and the potential for certain losses as a result of evacuation. Our main finding was that over half of the people (56%) who actually evacuated in a real flood situation reported inconvenience. The greatest inconveniences were the shortages of information and food. Evacuation inconvenience can be regarded as an important factor causing the low rate of evacuation in Japan. The WTP for avoiding current inconvenience was approximately half of the estimated economic value of evacuation, implying that the current budget for evacuation is too small and should be increased to improve the conditions of evacuation sites. The economic value of evacuation can be taken into consideration in the risk assessment process in order to evaluate the efficiency of risk reduction measures. Flood risk acceptability and home ownership are two major statistically significantly determinants of the WTP. Considering that those who accept flood risk have a lower WTP for flood risk control (ex ante measures) than those who reject it, it is reasonable to think that there may be a tradeoff between the public WTPs for ex ante or ex post measures.

Adult↗
PubMed1996

Leave and employment in families of preterm low birthweight infants.

OBJECTIVE: To determine how employment, income and out-of-pocket expenses changed in 224 families of low birthweight infants during the first 6 months after the infant was discharged home. DESIGN: Prospective, descriptive. POPULATION, SAMPLE, SETTING, YEARS: Families of preterm, low birthweight infants. A convenience sample of families of 224 preterm (< 37 weeks gestation) low birthweight (< 2500 grams) infants was obtained from one hospital in the Northeastern U.S.A. Mothers were interviewed over the telephone at each of the data points. Years of data collections were 1990-1994. METHODS: Mothers kept logs of expenses and were interviewed about changes in employment and income at infant discharge from the hospital and 1, 3, and 6 months later. FINDINGS: All but two of the employed mothers had to leave employment early because of pregnancy complications. After delivery, fewer mothers returned to work or returned later and worked less than mothers in national studies. Families spent 2% to 4% of their income in non-reimbursed out-of-pocket expenses; transportation was a major expense. CONCLUSIONS: Having a low birthweight infant results in unexpected changes in employment and in increased and unexpected out-of-pocket expenses. CLINICAL IMPLICATIONS: Study findings support the need for longer leave for mothers who have small infants.

Adult↗
PubMed2004

Willingness to pay for dentin regeneration in a sample of dentate adults.

OBJECTIVES: Measurement of individuals' valuation of dental treatments is important in the evaluation of new technologies. In this paper the value of dentin regeneration, a new treatment for teeth with reversible pulpitis, is measured based on what individuals say they would be willing to pay to receive the treatment. METHODS: A total of 611 randomly selected dentate adults answered willingness to pay (WTP) and dental insurance questions. Detailed descriptions of the process and expected outcomes for dentin regeneration were presented to subjects as part of a larger study measuring preferences for different treatments. WTP was determined for two different levels of success for dentin regeneration. RESULTS: At a success rate of 95%, the mean WTP for dentin regeneration was $262.70 (noninsured) and $11.00 per month (insured subjects). For success rate of 75%, the corresponding values were $210.90 and $9.20 per month. Multivariate analyses were used to identify any significant relationships between WTP and a range of variables covering socio-demographic, socio-economic, dental experience and oral health status variables. The findings indicate that individuals' valuations of treatments involve substantial unexplained variation. About half of the noninsured subjects would pay for dentin regeneration if it cost $200 per tooth. CONCLUSIONS: The data on the WTP for dentin regeneration indicate that a substantial percentage of adults will pay for this new technology. This study provides for the first time an estimate of WTP for dentin regeneration among the population.

Adult↗
PubMed2006

Challenges to dental access - England as a case study.

Access to dental services because of an insufficient workforce is a historic challenge faced by many developing countries. In recent years, however, it has become a major issue for many industrialized countries. The growing demand for cosmetic dentistry, an increase in patients' willingness to pay for dental treatment, and growing numbers of older dentate patients have all put pressure on dental systems. Ways of meeting these challenges and ensuring reasonable dental access will vary from country to country, but the solutions often lie in how the dental workforce is regulated. This case study of the dental reforms currently being implemented in England highlights progress at a particular point in time (Summer 2005). It is clear that it will take a number of years to find a new national dental payment system (the National Health Service) to replace the system which has changed little since 1948. However, the political pressure to address poor access to state-funded dental services calls for more immediate actions. The initial approach was to increase the dental workforce via international recruitment, and in the medium term to increase the number of dental students in training and to expand the numbers of other members of the dental team. An additional stratagem is to retain those already providing dental care under the National Health Service by the introduction of a new method of remuneration. England is trying to improve both access to care and the oral health of the population by creating a workforce more suitable to public demands and changing oral health needs.

Dental Health Services↗
PubMed2001

Assessing the difference between sociodental and normative approaches to assessing prosthetic dental treatment needs in dentate older people.

OBJECTIVE: To illustrate differences in assessed need using normative and sociodental approaches to assess prosthetic treatment needs of dentate older people. DESIGN: A cross-sectional study using non-random sample. SETTING: Metropolitan area of Chiang Mai, Thailand. SUBJECTS: 707 older individuals, 549 of the total sample were dentate, living independently, aged 60 to 74 years. RESULTS: The dentate population examined consisted of 289 classified as 'normal health' and 44 with a nutritional problem. Of the total population, 60% (333) had a normative need for partial dentures. Excluding the 44 with a nutritional problem, 50% (146) of the NTM group had 'impact-related treatment need' and of the latter 146, 69% (102) had a high propensity for health behaviour. 41% of the 102 who had 'impact-related' and 'propensity related treatment need' had 'accessible treatment need'. That is 14.5 per 100 of those with normative need. The gap between normative and 'accessible need' was greater among those with 'general health related treatment need' due to underweight. Of the 44 with a NTM and had a health problem, 45% (20) had a 'propensity related treatment need'. 40% of the group with a 'propensity related treatment need' had 'accessible treatment need'. Overall of the 44 older people with a normative need for a prosthesis and who had a health problem, only 2.4% had 'accessible treatment need' mainly due to lack of finance. If the treatment were subsidised then 45% of those with 'propensity related treatment need' would be eligible for treatment. CONCLUSION: Large differences of estimated treatment need were found between a sociodental and a normative approach to assess prosthetic dental treatment needs of older Thai people.

Activities of Daily Living↗
PubMed2000

Medical training debt and service commitments: the rural consequences.

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

Career Choice↗
PubMed2003

Veterans' system-of-care preferences for percutaneous transluminal coronary angioplasty in a rural setting.

CONTEXT: In the Veterans Health Administration (VHA), regionalization of high-technology health care services may influence veterans who live far from referral centers to obtain care locally, through the private sector. PURPOSE: To understand veterans' system-of-care preferences for a high-technology regionalized service. METHODS: The charts of 142 veterans who were referred for percutaneous transluminal coronary angioplasty (PTCA) by their VHA cardiologists were reviewed. FINDINGS: Fifty-two percent of these veterans obtained the procedure outside the VHA system. Insurance coverage and out-of-pocket costs were strongly associated with veterans' obtaining PTCA outside of the VHA system; travel distance was not. CONCLUSIONS: As the VHA begins to understand veterans' use of multiple systems of care, it will be important to understand the relationship between out-of-pocket costs and the system of care used for high-technology health care services.

Angioplasty, Balloon↗
PubMed2003

Use of and attitudes toward complementary and alternative medicine among family practice patients in small rural Illinois communities.

CONTEXT: Complementary and alternative medicine (CAM) use continues to increase in the United States. Data on rural patients' use and extent of integration of CAM with conventional medicine are lacking, although this is a population often associated with use of "folk remedies" and self-care strategies. PURPOSE: To examine rural primary care patients' attitudes toward and use of CAM. METHODS: A total of 176 surveys (70% response rate) were returned by patients at 5 geographically dispersed, rural Illinois family practice clinics to examine rural patients' use of, attitudes toward, and experiences with alternative medicine and providers. FINDINGS: Nearly two thirds of patients reported use of alternative medicine. Therapies most often used were vitamins/megavitamins, chiropractic, relaxation, and prayer/faith healing. Rural patients with more medical problems and a higher level of education were more likely to use alternative techniques. Three fifths of the patients felt that their doctor should discuss alternative medicine and therapies with them. CONCLUSIONS: Physician understanding and communication regarding CAM may be especially important in rural areas, where access to care is more limited and where there is greater reliance on the primary care physician as a "gatekeeper" for patient health.

Adult↗
PubMed2004

Insurance coverage of prescription drugs and the rural elderly.

CONTEXT: Rural impacts of a Medicare drug benefit will ultimately depend on the number of elderly who are currently without drug coverage, new demand by those currently without coverage, the nature of the new benefit relative to current benefits, and benefit design. PURPOSE: To enhance understanding of drug coverage among rural elderly Medicare beneficiaries and their expenditures for pharmaceuticals. METHODS: Estimates of the extent of coverage, expenditures, and sources of drugs were obtained using data are from the 1997 Medicare Current Beneficiary Survey and the Pharmacy Verification and Household Components of the 1996 Medical Expenditure Panel Survey. FINDINGS: Three-quarters of the urban elderly had some type of drug coverage in 1997 versus 59% of the elderly in rural areas. Urban residents were more likely to have obtained their drug coverage from an employer-sponsored supplemental plan, and rural residents were more likely to have self-purchased Medigap drug coverage. Expenditures and use of drugs by Medicare beneficiaries are greater for those with than without coverage, and differences are invariant with respect to geographic location. Coverage under self-purchased supplemental plans appears less generous than under employer-sponsored plans in both rural and urban areas. Rural and urban elderly are more than twice as likely to receive at least 1 prescribed medication through the mail than the general population. CONCLUSION: A well-designed Medicare drug benefit would be especially beneficial to the rural elderly because relatively more rural elderly currently lack coverage or have less generous coverage than urban beneficiaries. Mail-order distribution may help contain future program expenditures.

Aged↗
PubMed2005

Perceived barriers to health care access among rural older adults: a qualitative study.

CONTEXT: Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access. PURPOSE: To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication. METHODS: During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access. FINDINGS: Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration. CONCLUSIONS: Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

Aged↗