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PubMed2005

Patients' perceived barriers to active self-management of chronic conditions.

Few studies have elicited barriers to patient self-management of chronic conditions, and only one concerned people with two or more conditions. To inform development of Homing in on Health (HioH), a home delivery variant of the Chronic Disease Self-Management Program (CDSMP), we conducted 10 focus groups involving 54 chronically ill people, 46 (85%) of whom had multiple conditions. The goals were to elicit perceived barriers to active self-management and to accessing self-management support resources. Depression, weight problems, difficulty exercising, fatigue, poor physician communication, low family support, pain, and financial problems were the most frequently noted barriers to active self-management. The most common barriers to accessing self-management support resources were lack of awareness, physical symptoms, transportation problems, and cost/lack of insurance coverage. Our findings provided initial support for the Homing in on Health approach, since many of the barriers identified may be more amenable to home-based intervention than to centralized, facility-based programs.

California↗

PubMed1989

Providing service--or aiding and abetting discrimination?

Even though federal antidiscrimination laws do not include third-party liability, a number of states now have statutes containing aiding-and-abetting provisions that may provide a basis for causes of action. For instance, in a recent decision, the Colorado Supreme Court held that a third-party insurance company will be held liable along with the employer for providing health insurance coverage that does not cover normal pregnancy expenses. Similarly, cases involving newspapers have shown that newspaper classifieds may occasion liability solely to the newspaper, and not the advertiser, even absent intent. The author provides a full discussion of such issues as standard of proof and exactly who is liable and offers solutions to these new liability problems.

Civil Rights↗

PubMed2002

Self-reported mammography screening among Oklahoma women age 50 and older: Oklahoma Behavioral Risk Factor Surveillance System 1997-2001.

PURPOSE: To examine which factors were associated with mammography screening among women age 50 and older in Oklahoma from 1997-2001. METHODS: Using data from 4,338 women age 50 and older interviewed for the 1997-2001 Oklahoma Behavioral Risk Factor Surveillance System, this study examines the proportion of women receiving mammography screening services and assesses the associations between covariates of interest and mammography screening. RESULTS: Among Oklahoma women age 50 and older, 17.5% had never received a mammogram and 14.9% of those who had received a mammogram had not done so in the past two years. Women without health insurance coverage, those of lower socioeconomic status and those engaging in risky health behaviors were more likely to never have had a mammogram and, if they were screened, to have not had a mammogram in the past two years. CONCLUSIONS: These results show a need to focus mammography screening programs on women with lower socioeconomic status.

Aged↗

PubMed1986

Individual characteristics, gender differences and drop-out from alcoholism treatment.

Both male and female alcoholics who had dropped out of treatment had lower incomes, greater severity of drinking problems, but were less likely to have insurance coverage than were persons who completed or were still in treatment. Results suggest that somewhat different sets of predisposing characteristics, attitudes and beliefs, and personal enabling and social enabling factors are related to treatment drop-out for women and men alcoholics and that more variables are related to treatment drop-out for men.

Adolescent↗

PubMed2004

A cohort study found racial differences in dental insurance, utilization, and the effect of care on quality of life.

OBJECTIVE: To describe racial differences in receipt of dental services and dental insurance; and to determine the effectiveness of specific dental services in facilitating recovery in symptom-specific and race-specific subgroups. STUDY DESIGN AND SETTING: Using a restricted cohort analytic method, Florida Dental Care Study prospective cohort data were used to quantify associations between dental service use and the quality of life measure, "recovery" from oral disadvantage due to functional limitation. RESULTS: Non-Hispanic Whites (NHW) were more likely to have a dental visit [odds ratio (OR); 95% confidence interval: 3.5; 2.2-5.3], corrective treatment (OR=2.1; 1.3-3.3), caps (OR=28.8; 6.6-126.4), and dental insurance coverage for caps (OR=2.9; 1.4-5.9). After adjusting for other covariates: (1) among NHW with severe gum disease, those receiving extractions were more likely to recover (OR=7.8; 1.0-59.1), but those receiving caps were less likely to recover (OR=0.1; 0.01-0.6); (2) among Non-Hispanic Blacks (NHB) with a sensitive tooth, those receiving corrective treatment (OR=3.2; 1.2-8.8) or extractions (OR=3.8; 1.3-11.2) were more likely to recover; (3) among NHB with tooth disease, those receiving corrective treatment (OR=2.3; 1.0-5.0) and extractions (OR=2.8; 1.2-6.5) were more likely to recover. CONCLUSION: There were racial differences in dental insurance, in the receipt of dental services and in the effectiveness of dental services in improving oral health-related quality of life.

Black or African American↗

PubMed1989

The relationship between sponsorship and rehabilitation outcome following spinal cord injury.

The effect of sources of support on rehabilitation outcomes of 866 patients treated at the University of Alabama at Birmingham Spinal Cord Injury Care System since 1973 was assessed using multiple linear and logistic regression. System admission was delayed for Medicaid beneficiaries, while patients who were responsible for at least a portion of their incurred charges were admitted sooner than other patients. Increased lengths of stay were noted among vocational rehabilitation clients and patients with either Workers' Compensation or private insurance coverage. Patients with Workers' Compensation also had significantly higher average hospital charges. Medicaid patients were more likely to be rehospitalised after discharge from rehabilitation. Vocational rehabilitation clients averaged fewer days in nursing homes after injury while Medicaid and Medicare patients experienced longer stays in nursing homes. We conclude that source of support has a significant impact on numerous measures of outcome.

Humans↗

PubMed1994

America's health care reforms.

President Bill Clinton is currently proposing the most sweeping changes to American social policy since the New Deal by Roosevelt in the 1930s. Major concerns about escalating health care costs, a mushrooming health care bureaucracy and a growing proportion of the American population who can no longer afford adequate health care insurance coverage have motivated Clinton's plan for health care reform. Ideas about telemedicine, the electronic medical record and more comprehensive and advanced information systems are already being canvassed during the course of the debate. Australian clinicians and policy makers are following the American debate closely. So too, should health information managers. America watching should prove interesting, stimulating and professionally rewarding.

Australia↗

PubMed1990

How does Canada do it? A comparison of expenditures for physicians' services in the United States and Canada.

As a percentage of the gross national product, expenditures for health care in the United States are considerably larger than in Canada, even though one in seven Americans is uninsured whereas all Canadians have comprehensive health insurance. Among the sectors of health care, the difference in spending is especially large for physicians' services. In 1985, per capita expenditure was $347 in the United States and only $202 (in U.S. dollars) in Canada, a ratio of 1.72. We undertook a quantitative analysis of this ratio. We found that the higher expenditures per capita in the United States are explained entirely by higher fees; the quantity of physicians' services per capita is actually lower in the United States than in Canada. U.S. fees for procedures are more than three times as high as Canadian fees; the difference in fees for evaluation and management services is about 80 percent. Despite the large difference in fees, physicians' net incomes in the United States are only about one-third higher than in Canada. A parallel analysis of Iowa and Manitoba yielded results similar to those for the United States and Canada, except that physicians' net incomes in Iowa are about 60 percent higher than in Manitoba. Updating the analysis to 1987 on the basis of changes in each country between 1985 and 1987 yielded results similar to those obtained for 1985. We suggest that increased use of physicians' services in Canada may result from universal insurance coverage and from encouragement of use by the larger number of physicians who are paid lower fees per service. U.S. physicians' net income is not increased as much as the higher U.S. fees would predict, probably because of greater overhead expenses and the lower workloads of America's procedure-oriented physicians.

Canada↗

PubMed2004

Racial disparity in the use of ECT for affective disorders.

OBJECTIVE: Published reports indicate that African Americans are underrepresented among patients treated with ECT. The reason for this disparity in practice has not been determined. This study addressed this question by using existing data on a large series of patients treated with ECT at a single academic medical center. METHOD: The hospital's administrative databases were used to select Caucasian and African American patients with a diagnosis of major affective disorder treated over the period from November 1993 to March 2002. Independent variables were age, sex, treatment unit, readmission within 30 days, type of insurance, and geographic zone of residence. The dependent variable was likelihood of being treated with ECT, computed for each race group. RESULTS: Caucasians were more likely than African Americans to be treated with ECT (odds ratio=4.71; 95% confidence interval [CI]=3.77-5.90). None of the variables examined provided an explanation for this disparity. When all of the variables were controlled simultaneously, the likelihood of being treated with ECT remained significantly higher for Caucasians than for African Americans (odds ratio=2.48; 95% CI=1.89-3.25). CONCLUSIONS: The racial disparity in the use of ECT cannot be explained on the basis of the variables studied. It is not an artifact of the age of the patient population, nor can it be explained on the basis of insurance coverage, the social class of the patients, or their illnesses' being more treatment resistant. The authors propose several other hypotheses, including explanations relating to clinical presentation, differential response to other treatments, differences in patients' willingness to consent, and physicians' behavior, that could be explored by using other methods.

Academic Medical Centers↗

PubMedDate not supplied

Access to and participation in breast cancer screening: a review of recent literature.

Recently, attention has been focused on the incentives for access to and participation in breast cancer screening programs. The Healthy People 2000 health goals for the nation calls for 60% of women aged 50 years and older to have had mammograms and clinical breast exams within the preceding 2 years. To achieve this objective, the incentives for access to and participation in breast cancer screening programs must be identified. The present review examines incentive-based hypotheses dealing with lower socioeconomic status, lack of insurance coverage, physician referral, and self-referral. Policy-oriented solutions that have attempted to correct the disincentives associated with low access and participation were analyzed. The sophistication of screening technology is of primary importance; however, this review provides additional information that can be used to ensure the implementation of quality mammography screening programs.

Adult↗

PubMed1991

Utilization of dental services by older adults in four Ontario communities.

The elderly tend to use dental services less than most younger age groups. While the elderly's utilization rates may be rising, very low utilization by edentulous people depresses the overall rate for the group. We use data from the Ontario Study of the Oral Health of Older Adults to identify the variations in the use of dental services in the four study sites of Toronto, North York, Simcoe County and Sudbury and District. We reached 3,033 subjects by telephone and conducted dental examinations and a multi-item personal interview with 907 of them. The 907 subjects ranged in age from 50 to 87 years, 57 percent were female and two-thirds were born in Canada. Overall, 60.5 percent had seen a dentist or denturist in the previous year, but this was much lower among the edentulous (17 percent) when compared to the dentate (72 percent) (Chi-square test; p less than .0001). Of the 357 who did not visit a dentist or denturist in the previous year, nearly half (48 percent) felt they had nothing wrong and 20 percent reported they could not afford care. A high proportion (94 percent) of the edentulous reported visiting only for pain or trouble compared to 26 percent of the dentate (Chi-square test; p less than .0001). Using logistic regression, we found dental status (edentulous), community of residence (Sudbury), income (up to $20,000) and dental insurance coverage (none) were important factors in not making a dental visit in the last year. These same factors, plus education (elementary) were important where subjects reported visiting a dentist or denturist only when there was pain or trouble.

Aged↗

PubMed2003

Myths as barriers to health care reform in the United States.

The U.S. health care system is deteriorating in terms of decreasing access, increased costs, unacceptable quality, and poor system performance compared with health care systems in many other industrialized Western countries. Reform efforts to establish universal insurance coverage have been defeated on five occasions over the last century, largely through successful opposition by pro-market stakeholders in the status quo. Reform attempts have repeatedly been thwarted by myths perpetuated by stakeholders without regard for the public interest. Six myths are identified here and defused by evidence: (1) "Everyone gets care anyhow;" (2) "We don't ration care in the United States"; (3) "The free market can resolve our problems in health care"; (4) "The U.S. health care system is basically healthy, so incremental change will address its problems;" (5) "The United States has the best health care system in the world"; and (6) "National health insurance is so unfeasible for political reasons that it should not be given serious consideration as a policy alternative." Incremental changes of the existing health care system have failed to resolve its underlying problems. Pressure is building again for system reform, which may become more feasible if a national debate can be focused on the public interest without distortion by myths and disinformation fueled by defending stakeholders.

Delivery of Health Care↗

PubMed1993

Maxillofacial prosthetics: vital signs.

A maxillofacial prosthetics survey was designed to record the response rate of prosthodontists regarding the frequency of maxillofacial procedures and insurance coverage in 1991. The survey explored variability with respect to membership in professional organizations, region, education, primary activity, and age of the prosthodontist. A total of 342 survey instruments were received from a total of 690 mailed. A total of 18,410 maxillofacial procedures were performed by the survey population. Members of the American Academy of Maxillofacial Prosthetics performed procedures at a significantly higher rate than did the members of the American College of Prosthodontists. A greater procedure rate was observed for prosthodontists in the South Midwest and Southwestern regions; the hospital setting; with 2 plus 1 year additional postgraduate maxillofacial training; and the 45- to 54-year age group. Insurance covered most maxillofacial procedures, but was not uniformly distributed within predictor variables nor between procedures.

Adult↗

PubMed1988

Factors affecting the probability of use of general and medical health and social/community services for Mexican Americans and non-Hispanic whites.

Are individual characteristics associated with use of general and mental health and human service sectors similar for Mexican Americans (MAs) and non-Hispanic whites (NHWs)? We addressed this question using data from the Los Angeles site of the NIMH Epidemiologic Catchment Area Program. A random sample of the general population of two mental health catchment areas was interviewed in 1983-1984. With four exceptions, individual variation in sociodemographic factors, insurance coverage, and health status had similar effects on the probability of use of the general and mental health and human service sector for both NHWs and MAs. Recent psychiatric disorder was associated with greater use of general medical providers for mental health care for both NHWs and MAs, but significantly more so for NHWs. Female NHWs were more likely to use the human service sector (e.g., social service agencies) than male NHWs, but gender had no effect on this type of use for MAs. Higher job status was associated with greater use of outpatient general medical services, but significantly more so for NHWs than MAs. By contrast, having private health insurance was associated with a greater increase in use of outpatient general medical services for MAs than for NHWs.

Adult↗

PubMed1994

Socioeconomic disparities in preventive care persist despite universal coverage. Breast and cervical cancer screening in Ontario and the United States.

OBJECTIVE: To compare the association of income and education with breast and cervical cancer screening in Ontario, Canada, and the United States. DESIGN: Survey using data from the Ontario Health Survey and the US National Health Interview Survey. PARTICIPANTS: A multistage random sample of women aged 18 years and older living in households in Ontario (N = 23,521) and the United States (N = 23,932) in 1990. MAIN OUTCOME MEASURE: Persons were considered screened if they reported a Papanicolaou test within the previous 2 years, a clinical breast examination within the previous year, or a mammogram within the previous year. RESULTS: Papanicolaou test and clinical breast examination rates were similar between countries, but mammography rates were two to three times higher in the United States across all age groups. Compared with women with less than a high school degree, college graduates were more likely to receive screening (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2 to 1.7) and there was no difference between countries. Across all procedures, women with higher incomes were more likely to receive screening. For Papanicolaou test and clinical breast examination, there was no difference between countries. Compared with the lowest income, the OR was 1.7 (95% CI, 1.3 to 2.1) in Ontario and 1.9 (95% CI, 1.6 to 2.2) in the United States for Papanicolaou test and 2.1 (95% CI, 1.6 to 2.8) in Ontario and 2.1 (95% CI, 1.8 to 2.6) in the United States for the clinical breast examination for women with income greater than $45,600 (US dollars). For mammography screening, the association of income with use was greater in the United States: the OR was 1.8 (95% CI, 1.3 to 2.6) in Ontario and 2.7 (95% CI, 2.3 to 3.2) in the United States for women with income greater than $45,600 (US dollars). CONCLUSIONS: Despite the long-time presence of universal insurance coverage in Ontario the disparities in the use of cancer screening procedures by the poor were similar to the United States. Universal coverage is not sufficient to overcome the large disparities in screenings across socioeconomic status demonstrated in both countries.

Adult↗

PubMed2003

Racial/ethnic differences in the healthcare experience (coverage, utilization, and satisfaction) of US adults with diabetes.

OBJECTIVE: To examine racial/ethnic differences in healthcare coverage, utilization, and satisfaction, among US adults with diabetes. DESIGN AND SETTING: We conducted a cross-sectional analysis among 9443 adults with diabetes who participated in the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of the civilian non-institutionalized US population aged > or = 18 yrs. MAIN OUTCOME MEASURES: We compared healthcare coverage, utilization, and satisfaction across 4 race/ethnicity categories: non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), Hispanics (HSP), and others, and examined whether these factors were associated with self-rated health status. RESULTS: By self-report, more NHB (14.8%), HSP (20.7%), and members of other races (21.8%) were uninsured, compared to NHW (6.4%). Similarly, cost was a barrier to visiting a doctor for 23.9% of HSP, 19.5% of NHB, and 13.4% of members of other races; however, only 8.2% of non-Hispanic Whites reported cost as a barrier. More NHW (90.1%) and NHB (90.7) reported having had a check-up in the past year, compared to HSP (84.5%) or others (84.1%). All 3 variables exhibited significant differences by race or ethnicity (all P<.01). After adjustment for age, sex, income, education, and insulin use, the association with race/ethnicity persisted for health insurance coverage (P<.001), and for cost as a barrier (P<.003). Reporting cost as a barrier to visiting a doctor (P=.013), and rating one's overall health care as fair or poor (P=.001), were associated with poorer health status. CONCLUSIONS: These results suggest that ethnic minorities with diabetes report less healthcare coverage and more cost-related barriers to utilization, compared to non-Hispanic Whites. Persons with fair/poor health status were more likely to report cost barriers and poor satisfaction. Future research should focus on the reasons for such differences and on interventions to improve health care for minority populations.

Adult↗

PubMed1999

Differences in discharge medication after acute myocardial infarction in patients with HMO and fee-for-service medical insurance.

OBJECTIVE: To assess the impact of fee-for-service (FFS) versus HMO medical insurance coverage on receipt of aspirin, beta-blockers, and calcium channel blockers at the time of hospital discharge following an acute myocardial infarction. DESIGN: Prospective, population-based study. SETTING: All 16 community and tertiary care hospitals in the metropolitan area of Worcester, Massachusetts. PATIENTS: The study population consisted of patients under 65 years of age hospitalized with a validated acute myocardial infarction in all hospitals in the Worcester (Massachusetts) Standard Metropolitan Statistical Area (1990 census estimate, 437,000) during 1986, 1988, 1990, 1991, and 1993. MEASUREMENTS AND MAIN RESULTS: After adjustment for demographic and clinical variables as well as study year, the odds ratios for receipt of each medication for patients with HMO insurance compared with FFS were 1.05 (95% confidence interval [CI] 0.77, 1.44) for aspirin, 1.32 (95% CI 0.98, 1.76) for beta-blockers, and 0.72 (95% CI 0.54, 0.96) for calcium channel blockers. Examination of temporal trends in utilization of these agents suggests that observed decreases in use of calcium channel blockers and increases in use of beta-blockers over the period under study occurred more rapidly for HMO than for FFS patients. CONCLUSIONS: Overall, use of aspirin and beta-blockers was comparable among HMO and FFS patients and use of calcium channel blockers (deemed less effective or ineffective for secondary prevention) was lower among HMO patients. Differential adoption, over time, of evidence-based prescribing practices for medications between HMO and FFS patients who have had a myocardial infarction warrants further study.

Adrenergic beta-Antagonists↗

PubMed1992

Insurability of the adolescent and young adult with heart disease. Report from the Fifth Conference on Insurability, October 3-4, 1991, Columbus, Ohio.

By the mid-1990s there will be more than 500,000 young adults in the United States over the age of 21 with a cardiac malformation. Presently more than half of this population is denied insurance coverage entirely or in part because of their preexisting condition. Because some did not have coverage and because of uncertainty about whom to see for their cardiology care, patients assessed in NHS-II who were evaluated by their physician on an annual basis before the age of 21 were seen by a cardiologist only every 10 years after the age of 21. However, they have been shown by NHS-II to be well-educated, productive in the workplace, and to share an equal place in society with the general population. Their health-care costs are decidedly lower after the age of 21 than before. This group represents a microcosm of a general society of more than 37 million Americans who, for various reasons, are not insured. Dr. Wiener described an American health-care system in crisis. Smaller companies are no longer able to afford health insurance for all their employees, especially for those with preexisting conditions, because of an industry pricing concept based on a claims-experience standard rather than a community standard. The insurance industry, the government, and patients are demanding medical cost-containment. Health-care costs, 12.2% of the gross national product in 1990, are climbing, and no end to this increase is presently in sight.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗