Diabetes complications and adverse health outcomes after coronary revascularization.

AIMS: To examine effects of diabetes complications on health outcomes following coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), comparing outcomes for patients with diabetes complications to those without diabetes complications. METHODS: Retrospective analysis of discharge data for 61,566 patients with diabetes age 45 or older who had CABG or PCI in 2007 in United States community hospitals, using data from the Nationwide Inpatient Sample. Analysis included propensity score-adjusted logistic regression. RESULTS: Of all patients, 21.2% of the weighted sample had diabetes complications. Older patients, Blacks and Hispanics, and those with greater illness severity were more likely to have diabetes complications. Unadjusted rates of in-hospital mortality, postoperative stroke, and renal failure were higher for patients with diabetes complications (rate ratios 2.2, 1.8, and 9.8, respectively; all p<0.0001). In adjusted results, having diabetes complications was associated with higher odds of in-hospital mortality (odds ratio, OR 1.62, 95% confidence interval, CI 1.37-1.91) and renal failure (OR 3.03, CI 1.71-5.39). Compared to CABG, PCI was associated with extra risk of postoperative renal failure for those with diabetes complications. CONCLUSION: Among patients with diabetes having revascularization, those with diabetes complications have higher risks of in-hospital death and renal failure irrespective of having CABG or PCI.

Home and community-based services for well educated older caregivers: gender differences in attitudes, barriers, and use.

Using a sample of 169 well educated, relatively affluent older caregivers, we examined gender differences in attitudes about home and community-based services, service use, interest in services, and barriers to service use. We found significant gender differences in two attitudinal dimensions: preference for informal care and acceptance of government services. A higher proportion of men than women would rather use community services than ask family for help. A larger percentage of women than men believed the government should provide more services. Service use was modest. On average, caregivers were about 5 times more likely to express interest in a service than to have used one. Findings suggest that greater outreach by providers may usefully address service barriers.

Health care use of individuals with diabetes in an employer-based insurance population.

BACKGROUND: Individuals with diabetes use more health care resources than those without the disease. Much less is known about such differences associated with different forms of diabetes. METHODS: People with types 1 and 2 diabetes were identified from claims of a commercial insurer with an enrollment of 828 208. Age- and sex-adjusted rates and observed-to-expected ratios for health care services use, costs, and relative value units were compared for individuals with diabetes and the total plan population. RESULTS: We identified 13,563 individuals with diabetes (including 4349 with type 1 and 8810 with type 2 diabetes). The diabetic population was 1.6% of the total population, but had 9.4% of costs. Individuals with both types of diabetes had higher rates for use of inpatient, outpatient, and professional services. Compared with the total population, inpatient rates for the total diabetic population (for those with type 1 diabetes), were 4.9 (8.3) times higher for established complications of diabetes such as acute myocardial infarction, 9.8 (22.1) times higher for heart failure, 5.6 (8.3) times higher for coronary artery bypass, and 5.1 (8.9) times higher for cardiac catheterization (P <.001 for all). The following relative value unit ratios for physician services were substantially higher for the total diabetic population (for those with type 1 diabetes): 13.2 (27.9) times higher for endocrinologists, 6.3 (12.9) for ophthalmologists, and 9.4 (27.8) for nephrologists. CONCLUSIONS: Use, costs, and intensity of resources used were substantially higher for individuals with diabetes, and markedly higher for the population with type 1 diabetes. Our findings show that people with type 1 diabetes are at substantially higher risk for serious complications than those with type 2 diabetes.

Providing behavioral incentives for improved health in aging and Medicare cost control: a policy proposal for Universal Medical Savings Accounts.

This paper examines policy options for addressing health care challenges posed by the aging of the baby boom generation. Universal Medical Savings Accounts (UMSAs) are proposed. UMSAs are defined-contribution vouchers coupled with medical savings accounts. The proposal includes significant equity protections for those with low income/wealth, including balance billing limits and stop-loss protections, together with subsidies for risk-adjustment. The policy would control costs while promoting quality, accessible, and affordable health care. UMSAs provide new behavioral incentives, both for cost-conscious health care decision-making and for healthy lifestyle choices.

Utilization, costs, and access to primary care in fee-for-service and managed care plans.

This study compares access to primary care, utilization, and costs among enrollees in four forms of managed care and an indemnity plan. We use 1996 data from a commercial insurer. Most managed care enrollees had better access to primary care services than indemnity enrollees. This access was associated with a generally lower rate of preventable hospitalization. Per capita inpatient costs were notably lower in managed care plans than in the indemnity plan. We describe how health care managers can use readily available administrative data and straightforward statistical techniques to enhance routine monitoring for quality and costs. Policy makers can use this approach to identify health services trends, and to evaluate access to health services for individuals enrolled in various benefit plan types.

The morbidity compression debate: risks, opportunities, and policy options for women.

The morbidity compression theory proposes that we can compress the period of illness and disability in old age into an ever smaller period at the end of life. Although recent research offers fresh support for the theory, its validity remains uncertain. This paper demonstrates the importance of the theory and recent research in this area for women. It critiques the chief proponent and opposing views of the theory, and suggests a heightened emphasis on public policies promoting healthy lifestyles. These policies would reduce long-term care needs, save health care dollars, and improve the experience of aging.

Aging children and their older parents: the coming generation of caregiving.

This study uses a data set of older children and their older parents to examine caregiving relationships. Using the 1993 Panel Study of Income Dynamics and the 1993 Health Care Burden file, we examine help given by children to their parents. We distinguish between daughters who are household heads and daughters who are wives. We find parents receive substantially more care from daughters than from sons. The caregiving role of daughters who are household heads differs notably from that of wives. An analysis of caregiving, employment, and house-work shows that children who are caregivers devote more combined hours to these activities than children who do not provide care.

Geographic variation in preventable hospitalization of older women and men: implications for access to primary health care.

This study demonstrates how readily available data and small area analysis can be used to identify potential problems of access to primary care services for older women and men. Gender and socioeconomic differences in rates of preventable hospitalization are examined. Using hospital discharge data, five county and twenty-four intra-county areas in Upstate New York are studied. There is significant variation in preventable hospitalization within counties. Areas having significantly higher rates of these hospitalizations tend to have higher rates for both women and men. Problems of access are associated with lower income areas for women and men.