Health care expenditures among working-age adults with physical disabilities: variations by disability spans.

BACKGROUND: Data on health care costs for working-age adults with physical disabilities are sparse and the dynamic nature of disability is not captured. OBJECTIVES: To assess the effect of 3 types of disability status (persistent disability, temporary disability, and no disability) on health care expenditures, out-of-pocket (OOP) spending, and financial burden. METHODS: Data from Medical Expenditure Panel Survey panel 12 (2007-2008) were used. Respondents were classified into 3 groups. Medians of average annual expenditures, OOP expenditures, and financial ratios were weighted. The package R was used for quantile regression analyses. RESULTS: Fifteen percent of the working-age population reported persistent disabilities and 7% had temporary disabilities. The persistent disability group had the greatest unadjusted annual medians for total expenditures ($4234), OOP expenses ($591), and financial burden ratios (1.59), followed by the temporary disability group ($1612, $388, 0.71 respectively). The persistent disability group paid approximately 15% of total health care expenditures out-of-pocket, while the temporary disability group and the no disability group each paid 22% out-of-pocket. After adjusting for other factors, quantile regression shows that the persistent disability group had significantly higher total expenditures, OOP expenses, and financial burden ratios (coefficients 1664, 156, 0.58 respectively) relative to the no disability group at the 50th percentile. Results for the temporary disability group show a similar trend except for OOP expenses. CONCLUSIONS: People who have disabling conditions for a longer period have better financial protection against OOP health care expenses but face greater financial burdens because of their higher out-of-pocket expenditures and their socioeconomic disadvantages.

Vision insurance, eye care visits, and vision impairment among working-age adults in the United States.

OBJECTIVES: To compare rates of eye care visits and vision impairment among working-age adults with vision insurance vs without, among the total sample of Behavioral Risk Factor Surveillance Survey respondents and among a subsample of respondents who had diagnoses of glaucoma, age-related macular degeneration (ARMD), and/or cataract. DESIGN: Using the Behavioral Risk Factor Surveillance Survey 2008 vision module data, we examined the likelihood of an eye care visit within the past year and of self reported visual impairment among 27 152 adults aged 40 to 65 years and among a subset of 3158 persons (11.6%) with glaucoma, ARMD, and/or cataract. Multivariate logistic regression models were used. RESULTS: About 40% of both the study population and the subsample with glaucoma, ARMD, and/or cataract had no vision insurance. Respondents with vision insurance were more likely than those without to have had eye care visits (general population adjusted odds ratio [AOR], 1.90 [95% CI, 1.89-1.90]; glaucoma-ARMD-cataract subsample AOR, 2.15 [95% CI, 2.13-2.17]), to have no difficulty recognizing friends across the street (general population AOR, 1.24 [95% CI, 1.22-1.26]; eye-disease subsample AOR, 1.45 [95% CI, 1.42-1.49]), and to have no difficulty reading printed matter (general population AOR, 1.34 [95% CI, 1.33-1.35]; eye-disease subsample AOR, 1.37 [95% CI, 1.34-1.39]). Respondents from the total sample who had an eye care visit were better able to recognize friends across the street (AOR, 1.07) and had no difficulty reading printed matter (AOR, 1.70), and respondents from the eye-disease subsample who had an eye care visit also were better able to recognize friends across the street (AOR, 1.71) and had no difficulty reading printed matter (AOR, 1.45). CONCLUSIONS: Lack of vision insurance impedes eye care utilization, which, in turn, may irrevocably affect vision. Vision insurance for preventive eye care should cease to be a separate insurance benefit and should be mandatory in all health plans.

"PDSA-ADHD": a newly reported syndrome.

We present a satirical case report of a new syndrome, called "plan do study act-attention deficit hyperactivity disorder," or PDSA-ADHD. This syndrome is associated with the implementation of multiple simultaneous plan-do-study-act cycles as a quality improvement approach in a health care setting. This case represents a clinical warning sign of quality improvement impairment and suggests a new variant of organizational attention deficit disorder.

Obesity among working age adults: the role of county-level persistent poverty in rural disparities.

Little research has investigated the relationship between county-level poverty and obesity rates. We examined the factors related to obesity among residents of Rural Persistent Poverty counties, finding that these counties had a larger proportion of obese residents (34.5%) than Other Rural (28.4%) or Urban counties (24.9%). In adjusted analysis, the statistically significant association between persistent poverty and obesity was attenuated. Both individual characteristics (race, age) and county-level food availability and access factors were found to be significantly related to obesity. Improved access to quality food may be beneficial to residents of impoverished areas.

Rural-urban differences in the location of influenza vaccine administration.

BACKGROUND: Influenza vaccination rates remain lower than Healthy People 2010 goals. The lower rates are prevalent in rural areas despite an expansion of services to nontraditional settings. Little is known about disparities in influenza vaccination rates and location of receipt among rural residents. This study seeks to determine if rural residents differ from urban residents in where they obtain an influenza vaccination, and to determine what factors contribute to these differences. METHODS: Data from 2002-2005 BRFSS were used and combined with the 2006 Area Resource File (analytic n=70,468, unweighted, 48,392,455 weighted). Unadjusted analyses examined the proportions of influenza vaccinations obtained in traditional clinical settings vs. others across rurality: Urban, Large Rural and Small Rural. Multivariable logistic regression models were conducted to identify individual and county-level factors associated with the higher rate of vaccinations in clinical settings. RESULTS: Rural residents, particularly in Small Rural counties (80.8%) were more dependent upon clinical settings than Urban residents (69.1%) for influenza vaccinations. In adjusted analyzes, living in a Large or Small Rural county remained significant related to an increased odds of being vaccinated in a clinical setting (OR 1.17, 95% CI 1.06-1.29 and OR 1.45, 95% CI 1.24-1.69 respectively). Other related contributory factors included socioeconomic factors, health status, health condition, and per capita income of the county. CONCLUSIONS: Rural residents depend upon traditional, clinical settings when an influenza vaccination is sought. The results can be used for further research and programs to improve access to and delivery of influenza vaccinations for disparate populations.

Cancer screening delivery in persistent poverty rural counties.

BACKGROUND: Rural populations are diagnosed with cancer at different rate and stages than nonrural populations, and race/ethnicity as well as the area-level income exacerbates the differences. The purpose of this analysis was to explore cancer screening rates across persistent poverty rural counties, with emphasis on nonwhite populations. METHODS: The 2008 Behavioral Risk Factor Surveillance System was used, combined with data from the Area Resource File (analytic n = 309 937 unweighted, 196 344 347 weighted). Unadjusted analysis estimated screening rates for breast, cervical, and colorectal cancer. Multivariate analysis estimated the odds of screening, controlling for individual and county-level effects. RESULTS: Rural residents, particularly those in persistent poverty counties, were less likely to be screened than urban residents. More African Americans in persistent poverty rural counties reported not having mammography screening (18.3%) compared to 15.9% of urban African Americans. Hispanics had low screening rates across all service types. Multivariate analysis continued to find disparities in screening rates, after controlling for individual and county-level factors. African Americans in persistent poverty rural counties were more likely to be screened for both breast cancer (odds ratio, 1.44; 95% confidence interval, 1.12-1.85) and cervical cancer (1.46; 1.07-1.99) when compared with urban whites. CONCLUSIONS: Disparities in cancer screening rates exist across not only race/ethnicity but also county type. These disparities cannot be fully explained by either individual or county-level effects. Programs have been successful in improving screening rates for African American women and should be expanded to target other vulnerable women as well as other services such as colorectal cancer screening.

Personal and contextual factors that contribute to a higher out-of-pocket to total income ratio.

INTRODUCTION: This analysis sought to define the out-of-pocket healthcare spending to total income ratio for rural residents, as well as to explore the impact of county-level factors that may contribute to urban-rural differences. METHODS: Three years of pooled data were utilized from the Medical Expenditure Panel Survey (2003-2005). The dependent variable was the ratio of total out-of-pocket healthcare spending to total income, at the household level. Unadjusted and adjusted analyses estimated the factors associated with this ratio, including rurality, socio-demographics, and county-level factors. RESULTS: The unadjusted analysis indicated that small adjacent and remote rural residents had higher out-of-pocket to total income ratios than urban residents. The adjusted multivariate analysis indicated that when other factors are held equal, rurality is no longer a significant factor. Other factors such as insurance type, healthcare utilization, and income, which differ significantly by rurality, are better predictors of the ratio. CONCLUSIONS: The identification of factors that contribute to a higher ratio among some rural residents is necessary in order to better target interventions that will reduce this financial burden.