Impairment and Disability Identity and Perceptions of Trust, Respect, and Fairness.

Importance: Most studies use impaired functioning alone to specify populations with disabilities. However, some people with functional impairments do not identify as disabled. With functional status-based definitions, studies have shown disparate care quality for people with disabilities. Objective: To examine whether impairment and disability identity have different associations with perceived health care experiences and explore factors associated with disability identification. Design, Setting, and Participants: This cross-sectional study used a nationally representative survey of US adults conducted from April 20 through May 31, 2021, and analyzed between June 1 and August 31, 2022. Survey participants were 1822 English- or Spanish-speaking adults responding either online or via telephone. Exposures: Using 8 survey questions, participants were grouped according to presence of impairment and disability identity. Main Outcomes and Measures: Likert scale measures of trust, respect, and fairness (henceforth, procedural justice measures) were dichotomized. Sociodemographic characteristics and rates of procedural justice responses were compared across groups. Multivariable logistic regressions adjusting for baseline characteristics were performed to (1) estimate associations of impairment and disability identity with perceptions of procedural justice and (2) explore factors associated with disability identification. Analyses applied survey weights. Results: Of 6126 individuals invited to participate, 1854 (30.3%) completed the survey. Thirty-two were excluded due to unreportable gender, for a final analytic sample of 1822 participants. Participants with impairments (n = 816; mean [SD] age, 48.1 [17.0] years; 51.2% women, 48.8% men) had worse perceptions on 7 of 10 procedural justice measures (crude) compared with those without impairments (n = 1006; mean [SD] age, 49.6 [18.1] years, 55.1% female, 44.9% male). Among respondents with impairments, those who did (n = 340) vs did not (n = 476) identify as disabled gave better ratings for clinician communication efforts (a lot of effort, 38.8% vs 31.0%) and having health goals understood (understood very or fairly well, 77.2% vs 70.1%) but gave worse ratings for respect (almost never felt inferior or talked down to, 66.1% vs 59.1%). Disability identification was associated with more reports of unfair treatment (31.0% vs 22.4%; adjusted odds ratio, 1.65; 95% CI, 1.12-2.42) and of being unafraid to ask questions or disagree (50.5% vs 40.1%; adjusted odds ratio, 1.51; 95% CI, 1.04-20.19). Income and employment were associated with disability identification. Conclusions and Relevance: In this cross-sectional survey study of US adults, health care perceptions differed between groups defined by impairment status and disability identity. These findings suggest that, alongside functional measures, health systems should capture disability identity to better address disparities for people with impairments.

Employees' Baseline Food Choices and the Effect of a Workplace Intervention to Promote Healthy Eating: Secondary Analysis of the ChooseWell 365 Randomized Controlled Trial.

BACKGROUND: Little is known about whether the effectiveness of workplace wellness programs differs by employees' baseline health behaviors. OBJECTIVE: This study examined the association of baseline cafeteria food choices with the effect of a workplace intervention on cafeteria food choices, dietary quality, and body mass index (BMI). DESIGN: This was a secondary analysis of the ChooseWell 365 randomized controlled trial, testing a set of behavioral interventions to improve diet and prevent weight gain. PARTICIPANTS/SETTING: Participants were 602 employees of a Boston, MA, hospital who had purchased food from cafeterias, which used traffic-light food labeling. Data were collected in 2016-2020. INTERVENTION: The 12-month intervention (plus 12 months' follow-up) involved financial incentives and personalized feedback on cafeteria purchases. The control group received monthly letters with generic healthy eating and exercise tips. MAIN OUTCOME MEASURES: Healthy purchasing scores (HPS) were calculated by weighting color categories (red = 0, yellow = 0.5, green = 1) and scaling from 0 to 100 (healthiest); employees were categorized into baseline (pre-intervention) HPS tertiles (T1 = least healthy, T3 = healthiest). Healthy eating index (HEI-2015) scores were calculated from two 24-hour dietary recalls. Intervention effects on 12- and 24-month changes in HPS (primary outcome), HEI-2015 score, and BMI were compared among tertiles. Subgroup analyses examined whether changes by tertile varied with financial rewards received. STATISTICAL ANALYSES: Adjusting for baseline characteristics, multivariable linear regression assessed intervention effects across baseline HPS tertiles. RESULTS: Compared with T3, T1 employees had lower education; higher obesity, hypertension, and pre-diabetes; and lower HEI-2015 scores. The intervention increased HPS, but no change was observed in HEI-2015 scores or BMI; the intervention effect did not differ among tertiles at 12 or 24 months. Financial incentives were associated with a larger effect on 12-month HPS changes for T1 than for T2/T3 (P-interaction < 0.001). CONCLUSION: Compared with employees with healthier baseline food choices, employees with the least healthy food choices and highest cardiometabolic risk had similar improvements in the nutritional quality of cafeteria purchases as a result of the behavioral intervention, and they appeared to be more responsive to financial incentives.

Growth of Fee-for-Service Medicare Home-Based Medical Care Within Private Residences and Domiciliary Care Settings in the U.S., 2012-2019.

OBJECTIVES: Home-based medical care (HBMC) delivers physician or advanced practice provider-led medical services for patients in private residences and domiciliary settings (eg, assisted living facilities, group/boarding homes). We aimed to examine the time trends in HBMC utilization by care settings. DESIGN: Analyses of HBMC utilization at the national and state levels during the years 2012-2019. SETTING AND PARTICIPANTS: With Medicare public use files, we calculated the state-level utilization rate of HBMC among fee-for-service (FFS) Medicare beneficiaries, measured by visits per 1000 FFS enrollees, in private residences and domiciliary settings, both separately and combined. METHODS: We assessed the trend of HBMC utilization over time via linear mixed models with random intercept for state, adjusting for the following state-level markers of HBMC supply and demand: number of HBMC providers, state ranking of total assisted living and residential care capacity, and the proportion of FFS beneficiaries with dementia, dual eligibility for Medicaid, receiving home health services, and Medicare Advantage. RESULTS: Total HBMC visits in the United States increased from 3,911,778 in 2012 to 5,524,939 in 2019. The median (interquartile range) state-level HBMC utilization rate per 1000 FFS population was 67.6 (34.1-151.3) visits overall, 17.3 (7.9-41.9) visits in private residences, and 47.7 (23.1-86.6) visits in domiciliary settings. The annual percentage increase of utilization rates was significant for all care settings in crude models (3%-8%), and remained significant for overall visits and visits in domiciliary settings (2%-4%), but not in private residences. CONCLUSIONS AND IMPLICATIONS: The national-level growth in HBMC from 2012-2019 was largely driven by a growth of HBMC occurring in domiciliary settings. To meet the needs of a growing aging population, future studies should focus efforts on policy and payment issues to address inequities in access to HBMC services for homebound older adults, and examine drivers of HBMC growth at regional and local levels.