Place of care in the last three years of life for Medicare beneficiaries.

BACKGROUND: Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life. METHODS: Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated. RESULTS: The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states. CONCLUSIONS: This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning.

Functional impairment is associated with medical debt in male cancer survivors and credit card debt in female cancer survivors.

PURPOSE: To examine the associations of functional limitations with medical and credit card debt among cancer survivor families and explore sex differences in these associations. METHODS: This cross-sectional study used data from the 2019 wave of the Panel Study of Income Dynamics, a nationally representative, population-based survey of individuals and households in the US administered in both English and Spanish and includes all households where either the head of household or spouse/partner reported having been diagnosed with cancer. Participants reported on functional limitations in six instrumental activities of daily living (IADL) and seven activities of daily living (ADL). Functional impairment was categorized as 0, 1-2 and ≥ 3 limitations. Medical debt was defined as self-reported unpaid medical bills. Credit card debt was defined as revolving credit card debt. Multivariable logistic regression analyses were performed. RESULTS: Credit card debt was more common than medical debt (39.8% vs. 7.6% of cancer survivor families). Families of male cancer survivors were 7.3 percentage points more likely to have medical debt and 16.0 percentage points less likely to have credit card debt compared to families of female cancer survivors. Whereas male cancer survivors with increasing levels of impairment were 24.7 percentage point (p-value = 0.006) more likely to have medical debt, female survivors with more functional impairment were 13.6 percentage points (p-value = 0.010) more likely to have credit card debt. CONCLUSIONS: More research on medical and credit card debt burden among cancer survivors with functional limitations is needed.

Spirituality and financial toxicity among Hispanic breast cancer survivors in New Jersey.

OBJECTIVE: Cancer survivors often incur significant out-of-pocket costs; this can result in financial toxicity, defined as the adverse financial impact of cancer due to direct or indirect costs related to the disease. There has been little research on whether spirituality is associated with the experience of financial toxicity. In this study, we tested the hypothesis that spirituality would be inversely associated with financial toxicity. METHODS: We evaluated these associations in a cross-sectional study of Hispanic breast cancer survivors (n = 102) identified through the New Jersey State Cancer Registry. Participants completed the FACIT-Sp-12, which has two spirituality subscales (meaning/peace; faith). Financial toxicity was assessed using the 11-item COST measure; lower scores suggest worse toxicity. In multivariable linear regression analyses, we examined the associations between spirituality scores and financial toxicity, adjusting for age, race, education, household income, and insurance status. RESULTS: The spirituality total score (ß = 0.49, 95% confidence interval (CI): 0.17, 0.8), meaning/peace subscale score (ß = 0.71, 95% CI: 0.12, 1.31), and faith (ß = 0.71, 95% CI: 0.2, 1.21) subscale score were all inversely associated with financial toxicity. CONCLUSIONS: Spirituality may be an important factor in ameliorating the detrimental effects of financial toxicity among Hispanic breast cancer survivors and should be considered in interventions for financial toxicity in this population.

Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States.

Medical debt has grown dramatically over the past few decades. While cancer and diabetes are known to be associated with medical debt, little is known about the impact of other medical conditions and health behaviors on medical debt. We analyzed cross-sectional data on 9174 households - spanning lower-income, middle-income, and higher-income based on the Census poverty threshold - participating in the 2019 wave of the nationally representative United States Panel Study of Income Dynamics (PSID). The outcomes were presence of any medical debt and presence of medical debt≥ $2000. Respondents reported on medical conditions (diabetes, cancer, heart disease, chronic lung disease, asthma, arthritis, anxiety disorders, mood disorders) and on health behaviors (smoking, heavy drinking). Medical debt was observed in lower-income households with heart disease (OR = 2.64, p-value = 0.006) and anxiety disorders (OR = 2.16, p-value = 0.02); middle-income households with chronic lung disease (OR = 1.73, p-value = 0.03) and mood disorders (OR = 1.53, p-value = 0.04); and higher-income households with a current smoker (OR = 2.99, p-value<0.001). Additionally, medical debt ≥$2000 was observed in lower-income households with asthma (OR = 2.16, p-value = 0.009) and a current smoker (OR = 1.62, p-value = 0.04); middle income households with hypertension (OR = 1.65, p-value = 0.05). These novel findings suggest that the harms of medical debt extend beyond cancer, diabetes and beyond lower-income households. There is an urgent need for policy and health services interventions to address medical debt in a wider range of disease contexts than heretofore envisioned. Intervention development would benefit from novel conceptual frameworks on the causal relationships between health behaviors, health conditions, and medical debt that center social-ecological influences on all three of these domains.

Burnout and intent to leave during COVID-19: A cross-sectional study of New Jersey hospital nurses.

AIM: The aim of this work is to examine staffing, personal protective equipment (PPE) adequacy and physical exhaustion that contributed to burnout and intent to leave among hospital nurses during the first peak of the COVID-19 pandemic. BACKGROUND: Burnout is associated with adverse nurse and patient outcomes. Identifying the magnitude of burnout that occurred during the pandemic can prepare managers for the long-term mental health effects on nurses. METHODS: A cross-sectional, electronic survey was administered to examine perceptions of burnout and intent to leave among all New Jersey hospital nurses from October 6 to October 26, 2020. RESULTS: A total of 3030 nurses responded with 64.3% reporting burnout and 36.5% reporting intent to leave the hospital within a year. There was a significant association between high levels of burnout and intent to leave (χ2  = 329.4; p = .001). There was no association between staffing and burnout; however, reporting inadequate PPE (OR = 1.77 [95% CI: 1.34-2.34]) and physical exhaustion (OR = 3.89 [95% CI: 3.19-4.76]) remained predictors of burnout among nurses. CONCLUSION: Inadequate PPE and physical exhaustion coupled with short staffing contributed to burnout and intent to leave. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should continue to utilize evidence-based mental health interventions and advocate within their nursing professional organizations for relief funds to reduce burnout.

Racial and ethnic differences in vaccine hesitancy Among registered nurses in New Jersey: A cross-sectional survey.

Nurses play an important role in the vaccine readiness process and high vaccination rates among nurses are essential to ensuring successful vaccination programs. This study sought to examine whether the intention to get vaccinated varied by race and/or ethnicity among a large sample of registered nurses in New Jersey.

Income Shocks and Out-of-Pocket Health Care Spending: Implications for Single-Mother Families.

We examine how out-of-pocket health care spending by single-mother families responds to income losses. We use eleven two-year panels of the Medical Expenditure Panel Survey for the period 2004-2015 and apply the correlated random effects estimation approach. We categorize income in relation to the federal poverty line (FPL): poor or near-poor (less than 125% of the FPL); low income (125 to 199% of the FPL); middle income (200 to 399% of the FPL); and high income (400% of the FPL or more). Income losses among high-income single-mother families lead a decline in out-of-pocket spending toward office-based care and emergency room care of $119-$138 and $30-$60, respectively. Among middle-income single-mother families, income losses lead to a $30 decline in out-of-pocket spending toward family emergency room care and a $45-$91 decline in mother's out-of-pocket spending toward prescription medications. Further research should examine whether these declines compromise health status of single-mother family members.

Financial hardship among cancer survivors in Southern New Jersey.

PURPOSE: To identify predictors of financial hardship, operationalized as foregoing health care, making financial sacrifices, and being concerned about having inadequate financial and insurance information. METHODS: Cancer survivors (n = 346) identified through the New Jersey State Cancer Registry were surveyed from August 2018 to September 2019. Multivariable logistic regression analyses were performed. RESULTS: Cancer survivors with household incomes less than $50,000 annually were more likely than those earning $50,0000-$90,000 to report foregoing health care (15.8 percentage points, p < 0.05). Compared to retirees, survivors who were currently unemployed, disabled, or were homemakers were more likely to forego doctor's visits (11.4 percentage points, p < 0.05), more likely to report borrowing money (16.1 percentage points, p < 0.01), and more likely to report wanting health insurance information (25.7 percentage points, p < 0.01). Employed survivors were more likely than retirees to forego health care (16.8 percentage points, p < 0.05) and make financial sacrifices (20.0 percentage points, p < 0.01). Survivors who never went to college were 9.8 percentage points (p < 0.05) more likely to borrow money compared to college graduates. Black survivors were more likely to want information about dealing with financial and insurance issues (p < 0.01); men were more likely to forego health care (p < 0.05). CONCLUSION: Findings highlight the role of employment status and suggest that education, income, race, and gender also shape cancer survivors' experience of financial hardship. There is a need to refine and extend financial navigation programs. For employed survivors, strengthening family leave policies would be desirable.

Beyond Black and White: Mapping Misclassification of Medicare Beneficiaries Race and Ethnicity.

The Centers for Medicare and Medicaid Services administrative data contains two variables that are used for research and evaluation of health disparities: the enrollment database (EDB) beneficiary race code and the Research Triangle Institute (RTI) race code. The objective of this article is to examine state-level variation in racial/ethnic misclassification of EDB and RTI race codes compared with self-reported data collected during home health care. The study population included 4,231,370 Medicare beneficiaries who utilized home health care services in 2015. We found substantial variation between states in Medicare administrative data misclassification of self-identified Hispanic, Asian American/Pacific Islander, and American Indian/Alaska Native beneficiaries. Caution should be used when interpreting state-level health care disparities and minority health outcomes based on existing race variables contained in Medicare data sets. Self-reported race/ethnicity data collected during routine care of Medicare beneficiaries may be used to improve the accuracy of minority health and health disparities reporting and research.

HOW DO CHANGES IN INCOME, EMPLOYMENT AND HEALTH INSURANCE AFFECT FAMILY MENTAL HEALTH SPENDING?

Using eight two-year panels from the Medical Expenditure Panel Survey data for the period 2004 to 2012, we examine the effect of economic shocks on mental health spending by families with children. Estimating two-part expenditure models within the correlated random effects framework, we find that employment shocks have a greater impact on mental health spending than do income or health insurance shocks. Our estimates reveal that employment gains are associated with a lower likelihood of family mental health services utilization. By contrast employment losses are positively related to an increase in total family mental health. We do not detect a link between economic shocks and mental health spending on behalf of fathers.

Validity of Race and Ethnicity Codes in Medicare Administrative Data Compared With Gold-standard Self-reported Race Collected During Routine Home Health Care Visits.

BACKGROUND: Misclassification of Medicare beneficiaries' race/ethnicity in administrative data sources is frequently overlooked and a limitation in health disparities research. OBJECTIVE: To compare the validity of 2 race/ethnicity variables found in Medicare administrative data [enrollment database (EDB) and Research Triangle Institute (RTI) race] against a gold-standard source also available in the Medicare data warehouse: the self-reported race/ethnicity variable on the home health Outcome and Assessment Information Set (OASIS). SUBJECTS: Medicare beneficiaries over the age of 18 who received home health care in 2015 (N=4,243,090). MEASURES: Percent agreement, sensitivity, specificity, positive predictive value, and Cohen κ coefficient. RESULTS: The EDB and RTI race variable have high validity for black race and low validity for American Indian/Alaskan Native race. Although the RTI race variable has better validity than the EDB race variable for other races, κ values suggest room for future improvements in classification of whites (0.90), Hispanics (0.87), Asian/Pacific Islanders (0.77), and American Indian/Alaskan Natives (0.44). DISCUSSION: The status quo of using "good-enough for government" race/ethnicity variables contained in Medicare administrative data for minority health disparities research can be improved through the use of self-reported race/ethnicity data, available in the Medicare data warehouse. Health services and policy researchers should critically examine the source of race/ethnicity variables used in minority health and health disparities research. Future work to improve the accuracy of Medicare beneficiaries' race/ethnicity data should incorporate and augment the self-reported race/ethnicity data contained in assessment and survey data, available within the Medicare data warehouse.

The Role of Marketing Practices and Tobacco Control Initiatives on Smokeless Tobacco Sales, 2005-2010.

BACKGROUND: Little is known about how policies and industry activities impact smokeless tobacco demand. We examined how tobacco control policies and retail promotion may affect smokeless tobacco sales. METHODS: We used Nielsen market-level retail scanner data for smokeless tobacco sales in convenience stores in 30 US regions from 2005 to 2010. Tobacco policy variables, including excise taxes, state tobacco control program expenditures, and clean indoor air laws, were merged to Nielsen markets. We estimated regression models for per capita unit sales. RESULTS: Higher cigarette tax was significantly associated with lower sales volume of smokeless tobacco. Sales of smokeless tobacco in markets with a weight-based SLT excise tax were higher than in markets with an ad valorem tax. A higher average product price was associated with decreased sales overall but results varied by package quantity and brand. CONCLUSIONS: This study observed that smokeless tobacco products were both complements and substitutes to cigarettes. Thus, smokeless tobacco may act as complements for some population segments and substitutes for others. A weight-based tax generally favors premium smokeless tobacco products.

Infant Mortality in Moscow: the Perils of Progress in Russia's World City.

This paper examines changes in infant mortality (IM) in Moscow, Russia's largest and most affluent city. Along with some remarkable improvements in Moscow's health system over the period between 2000 and 2014, the overall IM rate for Moscow's residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow's 125 neighborhoods. Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.

The difference-in-difference method: assessing the selection bias in the effects of neighborhood environment on health.

This paper uses the difference-in-difference estimation approach to explore the self-selection bias in estimating the effect of neighborhood economic environment on self-assessed health among older adults. The results indicate that there is evidence of downward bias in the conventional estimates of the effect of neighborhood economic disadvantage on self-reported health, representing a lower bound of the true effect.

Neighborhoods and chronic disease onset in later life.

OBJECTIVES: To strengthen existing evidence on the role of neighborhoods in chronic disease onset in later life, we investigated associations between multiple neighborhood features and 2-year onset of 6 common conditions using a national sample of older adults. METHODS: Neighborhood features for adults aged 55 years or older in the 2002 Health and Retirement Study were measured by use of previously validated scales reflecting the built, social, and economic environment. Two-level random-intercept logistic models predicting the onset of heart problems, hypertension, stroke, diabetes, cancer, and arthritis by 2004 were estimated. RESULTS: In adjusted models, living in more economically disadvantaged areas predicted the onset of heart problems for women (odds ratio [OR] = 1.20; P < .05). Living in more highly segregated, higher-crime areas was associated with greater chances of developing cancer for men (OR = 1.31; P < .05) and women (OR = 1.25; P < .05). CONCLUSIONS: The neighborhood economic environment is associated with heart disease onset for women, and neighborhood-level social stressors are associated with cancer onset for men and women. The social and biological mechanisms that underlie these associations require further investigation.

The Wage Effects of Personal Smoking History.

Why do we observe a wage differential between smokers and non-smokers? Pooling reports of current and prior smoking activity across 15 years from the Panel Study of Income Dynamics (PSID) allows the reconstruction of individual smoking histories. Dividing the sample into smoking history groups, the four largest of which are: persistent smokers, never smokers, former smokers, and future quitters reveals that there is no observed wage gap between former smokers and those who have never smoked. There is, however, a wage gap between those smokers who will continue smoking and three other groups of individuals: (1) those smokers who will quit smoking in the future, (2) those smokers who have quit smoking already, and (3) those who never smoked. The wage gap between smokers and non-smokers, observed in the 1986 cross-section, is largely driven by those who persist as smokers, 1986-2001. These results support the hypothesis that the cross-sectional wage differential is not driven by smoking per se, but may be driven by a non-causal explanation. One plausible interpretation is that a common factor such as myopia, leads to reduced investment in both health capital or firm-specific or other human capital.

Neighborhoods and obesity in later life.

OBJECTIVES: We examined the influence of neighborhood environment on the weight status of adults 55 years and older. METHODS: We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability. RESULTS: When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese. CONCLUSIONS: The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.

The effect of friends on adolescent body weight.

Using the first wave of the National Longitudinal Study of Adolescent Health (Add Health) survey, this paper examines the influence of peers on adolescent weight. A peer group is defined as a close circle of friends that are identified by a respondent adolescent. After controlling for school fixed effects and for a number of individual, demographic and family characteristics, we find that a higher Body Mass Index (BMI) of close friends is correlated to a higher BMI of the respondent adolescent. However, after instrumental variable analysis is performed, the effect remains significant only among women. We also found that adolescents are more responsive to the body weight of their same gender friends.

Overweight children: assessing the contribution of the built environment.

OBJECTIVE: To examine the relationship between the built environment and overweight status in children. METHODS: Analyses were based on 2482 children aged 5-18 and their primary care givers who participated in the second wave of the Child Development Supplement (CDS-II) of the Panel Study of Income Dynamics (PSID). CDS-II is a nationally representative survey that was administered in October 2002-May 2003. A number of built environment characteristics were examined: population density, alpha index of connectivity, urban design, pedestrian fatality from motor vehicle crashes, restaurant density, and grocery store and convenience store densities. Also, interviewer's observations on neighborhood physical disorder, such as the condition and upkeep of the buildings and street surface on the block were analyzed. RESULTS: Living in a neighborhood with higher convenience store density (OR=1.3, p<0.05) and living in a neighborhood built after 1969 (OR=1.9, p<0.01) is associated with a higher probability of being overweight for children and adolescents. Living in the neighborhood where no physical disorder (OR=0.5, p<0.01) is observed is associated with a decreased likelihood of being overweight. CONCLUSIONS: The results of this study emphasize a particular importance of the built environment of the neighborhood for weight status of children and adolescents.

Neighborhoods and disability in later life.

This paper uses the US Health and Retirement Study to explore linkages between neighborhood conditions and stages of the disablement process among adults aged 55 years and older in the United States. We consider multiple dimensions of the neighborhood including the built environment as well as social and economic conditions. In doing so, we use factor analysis to reduce indicators into eight neighborhood scales, which we incorporate into two-level logistic regression models along with controls for individual-level factors. We find evidence that economic conditions and the built environment, but not social conditions, matter. Neighborhood economic advantage is associated with a reduced risk of lower body limitations for both men and women. We also find for men that neighborhood economic disadvantage is linked to increased chances of reporting personal care limitations, particularly for those aged 55-64 years, and that high connectivity of the built environment is associated with reduced risk of limitations in instrumental activities. Our findings highlight the distinctive benefits of neighborhood economic advantage early in the disablement process. In addition, findings underscore the need for attention in the design and evaluation of disability-prevention efforts to the benefits that accrue from more physically connected communities and to the potential harm that may arise in later life from living in economically disadvantaged areas.