Diabetes preventive services and policy implications in the U.S.

OBJECTIVE: To investigate whether the patient or physician practice characteristics predict the use of diabetes preventive care services. RESEARCH DESIGN AND METHODS: This was a cross-sectional study of a nationally representative sample of 27,169 adult ambulatory care visits, using the 2007 National Ambulatory Medical Care Survey data. The outcome variable is whether any preventive care services, defined as diagnostic tests (glucose, urinalysis, A1C, and blood pressure) or patient education (diet/nutrition, exercise, and stress management), were ordered/provided. Multivariate analysis was performed to identify independent predictors of diabetes preventive care services, controlling for patient and physician practice characteristics. All analyses were adjusted for the complex survey design and analytic weights. RESULTS: Compared with people without diabetes, diabetic patients were older (63 vs. 53 years; P < 0.01) and were more likely to be nonwhite and covered by Medicare insurance. In multivariate analyses, younger patients and the availability of primary care physicians, electronic medical records, and on-site laboratory tests were associated with more effective preventive care services (P < 0.05). If physician compensation relied on productivity, preventive care services were less likely (odds ratio 0.4 [95% CI 0.27-0.82 for men and 0.26-0.81 for women]). Although the patterns of patient education and diagnostic testing were similar, the provision of patient education was less likely than that of diagnostic testing. CONCLUSIONS: Primary care physicians and practice features seem to steer diabetes preventive services. Given the time constraints of physicians, strategies to strengthen structural capabilities of primary care practices and enhance partnerships with public health systems on diabetic patient education are recommended.

National trends in the United States of America physician assistant workforce from 1980 to 2007.

BACKGROUND: The physician assistant (PA) profession is a nationally recognized medical profession in the United States of America (USA). However, relatively little is known regarding national trends of the PA workforce. METHODS: We examined the 1980-2007 USA Census data to determine the demographic distribution of the PA workforce and PA-to-population relationships. Maps were developed to provide graphical display of the data. All analyses were adjusted for the complex census design and analytical weights provided by the Census Bureau. RESULTS: In 1980 there were about 29,120 PAs, 64% of which were males. By contrast, in 2007 there were approximately 97,721 PAs with more than 66% of females. In 1980, Nevada had the highest estimated rate of 40 PAs per 100,000 persons, and North Dakota had the lowest rate (three). The corresponding rates in 2007 were about 85 in New Hampshire and ten in Mississippi. The levels of PA education have increased from less than 21% of PAs with four or more years of college in 1980, to more than 65% in 2007. While less than 17% of PAs were of minority groups in 1980, this figure rose to 23% in 2007. Although nearly 70% of PAs were younger than 35 years old in 1980, this percentage fell to 38% in 2007. CONCLUSION: The trends of sustained increase and geographic variation in the PA workforce were identified. Educational level, percentage of minority, and age of the PA workforce have increased over time. Major causes of the changes in the PA workforce include educational factors and federal legislation or state regulation.

Changes in weight among U.S. adults aged 70 and over, 1993 to 2002.

OBJECTIVE: To describe the patterns and predictors of weight change among U.S. adults aged 70 and over. METHOD: The study is a retrospective cohort study of 7441 community-dwelling U.S. adults aged 70 years and over during 1993-2002. We examined changes in weight for men and women, and by race/ethnicity groups. We used multivariate linear regression analysis to determine predictors of weight change while controlling for key covariates at baseline. RESULTS: The mean body weight decreased in both genders and all ethnic groups. Unadjusted average weight loss was 3.41 kg for men and 3.29 kg for women over nine years. Black women had higher mean body weight at baseline and were more likely to report weight gains of 5 kg or more. Multivariate analysis showed that age and baseline weight were major predictors of weight loss. Physical activity was associated with less weight loss among men. CONCLUSION: The trends of weight change among U.S. adults aged 70 and over were more prone to weight loss than weight gain, with substantial variations. Public health messages regarding weight control should take into account the heterogeneity of this population and target weight loss as well as weight gain to meet diverse needs of the population.

Effect of physical activity on functional status among older middle-age adults with arthritis.

OBJECTIVE: To determine the effect of leisure time and work-related physical activity on changes in physical functioning among 3,554 nationally representative survey respondents, ages 53-63 years in 1994, with arthritis and joint symptoms, interviewed in the Health and Retirement Study (HRS). METHODS: In 1992-1994, light and vigorous exercise items were empirically categorized into recommended, insufficient, and inactive leisure time physical activity levels using data from the HRS. Leisure and work-related physical activity levels in 1994 were used to predict 1996 functional decline or improvement, controlling for baseline functional difficulties, health status, sociodemographic characteristics, and behavioral risk factors. RESULTS: Whereas 29.7% of respondents reported functional declines in 1996, 38.6% of those with baseline difficulties in 1994 reported improvement. Compared with inactive respondents, recommended and insufficient leisure time physical activity were equally protective against functional decline (odds ratio [OR] 0.59 and 0.62, respectively; P < 0.0001). Higher levels of physical activity were also modestly associated with functional improvement among respondents with baseline functional difficulties (OR 1.47, P = 0.05 and OR 1.45, P = 0.01, respectively). Work-related physical activity was not a significant predictor of decline or improvement. CONCLUSION: Given the high prevalence of arthritis, even modest increases in rates of lifestyle physical activity among older adults could make a substantial contribution to disability-free life expectancy.

Differences in leisure-time, household, and work-related physical activity by race, ethnicity, and education.

BACKGROUND: Racial and ethnic minority groups have lower levels of leisure-time physical activity (LTPA) than whites, but it is unclear how much of this is explained by differences in socioeconomic status and health. OBJECTIVE: To examine differences in LTPA, work-related physical activity (WRPA; heavy household chores and strenuous job activities), and total physical activity (TPA) by race, ethnicity, and education. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analyses of data from the 1992 Health and Retirement Study for a nationally representative cohort of 9,621 community-dwelling adults aged 51-61 years. MEASUREMENTS: Physical activity scores for LTPA, WRPA, and TPA based upon self-reported frequency of light or vigorous recreational activities, heavy household chores, and strenuous job-related physical activities. MAIN RESULTS: LTPA was lower for blacks and Hispanics compared to whites, and LTPA steadily declined with lower levels of education. WRPA showed the reverse pattern, being lowest for whites and persons with greater education. Education was far more important than race/ethnicity as a determinant of LTPA and WRPA in multivariate analyses. After adjusting for differences in overall health and physical functioning, mean TPA scores were similar across racial/ethnic and education categories; blacks (beta=1.0; 95% confidence interval [CI], 0.5 to 1.5) and Spanish-speaking Hispanics (beta=1.1; 95% CI, 0.3 to 1.9) had slightly higher levels of TPA than whites (P<.01 and P=.01, respectively). CONCLUSIONS: Differences in educational attainment and health status accounted for virtually all of the racial and ethnic differences in LTPA. After accounting for WRPA, TPA was similar across race, ethnicity, and education subgroups.

Modeling crisis decision-making for children in state custody.

We studied 1492 children in state custody over a 6-month period to investigate the relationship between children's hospital admissions and the crisis workers' clinical assessment. A 27-item standardized decision-support tool [the Childhood Severity of Psychiatric Illness (CSPI)] was used to evaluate the symptoms, risk factors, functioning, comorbidity, and system characteristics. The CSPI has been shown to have a reliability range from 0.70 to 0.80 using intraclass correlations. Logistic regression was used to calculate age-adjusted odds ratios (AOR) of hospitalization, their 95% confidence intervals, and corresponding P values. The results showed that risk factors, symptoms, functioning, comorbidities, and system characteristics were all associated with hospital admissions. Children with a recent suicide attempt, severe danger to others, or history of running away from home/treatment settings were more likely to be hospitalized (respective AOR=12.7, P<.0001; AOR=32.3, P<.0001; AOR=3.0, P=.001). In addition, hospitalization was inversely associated with caregiver knowledge of children (AOR=0.2, P=.01) and multisystem needs (AOR=0.3, P=.04). The decision to hospitalize children psychiatrically appears to be complex. As predicted, risk behaviors and severe symptoms were independent predictors of children's hospital admissions. Interestingly, the capacity of the caregiver and the children's involvement in multiple systems also predict children's hospital admissions.

Body mass index, physical activity, and the risk of decline in overall health and physical functioning in late middle age.

OBJECTIVES: We examined the relation between body mass index, exercise, overall health, and physical functioning. METHODS: We studied 7867 adults aged 51 to 61 years in 1992 to 1996. Adjusted relative risks for health decline and new physical difficulties were determined with logistic regression. RESULTS: Overweight and obesity were independently associated with health decline (adjusted relative risk [ARR] = 1.29 and 1.36) and development of a new physical difficulty (ARR = 1.27 and 1.45). Regular exercise significantly reduced the risk of health decline and development of a new physical difficulty, even among obese individuals. CONCLUSIONS: Maintaining ideal body weight is important in preventing decline in overall health and physical functioning. However, regular exercise can reduce the risk of health decline even among individuals who cannot achieve ideal weight.

Changes in weight among a nationally representative cohort of adults aged 51 to 61, 1992 to 2000.

BACKGROUND: Few studies have examined patterns and predictors of changes in body weight among adults in late middle age. METHODS: Prospective cohort study of 7391 community-dwelling U.S. adults aged 51 to 61 years at baseline (1992), using publicly available data files from the 1992, 1994, 1996, 1998, and 2000 Health and Retirement Survey interviews. Changes in weight and body mass index (BMI) were examined for different racial/ethnic groups of men and women. The predictors of changes in body weight and BMI were determined using gender-specific linear regression. RESULTS: Mean body weight and BMI increased in both genders and all ethnic groups. The mean weight gain was higher for women (1.67 kg, 95% confidence interval [CI]=1.34-1.99) than for men (1.43 kg, 95% CI=1.17-1.68). White men and women had the lowest baseline BMI but tended to gain more weight than other racial/ethnic groups. In multivariate analyses, individuals who were older or had higher baseline weight showed less weight gain. Men were less likely to gain weight if their self-reported overall health at baseline was poor compared to those in excellent health. Regular light or vigorous recreational activities and work-related activities were not associated with less weight gain. Race, education, and income were not associated with weight gain in multivariate analyses. CONCLUSIONS: All population subgroups are at risk for weight gain. Public health messages should target diverse populations. The current levels of physical activity attained by this population do not appear to protect against weight gain.