Viet Nam��s mandatory motorcycle helmet law and its impact on children

Objective

To measure the use of motorcycle helmets in children and to determine the reasons why children wear helmets less often than adults.

Methods

The frequency of helmet wearing among adults and children was ascertained by trained roadside observers, and randomized road user surveys were completed in four major centres in Viet Nam: Hanoi, Ho Chi Minh City, Can Tho and Da Nang. Survey data on key questions were cross tabulated, and χ² was calculated for significant differences between parents and non-parents (0.05).

Findings

The frequency of helmet use in the four study locations ranged from 90–99% among adults, from 15–53% among children ≤ 7 years of age, and from 38–53% among children > 7 but ≤ 14. Of the parents surveyed, 67% said the fear of neck injury was the most important reason their children did not wear a helmet.

Conclusion

Children wear motorcycle helmets much less often than adults. Legislation to penalize adults whose children do not wear motorcycle helmets has been proposed in Viet Nam. Furthermore, ongoing advocacy and social marketing efforts are being made to disseminate information about the safety benefits of helmets to combat erroneous public perceptions.     

Stroke among male professional drivers in Denmark, 1994-2003

Objectives

(1) To estimate the relative risk of stroke among various groups of professional drivers; (2) to determine if any excess risk should be attributed to infarction or haemorrhage; (3) to estimate the relative risk ratio for stroke among professional drivers living in Greater Copenhagen compared to those living outside the metropolis.

Methods

A cohort of 6285 bus drivers, 4204 car, taxi, and van drivers, and 25 879 heavy truck and lorry drivers were followed up for hospital admission due to stroke and sub‐diagnoses in the period 1994–2003. Using hospital admission for all economically active men as the standard, the standardised hospitalisation ratios (SHR) were calculated, taking age and county into consideration.

Results

There was a high SHR for stroke among all groups of professional drivers (SHR = 132; 95% CI 121–141). Among car, taxi, and van drivers the SHR was 157 (95% CI 132–189), among bus drivers it was 139 (95% CI 119–163), and among heavy truck and lorry drivers it was 124 (95% CI 113–136). The excess risk for all groups of professional drivers was highest for cerebrovascular infarction (SHR = 139; 95% CI 124–155) and lowest for non‐traumatic intracranial haemorrhage (SHR = 113; 95% CI 96–133). The excess risks for all groups were significantly higher for cerebrovascular infarction than for non‐traumatic intracranial haemorrhage (relative risk ratio (RRR) 1.23; 95% CI 1.01–1.51). The RRR of stroke among drivers in the metropolitan area compared to rural areas was 1.13 (95% CI 0.94–1.36). The RRR for stroke among car, taxi, and van drivers compared to drivers of heavy trucks and of lorries was 1.28 (95% CI 1.03–1.57).

Conclusion

All groups of professional drivers are at increased risk of stroke. The excess risk is more due to cerebral infarctions than to non‐traumatic intracranial haemorrhage. The risk of stroke is higher among drivers carrying passengers than among drivers carrying goods.     

The Relationship between Local Economic Conditions and Acute Myocardial Infarction Hospital Utilization by Adults and Seniors in the United States, 1995–2011

Objective

To assess the association between aggregate unemployment and hospital discharges for acute myocardial infarction (AMI) among adults and seniors, 1995–2011.

Data Sources/Study Setting

Community hospital discharge data from states collected for the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and economic data from the Bureau of Labor Statistics, 1995–2011.

Study Design

Quarterly time series study of unemployment and aggregate hospital discharges in local areas using fixed effects to control for differences between local areas.

Data Collection/Extraction Methods

Secondary data on inpatient stays and unemployment rates aggregated to micropolitan and metropolitan areas.

Principal Findings

For both adults and seniors, a 1 percentage point increase in the contemporaneous unemployment rate was associated with a statistically significant 0.80 percent (adults) to 0.96 percent (seniors) decline in AMI hospitalization during the first half of the study but was unrelated to the economic cycle in the second half of the study period.

Conclusions

The study found evidence that the aggregate relationship between health and the economy may be shifting for cardiovascular events, paralleling recent research that has shown a similar shift for some types of mortality (Ruhm 2013), self-reported health, and inpatient use among seniors (McInerney and Mellor 2012).     

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

Research Objective

To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent''s private health plan. Nearly one-in-three young adults lacked coverage before the ACA.

Study Design, Methods, and Data

Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.

Principal Findings

This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.

Conclusions and Implications

ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.     

Frequency of citrus fruit intake is associated with the incidence of cardiovascular disease: the Jichi Medical School cohort study

Background

It has been reported that fruit intake protects against cardiovascular disease (CVD). However, most of the relevant studies were conducted in Western countries, and only a few investigated Japanese populations. The present cohort study assessed the effect of citrus fruit intake on the incidence of CVD and its subtypes in a Japanese population.

Methods

A baseline examination consisting of physical and blood examinations and a self-administered questionnaire was conducted during the period from April 1992 through July 1995. Dietary habits were assessed using a food frequency questionnaire that was divided into 5 categories. Citrus fruit was examined separately due to its frequent consumption by the general Japanese population. Using the Cox proportional hazards model, data from 10 623 participants (4147 men, 6476 women) who had no history of CVD or carcinoma were analyzed to assess the association between frequency of citrus fruit intake and CVD incidence.

Results

Frequent intake of citrus fruit was associated with a lower incidence of CVD: the hazard ratio for almost daily intake versus infrequent intake of citrus fruit was 0.57 (95% confidence interval: 0.33–1.01, P for trend = 0.04) in men and 0.51 (0.29–0.88, P for trend = 0.02) in women. Frequent intake of citrus fruit was also associated with lower incidences of both all stroke and cerebral infarction, but not hemorrhagic stroke or myocardial infarction.

Conclusions

Frequent intake of citrus fruit may reduce the incidence of CVD, especially cerebral infarction, in men and women.Key words: citrus fruit, cardiovascular disease, cerebral infarction, cohort studies, Japan     

A Decade in Dental Care Utilization among Adults and Children (2001–2010)

Objective

To decompose the change in pediatric and adult dental care utilization over the last decade.

Data

2001 through 2010 Medical Expenditure Panel Survey.

Study Design

The Blinder-Oaxaca decomposition was used to explain the change in dental care utilization among adults and children. Changes in dental care utilization were attributed to changes in explained covariates and changes due to movements in estimated coefficients. Controlling for demographics, overall health status, and dental benefits variables, we estimated year-specific logistic regression models. Outputs from these models were used to compute the Blinder-Oaxaca decomposition.

Principal Findings

Dental care utilization decreased from 40.5 percent in 2001 to 37.0 percent in 2010 for adults and increased from 43.2 percent in 2001 to 46.3 percent in 2010 for children (p < .05). Among adults, changes in insurance status, race, and income contributed to a decline in adult dental care utilization (−0.018, p < .01). Among children, changes in controlled factors did not substantially change dental care utilization, which instead may be explained by changes in policy, oral health status, or preferences.

Conclusions

Dental care utilization for adults has declined, especially among the poor and uninsured. Without further policy intervention, disadvantaged adults face increasing barriers to dental care.     

HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data

Objective

To quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa.

Methods

We reviewed data from Demographic and Health Surveys (DHS). Although in these surveys all female respondents are < 50 years of age, 18 of the surveys contained data on HIV infection among men aged ≥ 50 years. To estimate the percentage of older adults (i.e. people ≥ 50 years of age) who were positive for HIV (HIV+), we extrapolated from data from the Joint United Nations Programme on HIV/AIDS on the estimated number of people living with HIV and on HIV infection prevalence among adults aged 15–49 years.

Findings

In 2007, approximately 3 million people aged ≥ 50 years were living with HIV in sub-Saharan Africa. The prevalence of HIV infection in this group was 4.0%, compared with 5.0% among those aged 15–49 years. Of the approximately 21 million people in sub-Saharan Africa aged ≥ 15 years that were HIV+, 14.3% were ≥ 50 years old.

Conclusion

To better reflect the longer survival of people living with HIV and the ageing of the HIV+ population, indicators of the prevalence of HIV infection should be expanded to include people > 49 years of age. Little is known about comorbidity and sexual behaviour among HIV+ older adults or about the biological and cultural factors that increase the risk of transmission. HIV services need to be better targeted to respond to the growing needs of older adults living with HIV.     

Causes of death and renal tubular dysfunction in residents exposed to cadmium in the environment

Objectives

To clarify the causes of death of residents with renal tubular dysfunction induced by cadmium (Cd) in the environment.

Methods

A 15 year follow up study was performed with the inhabitants living in the Cd polluted Kakehashi River basin in Japan. Standardised mortality ratios (SMRs) for causes of death, classified by ICD‐9, were computed using the person‐years method to investigate the excess mortality of subjects with urinary β2‐MG (microglobulin) ⩾1000 μg/gCr. Mortality risk analysis was performed using Cox''s proportional model to compare mortality between subjects with urinary β2‐MG ⩾1000 and <1000 μg/gCr, and to investigate the relationship between the degree of urinary β2‐MG and mortality.

Results

Excess mortality due to heart failure and cerebral infarction in both sexes, and nephritis and nephrosis in men, was observed among subjects with urinary β2‐MG ⩾1000 μg/gCr. Significant increases in mortality risk for cerebral infarction in men and for malignant neoplasms in women with urinary β2‐MG ⩾1000 μg/gCr were observed during the first five year observation period. For nephritis and nephrosis, the mortality risks for men and women with urinary β2‐MG ⩾1000 μg/gCr significantly increased over the 15 year observation period. The mortality risks for heart failure and cerebral infarction increased in proportion to the increased urinary β2‐MG in both sexes. Increased mortality risks for nephritis and nephrosis were identified in the subjects with urinary β2‐MG ⩾10000 μg/gCr in both sexes.

Conclusion

Renal tubular dysfunction induced by Cd affected the causes of death, and mortality for heart failure, cerebral infarction, and nephritis and nephrosis was increased among inhabitants living in a Cd polluted area in Japan. In women, cancer mortality may have been increased while Cd pollution was ongoing.     

Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

Temporal Changes in Survival after Cardiac Surgery Are Associated with the Thirty‐Day Mortality Benchmark

Objective

To assess the hypothesis that postoperative survival exhibits heterogeneity associated with the timing of quality metrics.

Data Sources

Retrospective observational study using the Nationwide Inpatient Sample from 2005 through 2009.

Study Design

Survival analysis was performed on all admission records with a procedure code for major cardiac surgery (n = 595,089). The day-by-day hazard function for all-cause in-hospital mortality at 1-day intervals was analyzed using joinpoint regression (a data-driven method of testing for changes in hazard).

Data Extraction Methods

A comprehensive analysis of a publicly available national administrative database was performed.

Principal Findings

Statistically significant shifts in the pattern of postoperative mortality occurred at day 6 (95 percent CI = day 5–8) and day 30 (95 percent CI = day 20–35).

Conclusions

While the shift at day 6 plausibly can be attributed to the separation between routine recovery and a complicated postoperative course, the abrupt increase in mortality at day 30 has no clear organic etiology. This analysis raises the possibility that this observed shift may be related to clinician behavior because of the use of 30-day mortality as a quality metric, but further studies will be required to establish causality.     

Peer Reviewed: Misclassification of Survey Responses and Black-White Disparity in Mammography Use, Behavioral Risk Factor Surveillance System, 1995-2006

Introduction

The validity of self-reported data for mammography differ by race. We assessed the effect of racial differences in the validity of age-adjusted, self-reported mammography use estimates from the Behavioral Risk Factor Surveillance System (BRFSS) from 1995 through 2006 to determine whether misclassification (inaccurate survey question response) may have obscured actual racial disparities.

Methods

We adjusted BRFSS mammography use data for age by using 2000 census estimates and for misclassification by using the following formula: (estimated prevalence − 1 + specificity) / (sensitivity + specificity − 1). We used values reported in the literature for the formula (sensitivity = 0.97 for both black and white women, specificity = 0.49 and 0.62, respectively, for black and white women).

Results

After adjustment for misclassification, the percentage of women aged 40 years or older in 1995 who reported receiving a mammogram during the previous 2 years was 54% among white women and 41% among black women, compared with 70% among both white and black women after adjustment for age only. In 2006, the percentage after adjustment for misclassification was 65% among white women and 59% among black women compared with 77% among white women and 78% among black women after adjustment for age only.

Conclusion

Self-reported data overestimate mammography use — more so for black women than for white women. After adjustment for respondent misclassification, neither white women nor black women had attained the Healthy People 2010 objective (≥70%) by 2006, and a disparity between white and black women emerged.     

Peer Reviewed: Effectiveness of a Multifactorial Cardiovascular Risk Reduction Clinic for Diabetes Patients with Depression

Introduction

Depression may attenuate the effects of diabetes interventions. Our ongoing Cardiovascular Risk Reduction Clinic simultaneously addresses hyperglycemia, hypertension, smoking, and hyperlipidemia. We examined the relationship between depression diagnosis and responsiveness to the Cardiovascular Risk Reduction Clinic.

Methods

We studied Cardiovascular Risk Reduction Clinic participants with diabetes who had a depression diagnosis and those with no mental health diagnosis. Our outcome measure was change in 20-year cardiovascular mortality risk according to the United Kingdom Prospective Diabetes Study (UKPDS) score.

Results

Of 231 participants, 36 (15.6%) had a depression diagnosis. Participants with a depression diagnosis had a higher baseline UKPDS score (56.8 [SD 21.3]) than participants with no mental health diagnosis (49.5 [SD 18.7], P = .04). After Cardiovascular Risk Reduction Clinic participation, mean UKPDS scores did not differ significantly (37.8 [SD 15.9] for no mental health diagnosis and 39.4 [SD 18.6] for depression diagnosis). Mean UKPDS score reduction was 11.6 [SD 15.6] for no mental health diagnosis compared with 18.4 [SD 15.9] for depression diagnosis (P = .03). Multivariable linear regression that controlled for baseline creatinine, number of Cardiovascular Risk Reduction Clinic visits, sex, and history of congestive heart failure showed significantly greater improvement in UKPDS score among participants with a depression diagnosis (β = 6.0, P = .04) and those with more Cardiovascular Risk Reduction Clinic visits (β = 2.1, P < .001).

Conclusion

The Cardiovascular Risk Reduction Clinic program reduced cardiovascular disease risk among patients with diabetes and a diagnosis of depression. Further work should examine how depressive symptom burden and treatment modify the effect of this collaborative multifactorial program and should attempt to determine the durability of the effect.     

A Differential Equation Model for the Dynamics of Youth Gambling

Objectives

We examine the dynamics of gambling among young people aged 16–24 years, how prevalence rates of at-risk gambling and problem gambling change as adolescents enter young adulthood, and prevention and control strategies.

Methods

A simple epidemiological model is created using ordinary nonlinear differential equations, and a threshold condition that spreads gambling is identified through stability analysis. We estimate all the model parameters using a longitudinal prevalence study by Winters, Stinchfield, and Botzet to run numerical simulations. Parameters to which the system is most sensitive are isolated using sensitivity analysis.

Results

Problem gambling is endemic among young people, with a steady prevalence of approximately 4–5%. The prevalence of problem gambling is lower in young adults aged 18–24 years than in adolescents aged 16–18 years. At-risk gambling among young adults has increased. The parameters to which the system is most sensitive correspond to primary prevention.

Conclusion

Prevention and control strategies for gambling should involve school education. A mathematical model that includes the effect of early exposure to gambling would be helpful if a longitudinal study can provide data in the future.     

Declines in physical performance by sex and age among nondisabled community-dwelling older Japanese during a 6-year period

Background

Few studies have examined whether declines over time in hand-grip strength (HGS) and fast walking speed (FWS) differ by sex and age among non-Western community-dwelling older adults. This study aimed to quantify changes in HGS and FWS over the 6-year period from 1994 to 2000 and examine whether these changes differed by sex and baseline age among older individuals in a Japanese community.

Methods

We conducted a community-based prospective cohort study. The participants were 513 nondisabled men and women aged 67 to 91 years at the 1994 survey. Independent variables regarding time since baseline, in addition to various time-dependent and time-independent covariates, were obtained in 1994, 1996, 1998, and 2000. The outcome variables were HGS and FWS assessed at each survey. All data on independent and dependent variables that were collected at each survey were simultaneously analyzed using a linear mixed-effects model.

Results

The linear mixed-effects model revealed significant declines in both HGS (−0.70 kg/year, P < 0.001) and FWS (−0.027 m/sec/year, P < 0.001) among nondisabled older participants who had analyzable data in any survey during the 6-year period. Sex was significantly associated with the rate of decline in HGS (P < 0.001), but not FWS (P = 0.211).

Conclusions

In this analysis of nondisabled older Japanese, a mixed-effects model confirmed a significant effect of aging on declines in HGS and FWS and showed that men had a significantly steeper decline in HGS than did women during a 6-year period.Key words: aged, aging, hand-grip strength, walking speed, longitudinal study     

Noninvasive measurements of arterial stiffness: repeatability and interrelationships with endothelial function and arterial morphology measures

Background

Many noninvasive arterial assessment techniques have been developed, measuring different parameters of arterial stiffness and endothelial function. However, there is little data available comparing different devices within the same subject. Therefore, the purpose of this study was to examine the repeatability and interrelationships between 3 different techniques to measure arterial stiffness and to compare this with forearm-mediated dilation.

Methods

Carotid-radial pulse wave velocity was measured by the Sphygmocor (SPWV) and Complior (CPWV) devices, cardio-ankle vascular index (CAVI) was measured by the VaSera device, vascular structure and function was assessed using ultrasonography and evaluated for reliability and compared in 20 apparently healthy, college-aged men and women.

Results

The intraclass correlation coefficient and standard error of the mean for the Sphygmocor (R = 0.56, SEM = 0.69), Complior (R = 0.62, SEM = 0.69), and VaSera (R = 0.60, SEM = 0.56), indicated moderate repeatability. Bland-Altman plots indicated a mean difference of 0.11 ± 0.84 for SPWV, 0.13 ± 1.15 for CPWV, and −0.43 ± 0.90 for CAVI. No significant interrelationships were found among the ultrasound measures and SPWV, CPWV, and CAVI.

Conclusions

The three noninvasive modalities to study arterial stiffness reliably measures arterial stiffness however, they do not correlate with ultrasound measures of vascular function and structure in young and apparently healthy subjects.     

Delay in seeing a doctor due to cost: disparity between older adults with and without disabilities in the United States

Objective

To examine the disparity in delaying seeing a doctor due to cost between older adults with and without disabilities, and whether the disparity could be explained by health and financial variables.

Data Sources

Nationally representative sample of community-dwelling adults aged ≥65 who have health insurance and a usual source of care from the 2006 Behavioral Risk Factor Surveillance System (n = 85,015).

Study Design

This cross-sectional study used sequential logistic regression models to examine the associations of delaying seeing a doctor due to cost with disability status, including demographic, health, and financial variables.

Principal Findings

Older adults with disabilities had significantly higher odds of delaying seeing a doctor due to cost compared to older adults without disabilities after controlling for demographic, health, and financial factors. Although health and financial variables collectively attenuated the disparity, they did not fully explain the disparity.

Conclusions

Despite having health insurance and a usual source of care, older adults with disabilities encountered greater economic difficulties in seeing a doctor than their counterparts without disabilities. Policy makers should continue addressing the economic burden to improve timely visits to health care providers.     

A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy

Objective

To compare patient profiles and health care use for physician-referred and self-referred episodes of outpatient physical therapy (PT).

Data Source

Five years (2003–2007) of private health insurance claims data, from a Midwest insurer, on beneficiaries aged 18–64.

Study Design

Retrospective analyses of health care use of physician-referred (N = 45,210) and self-referred (N = 17,497) ambulatory PT episodes of care was conducted, adjusting for age, gender, diagnosis, case mix, and year.

Data Collection/Extraction

Physical therapy episodes began with the physical therapist initial evaluation and ended on the last date of service before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of PT.

Principal Findings

The self-referred group was slightly younger, but the two groups were very similar in regard to diagnosis and case mix. Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00), after covariate adjustment, but did not differ in related health care utilization after PT.

Conclusions

Health care use during PT episodes was lower for those who self-referred, after adjusting for key variables, but did not differ after the PT episode.     

Reporting of Quality Indicators and Improvement in Hospital Performance: The P.Re.Val.E. Regional Outcome Evaluation Program

Objective

To evaluate whether reporting of hospital performance was associated with a change in quality indicators in Italian hospitals.

Data Sources/Study Setting

Nationwide Hospital Information System for 2006–2009.

Study Design

We performed a pre-post evaluation in Lazio (before and after disclosure of the Regional Outcome Evaluation Program P.Re.Val.E.) and a comparative evaluation versus Italian regions without comparable programs. We analyzed risk-adjusted proportions of percutaneous coronary intervention (PCI), hip fractures operated on within 48 hours, and cesarean deliveries.

Data Collection/Extraction Methods

Using standardized ICD-9-CM coding algorithms, we selected 381,053 acute myocardial infarction patients, 250,712 hip fractures, and 1,736,970 women who had given birth.

Principal Findings

In Lazio PCI within 48 hours changed from 22.49 to 29.43 percent following reporting of the P.Re.Val.E results (relative increase, 31 percent; p < .001). In the other regions this proportion increased from 22.48 to 27.09 percent during the same time period (relative increase, 21 percent; p < .001). Hip fractures operated on within 48 hours increased from 11.73 to 15.78 percent (relative increase, 34 percent; p < .001) in Lazio, and not in other regions (29.36 to 28.57 percent). Cesarean deliveries did not decrease in Lazio (34.57–35.30 percent), and only slightly decreased in the other regions (30.49–28.11 percent).

Conclusions

Reporting of performance data may have a positive but limited impact on quality improvement. The evaluation of quality indicators remains paramount for public accountability.     

Health Literacy,Cognitive Ability,and Functional Health Status among Older Adults

Objective

To investigate whether previously noted associations between health literacy and functional health status might be explained by cognitive function.

Data Sources/Study Setting

Health Literacy and Cognition in Older Adults (“LitCog,” prospective study funded by National Institute on Aging). Data presented are from interviews conducted among 784 adults, ages 55–74 years receiving care at an academic general medicine clinic or one of four federally qualified health centers in Chicago from 2008 to 2010.

Study Design

Study participants completed structured, in-person interviews administered by trained research assistants.

Data Collection

Health literacy was measured using the Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and Newest Vital Sign. Cognitive function was assessed using measures of long-term and working memory, processing speed, reasoning, and verbal ability. Functional health was assessed with SF-36 physical health summary scale and Patient Reported Outcomes Measurement Information System short form subscales for depression and anxiety.

Principal Findings

All health literacy measures were significantly correlated with all cognitive domains. In multivariable analyses, inadequate health literacy was associated with worse physical health and more depressive symptoms. After adjusting for cognitive abilities, associations between health literacy, physical health, and depressive symptoms were attenuated and no longer significant.

Conclusions

Cognitive function explains a significant proportion of the associations between health literacy, physical health, and depression among older adults. Interventions to reduce literacy disparities in health care should minimize the cognitive burden in behaviors patients must adopt to manage personal health.     

Peer Reviewed: Managed-Medicare Health Club Benefit and Reduced Health Care Costs Among Older Adults

Introduction

Our study was undertaken to determine the association between use of a health plan-sponsored health club benefit by older adults and total health care costs over 2 years.

Methods

This retrospective cohort study used administrative and claims data from a Medicare Advantage plan. Participants (n = 4766) were enrolled in the plan for at least 1 year before participating in the plan-sponsored health club benefit (Silver Sneakers). Controls (n = 9035) were matched to participants by age and sex according to the index date of Silver Sneakers enrollment. Multivariate regression models were used to estimate health care use and costs and to make subgroup comparisons according to frequency of health club visits.

Results

Compared with controls, Silver Sneakers participants were older and more likely to be male, used more preventive services, and had higher total health care costs at baseline. Adjusted total health care costs for Silver Sneakers participants and controls did not differ significantly in year 1. By year 2, compared with controls, Silver Sneakers participants had significantly fewer inpatient admissions (−2.3%, 95% confidence interval, −3.3% to −1.2%; P < .001) and lower total health care costs (−$500; 95% confidence interval, −$892 to −$106; P = .01]. Silver Sneakers participants who averaged at least two health club visits per week over 2 years incurred at least $1252 (95% confidence interval, −$1937 to −$567; P < .001) less in health care costs in year 2 than did those who visited on average less than once per week.

Conclusion

Regular use of a health club benefit was associated with slower growth in total health care costs in the long term but not in the short term. These findings warrant additional prospective investigations to determine whether policies to offer health club benefits and promote physical activity among older adults can reduce increases in health care costs.