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Public health researchers and practitioners have begun to recognize the dynamic nature of disability, promote the health of people with disabilities, and develop strategies to prevent secondary conditions among them. To understand the epidemiology of secondary conditions, the authors developed the Massachusetts Survey of Secondary Conditions, a longitudinal study of adults with major disabilities (n = 656) based on a conceptual framework linking disability, mediating factors, and health outcomes. This paper reports baseline data on the number of secondary conditions experienced by survey respondents. Respondents experienced a mean of 5.3 of 17 secondary conditions. More numerous secondary conditions were associated with fair or poor general health and number of days unable to do routine activities. Factors amenable to public health interventions included difficulty with weight and exercise maintenance, tobacco and marijuana use, and experiencing assault. Disability should be a focus in all public health research, policy, and programs.

Objective: To present preliminary data on the health-related consequences for people with spinal cord injury (SCI) of participation in a prepaid, risk-based, managed care plan. Design: Baseline data from a longitudinal interview survey. Setting: Massachusetts. Participants: Subjects were 114 independently living adults with SCI recruited from 6 independent living centers and 2 managed care plans; 45 received care from a risk-based prepaid managed care plan and 69 from other sources. Main Outcomes: Self-reports of use of health services; self-assessments of health, health at interview versus 12 months earlier; hospital admissions; numbers of secondary conditions, and experiences of specific secondary conditions (eg, pressure ulcers, depression, fatigue, and chronic pain). Results: Persons in the managed care plan do not differ from their counterparts in terms of age, gender, education, level of SCI, number of comorbid conditions, activity of daily living profiles, household composition, and reliance upon health maintenance programs and routines (eg, bowel and bladder care). In terms of processes of care, they appear generally better-served. There also are a few differences in outcome that are statistically significant, or approach significance, and generally favor the managed care plan. Conclusion: Preliminary data suggest that thoughtfully and sensitively designed and implemented risk-based managed care may improve both access and outcomes.

Disability and dependency are universal problems that every society has made at least some effort to resolve. Traditionally, we have studied these efforts in terms of national or state policies and programs, or individual ethnic, national, or religious groups' treatments of the aged, dependent, or chronically ill. As less-developed countries' populations age, they, too, will bear an increasing burden of chronic illness and disability. As this happens, they will compete with industrial countries for the human resources to meet these needs. This paper is an effort to describe disability, dependency, and disability relief as global problems, the expressions of which in one country are closely, perhaps inextricably, related to their expressions in other countries and which invite supranational solutions.

There is substantial evidence of the permanent disabling effects of such conditions as spinal cord and head injuries, cerebral palsy, paralytic polio, and such degenerative neurologic conditions as multiple sclerosis and muscular dystrophy.1 There is also considerable evidence that people with these conditions require extraordinary amounts of acute hospital care.1-7 However, there are few data on temporary morbidity or disability among those with major disabling conditions, particularly those who live independently in the community rather than in institutions.

On April 16, 1979, Massachusetts raised its legal drinking age from 18 to 20 years. Massachusetts was compared with New York State, exclusive of New York City and Nassau County. New York State retained an 18-year-old drinking age. Random telephone surveys with approximately 1,000 16-19 year olds in each state were undertaken prior to the law's enactment and twice at yearly intervals after the law to assess the law's impact on teenage drinking, driving after drinking, and non-fatal accident involvement. Fatal crash data reported to the US Department of Transportation by each state from April 16, 1976-April 15, 1981 were also analyzed. After the law, although the modes of procuring alcohol changed. No significant changes were observed in Massachusetts relative to New York in the proportion of surveyed teenagers who reported that they drank or in the volume of their consumption. The proportion of teenagers who drove after drinking heavily (six or more drinks at one time) did not decline in Massachusetts relative to New York. However, the frequency that teenagers reported driving after any drinking declined significantly in Massachusetts. Frequency of teenage driving after marijuana use and non-fatal teenage accidents declined at comparable rates in both states. The numbers of teenage nighttime single vehicle fatal accidents declined more in Massachusetts than New York, in the 18-19 year age group. Overall fatal accident trends among 16-19 year olds in the two states were similar.

We conducted an 18-month longitudinal evaluation of a model-managed medical care program for severely disabled, independently living adults. Regression analyses using an additive model (no interaction effects) suggest that persons in the study group did not have statistically significantly different utilization experiences than members of the comparison group. Regression analyses that include interaction effects suggest that, for certain segments of the cohort, the study group's utilization experience was significantly lower than that of members of the comparison group. Persons in the study group with higher baseline emergency room (ER) utilization had significantly fewer hospital admissions (P = 0.0055). The participants with better self-assessments of health experienced significantly fewer hospital days per person (P = 0.0075) and days per person hospitalized (P = 0.0056), and persons with organizational affiliations reported significantly fewer ER visits (P = 0.0264).