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OBJECTIVE: To examine by age, the veterans report on whether components of age-friendly health systems were discussed during primary care visits. DATA SOURCES AND STUDY SETTING: Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019. STUDY DESIGN: Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their providers office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity. DATA COLLECTION/EXTRACTION METHOD: Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data. PRINCIPAL FINDINGS: In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity. CONCLUSIONS: Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

Black men who have sex with men and women (BMSMW) experience pressure to fill hypermasculine ideals and may not identify with "gay" cultural norms. Existing measures of gender role expectations and internalized homophobia are not culturally appropriate for BMSMW. Researchers generally measure categorical identification with race, gender, and sexual orientation groups separately, whereas BMSMW may identify with multiple categories. We modified the Gender Role Conflict Scale to create the M-GRCS and the Internalized Homophobia Scale to include biphobia (Internalized Bi/Homophobia Scale, IBHS). To examine identification at the intersection of race, gender, and sexual orientation, we created 11 Integrated Race and Sexuality Scale (IRSS) items. With data from 429 BMSMW, we conducted exploratory factor analysis of the 59 items using categorical principal axis factoring with unweighted least squares extraction and Promax factor rotation. We created simple-summated multi-item scales and evaluated their construct validity. The rotated solution yielded four factors with 47 items and a simple factor structure: M-GRCS defined two factors (α = .93 for restricted emotionality/affection; .87 for success/power/competition); the IBHS (α = .89) and IRSS (α = .74) each defined a single factor. The IRSS factor was positively correlated with the Lukwago Racial Pride Scale, r(417) = .40. The IBHS factor was negatively correlated with the IRSS factor, r(414) = - .22. The two M-GRCS factors suggest that the construct of hypermasculinity impacts BMSMW. The high IBHS reliability indicates that homophobia and biphobia were positively correlated in this sample. These three scales have potential for future studies with BMSMW.

BackgroundStable, affordable housing is an established determinant of health. As affordable housing shortages across the USA threaten to displace people from their homes, it is important to understand the implications of cost-related residential moves for healthcare access.ObjectiveTo examine the relationship between cost-related moves and unmet medical needs.DesignWe performed a cross-sectional analysis of 7 waves (2011-2017) of the California Health Interview Survey.ParticipantsWe included all respondents ages 18 and older.Main measuresThe primary predictor variable was residential move history in the past 5 years (cost-related move, non-cost-related move, or no move). The primary outcome was unmet medical needs in the past year (necessary medications and/or medical care that were delayed or not received).Key resultsOur sample included 146,417 adults (42-47% response rate), representing a weighted population of 28,518,590. Overall, 20.3% of the sample reported unmet medical needs in the past year, and 4.9% reported a cost-related move in the past 5 years. In multivariable logistic regression models, adjusted risk of unmet medical needs increased for adults with both cost-related moves (aOR 1.38; 95% CI 1.19-1.59) and non-cost-related moves (aOR 1.17; 95% CI 1.09-1.26) compared to those with no moves. Among people who had moved, those with cost-related moves were more likely to report unmet medical needs compared to people with non-cost-related moves (p = 0.03).ConclusionsPeople who have moved due to unaffordable housing represent a population at increased risk for unmet medical needs. Policy makers seeking to improve population health should consider strategies to limit cost-related moves and to mitigate their adverse effects on healthcare access.

Black men who have sex with men and women (BMSMW) experience pressure to fill hypermasculine ideals and may not identify with "gay" cultural norms. Existing measures of gender role expectations and internalized homophobia are not culturally appropriate for BMSMW. Researchers generally measure categorical identification with race, gender, and sexual orientation groups separately, whereas BMSMW may identify with multiple categories. We modified the Gender Role Conflict Scale to create the M-GRCS and the Internalized Homophobia Scale to include biphobia (Internalized Bi/Homophobia Scale, IBHS). To examine identification at the intersection of race, gender, and sexual orientation, we created 11 Integrated Race and Sexuality Scale (IRSS) items. With data from 429 BMSMW, we conducted exploratory factor analysis of the 59 items using categorical principal axis factoring with unweighted least squares extraction and Promax factor rotation. We created simple-summated multi-item scales and evaluated their construct validity. The rotated solution yielded four factors with 47 items and a simple factor structure: M-GRCS defined two factors (α = .93 for restricted emotionality/affection; .87 for success/power/competition); the IBHS (α = .89) and IRSS (α = .74) each defined a single factor. The IRSS factor was positively correlated with the Lukwago Racial Pride Scale, r(417) = .40. The IBHS factor was negatively correlated with the IRSS factor, r(414) = - .22. The two M-GRCS factors suggest that the construct of hypermasculinity impacts BMSMW. The high IBHS reliability indicates that homophobia and biphobia were positively correlated in this sample. These three scales have potential for future studies with BMSMW.

ObjectiveTo examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.Data sourcesElectronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.Study designRacial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.Principal findingsMortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.ConclusionsNeighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure

Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored.

Objective: To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level. Data Source and Study Setting: We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients‐Patient Centered Medical Home for fiscal years 2016–2019. Study Design: We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person‐centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi‐Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender. Data Collection/Extraction Methods: We defined meaningful difference as both statistically significant at two‐tailed p < 0.05 with a relative difference ≥10% or ≤−10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person‐centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence. Principal Findings: Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi‐Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi‐Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi‐Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person‐centered care and care coordination. Conclusions: We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation. [ABSTRACT FROM AUTHOR]

PurposeTo evaluate whether exposure to MyFamilyPlan-a web-based preconception health education module-changes the proportion of women discussing reproductive health with providers at well-woman visits.DesignCluster randomized controlled trial. One hundred thirty participants per arm distributed among 34 clusters (physicians) required to detect a 20% change in the primary outcome.SettingUrban academic medical center (California).ParticipantsEligible women were 18 to 45 years old, were English speaking, were nonpregnant, were able to access the Internet, and had an upcoming well-woman visit. E-mail and phone recruitment between September 2015 and May 2016; 292 enrollees randomized.InterventionIntervention participants completed the MyFamilyPlan module online 7 to 10 days before a scheduled well-woman visit; control participants reviewed standard online preconception health education materials.MeasuresThe primary outcome was self-reported discussion of reproductive health with the physician at the well-woman visit. Self-reported secondary outcomes were folic acid use, contraceptive method initiation/change, and self-efficacy score.AnalysisMultilevel multivariate logistic regression.ResultsAfter adjusting for covariates and cluster, exposure to MyFamilyPlan was the only variable significantly associated with an increase in the proportion of women discussing reproductive health with providers (odds ratio: 1.97, 95% confidence interval: 1.22-3.19). Prespecified secondary outcomes were unaffected.ConclusionMyFamilyPlan exposure was associated with a significant increase in the proportion of women who reported discussing reproductive health with providers and may promote preconception health awareness; more work is needed to affect associated behaviors.

Purpose of the studyTo develop the Caregiver Orientation Scale for Mexican-Origin Women and evaluate its psychometric properties.Design and methodsWe developed a questionnaire to measure domains of cultural orientation to the caregiver role based on formative research and on the Cultural Justifications for Caregiving Scale. We conducted a series of exploratory factor analyses (EFAs) on data collected from 163 caregivers. We estimated internal consistency reliability (Cronbach's coefficient alpha) and assessed construct validity by estimating correlations between all latent factors and self-rated health, interview language, and weekly hours of care.ResultsEFAs suggested four factors representing familism, obligation, burden, and caregiving intensity that displayed good fit (χ2 (df = 63) = 70.52, p = .24; RMSEA = .03 [90% CI: 0.00, 0.06]; comparative fit index = .99). Multi-item scales representing the four domains had coefficient alphas ranging from .68 to .86. Obligation was positively associated with burden (.46, p < .001) and intensity (.34, p < .01), which were themselves positively correlated (.63, p < .001). Familism was positively associated with obligation (.25, p < .05) yet negatively associated with burden (-.35, p < .01) and intensity (-.22, p < .05). Weekly hours of care were positively associated with burden (.26, p < .01) and intensity (.18, p < .05), whereas self-rated health and burden (-.21, p < .05) and Spanish language and intensity (-.31, p < .001) were negatively correlated.ImplicationsThe study shows that Mexican-origin caregiver orientation is multidimensional and that caregivers may have conflicting motivations for caregiving.

ObjectivesTo compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus.DesignA survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥ 65) and younger (18-65) adults.SettingManaged care.ParticipantsPersons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341).MeasurementsThe primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire.ResultsAfter controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant.ConclusionThis analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment.

Diabetic patients are nearly three times as likely to have depression as their nondiabetic counterparts. Patients with diabetes are already at risk for poor cardiovascular health. Using cross-sectional data from the translating research into action for diabetes (TRIAD) study, the authors tested the association of depression with cardiovascular risk factors in diabetic patients. Depression was measured using the patient health questionnaire (PHQ8). Patients who scored greater than 9 on the PHQ8 were classified as depressed and were compared with those who were not depressed (n = 2,341). Depressed patients did not have significantly different blood pressure levels than those who were not depressed. However, those who were depressed had higher HbA1c levels than those who were not depressed (P < 0.01) and higher BMIs than those who were not depressed (P < 0.01). These results indicate that depressed diabetic patients are at greater risk of having poor control of cardiovascular risk factors and suggest that depression screening should be a standard practice among this patient group.

BackgroundAlthough Medicare Part D improved drug benefits for many beneficiaries, its impact on the coverage of Medicare Advantage Part D (MAPD) enrollees depended on their pre-existing benefits and whether they had gap coverage under Part D.ObjectiveTo examine changes in prescription drug utilization and expenditures associated with drug benefit changes resulting from the implementation of Part D.PatientsWe studied 248,773 continuously enrolled MAPD patients in eight states. Patients whose insurance product or Census block could not be identified or who had atypical benefits, low-income subsidies or Medicaid coverage were excluded.Main measuresThe main outcomes were changes in prescription drug days supply and expenditures from 2005 to 2006 and 2005 to 2007.DesignWe linked Census data with 2005-7 MAPD claims, encounter, enrollment, and benefits data and estimated associations of the outcomes with changes in drug benefits, controlling for 2005 comorbidities, demographics, and Census population characteristics.Key resultsMAPD enrollees whose drug benefits became potentially less generous after Part D had the smallest increases in drug utilization and expenditures (e.g., drug expenditures increased by $130 between 2005 and 2006), while those who potentially gained the most from Part D experienced the largest increases ($302). The differences in benefit design changes had a stronger association with drug utilization and outcomes among patients at high risk of gap entry than among the entire sample.ConclusionsAlthough Medicare Part D unambiguously improved drug coverage for many elderly, it led to heterogeneous changes in drug benefits among MAPD enrollees, who already had generic and sometimes branded drug benefits. After 2006, benefits were worse for individuals who had branded drug coverage in 2005 but now had a coverage gap, but benefits may have improved for individuals who acquired branded drug coverage. Commensurate with these differential changes in benefits following Part D, changes in drug utilization and expenditures varied substantially as well.

ObjectivesTo examine the association between drug coverage during the Medicare Part D coverage gap and medication cost-cutting behaviors of beneficiaries with diabetes mellitus who use and do not use insulin.DesignThe study was cross-sectional.SettingA network-model health system.Participants2007 survey of Medicare Advantage Part D (MAPD) and Prescription Drug Plan (PDP) beneficiaries who entered the gap by October 2006 (N=1,468, 57% response rate).MeasurementsThe primary predictor variable was no gap coverage versus generic-only gap coverage. Seven cost-cutting behaviors were examined as dependent variables, including cost-related nonadherence (CRN) to any medication. Covariates included race or ethnicity, education, health status, income, and comorbidities, as well as generic medication use in the first quarter. Logistic regression models were constructed using nonresponse weights to generate predicted percentages.ResultsIn multivariate analyses, beneficiaries taking insulin were less likely to report CRN if they had generic-only gap coverage than if they had no gap coverage (16% vs 29%, P=.03). No differences in CRN according to type of gap coverage were seen between beneficiaries not taking insulin.ConclusionMedicare beneficiaries using insulin are at high risk of CRN. Generic-only coverage during the gap is associated with an attenuated risk of CRN in insulin users, possibly because of savings on other, generic medications. Future research should evaluate CRN within alternative benefit designs covering selected brand name medications, such as insulin, during the gap.

BackgroundVersus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications.ObjectiveTo examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites.DesignCase-control study.SubjectsA total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans.MeasuresCases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c > or =8.0%, SBP > or =140 mmHg, LDL cholesterol > or =130 mg/dL) and controls were patients with good control of all 3 (HbA1c

ObjectivesTo determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.DesignCross-sectional survey.SettingA Medicare managed care plan (>400,000 members) in one state in 2002.ParticipantsOne thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.MeasurementsParticipants' preferences and experiences with providers discussing costs and participation in choosing medications.ResultsTwo-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.ConclusionProviders should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

ObjectiveTo examine the association between physician-reported percent of total compensation from salary and quality of diabetes care.DesignCross-sectional analysis.ParticipantsPhysicians (n = 1248) and their patients with diabetes mellitus (n = 4200) enrolled in 10 managed care plans.MeasurementsWe examined the associations between physician-reported percent compensation from salary and processes of care including receipt of dilated eye exams and foot exams, advice to take aspirin, influenza immunizations, and assessments of glycemic control, proteinuria, and lipid profile, intermediate outcomes such as adequate control of hemoglobin A1c, lipid levels, and systolic blood pressure levels, and satisfaction with provider communication and perceived difficulty getting needed care. We used hierarchical logistic regression models to adjust for clustering at the health plan and physician levels, as well as for physician and patient covariates. We adjusted for plan as a fixed effect, meaning we estimated variation between physicians using the variance within a particular health plan only, to minimize confounding by other unmeasured health plan variables.ResultsIn unadjusted analyses, patients of physicians who reported higher percent compensation from salary (>90%) were more likely to receive 5 of 7 diabetes process measures and more intensive lipid management and to have an HbA1c

BackgroundGeneric-only drug benefits are a way to provide some coverage, as opposed to no coverage.ObjectiveTo examine how switching from brand name to generic-only drug coverage affected seniors' medication use and financial burden.Study designData are from a 2002 cross-sectional survey conducted for a separate study on benefit caps. Participants belonged to a Medicare managed care plan in one state and had $2000 capped brand name benefits in 2001 but generic-only benefits in 2002.MethodsParticipants reported their cost-cutting strategies before and after the change to generic-only coverage, the medications affected, and their financial burden. We conducted bivariate and multivariate analyses of cost-cutting strategies and financial burden before and after implementation of generic-only benefits.ResultsAmong 611 participants (63% response), rates of switching medications increased after discontinuation of brand name coverage (27% vs 8%, P < .001). Switches were from brand name drugs to generic equivalents (14%) (eg, Prozac to fluoxetine hydrochloride), to nonequivalent generics (26%) (eg, Paxil to fluoxetine), and to different brand name drugs (45%) (eg, Paxil to Zoloft). Ninety percent of brand name switches remained in the same therapeutic class (eg, selective serotonin reuptake inhibitors). After discontinuation of brand name coverage, participants reported higher rates of decreased medication use (28% vs 17%) and greater difficulty paying for prescriptions (65% vs 37%) (P < .001 for both).ConclusionsChanging from brand name benefits to generic-only drug coverage led many participants to switch to less expensive medications but also decreased medication use and increased financial burden. Insurers need to actively help patients adjust to a discontinuation of brand name coverage.

ObjectiveTo examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model.Data sourcesPrimary data collected during 2000-2001 in 10 managed care plans.Study designMultilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive.Data collectionPatient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes.Principal findingsWithout controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model.ConclusionsPhysician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.

BackgroundAlthough disease management programs are widely implemented, little is known about their effectiveness.ObjectiveTo determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels.DesignCross-sectional study.SettingPatients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%).Patients8661 adults with diabetes who completed a survey (2000-2001) and had medical record data.MeasurementsPhysician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use.ResultsIncreased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management.LimitationsPhysician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups.ConclusionsDisease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.

PurposeThis study describes the development of a short version of the Expectations Regarding Aging Survey (ERA-38), a 38-item survey measuring expectations regarding aging.Design and methodsIn 1999, surveys containing the ERA-38 were mailed to 588 adults aged > or = 65 years who were recruited through physicians; 429 individuals (73%) returned completed surveys. The mean age of participants was 77 years; 76% were White. In 2001, we surveyed 643 adults aged > or = 65 years recruited at 14 senior centers. The mean age of participants was 78 years; 37% were Latino and 16% were African American. With the 1999 data, we selected items for the shorter version of the ERA-38 by using qualitative criteria and by evaluating the items' factor structure, internal consistency reliability of scales, and correlations with age and self-reported measures of health. Then, using the 2001 data, we evaluated the selected items with confirmatory factor analysis, and we reevaluated the internal consistency reliability and associations of the scales with age and self-reported measures of health.ResultsThe factor analyses of the ERA-12 on both samples provided support for three 4-item scales (expectations regarding physical health, expectations regarding mental health, and expectations regarding cognitive function), and one global expectations regarding aging scale combining all 12 items. In both samples, internal consistency reliability estimates for all scales exceeded 0.74, and the 12 items together explained over 88% of the variance in the ERA-38 total score. We found comparable associations of the ERA-12 scales with age and self-reported health measures in both samples.ImplicationsThe ERA-12 demonstrated acceptable reliability and validity to estimate expectations regarding aging.

ObjectiveTo make cultural and age-specific modifications to a self-care empowerment intervention.DesignFocus groups with self-administered surveys.SettingTwo public health diabetes and geriatrics clinic and two senior centers in and around South Los Angeles.ParticipantsAfrican Americans and Latinos aged > or = 55 years with diabetes (N=79), and two groups of health educators (N=16).Main outcome measuresAfter describing the proposed intervention, the focus group facilitators asked participants: 1) whether the community of interest would be interested in the proposed empowerment intervention; 2) why or why not; and 3) how the intervention could be modified to better address the concerns of the study community of interest. All groups were audiotaped, transcribed, and (when appropriate) translated into English. Three independent investigators read all transcripts and completed standardized coding forms for each transcript. In addition, at the end of each focus group, all participants completed a self-administered written survey asking them to rate aspects of the proposed intervention.ResultsOlder African Americans and Latinos endorsed the intervention but desired an expanded dietary educational component and identified disability as an important missing content area. Participants rejected the use of an audio learning tool and did not believe that matching group-facilitator sociodemographic characteristics was important as long as facilitators demonstrated cultural competency.ConclusionsThese findings illustrate a model of participatory research in which researchers and community members work together to develop an empowerment intervention that will meet community needs and will have greater cultural appropriateness. Modifying the intervention in accordance with these findings should enhance the relevance and impact of the self-care intervention.

ContextThe majority of Medicare drug benefits in managed care (Medicare + Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year. In the new national Medicare drug benefit, beneficiaries with high medication expenditures will also face a period without drug coverage when their total drug costs exceed annual caps but are not high enough to qualify for catastrophic coverage.ObjectiveTo describe strategies adopted by beneficiaries exceeding annual drug benefit caps to lower prescription costs, the type of medications involved, and their financial burden.Design, setting, and participantsA survey (completed in 2002) of Medicare + Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs (65% response rate). The different caps offered in different counties were used as a natural experiment. Study participants (n = 665) exceeded a 750 dollars or 1200 dollars yearly cap in 2001 and had coverage gaps of 75 to 180 days. Control participants (n = 643) had 2000 dollars caps, which they did not exceed. Study and control participants were matched by average total drug expenditures per month.Main outcome measuresProportion of beneficiaries reporting specific strategies to decrease medication costs, medications affected, and difficulty paying for prescriptions.ResultsIn multivariate analyses adjusting for demographic and health characteristics, a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18% vs 10%, respectively; P