Worry about health status among the elderly: patient management and health policy implications.

Health care reform depends on reducing inappropriate utilization and improving access. Elderly people, major consumers of primary care, are a place to begin reforms, but progress has been slow. We combined primary care screening questions for objective (medical condition as wellness) and subjective (perception of health as worry) health in a study of 767 elderly people in Youngstown, Ohio. The worried well (31.2%), a group likely to consume medical care inappropriately, and unconcerned ill (4.4%), a group likely to avoid seeking necessary medical care, account for more than one-third of the elderly. The unconcerned well (57.0%) and worried ill (6.9%) pose fewer problems. Family physicians can predict utilization and access problems for targeted groups (older people, minorities, and women), along with health beliefs and other indicators of health status. Although findings in this study are preliminary, they do point to positive uses in health policy and patient management. Extensive usage of the sure would require financial reimbursement to health care providers.

Urban/rural elderly health status differences: the dichotomy reexamined.

Health policy research analyzes urban/rural differences as a simple dichotomy. Research characterizes the rural elderly as having a higher incidence of sickness, dysfunction, disability, restricted mobility, and acute and chronic conditions than their urban counterparts. However, population density as a dichotomy may obscure urban, rural, or urban/rural differences. Interviews measuring health status were conducted with a representative sample of 2,300 elderly people in six Northeastern Ohio counties constituting an urban/rural continuum. On medical condition, use of medical aids, and symptoms, health status improved significantly when moving from rural to urban, but correlations were small. Using dichotomies, urban elderly reported fewer medical conditions and symptoms than rural elderly, but four other health-status variables revealed no significant association and results differed depending on how dichotomies were defined. When individual communities were compared few urban/rural patterns emerged. Controlling for demographics did not change interpretations. Findings question blanket assertions about urban/rural health-status differences. Medical resources may be misallocated. Rather than assuming poor health status among the rural elderly, researchers must verify differences through community-based research.

Alcohol, drugs, and urban violence in a small city trauma center.

Substance abuse and urban trauma go hand in hand. But research focuses on large cities served by major academic medical centers. Do small cities face the same problems? Two hundred thirty-three urban trauma inpatients from a metro area of 250,000 were studied using patient interviews and medical records. As in large cities, one half used alcohol or drugs when attacked. Seventy percent were likely to be young, male, poor African-Americans. Only 3% were gang members, but demographic characteristics failed to explain substance abuse as they have for larger cities. A culture of violence pervades the small city, as it does in large urban ghettos. Two fifths were repeat urban trauma victims. Two fifths witnessed assaults in the past year. One third carried a knife or gun. Fifteen percent used a weapon on another person in the last year. Contextual variables, like being hurt in a bar, were related to drinking and drugs. The best predictor of present substance abuse and urban trauma was medical history of substance abuse. The need for (a) toxicology screens for all trauma victims, (b) referrals to substance abuse programs, (c) targeting at-risk populations for prevention, and (d) eliminating environments fostering violence and substance abuse is supported.

Repeat victims of violence in an urban trauma center.

Repeat victims of violence are overwhelming urban trauma centers, yet little is written about them in the medical literature. This study combined medical record and survey data to study urban trauma recidivism among patients presenting at the Emergency Department [ED] of St. Elizabeth Hospital in Youngstown, Ohio during a 4-year period. Two-fifths of urban trauma patients were repeat victims. Repeat victims were more likely to be poor African-American males, have substance abuse and mental health problems, and live in neighborhoods where violence is pervasive. Most have no health insurance. Demographic characteristics were less important in explaining recidivism than were the circumstances surrounding violent behaviors. ED physicians must be trained to take into account a wide variety of environmental, personal, and circumstantial factors in treating and managing urban trauma patients. This may require reforms in health care financing.

Agreement between telephone survey and medical record data for the elderly patient.

OBJECTIVE: This study compares agreement between telephone survey and ambulatory medical record data for an elderly patient population. METHODS: Medical records and telephone survey responses are used to compare health status (chronic medical condition, symptomatology, and functional status) of 142 elderly patients randomly selected from a family practice residency and a geriatric fellowship practice. Chart abstraction was performed by two resident and two faculty physicians after a training period designed to assure high inter-reviewer reliability. Telephone surveys were completed by two professional interviewers. Health status measures were taken from standard, published instruments. The kappa statistic was used to measure the agreement between medical record and survey data. RESULTS: Overall, there is little agreement between the medical record and the telephone survey results on chronic medical condition, symptomatology, and functional status. CONCLUSIONS: Medical records abstractions and telephone survey methodologies did not yield comparable health status data when applied to the same elderly patient population. Functional status assessment and symptomatology are particularly problematic, but even the presence or absence of chronic diseases is often inconsistent in the two data sources.

Health status among elderly Hungarians and Americans.

Selected health status data for elderly populations from similar industrial cities-Youngstown, Ohio, USA, and Debrecen, Hungary-were compared. Because of their impoverished health care system, unregulated heavily industrialized society, and unhealthful life-styles Hungarians were hypothesized to have poorer health status than Americans, even after taking into account demographic mediating factors. The study provides a health status baseline for elderly Hungarians shortly after communism's fall in 1989-1990 and shows how great a gap exists between Hungarian health status and that in the West. Hungarians were in much poorer health as measured by functional status, symptomatology, medical condition, depression, and subjective health status. Distinctions persisted when controlling for gender, age, and education. Poverty-level (and income) did not explain health status differences. The paper concludes that Hungary should pay more attention to health promotion, prevention, and primary care, as well as to reforming patient management in hospitals, nursing homes, and home care programs.

Access to medical care among the elderly in rural northeastern Ohio.

BACKGROUND: Conventional wisdom holds that the elderly living in rural areas suffer poor health and have limited access to health care compared with their urban peers. The relation between poor health and limited access, however, has yet to be adequately defined. METHODS: We conducted a telephone survey of 1000 elderly persons living in four rural northeastern Ohio counties using a proportional random-digit dialing method. RESULTS: Many rural elderly respondents appeared to suffer poor health and have limited access to medical care. However, a detailed analysis revealed that poor health and limited access were more perceptual than actual. CONCLUSIONS: Elderly persons living independently in rural northeast Ohio have much better health and access to care than suggested by the literature.

The effect on retirees of losing retirement and health insurance benefits.

BACKGROUND AND OBJECTIVES: The recent economic downturn has led to instability in the private health insurance industry. Although loss of medical benefits is assumed to have a negative effect on health, documentation is lacking. LTV Corporation (Ling-Temco-Vought) filed for bankruptcy and interrupted medical insurance for its retirees for six months. METHODS: Using a structured interview format, we surveyed community-living LTV retirees whose medical insurance had been interrupted. We sought to predict health status using a variety of measures. RESULTS: The vast majority of retirees were generally unaffected by the loss of medical benefits. Of the 191 LTV retirees from Youngstown, Ohio, who were interviewed shortly after health benefit loss, 13.8% reported longer-term health effects (continued decline in subjective health status), whereas 8.5% had short-term effects (decline followed by return to good or excellent health status). Although 10.5% of workers experienced serious health problems during the crisis, only one worker was unable to pay for health care as a result of the benefits loss. A discriminant analysis yielded excellent results in predicting longer-term deteriorating health status. CONCLUSIONS: Implications for community-oriented primary care service models are discussed, as well as the utility of demographic targeting for retirees losing health benefits.

Volunteers for community health. An Ohio hospital sponsors parish nursing programs for area churches and synagogues.

Since 1989, St. Elizabeth Hospital Medical Center, Youngstown, OH, has been conducting a hospital-based, multidenominational volunteer parish nurse program, which now extends to 11 Roman Catholic, Lutheran, Presbyterian, Methodist, Jewish, and Greek Orthodox congregations. Seventeen volunteer nurses are involved, responding to needs within their congregations by providing a variety of healthcare and educational services while revitalizing the Church's healing ministry. Volunteers selected are competent, experienced registered nurses who can relate to and communicate with people of all ages, accurately assess health-related problems, and make appropriate nursing decisions. Parish nurses focus on preventive care, health maintenance, and personal responsibility for maintaining a healthy life-style. Volunteer nurses determine their own schedule, contributing as much time as they can. Each volunteer nurse is responsible for developing a record-keeping system, documenting his or her parish activities, and submitting a quarterly report of volunteer hours and activities to the hospital. Hospital supports include the initial two-day orientation; monthly meetings at the hospital for information sharing, education, and mutual support; and nursing continuing education programs In addition, an advisory committee provides program support and education. St. Elizabeth Hospital Medical Center is exploring several methods of enhancing its health ministry outreach to congregations in dire need of such services.

Worried wellness: how meaningful is the concept in managing elderly patients?

The concept of "worried wellness" is poorly defined for research purposes, and little is known about the worried-well elderly. To study the incidence of worried wellness in the elderly and define the clinical utility of the term, researchers conducted a structured interview with 733 independently living community elderly and 250 elderly patients from a family practice residency-teaching practice. The interview combined standard subjective health questions with specific additional measures of worry to form a "worry" scale. The worry data were cross-tabulated with "wellness" parameters that included symptomatology, presence of chronic medical conditions, use of medical equipment, and activities of daily living. A wide range of prevalences for worry were found, depending on the measure used. Wellness data were more consistent: though the vast majority of elderly were fully functional, 9 out of 10 subjects had at least one medical condition. Cross-tabulation based on individual items from the worry and wellness measures yielded a prevalence of one-third or less, depending on the measure used. However, composite analyses for both liberal and conservative measures of worry disclosed very few cases of worried wellness in the patient or community samples. This finding points to a very low incidence of the phenomenon among the elderly and raises significant doubt about the clinical utility of the term "worried wellness."

Assessing the denominator problem in community-oriented primary care.

Determination of health care needs is an essential cornerstone of community-oriented primary care (COPC). Many physicians, lacking research resources, may generalize their own patient registry data to the community. But practice populations are likely to differ significantly from community populations. This study compared demographics, health status, and medical care utilization in a sample of 990 elderly living in the community and 250 elderly patients registered at the St. Elizabeth Hospital Family Health Center in Youngstown, Ohio. The community survey and patient registries were comparable on key demographic characteristics. But statistically significant differences were observed for functional status and a number of chronic medical conditions. Comparisons of symptomatology, use of health aides, subjective health status, depression, and stress produced no significant differences. Overall health care utilization patterns were similar. The elderly family health center patients were more representative of the non-institutionalized elderly in the community than expected. And although the clinical significance remains uncertain, these findings suggest that this practice sample may be used with caution for COPC planning. But considerably more research must be undertaken in a variety of practice settings before the use of practice populations for COPC planning is widely applied.

Combating infant mortality. A hospital collaborates with other groups to offer prenatal care in a rural area.

Prenatal care services are often lacking in poor rural areas. Consequently, rates of infant mortality and negative birth outcomes are relatively high. To address these problems, since 1987 St. Elizabeth Hospital Medical Center (SEHMC), Youngstown, OH, has successfully operated an innovative rural-based prenatal care clinic for indigent women. The Leetonia Clinic serves residents of Leetonia, OH, and about 20 surrounding communities. It offers on-site medical care using SEHMC obstetrics and gynecology residents and volunteer nurses. The local Catholic Charities organization funds a professional social worker. A prolife advocacy group and a women's self-help group offer volunteer counseling and referral services. They also manage paperwork at the clinic. The local Catholic church provides space in one of its school buildings to house the clinic. SEHMC also provides patient education and outreach. Over the past 4 years the clinic has served about 165 patients annually. About half are on welfare, and the rest are primarily self-paying. Studies are under way to assess the program's effect on infant mortality and morbidity.

Long-term health impacts of forced early retirement among steelworkers.

BACKGROUND: Previous studies of the health impacts of retirement have not investigated the effects of forced early retirement following plant closings. METHODS: Using a geriatric database representative of elderly people, the health impacts on employees forced to take early retirement from steel mills in the Youngstown, Ohio, area were assessed. A study group of forced early retirees was compared with two control groups: (1) regular steel industry retirees, and (2) regular retirees from jobs outside the steel industry. Utilizing multivariate analysis techniques, the effects of retirement on a number of different health measures were isolated. RESULTS: Over the long term, the health of forced retirees does not seem adversely affected by sudden job loss and unexpected retirement, at least in the steel industry. CONCLUSIONS: Continuity theories of retirement--that workers do not experience abrupt catastrophic changes in lifestyle and in health--best explain the lack of negative health impacts.

Health and poverty among elderly persons: a community-oriented primary care survey.

Providing health care for independent-living elderly persons is important, yet family physicians often lack accurate information about needs and access to care. The Community-Oriented Primary Care (COPC) approach and health status models from health services research provide a framework for assessing need and access to care. Personal interviews were conducted with 990 noninstitutionalized elderly persons in Youngstown, Ohio. Results showed that poverty, gender, and race were not strongly related to health status as measured by numbers of symptoms, functional status, or subjective health status. In addition, elderly persons had fewer health care needs and greater access to care than expected. Simple models of health status, need, and access do not seem to apply. The study shows the usefulness of COPC in planning health services; however, more effort is needed to refine measures of health status, need, and access.

Good neighbors. A hospital and town cooperate to build a better community.

The healthcare market in many communities is changing dramatically, with declining and aging populations, severe economic problems, urban distress, and growing proverty. Community hospitals that are prepared to serve this new market will not only find new patients but also build better communities. To accomplish these tasks, St. Elizabeth Hospital Medical Center, Youngstown, OH, has created the Educational Research and Development Center (ERDC). The ERDC's internal purpose is to help St. Elizabeth improve the quality of patient care while enhancing the community's quality of life and economic vitality. In carrying out its mandate, the ERDC concentrates on three activities: researching the changing healthcare environment; educating hospital staff on healthcare policy issues community concerns, and research methodology and assisting the community on social and economic issues. The ERDC acts as a consultant to other group in the hospital, undertakes its own research, an pursues joint ventures with other institutions. The ERDC's Health Education Center extends the educational mission outside the hospital. In partnership with a local merchants' association, a neighborhood revitalization group, and Youngstown economic development department, the ERDC has prepared a land-use study of the neighborhood adjacent to St. Elizabeth's main facilities.