Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries.

BACKGROUND: Deintensification of diabetic therapy is often clinically appropriate for older adults, because the benefit of aggressive diabetes treatment declines with age, while the risks increase. OBJECTIVE: We examined rates of overtreatment and deintensification of therapy for older adults with diabetes, and whether these rates differed by medical, demographic, and socioeconomic characteristics. DESIGN, SUBJECTS, AND MAIN MEASURES: We analyzed Medicare claims data from 10 states, linked to outpatient laboratory values to identify patients potentially overtreated for diabetes (HbA1c < 6.5% with fills for any diabetes medications beyond metformin, 1/1/2011-6/30/2011). We examined characteristics associated with deintensification for potentially overtreated diabetic patients. We used multinomial logistic regression to examine whether patient characteristics associated with overtreatment of diabetes differed from those associated with undertreatment (i.e. HbA1c > 9.0%). KEY RESULTS: Of 78,792 Medicare recipients with diabetes, 8560 (10.9%) were potentially overtreated. Overtreatment of diabetes was more common among those who were over 75 years of age and enrolled in Medicaid (p < 0.001), and was less common among Hispanics (p = 0.009). Therapy was deintensified for 14% of overtreated diabetics. Appropriate deintensification of diabetic therapy was more common for patients with six or more chronic conditions, more outpatient visits, or living in urban areas; deintensification was less common for those over age 75. Only 6.9% of Medicare recipients with diabetes were potentially undertreated. Variables associated with overtreatment of diabetes differed from those associated with undertreatment. CONCLUSIONS: Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.

Racial/Ethnic Disparities in Medicare Beneficiaries' Care Coordination Experiences.

BACKGROUND: Little is known about racial/ethnic differences in the experience of care coordination. To the extent that they exist, such differences may exacerbate health disparities given the higher prevalence of some chronic conditions among minorities. OBJECTIVE: To investigate the extent to which racial/ethnic disparities exist in the receipt of coordinated care by Medicare beneficiaries. SUBJECTS: A total of 260,974 beneficiaries who responded to the 2013 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. METHODS: We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures of care coordination from race/ethnicity. RESULTS: Hispanic, black, and Asian/Pacific Islander (API) beneficiaries reported that their personal doctor had medical records and other relevant information about their care significantly less often than did non-Hispanic white beneficiaries (-2 points for Hispanics, -1 point for blacks, and -4 points for APIs on a 100-point scale). These 3 groups also reported significantly greater difficulty getting timely follow-up on test results than non-Hispanic white beneficiaries (-9 points for Hispanics, -1 point for blacks, -5 points for APIs). Hispanic and black beneficiaries reported that help was provided in managing their care significantly less often than did non-Hispanic white beneficiaries (-2 points for Hispanics, -3 points for blacks). API beneficiaries reported that their personal doctor discussed their medications and had up-to-date information on care from specialists significantly less often than did non-Hispanic white beneficiaries (-2 and -4 points, respectively). DISCUSSION: These results suggest a need for efforts to address racial/ethnic disparities in care coordination to help ensure high-quality care for all patients. Public reporting of plan-level performance data by race/ethnicity may also be helpful to Medicare beneficiaries and their advocates.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) performance with outcomes of enrollees with diabetes.

BACKGROUND: Few quality of care evaluations examine the relationship between clinical processes and patient outcomes. OBJECTIVE: To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes. RESEARCH DESIGN: Secondary data analysis of 2002 HEDIS and 2001-2003 HOS data. SUBJECTS: This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184). MEASURES: Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001-2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores. RESULTS: Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001). CONCLUSIONS: This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.

Differences in risk-adjusted mortality between medicaid-eligible patients enrolled in medicare advantage plans and those enrolled in the veterans health administration.

BACKGROUND: We compared risk-adjusted mortality rates between Medicaid-eligible patients in the Medicare Advantage plans ("MA dual enrollees") and Medicaid-eligible patients in the Veterans Health Administration ("VHA dual enrollees"). METHODS: We used the Death Master File to ascertain the vital status of 1912 MA and 2361 VHA dual enrollees. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: The 3-year mortality rates of VHA and MA dual enrollees were 15.8% and 19.0%, respectively. The adjusted HR of mortality in the MA dual enrollees was significantly higher than in the VHA dual enrollees (HR, 1.260 [95% CI, 1.044-1.520]). This was also the case for elderly patients and those from racial/ethnic minority groups. CONCLUSIONS: The VHA had better health outcomes than did MA plans. The VHA's performance is reassuring, given its emphasis on equal access to healthcare in an environment that is less dependent on patient financial considerations.

Imputation of race/ethnicity to enable measurement of HEDIS performance by race/ethnicity.

OBJECTIVE: To improve an existing method, Medicare Bayesian Improved Surname Geocoding (MBISG) 1.0 that augments the Centers for Medicare & Medicaid Services' (CMS) administrative measure of race/ethnicity with surname and geographic data to estimate race/ethnicity. DATA SOURCES/STUDY SETTING: Data from 284 627 respondents to the 2014 Medicare CAHPS survey. STUDY DESIGN: We compared performance (cross-validated Pearson correlation of estimates and self-reported race/ethnicity) for several alternative models predicting self-reported race/ethnicity in cross-sectional observational data to assess accuracy of estimates, resulting in MBISG 2.0. MBISG 2.0 adds to MBISG 1.0 first name, demographic, and coverage predictors of race/ethnicity and uses a more flexible data aggregation framework. DATA COLLECTION/EXTRACTION METHODS: We linked survey-reported race/ethnicity to CMS administrative and US census data. PRINCIPAL FINDINGS: MBISG 2.0 removed 25-39 percent of the remaining MBISG 1.0 error for Hispanics, Whites, and Asian/Pacific Islanders (API), and 9 percent for Blacks, resulting in correlations of 0.88 to 0.95 with self-reported race/ethnicity for these groups. CONCLUSIONS: MBISG 2.0 represents a substantial improvement over MBISG 1.0 and the use of CMS administrative data on race/ethnicity alone. MBISG 2.0 is used in CMS' public reporting of Medicare Advantage contract HEDIS measures stratified by race/ethnicity for Hispanics, Whites, API, and Blacks.

Overview of the SEER--Medicare Health Outcomes Survey linked dataset.

The Surveillance, Epidemiology, and End Results (SEER)--Medicare Health Outcomes Survey (MHOS) links cancer registry data with survey data from Medicare managed care enrollees. The linked file includes clinical information about the cancer with self-reported data about symptoms, functional status and health-related quality of life (HRQOL) for Medicare managed care enrollees. This article provides a description of the SEER-MHOS data as a tool to study cancer among Medicare enrollees. In order to highlight the strengths of the database, we also present some descriptive statistics from the database.

Disparities in HRQOL of cancer survivors and non-cancer managed care enrollees.

Health plan member survey and cancer registry data were analyzed to understand differences in health-related quality of life (HRQOL) among cancer survivors and those without a cancer diagnosis enrolled in Medicare managed care. HRQOL was measured by the physical component summary score (PCS) and mental component summary score (MCS) of the Medical Outcomes Study SF-36, version 1.0. Cancer survivors enrolled in Medicare managed care have lower PCS and MCS scores than those enrollees who have never been diagnosed with cancer. PCS scores are worse than the MCS scores, and lowest for cancer survivors who are Hispanic, Medicaid enrollees, and those who have low income or education. HRQOL disparities are greatest among cancer survivors diagnosed with lung cancer and those with multiple primary cancer diagnoses. The influence of these variables persists when controlling for multiple variables including comorbidity status. Health plans should focus on addressing these disparities.

Patients' self-report of diseases in the Medicare Health Outcomes Survey based on comparisons with linked survey and medical data from the Veterans Health Administration.

We evaluated the patient self-report questions about disease from the Medicare Health Outcomes Survey (HOS), using linked Veterans Health Administration (VA) data for patients who are eligible for both Medicare and Veterans Affairs (VA) care to estimate their utility as measures of illness burden. Patients were classified for 12 diseases on the basis of HOS question responses and these were compared with classifications based on similar questions from a VA survey or diagnostic codes from VA medical records. Agreement between classifications based on the 2 surveys was good with over 75% of patients affirming the disease in the HOS also affirming it in the VA survey for most diseases. HOS disease status also agreed well with VA-based disease status using diagnostic codes for most diseases, with reasonably good specificity (70%-94%) and sensitivity (65%-85%). The relatively poor measures of agreement for some of the conditions could be related to differences in question wording and other factors. These findings varied only slightly by education, age, and race. Furthermore, independent decrements in health status, derived from the SF-36 associated with each disease based on the survey questions, were similar in the 2 surveys. These results suggest that patients can provide reasonably good reports of their morbidity in survey questions and that patient self-report questions about disease can be used reliably in case-mix adjustments and in stratifications of patients by diseases.

The Limited English Proficient Population: Describing Medicare, Medicaid, and Dual Beneficiaries.

Purpose: The Limited English Proficient (LEP) population experiences well-documented suboptimal health outcomes and substandard provider experiences. The lack of national estimates on the size of the LEP population relative to the healthcare setting makes examining health outcomes for this population very difficult. This analysis addresses this limitation by publishing population estimates for LEP persons enrolled in Medicare, Medicaid, and Duals (enrolled in Medicare and Medicaid). Focusing on the Medicare and Medicaid programs provides an important foundation as these programs are not only the largest insurers in the United States but are also governed by legislation that requires LEP persons to receive equitable access to care. Methods: Data from the 2014 American Community Survey Public Use Microdata Sample (ACS PUMS) were used to produce national estimates and measures of statistical accuracy for the LEP population enrolled in Medicare and/or Medicaid (LEPMM). Results: In 2014, there were approximately 8.7 million LEP persons enrolled in Medicare, Medicaid, or both programs (Duals). The LEPMM was concentrated along the western and eastern coastlines and the southwestern region, with California and New York each containing more than 1 million LEPMMs. The LEPMM was also highly diverse with varying disability status, and most were racial or ethnic minorities and elderly. Conclusion: These findings provide a foundation for measuring an understudied and at-risk population that will enable population health professionals to develop effective culturally and linguistically, and appropriate services and policies that address health disparities in the LEPMM.

Management of urinary incontinence in Medicare managed care beneficiaries: results from the 2004 Medicare Health Outcomes Survey.

BACKGROUND: Despite the high prevalence of urinary incontinence (UI) among older persons and the existence of effective treatments, UI remains underreported by patients and underdiagnosed by clinicians. We measured the occurrence of UI problems in Medicare managed care beneficiaries, frequency of physician-patient communication regarding UI, and frequency of UI treatment. METHODS: We used cross-sectional data from the 2004 Medicare Health Outcomes Survey, which measured self-reported UI (accidental leakage of urine) and UI problems in the past 6 months, 36-Item Short-Form Health Survey health measures, discussions of UI with a health care provider, and receipt of UI treatment. RESULTS: The overall incidence of UI within the past 6 months was 37.3%, consistent with previous estimates. Problems with UI were strongly associated with poorer self-reported health. Mean 36-Item Short-Form Health Survey physical and mental health scores were lower by more than 5 points (on a 100-point scale, P<.001) for respondents with major UI problems when controlling for age, sex, race, Hispanic ethnicity, and major comorbidities. These differences were among the largest of any condition measured. Only 55.5% of those with self-reported UI problems reported discussing these problems during their recent visit to a physician or other health care provider. The rate of patient-reported UI treatment was 56.5% and was lower (P<.001) for older individuals (eg, 46.3% for those aged 90-94 years) or those with poor self-reported health status (50.5%). CONCLUSIONS: Among older persons, UI is common, underdiagnosed, and associated with substantial functional impairment. There appears to be considerable opportunity to mitigate the effects of UI on health and quality of life among community-dwelling older persons.

Data On Race, Ethnicity, And Language Largely Incomplete For Managed Care Plan Members.

The Affordable Care Act requires the federal government to collect and report population data on race, ethnicity, and language needs to help reduce health and health care disparities. We assessed data availability in commercial, Medicaid, and Medicare managed care plans using the Healthcare Effectiveness Data and Information Set. Data availability varied but remained largely incomplete.

Health Indicators for Older Sexual Minorities: National Health Interview Survey, 2013-2014.

PURPOSE: Advances in lesbian, gay, and bisexual (sexual minority [SM]) acceptance and equality have been made in the past decade. However, certain SM subgroups continue to be disadvantaged due to lack of data and, thus, lack of knowledge about these populations. Data for older sexual minorities are especially lacking and will be increasingly important as more sexual minorities enter older age. This research explores results from a nationally representative health survey to elucidate some health indicators for older sexual minorities. METHODS: Data from the 2013 and 2014 National Health Interview Surveys (NHIS) were pooled for increased sample size, and established research methods were followed as recommended by prior NHIS sexual orientation studies. We conducted descriptive analyses on the differences between SM and heterosexual groups, aged 65 years and older, for 12 health indicators. RESULTS: Four out of the 12 health indicators were significantly different for sexual minorities, and three out of those four indicated positive health outcomes or behaviors when compared with heterosexuals. Sexual minorities were more than three times as likely to receive HIV testing as heterosexual peers. Sexual minorities were more likely to receive an influenza vaccination, and much more likely to report excellent or very good health, than their heterosexual peers. Sexual minorities were more than twice as likely to report binge drinking, which is consistent with prior research for adult sexual minorities. CONCLUSION: This analysis is the first to examine national data on health indicators for sexual minorities, aged 65 years and older, using NHIS data. As more surveys begin to collect SMdata and more years of data are collected by NHIS, a clearer picture of the health of older adult sexual minorities should emerge.

Racial and Ethnic Differences in Satisfaction with Care Coordination Among VA and non-VA Medicare Beneficiaries.

Purpose: Patients who have multiple sources of care are at risk for fragmented and uncoordinated care, which can lead to poorer outcomes. Veteran Medicare beneficiaries who use the Veterans Health Administration (VHA) system (VA users), particularly racial/ethnic minorities, often have complex medical conditions that may require care from multiple sources, leaving them especially vulnerable to the effects of fragmented care. We examined racial/ethnic differences in the level of satisfaction with care coordination among Medicare beneficiaries, comparing those who do and do not use the VHA healthcare system. Methods: We conducted a retrospective, pooled, cross-sectional study of Medicare beneficiaries using the 2009-2011 Medicare Current Beneficiary Survey. The outcomes are self-reported satisfaction with care items related to three dimensions of care coordination: (1) integrated care, (2) care continuity, and (3) follow-up care. We present descriptive statistics and use generalized linear models to examine racial/ethnic differences across VA and non-VA users, after accounting for other demographic characteristics, health status, functional limitations, insurance coverage, and geographic variation. Results: VA users are more likely to be very satisfied with receiving both integrated and follow-up care compared with non-VA users. Despite the existence of significant racial/ethnic disparities in the likelihood of being very satisfied with receiving well-coordinated care in the larger Medicare population, racial/ethnic minority VA users are just as likely as White non-Hispanics to be very satisfied with receiving well-coordinated care. Conclusions: Future research should continue to study care coordination among VA users and reasons for preferring the VA over other healthcare systems, especially among racial/ethnic minority groups.

Improving Measures of Sexual and Gender Identity in English and Spanish to Identify LGBT Older Adults in Surveys.

PURPOSE: The goal of this research is to advance the study of health disparities faced by older sexual and gender minorities by assessing comprehension of and improving measures of sexual and gender identity in surveys. METHODS: Cognitive interviews were conducted by expert interviewers with 48 non-lesbian, gay, bisexual, and transgender (non-LGBT) and 9 LGBT older English and Spanish speakers. RESULTS: All respondents were able to answer questions about their sex assigned at birth and current gender identity successfully despite some cisgender respondents' lack of clear understanding of the transgender response option. On the contrary, while the vast majority of English speakers could answer the question about their sexual identity successfully, almost 60% of the non-LGBT Spanish speakers did not select the "heterosexual, that is, not gay (or lesbian)" response category. Qualitative probing of their response process pointed mainly to difficulties understanding the term "heterosexual," leading to their choosing "something else" or saying that they didn't know how to answer. A second round of testing of alternative response categories for the sexual identity question with Spanish speakers found a marked improvement when offered "not gay (or lesbian), that is, heterosexual" instead of beginning with the term "heterosexual." CONCLUSION: This research adds to our understanding of gender and sexual identity questions appropriate for population surveys with older adults. Inclusion of these measures in surveys is a crucial step in advancing insights into the needs of and disparities faced by LGBT older adults.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

PURPOSE: Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. METHODS: We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. RESULTS: Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. CONCLUSIONS: Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Identifying the Transgender Population in the Medicare Program.

Purpose: To identify and describe the transgender population in the Medicare program using administrative data. Methods: Using a combination of International Classification of Diseases ninth edition (ICD-9) codes relating to transsexualism and gender identity disorder, we analyzed 100% of the 2013 Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service (FFS) "final action" claims from both institutional and noninstitutional providers (∼1 billion claims) to identify individuals who may be transgender Medicare beneficiaries. To confirm, we developed and applied a multistage validation process. Results: Four thousand ninety-eight transgender beneficiaries were identified, of which ∼90% had confirmatory diagnoses, billing codes, or evidence of a hormone prescription. In general, the racial, ethnic, and geographic distribution of the Medicare transgender population tends to reflect the broader Medicare population. However, age, original entitlement status, and disease burden of the transgender population appear substantially different. Conclusions: Using a variety of claims information, ranging from claims history to additional diagnoses, billing modifiers, and hormone prescriptions, we demonstrate that administrative data provide a valuable resource for identifying a lower bound of the Medicare transgender population. In addition, we provide a baseline description of the diversity and disease burden of the population and a framework for future research.

Frequency of Disparities in Laboratory Testing After Statin Initiation in Subjects ≥65 Years.

Laboratory testing is important for the safety of older adults initiating statins, but there has been little examination of laboratory testing disparities by race/ethnicity, age, gender, Medicaid eligibility, and multimorbidity. The study's purpose was to examine disparities in guideline-concordant baseline laboratory testing and abnormal laboratory values among a retrospective cohort of 76,868 Medicare fee-for-service beneficiaries from 10 states in the eastern United States who had dyslipidemia and initiated a statin from July 1 to November 30, 2011. Guideline-concordant assessment of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) was defined as evidence of an outpatient claim for either test within 180 days before or 14 days after the date of the index statin fill. In 2011, baseline laboratory testing rates were 89.3% for ALT and 88.8% for AST. Older adults were somewhat more likely to have ALT and AST testing if they were dually enrolled in Medicaid (relative risk 1.01, 95% confidence interval [CI] 1.00 to 1.02) or had multiple chronic conditions (relative risk 1.03, 95% CI 1.00 to 1.06 for 2 to 3 conditions; odds ratio [OR] 1.08, 95% CI 1.05 to 1.11 for 4 to 5 conditions; OR 1.14, 95% CI 1.11 to 1.17 for 6+ conditions), compared with 0 to 1 conditions. Non-Hispanic blacks were less likely to receive baseline testing (OR 0.97, 95% CI 0.96 to 0.98) than non-Hispanic Whites, and male beneficiaries were somewhat less likely to receive testing than female beneficiaries (OR 0.99, 95% CI 0.98 to 0.99). Abnormal values were rare. In conclusion, ALT and AST assessment after statin initiation was commonly done as recommended, and there were negligible disparities in testing rates for beneficiaries.

Few Disparities in Baseline Laboratory Testing After the Diuretic or Digoxin Initiation by Medicare Fee-For-Service Beneficiaries.

BACKGROUND: Despite the persistence of significant disparities, few evaluations examine disparities in laboratory testing by race/ethnicity, age, sex, Medicaid eligibility, and number of chronic conditions for Medicare fee-for-service beneficiaries' newly prescribed medications. In Medicare beneficiaries initiating diuretics or digoxin, this study examined disparities in guideline-appropriate baseline laboratory testing and abnormal laboratory values. METHODS AND RESULTS: To evaluate guideline-concordant testing for serum creatinine and serum potassium within 180 days before or 14 days after the index prescription fill date, we constructed retrospective cohorts from 10 states of 99 711 beneficiaries who had heart failure or hypertension initiating diuretic in 2011 and 8683 beneficiaries who had heart failure or atrial fibrillation initiating digoxin. Beneficiaries initiating diuretics were less likely to have testing if they were non-Hispanic Black (relative risk [RR], 0.99; 95% confidence interval [CI], 0.98-0.99) than non-Hispanic White. Beneficiaries initiating diuretics and beneficiaries initiating digoxin were more likely to have testing if they had multiple chronic conditions relative to 0 to 1 conditions. Beneficiaries initiating diuretics with laboratory values were more likely to have an abnormal serum creatinine value at baseline if they were non-Hispanic Black (RR, 2.57; 95% CI, 1.91-3.44), other race (RR, 2.11; 95% CI, 1.08-4.10), or male (RR, 2.75; 95% CI, 2.14-3.52) or an abnormal serum potassium value if they were aged ≥76 years (RR, 1.29; 95% CI, 1.09-1.51) or male (RR, 1.17; 95% CI, 1.03-1.33). CONCLUSIONS: Testing rates were consistently high, so there were negligible disparities in guideline-concordant testing of creatinine and potassium after the initiation of digoxin or diuretics by Medicare beneficiaries.

The health status of elderly veteran enrollees in the Veterans Health Administration.

OBJECTIVES: To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations. DESIGN: Cross-sectional study. SETTING: Outpatient. PARTICIPANTS: A total of 1,406,049 veteran enrollees were surveyed, and 887,775 returned the questionnaire (63.1%). Of these, 663,729 (74%) were aged 65 and older. MEASUREMENTS: Patient demographics, comorbid conditions, and health status, which was assessed using the Veterans 36-item short form (SF-36), a reliable and valid measure of health-related quality of life (HRQoL). RESULTS: Elderly veteran enrollees are a group with poor health status across all scales of the Veterans SF-36. Significant decline in HRQoL was found in patients grouped by increasing age (65-74, 75-84, and > or =85). Of the Veterans SF-36 scales, the role physical and role emotional scales and physical functioning presented the largest decrements by age group. The elderly veteran enrollees had poorer health status than older people enrolled in Medicare managed care, ranging from 0.5 to 1 standard deviations worse. CONCLUSION: Elderly veteran enrollees have substantial disease burden, as reflected by major impairments across multiple dimensions of HRQoL. These findings bear important implications for use of services, suggesting that the Veterans Health Administration will require considerable resources to provide care for its aging population.

Smoking and functional status among Medicare managed care enrollees.

BACKGROUND: Smoking is a major determinant of health status and outcomes. Current smoking has been associated with lower scores on the Short Form-36 Health Survey (SF-36). Whether this occurs among the elderly and disabled Medicare populations is not known. This study assessed the relationships between smoking status and both physical and mental functioning in the Medicare managed-care population. METHODS: During the spring of 1998, data were collected from 134309 elderly and 8640 disabled Medicare beneficiaries for Cohort 1, Round 1 of the Medicare Health Outcomes Survey. We subsequently used these data to calculate mean standardized SF-36 scores, self-reported health status, and prevalence of smoking-related illness, by smoking status, after adjusting for demographic factors. RESULTS: Among the disabled, everyday and someday smokers had lower standardized physical component (PCS) and mental component (MCS) scores than never smokers (-2.4 to -4.5 points; p <0.01 for all). Among the elderly, the lowest PCS and MCS scores were seen among recent quitters (-5.1 and -3.7 points, respectively, below those for never smokers; p <0.01 for both), but current smokers also had significantly lower scores on both scales. For the elderly and disabled populations, MCS scores of long-term quitters were the same as nonsmokers. Similar patterns were seen across all eight SF-36 scales. Ever smokers had higher odds of reporting both less-than-good health and a history of smoking-related chronic disease. CONCLUSIONS: In the elderly and disabled Medicare populations, smokers report worse physical and mental functional status than never smokers. Long-term quitters have better functional status than those who still smoke. More effort should be directed at helping elderly smokers to quit earlier. Smoking cessation has implications for improving both survival and functional status.