Trends in medical conditions and functioning in the U.S. population, 1997-2017.

BACKGROUND: Over the last several decades, the federal disability rolls grew substantially, though this growth has slowed more recently. Many factors underlie these trends, including changes in demographics, policies, and disability prevalence. OBJECTIVE: We address two research questions: (1) How has the prevalence of certain potentially disabling conditions changed among working-age adults over the last two decades? and (2) Among individuals with these conditions, how has the share who report particular functional limitations changed over time? METHODS: We use nationally representative survey data from the National Health Interview Survey (NHIS) to document regression adjusted population trends since 1997 in some of the most commonly disabling chronic conditions and functional limitations among adult disability beneficiaries. RESULTS: We find that the prevalence of several conditions has increased in the U.S. population - most notably, obesity, endocrine conditions, and neoplasms. We also find notable changes in functional limitations. Hearing and vision limitations declined, while adults experienced increases in cognitive, social, and movement limitations. Alongside these long-term trends we find some evidence that reporting of conditions and limitations is countercyclical with the business cycle. CONCLUSIONS: These changes in condition prevalence and functional limitations are consistent with some but not all documented changes in the federal disability rolls. Increases in social limitations are consistent with the perception that Americans are increasingly socially isolated.

Effects of a community-based care management model for super-utilizers.

OBJECTIVES: Medicare, Medicaid, and commercial plans have all explored ways to improve outcomes for patients with high costs and complex medical and social needs. The purpose of this study was to test the effectiveness of a high-intensity care management program that the Rutgers University Center for State Health Policy (CSHP) implemented as an adaptation of a promising model developed by the Camden Coalition of Healthcare Providers. STUDY DESIGN: We estimated the impact of the program on 6 utilization and spending outcomes for a subgroup of beneficiaries enrolled in Medicare fee-for-service (n = 149) and a matched comparison group (n = 1130). METHODS: We used Medicare claims for all analyses. We used propensity score matching to construct a comparison group of beneficiaries with baseline characteristics similar to those of program participants. We employed regression models to test the relationship between program enrollment and outcomes over a 12-month period while controlling for baseline characteristics. RESULTS: A test of joint significance across all outcomes showed that the CSHP program reduced service use and spending in aggregate (P = .012), although estimates for most of the individual measures were not statistically significant. Participants had 37% fewer unplanned readmissions (P = .086) than did comparison beneficiaries. Although we did not find statistically significant results for the other 5 outcomes, the CIs for these outcomes spanned substantively large effects. CONCLUSIONS: Although these findings are mixed, they suggest that adaptations of the Camden model hold promise for reducing short-term service use and spending for Medicare super-utilizers.

Psychiatric versus physical disabilities: A comparison of barriers and facilitators to employment.

OBJECTIVE: Guided by the social model of disability (Nagi, 1965), this study aims to better identify barriers to and facilitators of employment for individuals with psychiatric disabilities and how these factors may differ for individuals with physical disabilities. METHOD: Our analysis uses data from the Survey of Disability and Employment on 2,148 individuals with psychiatric disabilities, physical disabilities, or both who in 2014 applied for services from 1 of 3 state vocational rehabilitation (VR) agencies. We identify type of disability based on respondents' open-ended descriptions of their impairments. We use univariate statistics and multivariate regression estimates to compare employment history, and potential barriers to and facilitators of employment between individuals with psychiatric and physical disabilities. RESULTS: VR applicants with psychiatric disabilities have had longer periods of nonemployment than individuals with physical disabilities alone. They are significantly more likely than individuals with physical disabilities alone to report nonhealth reasons, such as getting fired and lacking skills, as barriers to employment. We found that a number of accommodations, including flexible schedules and modified work duties, are significantly associated with continued employment. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: VR counselors should be aware that although most applicants with psychiatric disabilities place a great deal of importance on being employed, they face additional barriers to employment. (PsycINFO Database Record

Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial.

BACKGROUND: Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry. METHODS: SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices. DISCUSSION: Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care. TRIAL REGISTRATION: NCT02318108.

Can family caregiving substitute for nursing home care?

Informal care should be a substitute for nursing homes but empirical evidence often suggests the opposite. This may be because informal care receipt is positively correlated with unobserved negative health characteristics. We exploit variation in children's characteristics as instruments for informal care to provide Two-Stage Least Squares (TSLS) estimates of nursing home use among a sample of 6855 individuals from the 1993-2000 waves of the AHEAD survey. While OLS results suggest informal care is associated with greater future nursing home risk, TSLS estimates show that receipt of informal care statistically and substantially reduces the risk of nursing home entry. This finding has implications for Medicaid and private long-term care insurance markets.

Disability symptoms and the price of self-sufficiency.

OBJECTIVE: Disability symptoms are tiredness, slowness, and pain doing daily tasks made difficult by health. The authors study factors that increase and decrease disability symptoms, especially effects of equipment and personal assistance. METHOD: In National Health Interview Survey Disability Supplement Phase 2, people with personal care and household management disabilities were asked about fatigue, taking a long time, and pain when doing tasks on their own and with assistance. The authors study persons ages 55 and older. RESULTS: Poor overall health or disability and severe disability in tasks increase disability symptom chances by 11% to 18%. Assistance users are 19% to 20% less likely to have symptoms than nonusers. Personal help, alone, or with equipment, relieves symptoms better than equipment only, by 9% to 13%. DISCUSSION: Equipment-only users are self-sufficient, a highly prized situation. Because they actively engage in tasks, symptoms are still likely. This trade-off of psychological gain with comfort loss may be preferable to personal help.

Use, type, and efficacy of assistance for disability.

OBJECTIVES: Personal and equipment assistance are often used to reduce disability. This study predicts use of assistance, type of assistance, and its efficacy (improvement with assistance) for disabilities in personal care and household management tasks. METHODS: U.S. community-dwellers aged 55+ are studied using the 1994-1995 National Health Interview Survey Disability Supplement. Three types of assistance are considered: Personal Only, Equipment Only, and Both. Efficacy is measured by comparing the degree of difficulty doing a task with versus without assistance. RESULTS: Severe disability in a task and poor overall health/disability status increase use of assistance for the task, and especially both types rather than one. For people using one type of assistance, poor health/disability status is linked with personal help, but high severity is linked with equipment use. These results reflect high needs for assistance and limited potential for physiological improvement, joined possibly by a strong desire for self-sufficiency among persons who are severely disabled. Controlling for factors that route people to different types of assistance, equipment is more efficacious than personal assistance. Equipment may have distinctive technical and psychological advantages; for example, it can be tailored to a person's specific needs, is available when needed, and maintains self-sufficiency. DISCUSSION: The results about equipment give impetus to policies that promote development and dissemination of assistive technology.