Coverage and Access for Americans with Cardiovascular Disease or Risk Factors After the ACA: a Quasi-experimental Study.

BACKGROUND: Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the USA. Many with CVD or cardiovascular risk factors (CVRFs) lacked insurance coverage and access to care before enactment of the Affordable Care Act (ACA). OBJECTIVE: To assess the effect of the ACA on insurance coverage, access to care, and racial/ethnic disparities among non-elderly adults with CVD or CVRFs. DESIGN: Quasi-experimental policy intervention. PARTICIPANTS: Nationally representative, non-institutionalized sample of 1,014,450 adults aged 18 to 64 years with CVD or at least 2 established CVRFs in the pre-ACA (2012-2013) and post-ACA (2015-2016) periods. INTERVENTION: Implementation of ACA provisions on 1 January 2014. MAIN MEASURES: Insurance coverage, having a check-up, having a personal physician, and not having to forgo a needed physician visit because of cost. KEY RESULTS: Following ACA implementation, insurance coverage increased by 6.9 percentage points (95% CI, 6.6 to 7.2), not having to forgo a physician visit increased by 3.6 percentage points (CI, 3.3 to 3.9), having a check-up increased by 2.1 percentage points (CI, 1.8 to 2.6), and having a personal physician increased by 1 percentage point (0.6 to 1.3); changes were approximately doubled for those with lower incomes (< $35,000/year). Changes in coverage varied substantially by state and all outcomes improved more in Medicaid expansion states. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 13% black and 29% Hispanic adults continued to lack coverage and access to care post-ACA. CONCLUSION: The ACA increased coverage and access for adults with CVD or multiple CVRFs; substantial gaps remain, particularly for minorities and those in Medicaid non-expansion states.

Oral health of ambulatory care patients.

OBJECTIVES: This project assessed the clinical oral health status of Veterans Administration (VA) patients and examined the relationship between oral health and both sociodemographic factors and dental care utilization. METHODS: Data were collected on 538 users of VA ambulatory medical care. Oral health was assessed by clinical examinations, and dental use and sociodemographic information are based on self-report. RESULTS: Younger, more educated VA patients with higher incomes had more teeth, fewer untreated and treated root caries, and were less likely to be edentulous or to have dentures. Dental utilization emerged as the most important aspect of veterans' oral health status, even after sociodemographic factors were controlled. Compared with the general population, veterans have poorer oral health with the exception of coronal caries. CONCLUSION: Compared with national studies, VA patients appear to have worse oral health. The importance of sociodemographic factors and dental utilization that has been found in other studies applies to veterans' oral health as well.

Self-reported and clinical oral health in users of VA health care.

BACKGROUND: This article describes the oral health of users of Veterans Administration (VA) health care using both clinical and self-report measures, and models relationships between these measures and self-perceived oral health. METHODS: We conducted a cross-sectional study of 538 male users of VA outpatient care in the Boston area. Questionnaires assessed self-reported oral health, oral-specific health-related quality of life, health behaviors, and sociodemographic information. Clinical data were collected on oral mucosa status, number of teeth and root tips, dental caries, and periodontal treatment need. We report clinical and self-reported oral health status by age group (era of military service). We regressed models of self-perceived oral health on clinical indices and self-reported measures of the impact of oral health on daily life, adjusting for sociodemographic characteristics and health behavior. RESULTS: Among those participants aged 65 to 91 years old, 2.8%, 18.7%, and 41.5% rated their oral health as excellent, very good, or good, respectively. Among 50- to 64-year-old men, the corresponding values were 1.4%, 18.5%, and 40.4%, while among those aged 22 to 49 years old, the values were 2.3%, 17%, and 34.1%. Tooth loss was common among users of VA care; 34% of those aged 65-90 years, 28% of those aged 50-64 years, and 8% of those aged 25-49 years had no teeth. Periodontal treatment needs were uniformly high among persons with teeth; mild mucosal change was common, and 10% had root tips. Regression models showed self-perceived oral health was better in persons with more teeth and recent dental treatment, and worse with tooth mobility, coronal decay, and more medical problems. Measures of the impact of oral conditions on daily life added significantly to the amount of explained variance in self-perceived oral health. CONCLUSIONS: Clinical conditions and the impact of oral health on daily life are important determinants of self-perceived oral health.

Racial disparities in participation in biomedical research.

To determine whether minority patients were less likely to participate in biomedical research, perceive positive benefits from such participation, or to recommend research participation to other patients, an observational study was conducted. Sociodemographic and survey data were collected from 5436 users of Department of Veterans Affairs (VA) Ambulatory Care, which included questions about veterans' research participation and related attitudes. Bivariate and multivariate analyses were performed to determine if there were racial differences in the outcomes of interest, controlling for relevant sociodemographic factors. Bivariate and multivariate analyses indicated that there were no racial differences in self-reported research participation, but minority veterans were more likely to perceive a positive effect of research and less likely to recommend research to other veterans. However, subgroup analyses indicated that, of those veterans having negative attitudes about research, minority and less educated veterans were disproportionately represented. In the VA system, racial differences in research participation may dissipate because many sociodemographic factors are controlled. Although we did not observe consistent racial differences in research participation or attitudes, the fact that minority veterans were disproportionately represented among the group with the most negative attitudes about research suggests that further research is necessary to fully understand the racial dynamics of research participation in the VA.

Preventive dental behaviors and their association with oral health status in older white men.

While prevention practices are widely encouraged, the link between the performance of preventive behaviors and oral health status has rarely been examined. This study investigates the association between preventive dental behaviors (recent and long-term) and oral health status and compares the strength of such associations. Longitudinal data over six time points on 649 dentate white men were obtained from the VA Dental Longitudinal Study (DLS). Participants' oral health was measured through dental examinations, and preventive dental behaviors--i.e., toothbrushing, flossing, using interdental devices, seeking dental prophylaxis, and undergoing dental treatment-were assessed by self-report. Oral health status was measured in terms of (1) functioning teeth, (2) sound-equivalent teeth, (3) decayed, missing, and filled teeth, and (4) decayed and filled root surfaces. Pearson correlation and linear regression analysis revealed significant positive associations between most preventive behaviors and measures of oral health status. Dental prophylaxis emerged as the strongest predictor of oral health status. Long-term preventive dental behavior measures explained more variance in oral health status than short-term preventive behaviors measured cross-sectionally.

Patient satisfaction with Department of Veterans Affairs health care: do women differ from men?

This study compared the patient satisfaction of female and male veterans using Department of Veterans Affairs health care and examined the relationship between sociodemographic characteristics and satisfaction in men and women. Using data from the Department of Veterans Affairs Women's Health Project (N = 719) and the Veterans Health Study (N = 600), we examined women's and men's unadjusted and adjusted mean scores on three dimensions of satisfaction: location of health care facility, access to health care, and prescription services. Although the unadjusted results indicated that women were less satisfied with both location and access, there were no differences in satisfaction with prescription services. After adjusting for age and then for both age and a recent physician visit, women remained less satisfied with location but were more satisfied with prescription services; there were no differences on access ratings. In an exploratory analysis, we examined the relationships between sociodemographic, military experience, and health characteristics and satisfaction within each sample. Older age was the only characteristic consistently positively associated with each dimension of satisfaction among both women and men. General health perceptions were positively associated with all three dimensions of women's satisfaction but with only the location dimension for men. Although other characteristics were associated with satisfaction within each sample, these differed for women and men. The results suggest that although there were not consistent differences in mean satisfaction ratings by gender, the characteristics associated with satisfaction differed for men and women.

Comparing the impact of oral disease in two populations of older adults: application of the geriatric oral health assessment index.

OBJECTIVES: This study compares the distributional and psychometric properties of the Geriatric Oral Health Assessment Index (GOHAI) in two samples of older adults, and examines how the self-perceived impact of oral disease, as measured by the GOHAI, varies in accordance with sample sociodemographic and health characteristics. METHODS: Results are based on survey data from two samples of older men: a Medicare sample of patients using community physicians (n = 799; mean age = 74) and users of VA ambulatory health care (n = 542; mean age = 72). RESULTS: The findings indicate significant differences between samples in mean GOHAI scores, with the VA sample exhibiting worse scores. A number of similarities in psychometric properties of the instrument across the two samples were found: high internal consistency reliability and similar inter-item and item-scale correlations. Factors analyses revealed somewhat different structures between the two samples, but explained similar amounts of variance; regression analyses indicated that income and self-rated oral health were significant predictors of GOHAI scores in both samples. CONCLUSIONS: The GOHAI exhibits satisfactory psychometric properties in both samples of older men. Results suggest continued use of the GOHAI as an indicator of the impact of oral conditions on functioning and well-being in a variety of samples.