Factors associated with self-reports of limitations in activities of daily living among Medicare Fee-for-Service recipients.

BACKGROUND: Physical function is an important indicator of physical health and predicts mortality. This study identified characteristics associated with limitations in Medicare recipients' activities of daily living. METHODS: 2019 Consumer Assessment of Healthcare Providers and Systems Fee-for-Service Medicare Survey data: 79,725 respondents (34% response rate) who were 65 and older and 53% female; 7% Black, 5% Hispanic, 4% Asian American, Native Hawaiian, or other Pacific Islander, 2% Multiracial, 1% American Indian/Alaskan Native; 35% with high school education or less. Walking, getting in and out of chairs, bathing, dressing, toileting, and eating (scored as having no difficulty versus being able to do with difficulty or unable to do) and a scale of these items were regressed on patient characteristics. RESULTS: After adjustment for all characteristics, function limitations were found for those who smoked (effect sizes of significant associations range .04-.13), had chronic health conditions (.02-.33), were 85 years or older (.09-.46), needed assistance completing the survey (.32-1.29), were female (.05-.07), and had low income and assets (.15-.47). CONCLUSIONS: These nationally representative U.S. estimates of physical function characteristics are useful for interventions for vulnerable population subgroups.

The impact of long-term acclimation to different growth light intensities on the regulation of zeaxanthin epoxidase in different plant species.

Proper short- and long-term acclimation to different growth light intensities is essential for the survival and competitiveness of plants in the field. High light exposure is known to induce the down-regulation and photoinhibition of photosystem II (PSII) activity to reduce photo-oxidative stress. The xanthophyll zeaxanthin (Zx) serves central photoprotective functions in these processes. We have shown in recent work with different plant species (Arabidopsis, tobacco, spinach and pea) that photoinhibition of PSII and degradation of the PSII reaction center protein D1 is accompanied by the inactivation and degradation of zeaxanthin epoxidase (ZEP), which catalyzes the reconversion of Zx to violaxanthin. Different high light sensitivity of the above-mentioned species correlated with differential down-regulation of both PSII and ZEP activity. Applying light and electron microscopy, chlorophyll fluorescence, and protein and pigment analyses, we investigated the acclimation properties of these species to different growth light intensities with respect to the ability to adjust their photoprotective strategies. We show that the species differ in phenotypic plasticity in response to short- and long-term high light conditions at different morphological and physiological levels. However, the close co-regulation of PSII and ZEP activity remains a common feature in all species and under all conditions. This work supports species-specific acclimation strategies and properties in response to high light stress and underlines the central role of the xanthophyll Zx in photoprotection.

The Contribution of First-name Information to the Accuracy of Racial-and-Ethnic Imputations Varies by Sex and Race-and-Ethnicity Among Medicare Beneficiaries.

BACKGROUND: Data on race-and-ethnicity that are needed to measure health equity are often limited or missing. The importance of first name and sex in predicting race-and-ethnicity is not well understood. OBJECTIVE: The objective of this study was to compare the contribution of first-name information to the accuracy of basic and more complex racial-and-ethnic imputations that incorporate surname information. RESEARCH DESIGN: We imputed race-and-ethnicity in a sample of Medicare beneficiaries under 2 scenarios: (1) with only sparse predictors (name, address, sex) and (2) with a rich set (adding limited administrative race-and-ethnicity, demographics, and insurance). SUBJECTS: A total of 284,627 Medicare beneficiaries who completed the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey and reported race-and-ethnicity were included. RESULTS: Hispanic, non-Hispanic Asian/Pacific Islander, and non-Hispanic White racial-and-ethnic imputations are more accurate for males than females under both sparse-predictor and rich-predictor scenarios; adding first-name information increases accuracy more for females than males. In contrast, imputations of non-Hispanic Black race-and-ethnicity are similarly accurate for females and males, and first names increase accuracy equally for each sex in both sparse-predictor and rich-predictor scenarios. For all 4 racial-and-ethnic groups, incorporating first-name information improves prediction accuracy more under the sparse-predictor scenario than under the rich-predictor scenario. CONCLUSION: First-name information contributes more to the accuracy of racial-and-ethnic imputations in a sparse-predictor scenario than in a rich-predictor scenario and generally narrows sex gaps in accuracy of imputations.

Training Death Investigators to Identify Decedents' Sexual Orientation and Gender Identity: A Feasibility Study.

ABSTRACT: There is growing impetus within mortality surveillance to identify decedents' sexual orientation and gender identity (SOGI), but key personnel to this effort (eg, death investigators) are not currently trained to collect SOGI information. To address this gap, we developed a training for death investigators on this topic and tested its feasibility with 114 investigators in 3 states. Participants completed pretraining and posttraining questionnaires that measured 4 perceived outcomes: training relevance, success of delivery, adequacy for future use, and likelihood of future use. Overall, strongly positive responses affirmed the training's relevance, success of delivery, and adequacy for future use. Responses about attempting to identify the decedent's SOGI in future cases were not quite as positive, with close to 80% of the participants saying that they were at least "somewhat likely" to collect this information. Despite design limitations, the study results support the feasibility of training death investigators to gather SOGI information. Although not systematically assessed in the study, investigators' positive endorsement of training outcomes seemed higher in training sites where leadership strongly supported SOGI identification, suggesting that the role of leadership may be key to encouraging SOGI identification among death investigators.

Broken Windows, Broken Zzs: Poor Housing and Neighborhood Conditions Are Associated with Objective Measures of Sleep Health.

African Americans and socioeconomically disadvantaged individuals have higher rates of a variety of sleep disturbances, including short sleep duration, poor sleep quality, and fragmented sleep. Such sleep disturbances may contribute to pervasive and widening racial and socioeconomic (SES) disparities in health. A growing body of literature demonstrates that over and above individual-level SES, indicators of neighborhood disadvantage are associated with poor sleep. However, there has been scant investigation of the association between sleep and the most proximal environments, the home and residential block. This is the first study to examine the association between objective and self-reported measures of housing and block conditions and sleep. The sample included 634 adults (mean age = 58.7 years; 95% African American) from two low-income urban neighborhoods. Study participants reported whether they experienced problems with any of seven different housing problems (e.g., broken windows) and rated the overall condition of their home. Trained data collectors rated residential block quality. Seven days of wrist actigraphy were used to measure average sleep duration, efficiency, and wakefulness after sleep onset (WASO), and a sleep diary assessed sleep quality. Multivariate regression analyses were conducted for each sleep outcome with housing or block conditions as predictors in separate models. Participants reporting "fair" or "poor" housing conditions had an adjusted average sleep duration that was 15.4 min shorter than that of participants reporting "good" or "excellent" conditions. Those reporting any home distress had 15.9 min shorter sleep and .19 units lower mean sleep quality as compared with participants who did not report home distress. Poor objectively measured block quality was associated with 14.0 min shorter sleep duration, 1.95% lower sleep efficiency, and 10.7 additional minutes of WASO. Adverse housing and proximal neighborhood conditions are independently associated with poor sleep health. Findings highlight the importance of considering strategies that target upstream determinants of sleep health disparities.

Food Insecurity is Associated with Objectively Measured Sleep Problems.

Objective/Background: Food Insecurity (FI) can be a profound source of stress, which may increase the risk for sleep disturbance. This is the first study to examine the association between FI and objectively and subjectively measured sleep. Participants: The sample included 785 adults living in two low-income neighborhoods (mean age = 56; 95% African American). Methods: FI was measured using a validated 10-item survey that assesses conditions and behaviors that characterize households when they lack financial resources to meet basic food needs. Sleep duration, efficiency, wakefulness after sleep onset (WASO), and variability in sleep duration were measured via actigraphy. Sleep quality was assessed via sleep diary. Sleep outcomes were analyzed as a function of FI, adjusting for covariates. Psychological distress was tested as a potential mediator. Results: Greater FI was associated with shorter actigraphy-assessed sleep duration (B = -2.44; SE = 1.24; i.e., 24 minutes shorter for the most as compared to least insecure group), poorer sleep efficiency (B = -.27; SE = .13); p's < .05), and poorer subjective sleep quality (B = -.03; SE = .01; p < .01). Greater FI was also associated with greater likelihood of short (<7 hours; OR = 1.11; CI: 1.02-1.21) and long sleep (>9 hours; OR = 1.19; CI: 1.01-1.39), compared to the recommended sleep duration of 7-9 hours. Psychological distress partially mediated the association between FI and subjective sleep quality. Conclusions: Addressing or mitigating food insecurity may present a novel opportunity for improving sleep health among low-income populations.

The association between discrimination and PTSD in African Americans: exploring the role of gender.

Background: Research has demonstrated the adverse impact that discrimination has on physical and mental health. However, few studies have examined the association between discrimination and symptoms of posttraumatic stress disorder (PTSD). There is evidence that African Americans experience higher rates of PTSD and are more likely to develop PTSD following trauma exposure than Whites, and discrimination may be one reason for this disparity. Purpose: To examine the association between discrimination and PTSD among a cross-sectional sample largely comprising African American women, controlling for other psychosocial stressors (psychological distress, neighborhood safety, crime). Methods: A sample of 806 participants was recruited from two low-income predominantly African American neighborhoods. Participants completed self-report measures of PTSD symptoms, perceived discrimination, perceived safety, and psychological distress. Information on neighborhood crime was obtained through data requested from the city. Multivariate linear regression models were estimated to assess adjusted relationships between PTSD symptoms and discrimination. Results: Discrimination was significantly associated with PTSD symptoms with a small effect size, controlling for relevant sociodemographic variables. This association remained consistent after controlling for psychological distress, perceived safety, and total neighborhood crime. There was no evidence of a gender by discrimination interaction. Participants who experienced any discrimination were significantly more likely to screen positive for PTSD. Conclusions: Discrimination may contribute to the disparate rates of PTSD experienced by African Americans. PTSD is associated with a range of negative consequences, including poorer physical health, mental health, and quality of life. These results suggest the importance of finding ways to promote resilience in this at-risk population.

Indirect Estimation of Race/Ethnicity for Survey Respondents Who Do Not Report Race/Ethnicity.

BACKGROUND: Researchers are increasingly interested in measuring race/ethnicity, but some survey respondents skip race/ethnicity items. OBJECTIVES: The main objectives of this study were to investigate the extent to which racial/ethnic groups differ in skipping race/ethnicity survey items, the degree to which this reflects reluctance to disclose race/ethnicity, and the utility of imputing missing race/ethnicity. RESEARCH DESIGN: We applied a previously developed method for imputing race/ethnicity from administrative data (Medicare Bayesian Improved Surname and Geocoding 2.0) to data from a national survey where race/ethnicity was usually self-reported, but was sometimes missing. A linear mixed-effects regression model predicted the probability of self-reporting race/ethnicity from imputed racial/ethnic probabilities. SUBJECTS: In total, 508,497 Medicare beneficiaries responding to the 2013-2014 Medicare Consumer Assessment of Healthcare Providers and Systems surveys were included in this study. MEASURES: Self-reported race/ethnicity and estimated racial/ethnic probabilities. RESULTS: Black beneficiaries were most likely to not self-report their race/ethnicity (6.6%), followed by Hispanic (4.7%) and Asian/Pacific Islander (4.7%) beneficiaries. Non-Hispanic whites were the least likely to skip these items (3.2%). The 3.7% overall rate of missingness is similar to adjacent demographic items. General patterns of item missingness rather than a specific reluctance to disclose race/ethnicity appears to explain the elevated rate of missing race/ethnicity among Asian/Pacific Islander and Hispanic beneficiaries and most but not all among Black beneficiaries. Adding imputed cases to the data set did not substantially alter the estimated overall racial/ethnic distribution, but it did modestly increase sample size and statistical power. CONCLUSIONS: It may be worthwhile to impute race/ethnicity when this information is unavailable in survey data sets due to item nonresponse, especially when missingness is high.

Collecting Sexual Orientation and Gender Identity Information at Death.

Currently, no US jurisdiction or agency routinely or systematically collects information about individuals' sexual orientation and gender identity (SOGI) at the time of death. As a result, little is known about causes of death in people having a minority sexual orientation or gender identity. These knowledge gaps have long impeded identification of mortality disparities in sexual and gender minority populations and hampered the development of targeted public health interventions and prevention strategies. We offer observations about the possibilities and challenges of collecting and reporting accurate postmortem SOGI information on the basis of our past four years of working with death investigators, coroners, and medical examiners. This work was located primarily in New York, New York, and has extended from January 2015 to the present. Drawing on our experiences, we make recommendations for future efforts to include SOGI among the standard demographic variables used to characterize individuals at death.

How are medical groups identified as high-performing? The effect of different approaches to classification of performance.

BACKGROUND: Payers and policy makers across the international healthcare market are increasingly using publicly available summary measures to designate providers as "high-performing", but no consistently-applied approach exists to identifying high performers. This paper uses publicly available data to examine how different classification approaches influence which providers are designated as "high-performers". METHODS: We conducted a quantitative analysis of cross-sectional publicly-available performance data in the U.S. We used 2014 Minnesota Community Measurement data from 58 medical groups to classify performance across 4 domains: quality (two process measures of cancer screening and 2 composite measures of chronic disease management), total cost of care, access (a composite CAHPS measure), and patient experience (3 CAHPS measures). We classified medical groups based on performance using either relative thresholds or absolute values of performance on all included measures. RESULTS: Using relative thresholds, none of the 58 medical groups achieved performance in the top 25% or 35% in all 4 performance domains. A relative threshold of 40% was needed before one group was classified as high-performing in all 4 domains. Using absolute threshold values, two medical groups were classified as high-performing across all 4 domains. In both approaches, designating "high performance" using fewer domains led to more groups designated as high-performers, though there was little to moderate concordance across identified "high-performing" groups. CONCLUSIONS: Classification of medical groups as high performing is sensitive to the domains of performance included, the classification approach, and choice of threshold. With increasing focus on achieving high performance in healthcare delivery, the absence of a consistently-applied approach to identify high performers impedes efforts to reliably compare, select and reward high-performing providers.

Associations of CAHPS Composites With Global Ratings of the Doctor Vary by Medicare Beneficiaries' Health Status.

RESEARCH OBJECTIVE: Care coordination among health care providers is essential for high-quality care and it is strongly associated with overall ratings of doctors. Care coordination may be especially important for sicker and chronically ill patients because of the multiple providers involved in their care. This study examines whether the association of care coordination with global ratings of one's personal doctor varies by number of chronic conditions and self-rated health. STUDY DESIGN: We used nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to evaluate care coordination, doctor communication, getting needed care, getting care quickly, count of 6 chronic conditions (angina, cancer, chronic obstructive pulmonary disease, diabetes, heart attack, stroke), self-rated general health (5-point scale, poor to excellent, scored linearly), and interactions among them as predictors of the CAHPS global rating of personal doctor (scored 0-100 with 100 being best possible personal doctor) using linear regression models. The analytic sample included 242,871 Medicare fee-for-service and managed care beneficiaries in 2013: 56% female; 14% 18-64, 47% 65-74, 27% 75-84, and 11% 85 and older; and 48% high school education or less. RESULTS: The CAHPS composites (of care coordination, doctor communication, getting needed care, and getting care quickly) and number of chronic conditions were significantly positively associated with ratings of personal doctor (P<0.05). Care coordination and doctor communication had a stronger association with positive ratings of the personal doctor among those with worse self-rated health (P<0.001). DISCUSSION: Results were consistent with the hypothesis that patients in worse health weigh care coordination more heavily in global physician assessments than patients in better health. Emphasis on improving care coordination, especially for patients in poorer health, may improve patients' overall assessments of their providers. The study provides further evidence for the importance of care coordination experiences in the era of patient-centered care.

Predictors of Retention in an Alcohol and Risky Sex Prevention Program for Homeless Young Adults.

Homeless young adults are at risk for alcohol and other drug (AOD) use and risky sexual behavior. Interventions are needed to help these young people reduce their risky behavior, but this population is often difficult to engage and retain in services. We offered a four-session AOD and risky sex reduction program to 100 participants and examined if retention in the program was predicted by a number of factors: demographics, homelessness severity, other service use, AOD behaviors, mental health symptoms, sexual risk behaviors, and readiness to change AOD and condom use. Nearly half (48%) of participants completed all sessions. In bivariate analyses, participants were significantly less likely to be retained in the program if they had slept outdoors in the past month, engaged in more alcohol and marijuana use, experienced more alcohol-related consequences, and received the program in an urban drop-in center (as opposed to a drop-in center near the beach). When controlling for all significant bivariate relationships, only sleeping outdoors and receipt of the program in the urban setting predicted fewer sessions completed. The most endorsed reasons for program non-completion were being too busy to attend and inconvenient day/time of the program. Findings can help outreach staff and researchers better prepare methods to engage higher risk homeless youth and retain them in services. Finding unique ways to help youth overcome barriers related to location of services appears especially necessary, perhaps by bringing services to youth where they temporarily reside or offering meaningful incentives for program attendance.

What Matters Most to Whom: Racial, Ethnic, and Language Differences in the Health Care Experiences Most Important to Patients.

BACKGROUND: Some aspects of patient experience are more strongly related to overall ratings of care than others, reflecting their importance to patients. However, little is known about whether the importance of different aspects of this experience differs across subgroups. OBJECTIVES: To determine whether the aspects of health care most important to patients differ according to patient race, ethnicity, and language preference. RESEARCH DESIGN: In response to the 2013 Medicare Consumer Assessment of Health Plans Study (CAHPS) survey, patients rated their overall health care and completed items measuring five patient experience domains. We estimated a linear regression model to assess associations between overall rating of care and the 5 domains, testing for differences in these relationships for race/ethnicity/language groups, controlling for covariates. SUBJECTS: In total 242,782 Medicare beneficiaries, age 65 years or older. MEASURES: Overall rating of health care, composite patient experience scores for: doctor communication, getting needed care, getting care quickly, customer service, and care coordination. RESULTS: A joint test of the interactions between the composite scores and the 5 largest racial/ethnic/language subgroups was statistically significant (P <0.0001), suggesting the importance of domains varied across subgroups. Doctor communication had the strongest relationship with care ratings for non-Hispanic whites and English-preferring Hispanics. Getting needed care had the strongest relationship for Spanish-preferring Hispanics and Asian/Pacific Islanders. Doctor communication and getting care quickly were strongest for African Americans. CONCLUSIONS: Tailoring quality improvement programs to the factors most important to the racial, ethnic, and language mix of the patient population of the practice, hospital, or plan may more efficiently reduce disparities and improve quality.

Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores.

BACKGROUND: Asian Americans (hereafter "Asians") generally report worse experiences with care than non-Latino whites (hereafter "whites"), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Tendency (ERT)-they less frequently use responses at extreme ends of the scale than whites. OBJECTIVE: To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites. PROCEDURE: A representative US sample (n=575 Asian; n=505 white) was presented with 5 written vignettes describing doctor-patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions. RESULTS: Case-mix-adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P<0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician responsiveness, the increase was 15% less for Asian than white respondents. CONCLUSIONS: Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predominantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement.

Effects of a Pilot Church-Based Intervention to Reduce HIV Stigma and Promote HIV Testing Among African Americans and Latinos.

HIV-related stigma and mistrust contribute to HIV disparities. Addressing stigma with faith partners may be effective, but few church-based stigma reduction interventions have been tested. We implemented a pilot intervention with 3 Latino and 2 African American churches (4 in matched pairs) in high HIV prevalence areas of Los Angeles County to reduce HIV stigma and mistrust and increase HIV testing. The intervention included HIV education and peer leader workshops, pastor-delivered sermons on HIV with imagined contact scenarios, and HIV testing events. We surveyed congregants at baseline and 6 month follow-up (n = 1235) and found statistically significant (p < 0.05) reductions in HIV stigma and mistrust in the Latino intervention churches but not in the African American intervention church nor overall across matched African American and Latino pairs. However, within matched pairs, intervention churches had much higher rates of HIV testing (p < 0.001). Stigma reduction and HIV testing may have synergistic effects in community settings.

Predictors of HIV-related stigmas among African American and Latino religious congregants.

OBJECTIVES: To inform church-based stigma interventions by exploring dimensions of HIV stigma among African American and Latino religious congregants and determining how these are related to drug addiction and homosexuality stigmas and knowing someone HIV-positive. METHOD: In-person, self-administered surveys of congregants 18+ years old across 2 African American and 3 Latino churches (n = 1,235, response rate 73%) in a western U.S. city with high HIV prevalence. Measures included 12 items that captured dimensions of HIV stigma, a 5-item scale that assessed attitudes toward people who are addicted to drugs, a 7-item scale assessing attitudes toward homosexuality, and questions regarding sociodemographics and previous communication about HIV. RESULTS: Of the survey participants, 63.8% were women, mean age was 40.2 years, and 34.4% were African American, 16.8% were U.S.-born Latinos, 16.0% were foreign-born, English-speaking Latinos, and 32.9% were foreign-born, Spanish-speaking Latinos. Exploratory and confirmatory factor analyses identified 4 dimensions of HIV stigma: discomfort interacting with people with HIV (4 items, α = .86), feelings of shame "if you had HIV" (3 items, α = .78), fears of rejection "if you had HIV" (3 items, α = .71), and feelings of blame toward people with HIV (2 items, α = .65). Across all dimensions, after controlling for sociodemographic characteristics and previous communication about HIV, knowing someone with HIV was associated with lower HIV stigma, and greater stigma concerning drug addiction and homosexuality were associated with higher HIV stigma. CONCLUSIONS: Congregation-based HIV stigma reduction interventions should consider incorporating contact with HIV-affected people. It may also be helpful to address attitudes toward drug addiction and sexual orientation. (PsycINFO Database Record

US Religious Congregations' Programming to Support Veterans: A Mixed Methods Study.

Religious congregations may be well equipped to address veterans' reintegration needs, but little is known about the prevalence and nature of such support. We conducted a mixed methods study using nationally representative congregational survey data and in-depth interviews with congregational leaders. Overall, 28% of congregations nationally reported having programming to support veterans and positive, independent predictors included: community context (county veteran presence, high-poverty census tract, rural compared to urban location); congregational resources (more adult attendees, having a paid employee that spent time on service programs); and external engagement (assessing community needs, collaboration, and social service participation). Qualitative interviews revealed a range of activities, including attending to spiritual issues, supporting mental, physical and social well-being, and addressing vocational, legal, financial, and material needs.