US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Cognition and Wealth Changes in Mid-to-later Life: A Latent Class Trajectories Approach Using the Health and Retirement Study.

ObjectivesTo assess how cognitive trajectories from mid-to-later life relate to wealth change, overall and by mid-life income. Methods: Data were from participants (51-64 years) in the 2000-2018 U.S. Health and Retirement Study who were cognitively healthy at baseline (year 2000; unweighted n = 3821). Longitudinal latent class analyses generated cognitive and wealth trajectories, independently, and multinomial logistic regressions estimated the association between cognitive trajectories and wealth profiles, overall and by median income. Results: We identified three cognitive: cognitively healthy (CH), increasing cognitive impairment (ICI), and increasing dementia (ID) and four wealth profiles: stable wealth loss (SWL), delayed gradual wealth loss (DGWL), stable wealth gain (SWG), and gradual wealth gain (GWG). The ID group had higher probability of being in the SWL group and lower probability of SWG, which was more pronounced in respondents with greater median income. Discussion: Individuals with ID may be vulnerable to wealth loss, particularly for middle-class households.

The intersectional importance of race/ethnicity, disability, and age in flu vaccine uptake for U.S. adults.

Improving vaccination rates among marginalized populations is an important priority among public policy makers and healthcare providers in the United States of America (U.S.). Racial/ethnic minorities have a long history of reduced vaccination rates relative to white Americans (Khan, Hall, Tanner, & Marlow, 2018), while people with disabilities (PWD) have varied rates of vaccine use (Diab & Johnston, 2004; O'Neill, Newall, Antolovich, Lima, & Danchin, 2019). Yet, little is known about vaccine use among individuals who belong to both groups. This study examines the intersectional effects of race/ethnicity and disability on flu vaccine use. We used the 2015-2018 National Health Interview Survey to examine the odds of flu vaccine use by race/ethnicity, disability, and their interaction among adults aged 18+ in the U.S. non-institutionalized, civilian population stratified by age groups. For each unit increase in disability scores, we found a significant race-by-disability interaction for young black adults (18-39 years) who had higher odds of getting the flu vaccine compared to white adults in the same age group. A significant interaction occurred for middle-aged Hispanic vs. white adults (40-64 years) who had higher odds of getting the flu vaccine as their disability scores increased. Black vs. white adults were less likely to get the flu vaccine across all age groups irrespective of disability and other covariates, while results were more mixed among other racial/ethnic groups. Additionally, people with disabilities had higher odds of flu vaccination. Further, race/ethnicity had a moderating effect on the relationship between disability and flu vaccination and an interaction effect occurred between disability and certain racial/ethnic groups when stratified by age.

Use of Health Information Varies by Region Among Older Adults in the U.S.

Objective: To examine geographic variations in health information use among older adults in the United States. Methods: We compared 15,531 adults (age 45 and older) across four U.S. regions. Descriptive analyses were conducted to assess health information seeking and use by year. The relationship between health information seeking or use and regional changes were assessed using binomial logistic regression. Binomial models were adjusted by socio-demographics, chronic conditions, and health information sources. Magnitude and direction of relationships were assessed using adjusted odds ratios (aORs), 95% confidence intervals (CIs), and p-values. Results: Only the Northeast region showed increases in health information seeking (3.8%) and use (4.5%) among older adults. However adjusted models showed those living in the Northeast were 28% less likely to use health information to maintain their health and 32% less likely to use health information to treat illness. Conclusion: As a result of the current pandemic, older adults are facing a growing burden from health care expenses. Inability to gather and use health information for personal safety or self care can potentially increase inequalities in health, especially for older adults without personal health care providers.

Chronic Conditions May Be More Important Than Race or Ethnicity in Relation to Health Information Seeking and Use.

OBJECTIVE: This research examines health information (HI) seeking and use among middle-aged and older adults with chronic health conditions. METHOD: We used logistic regression models to analyze HI seeking ( N = 7,822) and use (N = 4,541-4,547) among participants (aged 45+ years) with chronic conditions from the nationally-representative Health Tracking Household Survey. RESULTS: Adults aged 45+ years with chronic conditions were significantly more likely to seek and use HI; however, these results varied based on the age and education. Compared with Whites, Latinos were less likely to seek HI but more likely to use HI to treat illness, and African Americans were more likely to use HI to maintain health. CONCLUSION: Middle-aged and older adults with chronic conditions are prominent HI seekers and users. Proficient HI seeking and use may have the potential to enhance control over one's own health, maintain independence in the community, and reduce the impact of negative health consequences on the health care system.

Who Works Among Older Black and White, Well-Functioning Adults in the Health, Aging, and Body Composition Study?

Objective: The aim of this study is to examine social, economic, and health factors related to paid work in well-functioning older adults and if and how these factors vary by race. Method: We used sex-stratified logistic and multinomial logistic regression to examine cross-sectional data in the Health, Aging, and Body Composition cohort study. The sample included 3,075 community-dwelling Black (42%) and White adults aged 70 to 79 at baseline. Results: Multinomial logistic regression analyses show Black men were more likely to work full-time, and Black women were more likely to work part-time. Men with ≥US$50,000 family income were more likely to work full-time. Men with better physical functioning were more likely to work full- and part-time. Women with ≥US$50,000 family income and fewer chronic diseases were more likely to work full-time. Women who were overweight and had fewer chronic diseases were more likely to work part-time. Discussion: Results suggest that well-functioning, older Black adults were more likely to work than their White counterparts, and working relates to better health and higher income, providing support for a productive or successful aging perspective.

Neighborhood Influences and BMI in Urban Older Adults.

OBJECTIVE: Increases in body weight and declining physical activity that may accompany aging are linked to a range of problems affecting daily life (i.e., decreased mobility and overall quality of life). This study investigates the actual and perceived neighborhood environment on overweight and obese urban older adults. METHOD: We selected 217 individuals aged 65+ who answered questions about their neighborhood on the 2009 Speak to Your Health survey. Using multinomial regression models and geospatial models, we examined relationships between neighborhood environment and BMI. RESULTS: We found that obese older adults were 63% less likely to have a park within their neighborhood ( p = .04). Our results also show that older adults who perceive their neighborhood crime as very high are 12 times more likely to be overweight ( p = .04). DISCUSSION: Findings suggest that parks may affect BMI in older adults; however, neighborhood perceptions play a greater role.

Accelerated Health Declines among African Americans in the USA.

The weathering hypothesis, an explanation for race disparities in the USA, asserts that the health of African Americans begin to deteriorate prematurely compared to whites as a consequence of long-term exposure to social and environmental risk factors. Using data from 2000-2009 National Health Interview Surveys (NHIS), we sought to describe differences in age-related health outcomes in 619,130 African Americans and whites. Outcome measures included hypertension, diabetes, stroke, and cardiovascular disease. Using a mixed models approach to age-period-cohort analysis, we calculated age- and race-specific prevalence rates that accounted for the complex sampling design of NHIS. African Americans exhibited higher prevalence rates of hypertension, diabetes, and stroke than whites across all age groups. Consistent with the weathering hypothesis, African Americans exhibited equivalent prevalence rates for these three conditions 10 years earlier than whites. This suggests that African Americans are acquiring age-related conditions prematurely compared to whites.

Race/ethnicity, nativity and trends in BMI among U.S. adults.

OBJECTIVE: The average BMI is rising even as the U.S. population grows increasingly diverse. Prior research by examining BMI trends in diverse groups including whites, blacks, Chinese, Filipinos, Asian Indians, Mexicans, Puerto Ricans, and Cubans who are U.S. born, recent immigrants, or long-term immigrants was extended. METHODS: Cross-sectional data from the 1989 to 2011 waves of the National Health Interview Survey (N = 989,273) have been pooled and linear regression models to examine trends in BMI among U.S. adults have been used. RESULTS: Annual increases in BMI are greatest among U.S.-born Puerto Ricans and Mexicans and slowest among foreign born Chinese. Among the U.S. born in 2011, Chinese adults have an average BMI below the threshold for overweight, whereas blacks, Mexicans, and Puerto Ricans have average BMIs in the obese range. Foreign-born adults average lower BMIs than U.S. born adults in most race/ethnic groups, and nativity disparities generally widen over time. BMI increases across calendar periods rather than birth cohorts. CONCLUSION: Our results suggest that calendar period interventions may be particularly useful in reversing rising BMIs in the United States. However, interventions must be tailored to different race/ethnic and nativity groups in order to reduce disparities in body mass.

Health information seeking and use outside of the medical encounter: is it associated with race and ethnicity?

Increasing numbers of adults in the United States of America (USA) are seeking and using health information within their medical encounters. The theory of uncertainty management suggests that patients reduce health care uncertainty by increasing their understanding of disease etiology or treatment options, improving patient-doctor communication, and enhancing knowledge of disease self-management through health information seeking. However, research shows racial and ethnic minorities are less likely than Whites to seek health information and use it in their physician visits. How racial and ethnic minorities use health information outside of their medical encounters is unknown. In this study we used data from the 2007 USA Health Tracking Household survey, a nationally-representative survey of civilian, non-institutionalized Americans (n = 12,549). Using logistic regression we found African Americans were no different from Whites in seeking health information and using it when they talked with their doctors. Latinos were significantly less likely than Whites to seek health information and less likely to use it when they talked with their doctors. But, among those who sought health information, African Americans and Latinos were significantly more likely than Whites to use health information to change their approach to maintaining their health and better understand how to treat illnesses. Also, education significantly moderated the relationship between race/ethnicity and health information seeking. However, results were mixed for education as a moderator in the relationship between race/ethnicity and health information use. Future research should focus on interventions to improve how African Americans and Latinos interface with providers and ensure that health information sought and used outside of their medical encounters augments treatment protocols.

Race, socioeconomic resources, and late-life mobility and decline: findings from the Health, Aging, and Body Composition study.

BACKGROUND: This study examines the relationship between race and mobility over 5 years in initially well-functioning older adults and evaluates how a broad set of socioeconomic status indicators affect this relationship. METHODS: Data were from 2,969 black and white participants aged 70-79 from the Health, Aging, and Body Composition study. Mobility parameters included self-reported capacity to walk a quarter mile and climb 10 steps and usual gait speed. Incident mobility limitation was defined as reported difficulty walking a quarter mile or climbing 10 steps at two consecutive semiannual assessments. Gait speed decline was defined as a 4% reduction in speed per year. RESULTS: At baseline, even though all participants were free of mobility limitation, blacks had slower walking speed than their white counterparts, which was not explained by poverty, education, reading level, or income adequacy. After 5 years, accounting for age, site, and baseline mobility, blacks were more likely to develop mobility limitation than whites. Adjusting for prevalent conditions at baseline eliminated this difference in women; controlling for education eliminated this difference in men. No differences in gait speed decline were identified. CONCLUSIONS: Higher rates of mobility loss observed in older blacks relative to older whites appear to be a function of both poorer initial mobility status and existing health conditions particularly for women. Education may also play a role especially for men.

Health information technology and physician career satisfaction.

PURPOSE: Health information technology (HIT) and physician career satisfaction are associated with higher-quality medical care. However, the link between HIT and physician career satisfaction, which could potentially reduce provider burnout and attrition, has not been fully examined. This study uses a nationally representative survey to assess the association between key forms of HIT and career satisfaction among primary care physicians (PCPs) and specialty physicians. METHODS: We performed a retrospective, cross-sectional analysis of physician career satisfaction using the Community Tracking Study Physician Survey, 2004-2005. Nine specific types of HIT as well as the overall adoption of HIT in the practice were examined using multivariate logistic regression. RESULTS: Physicians who used five to six (odds ratio [OR] = 1.46) or seven to nine (OR = 1.47) types of HIT were more likely than physicians who used zero to two types of HIT to be "very satisfied" with their careers. Information technology usages for communicating with other physicians (OR = 1.31) and e-mailing patients (OR = 1.35) were positively associated with career satisfaction. PCPs who used technology to write prescriptions were less likely to report career satisfaction (OR = 0.67), while specialists who wrote notes using technology were less likely to report career satisfaction (OR = 0.75). CONCLUSIONS: Using more information technology was the strongest positive predictor of physicians being very satisfied with their careers. Toward that end, healthcare organizations working in conjunction with providers should consider exploring ways to integrate various forms of HIT into practice.

Racial differences in self-rated health at similar levels of physical functioning: an examination of health pessimism in the health, aging, and body composition study.

BACKGROUND: The health pessimism hypothesis suggests that Black elders are more pessimistic about health than Whites and therefore tend to report lower self-rated health (SRH) at comparable health status. The current analysis examined the factors associated with SRH and tested the health pessimism hypothesis among older adults at similar levels of physical functioning. METHODS: The study example included 2,729 Health, Aging, and Body Composition study participants aged 70-79 years. We used hierarchical logistic regression to examine the association between race and SRH while adjusting for demographic, physical health, and psychosocial factors. The analyses were repeated for participants at similar levels of objective functioning to test the health pessimism hypothesis. RESULTS: The association between race and SRH remained independent of physical and psychosocial health variables, with Whites being 3.7 times more likely than Black elders to report favorable SRH. This association was significant at each level of physical functioning and greater at the higher (odds ratio [OR] = 5.5) versus lower (OR = 2.2) levels of functioning. CONCLUSIONS: The results suggest greater health pessimism among Black elders and expand previous work by including objective functioning in multidimensional models to deconstruct race variations in the SRH of older adults.

Racial disparities in health care access and cardiovascular disease indicators in Black and White older adults in the Health ABC Study.

OBJECTIVE: Black adults consistently exhibit higher rates of and poorer health outcomes due to cardiovascular disease (CVD) than other racial groups, independent of differences in socioeconomic status (SES). Whether factors related to health care access can further explain racial disparities in CVD has not been thoroughly examined. METHOD: Using logistic regression, the authors examined racial and health care (i.e., health insurance and access to care) associations with CVD indicators (i.e., hypertension, low ankle-arm index, and left ventricular hypertrophy) in the Health, Aging, and Body Composition Study, a longitudinal study of well-functioning older adults. RESULTS: Older Black versus White adults had significantly worse health care. Overall, health care reduced the significant association between being Black and CVD only slightly, while race remained strongly associated with CVD after adjusting for demographics, SES, body mass index, and comorbidity. DISCUSSION: Research on health care quality may contribute to our understanding of these disparities.

Limited literacy in older people and disparities in health and healthcare access.

OBJECTIVES: To determine the relationship between health literacy, demographics, and access to health care. DESIGN: Cross-sectional study, Health, Aging and Body Composition data (1999/2000). SETTING: Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Two thousand five hundred twelve black and white community-dwelling older people who were well functioning at baseline (without functional difficulties or dementia). MEASUREMENTS: Participants' health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Scores were categorized into 0 to sixth-, seventh- to eighth-, and ninth-grade and higher reading levels (limited health literacy defined as <9th grade). Participants' demographics, socioeconomic status, comorbidities, and three indicators of healthcare access (whether they had a doctor/regular place of medical care, an influenza vaccination within the year, or insurance for medications) were also assessed. RESULTS: Participants' mean age was 75.6, 52% were female, 38% were black, and 24% had limited health literacy. After adjusting for sociodemographics, associations remained between limited health literacy and being male, being black, and having low income and education, diabetes mellitus, depressive symptoms, and fair/poor self-rated health (P<.02). After adjusting for sociodemographics, health status, and comorbidities, older people with a sixth-grade reading level or lower were twice as likely to have any of the three indicators of poor healthcare access (odds ratio=1.96, 95% confidence interval=1.34-2.88). CONCLUSION: Limited health literacy was prevalent and was associated with low socioeconomic status, comorbidities, and poor access to health care, suggesting that it may be an independent risk factor for health disparities in older people.

Association of inflammatory markers with socioeconomic status.

BACKGROUND: This study examines the association between socioeconomic status (SES) and inflammatory markers in well-functioning older adults and seeks to determine whether any association remains after adjusting for biomedical and behavioral factors typically related to elevated serum levels of inflammatory markers. METHODS: Data were obtained from 3044 men and women, aged 70-79 from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition study. Three indicators of SES were used: education, income, and ownership of financial assets. Serum levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha were measured. RESULTS: Low SES was associated with significantly elevated levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha compared to high SES. Behavioral factors (including smoking, drinking, obesity) explained a substantial part of the inverse association between SES and inflammatory markers. Adjustment for prevalent diseases (including heart diseases, lung disease, and diabetes) associated with inflammation explained less of the association. CONCLUSIONS: This study suggests that interventions to improve health behaviors, even in old age and especially in low SES groups, may be useful in reducing risks associated with inflammation.

Is there a biomedical explanation for socioeconomic differences in incident mobility limitation?

BACKGROUND: The association between low socioeconomic status and poor physical functioning has been well described; biomedical factors may play an important role in explaining these differences. This study examines the association between socioeconomic status and incident mobility limitation in well-functioning older adults, and seeks to determine whether this link could be explained by biomedical factors. METHODS: Data were obtained from 3066 men and women, aged 70--79 years from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition (Health ABC) study. Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Mobility limitation was defined as reporting difficulty walking 1/4 mile or climbing 10 steps during two consecutive semiannual assessments over 4.5 years. Biomedical factors included a wide range of diseases (e.g., heart and cerebrovascular disease) and biological risk factors (e.g. hypertension, poor pulmonary function, and high serum levels of inflammatory markers). RESULTS: Adjusted hazard ratios of incident mobility limitation were significantly higher in those persons with low education, low income, and few assets. Hazard ratios ranged from 1.66 to 2.80 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the hazard ratios by an average of 41% for education, 17% for income, and 29% for assets. CONCLUSION: Biomedical factors can account for some of the association between socioeconomic status and incident mobility limitation. However, to reduce physical disabilities and, in particular, the socioeconomic differences therein, it may not be sufficient to solely intervene upon biological risk factors and risks of diseases.

Socioeconomic differences in cognitive decline and the role of biomedical factors.

PURPOSE: This study examines the association between socioeconomic status and cognitive decline in a community-based cohort of well-functioning older adults and seeks to determine whether this link could be explained by biomedical factors. METHODS: Data are from 2574 men and women aged 70 to 79 years from Pittsburgh, PA, and Memphis, TN, participating in the Health, Aging and Body Composition study (Health ABC). Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Cognitive decline over 4 years was defined as a decrease of five points or more in the Modified Mini-Mental State Examination (3MS) score. Biomedical factors measured at baseline, included heart disease, cerebrovascular disease, diabetes, hypertension, poor pulmonary function, and high serum levels of inflammatory markers. RESULTS: Adjusted odds ratios were significantly higher in those with low education, low income, and few assets. Odds ratios ranged from 1.51 to 2.16 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the odds ratios of cognitive decline by an average of 2% for education, 5% for income, and 8% for the number of assets. CONCLUSIONS: Low socioeconomic status predicts a decline in cognitive function in older adults and this relationship is not mediated by biomedical factors.

Racial differences in glycemic control in a well-functioning older diabetic population: findings from the Health, Aging and Body Composition Study.

OBJECTIVE: To evaluate racial differences and factors associated with worse glycemic control in well-functioning older individuals with type 2 diabetes. Our hypothesis was that glycemic control would be worse among black than white diabetic individuals but that this association would be explained by differences in severity of diabetes, health status, health care indicators, and social, psychological, or behavioral factors. We further hypothesized that the association of race with poorer glycemic control would be limited to those with lower education or lower income. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 468 diabetic participants among a cohort of 3,075 nondisabled blacks and whites aged 70-79 years living in the community enrolled in the Health, Aging and Body Composition Study. Glycemic control was measured by the level of HbA(1c). RESULTS: A total of 58.5% of the diabetic individuals were black. Although control was poor in all diabetic participants (HbA(1c) > or =7% in 73.7%), blacks had worse glycemic control than whites (age- and sex-adjusted mean HbA(1c), 8.4% in blacks and 7.4% in whites; P < 0.01). Race differences in glycemic control remained significant, even after adjusting for current insulin therapy, cardiovascular disease, higher total cholesterol, and not receiving a flu shot in the previous year, all of which were associated with higher HbA(1c) concentrations. Controlling for these factors reduced the association by 27%. Race remained an important factor in glycemic control, even when results were stratified by education or income. CONCLUSIONS: HbA(1c) concentrations were higher in older black diabetic individuals. Differences in glycemic control by race were associated with disease severity, health status, and poorer quality of care, but these factors did not fully explain the higher HbA(1c) levels in older black diabetic individuals.