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.

Snacking habits and caries in young children.

Dental caries is caused by a combination of infection and diet. This disease, if left untreated, may lead to pain, and impair the quality of life, nutritional status and development of young children. The objective was to investigate the association between snacking and caries in a population at high risk of dental caries. American preschool children (n = 1,206) were recruited in the offices of paediatricians. Data on sociodemographic characteristics, oral hygiene, breast-feeding, use of bottle and snacking were collected by questionnaire. Plaque presence, the number of teeth and their caries status (deft) were scored. The children sampled were 61% Black, 27% White and 10% Asian. Of the 1- to 2-, 2- to 3- and 3- to 4-year-old children, 93.8, 82.4 and 77.3% were caries free, and their mean caries scores were 0.16, 0.58 and 0.93, respectively. Multivariate partial least squares (PLS) modelling revealed plaque presence, lowest income, descriptors for tooth exposure time (number of teeth and age) and cariogenic challenge (total intake of sugar-containing snacks and chips/crisps, and chips intake with a sugar-containing drink) to be associated with more caries. These differences were also found in univariate analyses; in addition, children who continued breast-feeding after falling asleep had significantly higher deft values than those who did not. PLS modelling revealed that eating chips clustered with eating many sweet snacks, candies, popcorn and ice cream. We conclude that, in addition to the traditional risk indicators for caries - presence of plaque, sugar intake and socioeconomic status -, consumption of chips was associated with caries in young children.

Microbial risk markers for childhood caries in pediatricians' offices.

Dental caries in pre-school children has significant public health and health disparity implications. To determine microbial risk markers for this infection, this study aimed to compare the microbiota of children with early childhood caries with that of caries-free children. Plaque samples from incisors, molars, and the tongue from 195 children attending pediatricians' offices were assayed by 74 DNA probes and by PCR to Streptococcus mutans. Caries-associated factors included visible plaque, child age, race, and snacking habits. Species were detected more frequently from tooth than tongue samples. Lactobacillus gasseri (p < 0.01), Lactobacillus fermentum, Lactobacillus vaginalis, and S. mutans with Streptococcus sobrinus (all p < 0.05) were positively associated with caries. By multifactorial analysis, the probiotic Lactobacillus acidophilus was negatively associated with caries. Prevotella nigrescens was the only species (p < 0.05) significantly associated with caries by the 'false discovery' rate. Analysis of the data suggests that selected Lactobacillus species, in addition to mutans streptococci, are risk markers for early childhood caries.

Oral health-related quality of life of periodontal patients.

BACKGROUND AND OBJECTIVE: The purpose of this study was to assess the oral health-related quality of life of patients presenting to a periodontal specialist by means of six questions, and to assess the perceived oral health by means of one question. Self-assessments of oral health were associated with clinical characteristics. MATERIAL AND METHODS: Logistic regression models were used to associate self-assessments with clinical characteristics in a cross-sectional study. RESULTS: On the six-item questionnaire, close to 20% (295/1480) of the patients reported that teeth, gums or dentures had an impact fairly often or very often on one or more items (eating, relaxing, avoiding going out, feeling self-conscious, pain or discomfort). On the single question requesting a self-assessment of oral health, 42% (628/1468) rated their oral health as fair or poor. Both common oral health-related quality of life problems and worse perceived oral health were associated with having more than eight teeth with>5 mm periodontal pockets (odds ratio=1.45, 95% confidence interval=1.01-2.08; and odds ratio=2.83, 95% confidence interval=2.08-3.84, respectively), compared with patients who had fewer than three teeth with>5 mm periodontal pockets. CONCLUSION: Oral health-related problems in patients presenting to a periodontal specialist office negatively affect their quality of life. If some of the findings of this study can be confirmed in other studies, it could change the perception of chronic periodontitis as a silent disease.

Spurious associations in oral epidemiological research: the case of dental flossing and obesity.

BACKGROUND: Individuals with increased oral health awareness may also have increased general health awareness, and vice versa. Such associations between oral and general health awareness has the potential to induce spurious associations in oral epidemiological research. OBJECTIVE: To assess the extent to which oral self-care patterns and general health awareness are confounded, we investigated the association between flossing and obesity, two lifestyle factors that are unlikely to be causally related. METHODS: A cross-sectional study of 1497 individuals presenting for an initial periodontal exam by the specialist. Self-reported flossing behaviors and body mass index (BMI) categories were related using logistic regression models. RESULTS: After adjustment for confounding variables, lack of daily flossing was associated in a dose-dependent way with morbid obesity (odds ratio (OR), 20.3; 95% confidence interval (CI), 2.7-154.0), obesity (OR, 2.1; 95% CI, 1.5-2.9), and being overweight (OR, 1.7; 95% CI, 1.3-2.2). When restricting to never smokers, a significant relationship between obesity and lack of flossing remained. CONCLUSION: The strong associations between two causally unrelated oral and general lifestyle characteristics indicate that simplistic epidemiologic methodology is unlikely to provide insights into causal mechanisms of oral diseases or oral-systemic relationships.

Increased preventive practices lead to greater tooth retention.

Prior research has rarely examined the impact of ADA-recommended preventive practices on tooth retention. We hypothesized that better oral hygiene leads to increased tooth retention. We examined the association of cross-sectional and long-term assessments of preventive practices, as well as various combinations of hygiene practices, with tooth retention. Among 736 male participants in the VA Dental Longitudinal Study, we utilized cross-sectional and longitudinal self-reports of toothbrushing, dental floss use, annual prophylaxis, and combinations of such behaviors, and examined their association with clinically assessed numbers of teeth. Baseline and long-term hygiene behaviors (except brushing) were associated with an increased baseline number of teeth and decreased subsequent tooth loss. Use of multiple hygiene behaviors was associated with greater tooth retention, cross-sectionally and longitudinally. Adherence to ADA recommendations for preventive care leads to better oral health, and consistently practicing preventive behaviors over the long term confers greater benefits than doing so over the short term.

Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research.

PURPOSE: The cause of racial disparities in the use of invasive cardiac procedures remains unclear. To summarize, evaluate, and clarify gaps in the literature, studies examining racial differences in cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) were reviewed. DATA SOURCES: MEDLINE search for English-language articles published from 1966 to May 2000. STUDY SELECTION: Empirical studies of adults. DATA EXTRACTION: The odds ratios for procedure use by race were examined for each study; cohorts and covariates were also documented. DATA SYNTHESIS: Literature was classified as one of three groups on the basis of study design. For the first group, which used administrative data, odds ratios (ORs) for African-American patients compared with white patients ranged from 0.41 to 0.94 for cardiac catheterization, from 0.32 to 0.80 for PTCA, and from 0.23 to 0.68 for CABG. Procedure rates were also lower for Hispanic and Asian patients. In the second group, which used detailed clinical data, African-American patients remained disproportionately less likely to receive cardiac catheterization (OR, 0.03 to 0.85), PTCA (OR, 0.20 to 0.87), and CABG (OR, 0.22 to 0.68). A few studies noted that Hispanic and Asian patients were also disproportionately less likely to receive such procedures. The third group used survey methods but found conflicting results regarding patient refusals as a source of racial variation. Less-educated patients and patients who were not as experienced with the procedure were more likely to decline PTCA. Physician bias was also associated with racial variation in recommendations for treatment. CONCLUSIONS: Racial differences in invasive cardiac procedure use were found even after adjustment for disease severity. Future studies should comprehensively and simultaneously examine the full range of patient, physician, and health care system variables related to racial differences in the provision of invasive cardiac procedures.

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.

Heart murmurs: are older male dental patients aware of their existence?

BACKGROUND: The American Heart Association recommends that patients with certain abnormal and prosthetic heart valves receive antibiotic prophylaxis before undergoing invasive dental treatment, owing to the risk of bacterial endocarditis, or BE. However, it is not known how many patients are aware that they have such conditions and understand such recommendations. METHODS: The authors conducted a study to determine how many male users of three U.S. Department of Veterans' Affairs ambulatory medical care centers denied having a heart murmur, even though a murmur was noted in their medical record. The authors asked 637 potential subjects a series of questions to identify those who had a heart murmur that might place them at risk of developing BE. The authors then reviewed each subject's medical records for documentation of a heart murmur. RESULTS: Four hundred ninety-seven dentate men (mean age: 61.0 years) denied having a heart murmur. Seventy (14.1 percent) of these men had documentation of a heart murmur in their medical records, and 13 (2.6 percent) had murmurs that were likely to be pathological. The failure to accurately report having a heart murmur and having a potentially pathological heart murmur were positively related to age (P = .001). Failure to accurately report having a heart murmur also was related to lower educational levels. CONCLUSIONS: These results indicate that a substantially larger number of older men than younger men were unaware that they had a heart murmur. Since some of these murmurs necessitate administration of antibiotic prophylaxis before dental procedures, this failure to communicate their correct medical status may put them at risk of developing BE. CLINICAL IMPLICATIONS: Dental health care providers should be aware that patient self-report may not be a reliable indicator of cardiac status, particularly in older patients.

Is negative affectivity associated with oral quality of life?

OBJECTIVES: The personality trait of negative affectivity (NA) is associated with reports of worse physical health, more symptoms and worse health-related quality of life but its associations with oral quality of life (OQOL) are unexplored. In this study we examined the association of NA with OQOL. METHODS: We drew on data from two samples of older men: The VA Dental Longitudinal Study (DLS; n=177) and the Veterans Health Study (VHS; n=514), which included three measures of oral quality of life: the Oral Health-Related Quality of Life Measure (OHQOL), the Oral Health Impact Profile (OHIP), and the Geriatric Oral Health Assessment Instrument (GOHAI). For each OQOL measure, and the GOHAI and OHIP subscales, two regression models were estimated to examine the marginal change in variance due to NA: the first model included age, number of teeth, and self-rated oral health, and the second added NA. RESULTS: In both bivariate and multivariate analyses, higher NA was consistently associated with worse scores on the OQOL measures. In the regression analyses, NA explained an additional.01 to 18% of the variance in OQOL, explaining the most variance in the OHIP and the least in the OHQOL. The addition of NA explained more variance in the more subjective, psychologically oriented GOHAI and OHIP subscales than it did in the more objective, physical function oriented subscales. CONCLUSIONS: Psychosocial factors such as personality are significantly associated with quality of life ratings. Such associations should be taken into account when OQOL measurements are used and interpreted.

Negative affectivity and health-related quality of life.

OBJECTIVES: Although personality is known to influence patients' self-ratings of health, its effects on reports of health-related quality of life (HRQOL) have not been fully described. We examined the relationship between a dimension of personality called negative affectivity (NA; a general disposition to experience negative mood states) and HRQOL, controlling for age and common chronic physical and mental diseases. METHODS: We used data from 3 samples of veterans: the Department of Veterans Affairs (VA) Normative Aging Study (NAS), the Veterans Health Study (VHS), and the VA Women's Health Project (VA WHP). For each of the 8 SF-36 scales and the physical and mental component summary scales, 2 regression models were estimated, the first of which included only chronic diseases and age and the second of which added NA. RESULTS: NA was consistently negatively associated with SF-36 scale scores in bivariate analyses. The regression models indicated that across the 3 samples, NA explained between 0% and 13.9% additional variance in the scales, with the least additional variance in the physical function domains (range 0-2.6%) and the most in the mental function domains (range 0-13.9%). Results from the summary scales were similar: NA explained none of the variance in the physical component summary and 3.5% to 10.4% in the mental component summary. These results were largely consistent across the 3 samples. CONCLUSIONS: These results suggest the importance of NA in patients' ratings of HRQOL beyond that of age and chronic conditions. Thus, clinicians and researchers who rely on measures such as the SF-36 to assess health status should consider that personality, as well as underlying health, can affect self-ratings of HRQOL.

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.

Comparing the health status of male and female veterans who use VA health care: results from the VA Women's Health Project.

BACKGROUND: In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services. METHODS: Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services. RESULTS: Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users. There were more pronounced differences for women on scales measuring emotional health. CONCLUSIONS: Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.

Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.

To profile differences in current physical symptoms and medical conditions among women users of Veterans Administration (VA) health services with and without a self-reported history of sexual assault sustained during military service, we conducted a cross-sectional analysis of a nationally representative, random sample of women veterans using VA outpatient services (n = 3632). A self-administered, mailed survey asked whether women had sustained sexual assault while in the military and requested information about a spectrum of physical symptoms and medical conditions. A history of sexual assault while in the military was reported by 23% of women VA users and was associated with current physical symptoms and medical conditions in every domain assessed. For example, women who reported sexual assault were more likely to indicate that they had a "heart attack" within the past year, even after adjusting for age, hypertension, diabetes, and smoking history (OR 2.3, 95% CI 1.3-4.0). Among women reporting a history of sexual assault while in the military, 26% endorsed > or = 12 of 24 symptoms/conditions, compared with 11% of women with no reported sexual assault while in the military (p < 0.001). Clinicians need to be attuned to the high frequency of sexual assault occurring while in the military reported by women VA users and its associated array of current physical symptoms and medical conditions. Clinicians should consider screening both younger and older patients for a sexual violence history, especially patients with multiple physical symptoms.

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.

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.

Conference summary: assessing oral health outcomes--measuring health status and quality of life.

OBJECTIVE: This paper summarises proceedings of a conference that aimed to evaluate existing measures of oral health related quality of life and to recommend new directions for their use in oral health outcomes research. METHOD: A two day conference was held in Chapel Hill, North Carolina, USA, in June 1996. Background papers, poster-discussion sessions, small group discussions and reactor papers were used to analyse 11 oral health related quality of life instruments and to evaluate their potential for use in health outcomes research. RESULTS: Speakers emphasised the need to include quality of life in multidimensional assessments of oral health outcomes. Existing instruments capture numerous quality of life dimensions using a variety of question- and response-formats. The instruments have been used primarily in cross-sectional, observational studies rather than longitudinal, intervention studies that evaluate health outcomes. There is little experience from their use in long-term follow-up studies and with some special population sub-groups. Recommendations for further research are presented in papers that follow this summary paper. CONCLUSIONS: There has been substantial development and use of quality of life measures in oral health surveys, and there is an immediate need for further research that modifies and uses those instruments in oral health outcomes research.

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.