Does the Relationship Between Neighborhood Socioeconomic Status and Health Outcomes Persist Into Very Old Age? A Population-Based Study

Objective: The purpose of this article is (a) to extend previous research on the relationship between neighborhood socioeconomic status (SES) and health by considering a wide range of health-related measures derived from administrative health care records and (b) to explore whether this relationship persists into old age. Method: The study involved a complete cohort of community-dwelling residents in Winnipeg, Canada, who were 65 years or older in 2004/2005 ( N = 77,930). Health measures were derived from administrative claims data. Census data were used to derive neighborhood-level SES. Results: Multilevel logistic regressions indicated that, relative to individuals living in the most affluent areas, those in the poorest areas had significantly higher odds of having arthritis, diabetes, hypertension, congestive heart failure, ischemic heart disease, chronic obstructive pulmonary disease, depression, and stroke. Significant neighborhood income effects tended to be evident among individuals age 65 to 75 as well as those age 75+. Discussion: A wide range of health conditions among older adults are disproportionately clustered into the poorest areas. Programs and services should be designed to meet the needs of older adults of any age in such neighborhoods.

Transfers to acute care hospitals at the end of life: do rural/remote regions differ from urban regions?

INTRODUCTION

In population-based studies, transfers into hospitals and hospital deaths are typically considered to be indicators of potentially inappropriate care settings at the end of life. Despite a plethora of research into where people die, few studies have examined whether hospital transfers at the end of life differ in rural versus urban areas. In the present study hospitalizations in the last month before death in one mid-Western Canadian province were examined. The study had three main objectives, to: (1) compare hospitalizations in rural/remote with urban regions; (2) examine the role of healthcare resources in hospitalizations; and (3) explore more specifically whether day-to-day patterns of hospitalization shortly before death differ between rural/remote and urban areas.

METHODS

The source of data was administrative healthcare records, with the study including all adults (aged over 19 years; excluding nursing home residents) who died in the province of Manitoba in 2003-2004 (n = 6523). Whether the decedents were hospitalized in the 30 days before death was determined from hospital files. The number of hospital days incurred was counted. Region of residence was defined along regional health authority boundaries, with 7 regions identified as rural/remote and 2 as urban. Healthcare resources were measured in terms of the number of: physicians, hospital beds, nursing home beds, and home care services per 1000 population. Age, sex and trajectory groups, which categorized decedents according to their cause of death, were included in all analyses.

RESULTS

Residents of 4 of the 7 rural/remote regions had increased odds of being hospitalized relative to the comparison, the larger urban region (adjusted odds ratios [AOR] ranged from 1.25 to 1.70). Hospital days did not differ across regions. Further analyses showed that having more physicians (AOR = .75) and more hospital beds per 1000 population (AOR = .95) both significantly reduced the odds of being hospitalized. Nursing home beds and home care services were not related to hospitalizations. Growth curve models indicated that daily patterns of hospitalizations generally did not differ across rural/remote versus urban regions.

CONCLUSION

The findings suggest that residents of some rural/remote regions were at a disadvantage in terms of access to an appropriate care setting at the end of life. The regional variation in hospitalization can, at least in part, be attributed to the availability of healthcare resources, specifically the number of physicians and hospital beds (per 1000 population). However, the variation that emerged across regions also suggests that conclusions should not be over-generalized to all rural/remote regions; rather, local differences in healthcare resources should be considered when examining healthcare usage at the end of life.

Hospitalizations at the end of life among long-term care residents

BACKGROUND

Concerns have been raised over transfers into acute care hospitals at the end of life. The objective of this study was to examine (a) the extent of and (b) factors related to hospitalization in the last 180 days before death among long-term care (LTC) residents.

METHODS

The study included all LTC residents from 60 facilities in the province of Manitoba, Canada, who died in 2003/04 (N = 2,379), with data derived from administrative health care records. Multilevel regression analyses were conducted to examine the relationship between resident and facility characteristics and the following: location of death (in hospital vs the LTC facility); whether individuals were hospitalized in the last 180 days before death; and number of hospital days in the last 180 days.

RESULTS

Overall, 19.1% of LTC residents died in hospital; however, 40.7% were hospitalized at least once in the last 6 months before death. Several resident characteristics (age, trajectory group, and level of care) were related to the outcome measures. Living in a not-for-profit LTC facility decreased the odds of dying in hospital (adjusted odds ratio [OR] = 0.589; 95% confidence interval [CI] = 0.402-0.863) or being hospitalized (adjusted OR = 0.647; 95% CI = 0.452-0.926).

CONCLUSIONS

Hospitalization at the end of life is common among LTC residents, and the likelihood of hospital transfers is increased for residents who are younger, have organ failure, lower care level needs, as well as among those who live in for-profit facilities. Particular emphasis should, therefore, be placed on targeting these groups to determine the appropriateness of hospital admission and possible ways of reducing transfers.

Health care use at the end of life among older adults: does it vary by age?

BACKGROUND

Issues around end-of-life health care have attracted increasing attention in the last decade. One question that has arisen is whether very elderly individuals receive overly aggressive treatment at the end of life. The purpose of this study was to address this issue by examining whether health care use at the end life varies by age.

METHODS

The study included all adults 65 years old or older who died in Manitoba, Canada in 2000 (N = 7678). Measures were derived from administrative data files and included location of death, hospitalizations, intensive care unit (ICU) admission, long-term care (LTC) use, physician visits, and prescription drug use in the last 30 days versus 180 days before death, respectively.

RESULTS

Individuals 85 years old or older had increased odds of being in a LTC institution and also dying there than did individuals 65-74 years old. They had, correspondingly, lower odds of being hospitalized and being admitted to an ICU. Although some statistically significant age differences emerged for physician visits, the effects were small. Prescription drug use did not vary by age.

CONCLUSIONS

These findings indicate that very elderly individuals tended to receive care within LTC settings, with care that might be considered aggressive declining with increasing age. However, health care use among all age groups was substantial. A critical issue that needs to be examined in future research is how to ensure quality end-of-life care in a variety of clinical contexts and care settings for individuals of all ages.

Ethnic differences in self-rated health among older adults: a cross-sectional and longitudinal analysis

The objectives of this study were to examine whether self-rated health differs among older adults of different ethnic backgrounds and to explore what factors may account for potential differences. The study was based on the 1983 and 1996 waves of the Aging in Manitoba study. A self-report measure of ethnic background was used to categorize participants into four groups: British/Canadian, Northern/Central European, Eastern European, and Other. In both 1983 and 1996, older Eastern European adults had significantly reduced odds of rating their health as good or excellent relative to British/Canadian adults. Controlling for demographic variables, socioeconomic status, language spoken, and health status attenuated but did not eliminate the difference. Global, subjective ratings of health are frequently used to measure health. The ethnic differences found here suggest, however, that ratings may be influenced by cultural factors, which may warrant some caution in making comparisons across ethnic groups.

Trends in the health status of older Manitobans, 1985 to 1999

Trends in the health status of the entire senior population aged 65 years or older in Manitoba were examined over a 14-year period (1985-1999) using administrative data (about 50,000 individuals). Significant health gains were apparent for a number of important indicators, including acute myocardial infarction, stroke, cancer, and hip fractures, although some of these gains were restricted to urban areas. Improvements in these health indicators are significant, as they can have major implications for individuals' need for health services and ability to live independently. In contrast, chronic diseases were on the rise, with the prevalence of diabetes, hypertension, and dementia increasing substantially over the 14-year period. These trends suggest a need for a policy emphasis on prevention, such as reducing the prevalence of obesity, which is one risk factor for diabetes. Moreover, having sufficient care options in place for the growing number of individuals with dementia is an issue that will have to be addressed.

Exploring reasons for bed pressures in Winnipeg acute care hospitals

Hospital overcrowding has plagued Winnipeg and other Canadian cities for years. This study explored factors related to overcrowding. Hospital files were used to examine patterns of hospital use from fiscal years 1996/1997 to 1999/2000. Chart reviews were conducted to examine appropriateness of admissions and hospital stays during one pressure week. Results indicate that pressure periods in the hospital system were driven by an influx of older adults with influenza-associated respiratory illnesses. Moreover, examination of one specific pressure week showed that at least 100 beds were occupied by patients who likely did not require acute care. The chart review revealed that a substantial proportion of non-acute patient-days were spent awaiting home care, long-term care, or diagnostic testing services. These findings suggest future bed pressures might be prevented through influenza vaccination and an increase in the availability of--and timely transfer to--alternative levels of care.

Does continuity of care matter in a universally insured population?

OBJECTIVE

To examine the relation between continuity of care and preventive health care and emergency department (ED) use in a universal health care system.

DATA SOURCES/STUDY SETTING

Administrative data that capture health care use of the entire population of a midwestern Canadian city.

STUDY DESIGN

A population-based, retrospective study of all individuals who had a least one physician contact in 1998 or 1999 (total N=536,893).

METHODS

Logistic regressions were conducted to examine the relation between continuity of care, defined in terms of the proportion of total visits to family physicians (FPs) made to the same FP, and cervical cancer screening, breast cancer screening, influenza vaccination, pneumococcal vaccination, and ED visits, controlling for demographic variables, socioeconomic status (defined in terms of relative affluence of neighborhood of residence), and health status.

PRINCIPAL FINDINGS

Continuity of care was related to better preventive health care and reduced ED use. A consistent socioeconomic gradient also emerged. For instance, the odds of having a mammogram was double for individuals living in the wealthiest neighborhoods, relative to those in the poorest neighborhoods (adjusted odds ratio=2.31, 99 percent CI 2.13-2.50).

CONCLUSIONS

Having a long-term relationship with a single physician makes a difference even in a universal health care system. Moreover, socioeconomic disparities remain, suggesting the need to target specifically individuals from lower socioeconomic strata for preventive health care.

Seasonal patterns of hospital use in Winnipeg: implications for managing winter bed crises

This study examined whether Winnipeg hospitals experience predictable "high-volume periods" in order to determine whether hospital overcrowding might be anticipated and, therefore, avoided. We found that high-volume periods among medical patients occurred during all but one year between 1987 and 1998. Most high-volume periods occurred during influenza seasons. Preventing such recurrent bed pressures requires a multi-faceted approach, involving preventive efforts to reduce hospital admissions (influenza vaccination) and alternatives to managing the hospital system.

The impact of influenza-associated respiratory illnesses on hospitalizations, physician visits, emergency room visits, and mortality

OBJECTIVES

Although the increased risk of hospitalization and mortality during influenza seasons has been documented extensively, there is a relative paucity of research on the impact of influenza-related illnesses on other health care use indicators, such as physician use. The purpose of this study was to examine the impact of influenza-associated respiratory illnesses on the Winnipeg health care system, including hospitalizations, physician visits and emergency room visits. Their impact on mortality was also examined.

METHODS

Administrative data were used to track health care use and mortality over four influenza seasons (1995-96 to 1998-99). Excess health care use and deaths were calculated by subtracting rates during influenza seasons from those during weeks when influenza viruses were not circulating.

RESULTS

Significant excess hospitalization, physician visit, and emergency room visit rates emerged for influenza and pneumonia, acute respiratory diseases, and chronic lung disease, especially among children and adults aged 65 and over. Considerable excess mortality due to influenza and pneumonia and chronic lung disease among individuals aged 65 and over also emerged, particularly among nursing home residents.

DISCUSSION

Influenza-associated respiratory illnesses have a substantial impact on the health care system. Given the burden of illness among children during influenza seasons, the study further suggests that influenza vaccination might be considered for this age group.

The relation between everyday activities and successful aging: a 6-year longitudinal study

OBJECTIVES

Activity has long been thought to be related to successful aging. This study was designed to examine longitudinally the relation between everyday activities and indicators of successful aging, namely well-being, function, and mortality.

METHODS

The study was based on the Aging in Manitoba Study, with activity being measured in 1990 and function, well-being, and mortality assessed in 1996. Well-being was measured in terms of life satisfaction and happiness; function was defined in terms of a composite measure combining physical and cognitive function.

RESULTS

Regression analyses indicated that greater overall activity level was related to greater happiness, better function, and reduced mortality. Different activities were related to different outcome measures; but generally, social and productive activities were positively related to happiness, function, and mortality, whereas more solitary activities (e.g., hand-work hobbies) were related only to happiness.

DISCUSSION

These findings highlight the importance of activity in successful aging. The results also suggest that different types of activities may have different benefits. Whereas social and productive activities may afford physical benefits, as reflected in better function and greater longevity, more solitary activities, such as reading, may have more psychological benefits by providing a sense of engagement with life.

The impact of influenza-associated respiratory illnesses on hospitalizations, physician visits, emergency room visits, and mortality

OBJECTIVES

Although the increased risk of hospitalization and mortality during influenza seasons has been documented extensively, there is a relative paucity of research on the impact of influenza-related illnesses on other health care use indicators, such as physician use. The purpose of this study was to examine the impact of influenza-associated respiratory illnesses on the Winnipeg health care system, including hospitalizations, physician visits and emergency room visits. Their impact on mortality was also examined.

METHODS

Administrative data were used to track health care use and mortality over four influenza seasons (1995-96 to 1998-99). Excess health care use and deaths were calculated by subtracting rates during influenza seasons from those during weeks when influenza viruses were not circulating.

RESULTS

Significant excess hospitalization, physician visit, and emergency room visit rates emerged for influenza and pneumonia, acute respiratory diseases, and chronic lung disease, especially among children and adults aged 65 and over. Considerable excess mortality due to influenza and pneumonia and chronic lung disease among individuals aged 65 and over also emerged, particularly among nursing home residents.

DISCUSSION

Influenza-associated respiratory illnesses have a substantial impact on the health care system. Given the burden of illness among children during influenza seasons, the study further suggests that influenza vaccination might be considered for this age group.

Hospitalizations and Deaths Due to Respiratory Illnesses During Influenza Seasons: A Comparison of Community Residents, Senior Housing Residents, and Nursing Home Residents

BACKGROUND

Although research indicates that influenza is a major cause of morbidity and mortality among older adults, few studies have tried to identify which seniors are particularly at risk of experiencing complications of influenza. The purpose of this study was to compare hospitalizations and deaths due to respiratory illnesses during influenza seasons among seniors (aged 65+) living in the community, senior residences (apartments reserved for seniors), and nursing homes.

METHODS

Using administrative data, all hospital admissions and deaths due to respiratory illnesses (pneumonia and influenza, chronic lung disease, and acute respiratory diseases) were identified for all individuals aged 65 and older living in Winnipeg, Canada (approximately 88,000 individuals) during four influenza seasons (1995-1996 to 1998-1999).

RESULTS

Hospitalization and death rates for respiratory illnesses increased significantly during influenza seasons, compared to fall periods (e.g., 42.7 vs 25.2 hospitalizations per 1000 population aged 80 and older). Moreover, hospitalization rates for pneumonia and influenza, chronic lung disease, and acute respiratory diseases were higher among individuals living in senior residences (42.5 per 1000 for all respiratory illnesses combined) than their counterparts living in the community (22.8 per 1000). Furthermore, deaths due to pneumonia and influenza and chronic lung disease were higher among senior housing residents (4.2 per 1000) than community residents (2.6 per 1000) and were particularly high among nursing home residents (52.1 per 1000).

CONCLUSIONS

Individuals living in seniors residences are at increased risk of being hospitalized for and dying of respiratory illnesses during influenza seasons. Given that influenza vaccination is currently the best method to reduce influenza-associated illnesses among seniors, this suggests that influenza vaccination strategies should be targeted at this population.

Characteristics of patients with a regular source of care

This study was designed to describe patient characteristics associated with having a regular source of care among all patients who received care from large urban clinics in Manitoba over a three-year period (N = 298,222). Using administrative data, patients were classified as having a regular source of care if they made 75% or more of their total ambulatory visits to the same clinic. Overall, 44.2% of patients had a regular source of care. A logistic regression showed that children and adults aged 45 and older were more likely to have a regular source of care than patients aged 18-44. Moreover, patients with a regular source of care tended to live in more affluent neighbourhoods and were healthier than individuals with no regular source of care. Systemic changes might be needed to enhance continuity of care (e.g., mechanisms to enhance access) among vulnerable segments of the population like the poor.

Observers' Reactions to Genetic Testing: The Role of Hindsight Bias and Judgments of Responsibility1

In 3 studies, we examined the effect of birth outcome on observers' reactions to genetic testing. Participants read a scenario in which a woman declined to take a genetic screening test and subsequently gave birth to a child with a genetic disorder (negative outcome) or a healthy child (positive outcome). Retrospective judgments of the likelihood that the child would have a genetic disorder were higher given negative than positive outcome knowledge under conditions of high genetic risk. Moreover, the more likely a negative outcome was perceived to be, the more responsible the mother was held for not taking the genetic screening test. Consistent with Weiner's (1993) theory, responsibility judgments were linked to displeasure and sympathy, with sympathy in turn being related to help judgments.

Primary and secondary control-enhancing strategies: implications for health in later life

OBJECTIVES

The major goal of this article was to assess the link between control-enhancing strategies and health in an older population. In particular, the use of primary-control strategies, which involve modifying the environment (e.g., actively persisting) and compensatory secondary-control strategies, which involve modifying the self (e.g., expecting less of oneself) was studied.

METHODS

Participants (n = 241) in a large-scale longitudinal study were interviewed to assess their use of strategies and their health.

RESULTS

Health (physical and perceived) was found to vary for those using primary- and compensatory secondary-control strategies; however, the nature of this variation depended on age.

DISCUSSION

The findings may indicate that primary-control strategies have positive health implications for the young-old but that these same strategies become detrimental to health in late life. The findings could further suggest that compensatory secondary-control strategies become increasingly more adaptive in late life.

Self-perceptions of health: a prospective analysis of mortality, control, and health

A growing number of studies show that self-perceptions of health are an important predictor of mortality. The present study was designed to extend this research by examining the relation between health perceptions and a range of other outcome measures besides mortality, including control beliefs and morbidity. The results show that older adults who rated their health as "bad/poor" and "fair" were more than twice as likely to die within three to three-and-a-half years following the initial survey than those who perceived their health as "excellent." However, although health perceptions assessed in 1991/92 were related to health perceptions four years later, they did not predict morbidity. Health perceptions also predicted perceived control and use of control-enhancing strategies in dealing with age-related challenges, as assessed in 1995. These findings contribute to our understanding of the benefits of positive health perceptions by showing that they are connected to an adaptive psychological profile including perceptions of control and use of control-enhancing strategies that are linked to health and well-being.

The interactive effect of perceived control and functional status on health and mortality among young-old and old-old adults

The effect of perceived control on health has been examined extensively in the gerontological literature. A question that has received little attention, however, is whether perceived control affords similar benefits to all other adults. In a longitudinal study we examined the effect of perceived control, in combination with functional status and age, on perceived health, morbidity, hospitalization, and mortality. The analyses showed that perceived control interacted with functional status for old-old (80+ years old) adults, but not for young-old (65-79 years old) adults in terms of perceived health, hospitalization, and mortality. For perceived health, feeling in control was of benefit of old-old adults with some functional impairment, but not to those with little impairment. Moreover, a greater sense of control was associated with lower rates of hospitalization and mortality for old-old individuals with little functional impairment. These results highlight the usefulness of examining the buffering effects of perceived control in relation to different age groups.

Remaining active in later life. The role of locus of control in seniors' leisure activity participation, health, and life satisfaction

Although the physical and psychological benefits of feeling in control are well-documented in the research literature, the mechanisms that account for these effects have received less attention. The present study was designed to examine the potential mediating role of exercising and participation in nonphysical leisure activities, such as attending cultural events, involvement in volunteer organizations, and so on, in the relation between perceived control and well-being in seniors. The results indicated that an internal locus of control was positively related to exercising and participation in leisure activities. Exercising and leisure activity participation, in turn, were predictive of better perceived health and greater life satisfaction. These findings point to the potential benefits of increasing seniors' sense of control as a means to promote exercising and to increase leisure activity participation and, consequently, to enhance well-being.

Reactions to stigmas. The effect of targets' age and controllability of stigmas

Reactions toward older adults have been widely researched, but the question of whether such reactions are due to age per se or due to the presence of other stigmas (e.g., physical disabilities) has received little attention. This study was designed to investigate emotional reactions and willingness to help older versus younger adults who exhibited a wide range of stigmas, including AIDS, leg amputation, depression, and so on. Guided by attribution theory, the cause of the stigmas was further ascribed to either uncontrollable or controllable factors. Older adults evoked less anger than younger individuals, particularly in the case of blindness, depression, leg amputation, lung cancer, and unemployment. Subjects were also more willing to help an older than a younger amputee. Moreover, stigmas ascribed to uncontrollable factors generally produced less anger, more pity, and greater willingness to help than stigmas described as due to controllable causes. These results provide little support for the notion of ageism, at least within an age range of up to 65 years, but suggest that responses to older adults with stigmas may be subject to positive stereotyping.