Barriers to health care access among the elderly and who perceives them

Health behavior and adherence to treatment for sleep breathing disorder in the patient with heart failure

BACKGROUND

Heart failure can be complicated by a variety of comorbidities including sleep breathing disorder (SBD). Treatment for SBD in the heart failure patient can improve quality of life and decrease mortality. Few studies have sought to examine the reasons why patients with heart failure who screen positive for SBD do not follow through with diagnostic testing and recommendations for evidence based treatments.

PURPOSE

The purpose of this study was to describe and compare the characteristics of patients with heart failure who adhered to recommendations for evaluation and treatment of SBD with those who did not. Additionally, the study sought to examine reasons for nonadherence.

METHODS

A descriptive comparative design was used. Descriptive statistics were used to define and compare the study population in terms of demographic data, which included age, gender, ethnicity, New York Heart Association heart failure classification, and comorbidities. Additionally, patients were surveyed to determine reasons for nonadherence to recommended overnight sleep study evaluation and or treatment with positive airway pressure.

RESULTS

Demographics with higher percentages of adherence to evaluation and treatment included younger individuals and male gender. Prevalent reasons for nonadherence for evaluation and treatment included negative perceptions of an overnight sleep study evaluation and advanced age.

IMPLICATIONS FOR PRACTICE

The community nurse educator can use the descriptive comparative findings in this study to tailor educational programs toward individuals with heart failure who have screened positive for SBD who are most at risk for nonadherence.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

The influence of stress, depression, and anxiety on PSA screening rates in a nationally representative sample

BACKGROUND

Prostate-specific antigen (PSA) testing for prostate cancer is controversial, with concerning rates of both overscreening and underscreening. The reasons for the observed rates of screening are unknown, and few studies have examined the relationship of psychological health to PSA screening rates. Understanding this relationship can help guide interventions to improve informed decision-making for screening.

METHODS

A nationally representative sample of men 57-85 years old without prostate cancer (N = 1169) from the National Social life, Health and Aging Project was analyzed. The independent relationship of validated psychological health scales measuring stress, anxiety, and depression to PSA testing rates was assessed using multivariable logistic regression analyses.

RESULTS

PSA screening rates were significantly lower for men with higher perceived stress [odds ratio (OR) = 0.76, P = 0.006], but not for higher depressive symptoms (OR = 0.89, P = 0.22) when accounting for stress. Anxiety influences PSA screening through an interaction with number of doctor visits (P = 0.02). Among the men who visited the doctor once those with higher anxiety were less likely to be screened (OR = 0.65, P = 0.04). Conversely, those who visited the doctor 10+ times with higher anxiety were more likely to be screened (OR = 1.71, P = 0.04).

CONCLUSIONS

Perceived stress significantly lowers PSA screening likelihood, and it seems to partly mediate the negative relationship of depression with screening likelihood. Anxiety affects PSA screening rates differently for men with different numbers of doctor visits. Interventions to influence PSA screening rates should recognize the role of the patients' psychological state to improve their likelihood of making informed decisions and improve screening appropriateness.

Mobility and aging: new directions for public health action

Optimal mobility, defined as relative ease and freedom of movement in all of its forms, is central to healthy aging. Mobility is a significant consideration for research, practice, and policy in aging and public health. We examined the public health burdens of mobility disability, with a particular focus on leading public health interventions to enhance walking and driving, and the challenges and opportunities for public health action. We propose an integrated mobility agenda, which draws on the lived experience of older adults. New strategies for research, practice, and policy are needed to move beyond categorical promotion programs in walking and driving to establish a comprehensive program to enhance safe mobility in all its forms.

Depressive symptoms and reduced preventive care use in older adults: the mediating role of perceived access

BACKGROUND

Depressive symptomatology is common in older adults and is associated with reduced adherence to recommended preventive care, but little is known as to why. Understanding how depressive symptoms may interfere with adherence can help to identify leverage points for interventions to increase preventive service use.

OBJECTIVE

This study examined perceived access to medical care as a possible mediator linking depressive symptomatology to reduced preventive service use in older adults.

METHODS

We analyzed data from 5465 respondents completing the 1993 and 2003/2004 waves of the Wisconsin Longitudinal Study. Depressive symptomatology was assessed using the Center for Epidemiologic Studies Depression Scale. Perceived access survey items were organized through factor analysis to represent key dimensions of access: availability/accessibility, affordability, acceptability, and accommodation. The primary outcome was the total number of 7 recommended preventive services that respondents received. Multivariate path analysis was used to estimate direct and indirect effects between depressive symptomatology, perceived access, and preventive service use.

RESULTS

Older adults with depressive symptomatology received fewer recommended services. Depressive symptomatology reduced preventive service use by adversely affecting 2 dimensions of perceived access: (1) acceptability, pertaining to poor patient-provider trust and communication, and (2) accommodation, pertaining to inconveniently organized services.

CONCLUSIONS

Depressive symptomatology may negatively alter older adults' perceptions of access and, in turn, negatively impact their preventive service use. In addition to treating depression, interventions designed to mitigate the impact of depression on the patient-provider relationship, and organizational changes to practice that better accommodate the needs of depressed patients, may increase adherence to preventive care guidelines in depressed older adults.

Differences in blood pressure control in a large population-based sample of older African Americans and non-Hispanic whites

BACKGROUND

Cardiovascular disease is the main cause of death in older adults. Uncontrolled blood pressure is an important risk factor for cardiovascular disease. African Americans have poorer blood pressure control than non-Hispanic whites. Little is known about whether this difference persists in older ages or the factors that contribute to this racial gap.

METHODS

Data were obtained from participants of the Chicago Health and Aging Program. Blood pressure control was defined according to JNC-7 criteria. Univariate chi-square analyses were used to determine racial differences in hypertension and blood pressure control, whereas sequential multivariate logistic regression models were used to determine the effect of race on blood pressure control.

RESULTS

African Americans had a higher prevalence of hypertension (74% vs 63%; p < .001), higher awareness of hypertension (81% vs 72%; p < .001), and poorer blood pressure control (45% vs 51%, p < .001) than non-Hispanic whites. Racial differences in blood pressure control persisted after adjustment for socioeconomic status, medical conditions, obesity, and use of antihypertensive medications (odds ratio = 0.84, 95% confidence interval = 0.70-0.94). From 1993 to 2008, blood pressure control improved more among non-Hispanic whites than among African Americans.

CONCLUSIONS

Racial differences in blood pressure control in older adults were not explained by socioeconomic status. The racial disparity in the prevalence and control of hypertension remained consistent for older hypertensive individuals eligible for Medicare. Although the rates of hypertension control improved for both racial groups, the improvement was greater among whites, thus widening the gap in this older population at high risk for cardiovascular disease.

The effects of sociocultural factors on older Asian Americans' access to care

Most Asian American elders are immigrants to the United States, and sociocultural factors such as English proficiency and immigration status are prominent factors in their lives. Using data from the California Health Interview Surveys to focus on Asian Americans over age 50, this study seeks to identify interethnic differences, and the effects of English proficiency and immigration status in the way older Asian Americans access healthcare. The results indicated that Asian ethnicity, English proficiency, and immigration status have significant independent effects on older Asian Americans' access to care. Implications for social work's role in addressing access disparities are discussed.

Telemedicine can help to ensure that patients receive timely medical care

We describe a case illustrating that telephone consultations can help to lower the psychological threshold for accessing medical care in people who are not aware of the seriousness of their symptoms, or who might otherwise be reluctant to access face-to-face care. A 69-year-old male patient called a teleconsultation service at the weekend because of acute fever. The patient was scheduled to have a hip replacement and the usual pre-operative check-up done the day before had been normal. However, a careful medical history taken during the teleconsultation revealed potentially serious symptoms. We therefore referred the patient to the emergency room immediately with the suspicion of severe infection, possibly due to colon cancer. The patient was subsequently diagnosed with septicaemia and adenocarcinoma of the sigmoid. This demonstrates that teleconsultation is not only a powerful tool for triage and diagnosis, but can also help to reduce delay in diagnosing severe diseases in primary health care.

Patterns of perceived barriers to medical care in older adults: a latent class analysis

BACKGROUND

This study examined multiple dimensions of healthcare access in order to develop a typology of perceived barriers to healthcare access in community-dwelling elderly. Secondary aims were to define distinct classes of older adults with similar perceived healthcare access barriers and to examine predictors of class membership to identify risk factors for poor healthcare access.

METHODS

A sample of 5,465 community-dwelling elderly was drawn from the 2004 wave of the Wisconsin Longitudinal Study. Perceived barriers to healthcare access were measured using items from the Group Health Association of America Consumer Satisfaction Survey. We used latent class analysis to assess the constellation of items measuring perceived barriers in access and multinomial logistic regression to estimate how risk factors affected the probability of membership in the latent barrier classes.

RESULTS

Latent class analysis identified four classes of older adults. Class 1 (75% of sample) consisted of individuals with an overall low level of risk for perceived access problems (No Barriers). Class 2 (5%) perceived problems with the availability/accessibility of healthcare providers such as specialists or mental health providers (Availability/Accessibility Barriers). Class 3 (18%) perceived problems with how well their providers' operations arise organized to accommodate their needs and preferences (Accommodation Barriers). Class 4 (2%) perceived problems with all dimension of access (Severe Barriers). Results also revealed that healthcare affordability is a problem shared by members of all three barrier groups, suggesting that older adults with perceived barriers tend to face multiple, co-occurring problems. Compared to those classified into the No Barriers group, those in the Severe Barrier class were more likely to live in a rural county, have no health insurance, have depressive symptomatology, and speech limitations. Those classified into the Availability/Accessibility Barriers group were more likely to live in rural and micropolitan counties, have depressive symptomatology, more chronic conditions, and hearing limitations. Those in the Accommodation group were more likely to have depressive symptomatology and cognitive limitations.

CONCLUSIONS

The current study identified a typology of perceived barriers in healthcare access in older adults. The identified risk factors for membership in perceived barrier classes could potentially assist healthcare organizations and providers with targeting polices and interventions designed to improve access in their most vulnerable older adult populations, particularly those in rural areas, with functional disabilities, or in poor mental health.

Activity Limitations and Healthcare Access as Correlates of Frequent Mental Distress in Adults 65 Years and Older

Objectives: Poor mental health is a major source of distress, disability, and social burden in older adults. The objective of this study was to determine if activity limitation and healthcare access are associated with frequent mental distress (FMD) in adults 65 years and older. Methods: Of the 123 427 study participants aged 65 years or older, 120 445 participants responded to the Behavioral Risk Factors Surveillance System (BRFSS) survey question on number of mentally unhealthy days. Participants who reported having 14 or more mentally unhealthy days during the past 30 days were considered as having FMD. Activity limitation, avoidance of medical care due to cost, and availability of personal doctor were examined for their association with FMD in multivariable logistic regression analysis. Age, sex, race/ethnicity, marital and employment status, emotional support, and life satisfaction were included as potential confounders. Results: The prevalence of FMD in this study population was 6.5% (95% CI = 6.3-6.8) with estimates significantly greater among women (7.2%, 95% CI = 6.9-7.6) as compared to men (5.5%, 95% CI = 5.1-6.0). The odds of FMD were more than 2-fold elevated for those who reported activity limitations due to physical, mental, or emotional problems (adjusted OR = 2.59, 95% CI = 2.33-2.87), and among those who reported health care cost as a barrier to see a doctor (adjusted OR = 2.14, 95% CI = 1.75-2.61). There was no significant relationship between availability of personal doctor and FMD observed in the study. Conclusions: The findings of this study showed that activity limitation and cost of medical care are associated with FMD in the US elderly population.

Accessibility to health care facilities in Montreal Island: an application of relative accessibility indicators from the perspective of senior and non-senior residents

BACKGROUND

Geographical access to health care facilities is known to influence health services usage. As societies age, accessibility to health care becomes an increasingly acute public health concern. It is known that seniors tend to have lower mobility levels, and it is possible that this may negatively affect their ability to reach facilities and services. Therefore, it becomes important to examine the mobility situation of seniors vis-a-vis the spatial distribution of health care facilities, to identify areas where accessibility is low and interventions may be required.

METHODS

Accessibility is implemented using a cumulative opportunities measure. Instead of assuming a fixed bandwidth (i.e. a distance threshold) for measuring accessibility, in this paper the bandwidth is defined using model-based estimates of average trip length. Average trip length is an all-purpose indicator of individual mobility and geographical reach. Adoption of a spatial modelling approach allows us to tailor these estimates of travel behaviour to specific locations and person profiles. Replacing a fixed bandwidth with these estimates permits us to calculate customized location- and person-based accessibility measures that allow inter-personal as well as geographical comparisons.

DATA

The case study is Montreal Island. Geo-coded travel behaviour data, specifically average trip length, and relevant traveller's attributes are obtained from the Montreal Household Travel Survey. These data are complemented with information from the Census. Health care facilities, also geo-coded, are extracted from a comprehensive business point database. Health care facilities are selected based on Standard Industrial Classification codes 8011-21 (Medical Doctors and Dentists).

RESULTS

Model-based estimates of average trip length show that travel behaviour varies widely across space. With the exception of seniors in the downtown area, older residents of Montreal Island tend to be significantly less mobile than people of other age cohorts. The combination of average trip length estimates with the spatial distribution of health care facilities indicates that despite being more mobile, suburban residents tend to have lower levels of accessibility compared to central city residents. The effect is more marked for seniors. Furthermore, the results indicate that accessibility calculated using a fixed bandwidth would produce patterns of exposure to health care facilities that would be difficult to achieve for suburban seniors given actual mobility patterns.

CONCLUSIONS

The analysis shows large disparities in accessibility between seniors and non-seniors, between urban and suburban seniors, and between vehicle owning and non-owning seniors. This research was concerned with potential accessibility levels. Follow up research could consider the results reported here to select case studies of actual access and usage of health care facilities, and related health outcomes.

Prevalence and correlates of poor self-rated health in the United States: the national elder mistreatment study

OBJECTIVES

Despite its subjective nature, self-report of health status is strongly correlated with long-term physical morbidity and mortality. Among the most reliable predictors of self-reported poor health is older age. In younger adult populations, the second reliable predictor of reported poor health is the experience of domestic and other interpersonal violence. However, very little research exits on the connection between elder mistreatment and self-reports of poor health. The aim of this study was to examine the level of, and correlates for, poor self-rated health in a community sample of older adults with particular emphasis on elder mistreatment history, demographics, and social dependency variables.

DESIGN

Random digit dialing telephone survey methodology.

SETTING

A national representative phone survey of noninstitutionalized U.S. household population.

PARTICIPANTS

Five thousand seven hundred seventy-seven U.S. adults, aged 60 years and older.

MEASUREMENTS

Individuals participated in a structured interview assessing elder mistreatment history, demographics, and social dependency variables.

RESULTS

Poor self-rated health was endorsed by 22.3% of the sample. Final multivariable logistic regression models showed that poor self-rated health was associated with unemployment, marital status, low income, low social support, use of social services, needing help in activities of daily living, and being bothered by emotional problems. Secondary analyses revealed a mediational role of emotional symptoms in the association between physical maltreatment and poor health.

CONCLUSIONS

Results suggest that poor health is common among older adults. This study also identified correlates of poor health that may be useful in identification of those in need of intervention.

Rural public health education as a pharmacist-led team endeavor

OBJECTIVE

To examine the state of public health provision and education in North Dakota and to identify the current and potential future roles pharmacists and pharmacy educators play in these activities.

SETTING

Rural, medically underserved areas of North Dakota, as well as professional training sites for the practitioners working in these areas.

PRACTICE DESCRIPTION

Practice sites encompass both rural community pharmacies and critical-access hospital pharmacies. The primary education practice site is North Dakota State University.

PRACTICE INNOVATION

Pharmacists in rural North Dakota are proactive leaders in providing public health care to their patients. For example, they participate in a statewide diabetes disease management project similar to the Asheville, NC, project. Pharmacy educators are leading the formation of a new interprofessional Master of Public Health program.

MAIN OUTCOME MEASURE

Development of an interprofessional public health education program that allows for greater collaboration among rural health practitioners.

RESULTS

The new degree program is successfully negotiating the academic approval process.

CONCLUSION

Because of the efforts of pharmacists and pharmacy educators, North Dakota is better prepared to face current and future public health challenges.

Shared medical appointments: improving access, outcomes, and satisfaction for patients with chronic cardiac diseases

Improving access to care, health outcomes, and patient satisfaction are primary objectives for healthcare practices. This article outlines benefits, concerns, and possible challenges of shared medical appointments (SMAs) for patients and providers. The SMA model was designed to support providers' demanding schedules by allowing patients with the same chronic condition to be seen in a group setting. By concentrating on patient education and disease management, interactive meetings provide an opportunity for patients to share both successes and struggles with others experiencing similar challenges. Studies demonstrated that SMAs improved patient access, enhanced outcomes, and promoted patient satisfaction. This article describes the potential benefits of SMAs for patients with chronic heart disease, which consumes a large number of healthcare dollars related to hospital admissions, acute exacerbations, and symptom management. Education for self-management of chronic disease can become repetitive and time consuming. The SMA model introduces a fresh and unique style of healthcare visits, allowing providers to devote more time and attention to patients and improve productivity. The SMA model provides an outstanding method for nurse practitioners to demonstrate their role as a primary care provider, by leading patients in group discussions and evaluating their current health status. Patient selection, preparation, and facilitation of an SMA are discussed to demonstrate the complementary nature of an SMA approach in a healthcare practice.

Are there enough doctors in my rural community? Perceptions of the local physician supply

PURPOSE

To assess whether people in the rural Southeast perceive that there is an adequate number of physicians in their communities, assess how these perceptions relate to county physician-to-population (PtP) ratios, and identify other factors associated with the perception that there are enough local physicians.

METHODS

Adults (n = 4,879) from 150 rural counties in eight southeastern states responded through a telephone survey. Agreement or disagreement with the statement "I feel there are enough doctors in my community" constituted the principal outcome. Weighted chi-square analysis and a generalized estimating equation (GEE) assessed the strength of association between perceptions of an adequate physician workforce and county PtP ratios, individual characteristics, attitudes about and experiences with medical care, and other county characteristics.

FINDINGS

Forty-nine percent of respondents agreed there were enough doctors in their communities, 46% did not agree, and 5% were undecided. Respondents of counties with higher PtP ratios were only somewhat more likely to agree that there were enough local doctors (Pearson's correlation coefficient = 0.09, P < .001). Multivariate analyses revealed that perceiving that there were enough local physicians was more common among men, those 65 and older, whites, and those with lower regard for physician care. Perceptions that the local physician supply was inadequate were more common for those who had longer travel distances, problems with affordability, and little confidence in their physicians. Perceptions of physician shortages were more common in counties with higher poverty rates.

CONCLUSIONS

County PtP ratios only partially account for rural perceptions that there are or are not enough local physicians. Perceptions of an adequate local physician workforce are also related to how much people value physicians' care and whether they face other barriers to care.

Perceived problems with access to medical care and depression among older Puerto Ricans, Dominicans, other Hispanics, and a comparison group of non-Hispanic Whites

The relationship between problems accessing medical care and depression is examined in a sample of older Hispanics (Puerto Rican, Dominican, and Other Hispanic) in Massachusetts and a comparison group of same-neighborhood non-Hispanic Whites. The research questions are: Do older Hispanics experience more problems with access to medical care than do older non-Hispanic Whites? What types of access problems do Hispanics encounter, and how do these relate to depression symptoms? The data come from the Massachusetts Hispanic Elders Study; descriptive and multivariate regression analysis procedures are used. Older Hispanics report more problems obtaining medical care than do older non-Hispanic Whites. Puerto Ricans report significantly more transportation problems to access medical care. For Dominicans and Puerto Ricans, being female, living alone, and lower education attainment are associated with depression. For Puerto Ricans, health problems, disability, and access problems are also significant.

Non-medical factors influencing access to renal transplantation

Considering the scarcity of available donor kidneys and the increasing number of patients with end-stage renal disease (ESRD) who would potentially benefit from renal transplantation, objective and equitable patient selection and equitable access to renal transplantation bear substantial importance. Inequalities in access to renal transplantation have been extensively documented over the last 2 decades with regard to age, gender, ethnicity, socioeconomic and psycho-social factors. In this paper we review a wide spectrum of social, patient and system-related factors along the transplantation process that may be associated with disparities, and we aim to describe the complex interrelationship between these factors that might influence treatment decisions by patients and health-care professionals. Understanding potentially modifiable barriers to kidney transplantation may allow designing targeted interventions in order to guarantee fair recipient selection and equal access to renal transplantation.

Differences in Accessibility, Affordability, and Availability (AAA) of Medical Specialists Among Three Age-Groups of Elderly People in Israel

Objectives: Older people use more health services due to health problems, but various reasons impede their ability to use health services. The purpose of this study is to examine difficulties in accessing and affording specialist services and to explore the factors that explain these difficulties among elderly people. Methods: The sample included 1,255 respondents in three age-groups: 65-75, 76-89, and 90+ years who were interviewed face-to-face in their homes. Results: The findings showed that between 21% and 41% of the respondents encountered difficulties in visiting specialists. Those aged 90+ encountered more accessibility problems and fewer affordability problems compared to their younger counterparts, and those aged 76-89 encountered more availability problems compared to the other two age-groups. Enabling and need factors were the most significant factors in explaining problems in accessing and affording specialist services. Discussion: Recommendations for policy and practice are discussed.

An Improved Approach to Followup Care for the Urological Patient: Drop-in Group Medical Appointments

PURPOSE

To increase prompt access to routine office visits the concept of the group appointment was developed in the primary care setting. Drop-in group medical appointments have been piloted at our department. We hypothesized that 1) efficiency could be improved by seeing 6 to 14 patients at 1 appointment, 2) access to appointment times would increase and 3) patient satisfaction would be enhanced with 60 minutes of didactic contact and discussion with the urologist.

MATERIALS AND METHODS

Patients were invited to participate in a drop-in group medical appointment. Appointments were made based on sex and not on diagnosis. A 60-minute group teaching session was followed by a private 2 to 5-minute physical examination or further testing, as indicated. Confidential satisfaction surveys were administered to drop-in group medical appointment participants and patients seen at traditional individual (solo) appointments. Results were compared.

RESULTS

From September 22, 2003 to August 30, 2004, 279 patients attended a drop-in group medical appointment. Mean patient age was 63 years and 142 patients were 65 years or older. Most diagnoses were prostate cancer, erectile dysfunction, benign prostatic hyperplasia, incontinence, neurogenic bladder and chronic discomfort syndromes. Of the patients 287 were surveyed, including 177 at drop-in group medical appointments and 110 at solo appointments. Patient satisfaction with the drop-in group medical appointment format was as high as that of solo patients with 87% of drop-in group medical appointment patients rating their experience as excellent or very good vs 88% by solo patients.

CONCLUSIONS

Drop-in group medical appointments can be implemented successfully in a urological practice with high patient satisfaction despite the sensitive nature of topics discussed. Ideal patients are those with chronic or complex conditions and those requiring repetitive discussions, such as elderly individuals.