Screening for Elder Abuse in the Veterans Health Administration: Varied Approaches Across a National Health System

BACKGROUND

Elder abuse (EA) is common and has devastating health consequences yet is rarely detected by healthcare professionals. While EA screening tools exist, little is known about if and how these tools are implemented in real-world clinical settings. The Veterans Health Administration (VHA) has experience screening for, and resources to respond to, other forms of interpersonal violence and may provide valuable insights into approaches for EA screening.

OBJECTIVE

Describe EA screening practices across a national integrated healthcare system serving a large population of older adults at risk for EA.

DESIGN

Survey of all 139 VHA medical centers from January to August 2021.

PARTICIPANTS

Surveys were completed by the Social Work Chief, or delegate, at each site.

MAIN MEASURES

The survey assessed the presence and characteristics of EA-specific screening practices as well as general abuse/neglect screening conducted with patients of all ages, including older adults. Follow-up emails were sent to sites that reported screening requesting additional details not included in the initial survey.

KEY RESULTS

Overall, 130 sites (94%) responded. Among respondents, 5 (4%) reported screening older adults for EA using a previously published tool, while 6 (5%) reported screening for EA with an unstudied or locally developed tool. Forty-eight percent reported screening patients of all ages for general abuse/neglect using unstudied questions/tools, and 44% reported no EA screening at their site. Characteristics of screening programs (e.g., frequency, clinical setting, provider type) varied widely between sites, as did respondents' understanding of the definition of screening.

CONCLUSIONS

High variability in screening practices for abuse/neglect and lack of EA-specific screening in a system that has successfully deployed other standardized screening approaches present an important opportunity to standardize and improve EA detection practices. Lessons learned in VHA could help advance the evidence base for EA screening more broadly to increase overall detection rates for EA nationally.

Initial steps in addressing the challenges of elder mistreatment evaluation: Protocol for evaluating the Vulnerable Elder Protection Team

INTRODUCTION

Although many programmes have been developed to address elder mistreatment, high-quality, rigorous evaluations to assess their impact are lacking. This is partly due to challenges in conducting programme evaluation for such a complex phenomenon. We describe here the development of a protocol to mitigate these challenges and rigorously evaluate a first-of-its-kind emergency department/hospital-based elder mistreatment intervention, the Vulnerable Elder Protection Team (VEPT).

METHODS AND ANALYSIS

We used a multistep process to develop an evaluation protocol for VEPT: (1) creation of a logic model to describe programme activities and relevant short-term and long-term outcomes, (2) operationalisation of these outcome measures, (3) development of a combined outcome and (4) design of a protocol using telephone follow-up at multiple time points to obtain information about older adults served by VEPT. This protocol, which is informing an ongoing evaluation of VEPT, may help researchers and health system leaders design evaluations for similar elder mistreatment programmes.

ETHICS AND DISSEMINATION

This project has been reviewed and approved by the Weill Cornell Medicine Institutional Review Board, protocol #20-02021422. We aim to disseminate our results in peer-reviewed journals at national and international conferences and among interested patient groups and the public.

Adult Protective Services Perspectives on Responding to Elder Abuse and Serving Clients During the COVID-19 Pandemic

The initial COVID-19 pandemic and subsequent public health measures dramatically impacted Adult Protective Services (APS), requiring rapid adjustments. Our goal was to describe challenges for APS and strategies developed to respond. We conducted six focus groups and seven interviews during March-April 2021 using a semi-structured topic guide, with 31 participants from APS leadership, supervisors, and caseworkers in New York City, a community hard hit by the initial COVID surge. Data from transcripts were analyzed to identify themes. Participants identified challenges faced by APS (e.g., clients less willing to engage with APS, inability to perform necessary job tasks remotely, and low staffing levels) as well as strategies APS used in response (e.g., increasing collaboration with other community-based programs and service providers, enabling remote court hearings through technology and in-person facilitation, and ensuring staff had access to personal protective equipment). These findings may inform APS planning for future large-scale societal disruptions.

Frailty predicts referral for elder abuse evaluation in a nationwide healthcare system-Results from a case-control study

BACKGROUND

Elder abuse (EA) is common and has devastating health impacts. Frailty may increase susceptibility to and consequences of EA for older adults, making healthcare system detection more likely, but this relationship has been difficult to study. We examined the association between a recently validated frailty index and referral to social work (SW) for EA evaluation in the Veterans Administration (VA) healthcare system.

METHODS

We conducted a case-control study of veterans aged ≥60 years evaluated by SW for suspected EA between 2010 and 2018 (n = 14,723) and controls receiving VA primary care services in the same 60-day window (n = 58,369). We used VA and Medicare claims data to measure frailty (VA Frailty Index) and comorbidity burden (the Elixhauser Comorbidity Index) in the 2 years prior to the index. We used adjusted logistic regression models to examine the association of frailty or comorbidity burden with referral to SW for EA evaluation. We used Akaike Information Criterion (AIC) values to evaluate model fit and likelihood ratio (LR) tests to assess the statistical significance of including frailty and comorbidity in the same model.

RESULTS

The sample (n = 73,092) had a mean age 72 years; 14% were Black, and 6% were Hispanic. More cases (67%) than controls (36%) were frail. LR tests comparing the nested models were highly significant (p < 0.001), and AIC values indicated superior model fit when including both frailty and comorbidity in the same model. In a model adjusting for comorbidity and all covariates, pre-frailty (aOR vs. robust 1.7; 95% CI 1.5-1.8) and frailty (aOR vs. robust 3.6; 95% CI 3.3-3.9) were independently associated with referral for EA evaluation.

CONCLUSIONS

A claims-based measure of frailty predicted referral to SW for EA evaluation in a national healthcare system, independent of comorbidity burden. Electronic health record measures of frailty may facilitate EA risk assessment and detection for this important but under-recognized phenomenon.

Leveraging VA geriatric emergency department accreditation to improve elder abuse detection in older Veterans using a standardized tool

Elder abuse (EA) is common and has devastating health impacts, yet most cases go undetected limiting opportunities to intervene. Older Veterans receiving care in the Veterans Health Administration (VHA) represent a high-risk population for EA. VHA emergency department (ED) visits provide a unique opportunity to identify EA, as assessment for acute injury or illness may be the only time isolated older Veterans leave their home, but most VHA EDs do not have standardized EA assessment protocols. To address this, we assembled an interdisciplinary team of VHA social workers, physicians, nurses, intermediate care technicians (ICTs; former military medics and corpsmen who often conduct screenings in VHA EDs) and both VHA and non-VHA EA subject matter experts to adapt the Elder Mistreatment Screening and Response Tool (EM-SART) to pilot in the Louis Stokes Cleveland VA Medical Center geriatric ED (GED) program. The cornerstone of their approach is an interdisciplinary GED consultation led by ICTs and nurses who screen high-risk older Veterans for geriatric syndromes and unmet needs. The adapted EM-SART was integrated into the electronic health record and GED workflow in December 2020. By July 2022, a total of 251 Veterans were screened with nine (3.6%) positive on the prescreen and five (2%) positive on the comprehensive screen. Based on the first-year pilot experience, the interdisciplinary team was expanded and convened regularly to further adapt the EM-SART for wider use in VHA, including embedding flexibility for both licensed and nonlicensed clinicians to complete the screening tool and tailoring response options to be specific to VHA policy and resources. The national momentum for VHA EDs to improve care for older Veterans and secure GED accreditation offers unique opportunities to embed this evidence-based approach to EA assessment in the largest integrated health system in the United States.

Vulnerable Elder Protection Team: Initial experience of an emergency department-based interdisciplinary elder abuse program

BACKGROUND

An emergency department (ED) visit provides a unique opportunity to identify elder abuse and initiate intervention, but emergency providers rarely do. To address this, we developed the Vulnerable Elder Protection Team (VEPT), an ED-based interdisciplinary consultation service. We describe our initial experience in the first two years after the program launch.

METHODS

We launched VEPT in a large, urban, academic ED/hospital. From 4/3/17 to 4/2/19, we tracked VEPT activations, including patient characteristics, assessment, and interventions. We compared VEPT activations to frequency of elder abuse identification in the ED before VEPT launch. We examined outcomes for patients evaluated by VEPT, including change in living situation at discharge. We assessed ED providers' experiences with VEPT via written surveys and focus groups.

RESULTS

During the program's initial two years, VEPT was activated and provided consultation/care to 200 ED patients. Cases included physical abuse (59%), neglect (56%), financial exploitation (32%), verbal/emotional/psychological abuse (25%), and sexual abuse (2%). Sixty-two percent of patients assessed were determined by VEPT to have high or moderate suspicion for elder abuse. Seventy-five percent of these patients had a change in living/housing situation or were discharged with new or additional home services, with 14% discharged to an elder abuse shelter, 39% to a different living/housing situation, and 22% with new or additional home services. ED providers reported that VEPT made them more likely to consider/assess for elder abuse and recognized the value of the expertise and guidance VEPT provided. Ninety-four percent reported believing that there is merit in establishing a VEPT Program in other EDs.

CONCLUSION

VEPT was frequently activated and many patients were discharged with changes in living situation and/or additional home services, which may improve safety. Future research is needed to examine longer-term outcomes.

Family caregivers navigating the health care system: Evolving roles during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has altered access to health care; it remains unclear how patients with chronic illness and disability and their family caregivers are adapting to these changes. In this study, we examined changes in family caregiver roles helping care recipients with chronic illness and disability navigate health care needs during the COVID-19 pandemic.

METHODS

From April 15 to May 27, 2020, we distributed online and telephone surveys to family caregiver members of a population-based regional research registry. Caregivers reported whether they were helping "more," "less," or the "same" with ten health care activities (e.g., filling prescriptions, attending medical appointments) now, compared to before the coronavirus pandemic. Using multivariable logistic regression models, we examined caregiver and caregiving context characteristics associated with helping more with 1 or more health care activities.

RESULTS

Of 561 caregiver respondents, mean age was 59 years, 76% were women, and 56% co-resided with care recipients. Many caregivers (59%) reported increased help with 1 or more health care activities since the pandemic. Caregivers reported greater help getting medical supplies (31%) and attending care recipients' phone (21%) and video (16%) medical appointments. Women (OR 1.55; 95% CI 1.02-2.36) and caregivers assisting with short-term physical conditions were more likely to help more with 1 or more health care activities (OR 2.81; 95% CI 1.20-6.59).

DISCUSSION

Family caregivers reported their responsibilities helping care recipients with chronic conditions and disabilities stay engaged with health care increased since the pandemic. Providers and health systems should consider targeted strategies to support caregivers helping vulnerable patients access necessary care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Medical and Social Factors Associated with Referral for Elder Abuse Services in a National Healthcare System

BACKGROUND

Elder abuse (EA) is common and has devastating health consequences yet is not systematically assessed or documented in most health systems, limiting efforts to target healthcare-based interventions. Our objective was to examine sociodemographic and medical characteristics associated with documented referrals for EA assessment or services in a national US healthcare system.

METHODS

We conducted a national case-control study in US Veterans Health Administration facilities of primary care (PC)-engaged Veterans age ≥60 years who were evaluated by social work (SW) for EA-related concerns between 2010-18. Cases were matched 1:5 to controls with a PC visit within 60 days of the matched case SW encounter. We examined the association of patient sociodemographic and health factors with receipt of EA services in unadjusted and adjusted models.

RESULTS

Of 5,567,664 Veterans meeting eligibility criteria during the study period, 15,752 (0.3%) received services for EA (cases). Cases were mean age 74, and 54% unmarried. In adjusted logistic regression models (aOR; 95%CI), age ≥85 (3.56 v. age 60-64; 3.24-3.91), female sex (1.96; 1.76-2.21), child as next-of-kin (1.70 v. spouse; 1.57-1.85), lower neighborhood socioeconomic status (1.18 per higher quartile; 1.15-1.21), dementia diagnosis (3.01; 2.77-3.28) and receiving a VA pension (1.34; 1.23-1.46) were associated with receiving EA services.

CONCLUSION

In the largest cohort of patients receiving EA-related healthcare services studied to date, this study identified novel factors associated with clinical suspicion of EA that can be used to inform improvements in healthcare-based EA surveillance and detection.

Diagnostic Coding of Elder Mistreatment: Results From a National Database of Medicare Advantage and Private Insurance Patients, 2011-2017

Health care providers may play an important role in detection of elder mistreatment, which is common but underrecognized. We used the Health Care Cost Institute insurance claims database to describe elder mistreatment diagnosis among Medicare Advantage (MA) and private insurance patients in the United States from 2011 to 2017. We used International Classification of Diseases (ICD) coding to identify cases, examining the impact of transition from ICD-9 (Ninth Revision) to ICD-10 (Tenth Revision), which occurred in October 2015 and added 14 new codes for "suspected" mistreatment. 8,127 patients (0.051% of all aged ≥ 65), including 6,304 with MA (0.058%) and 1,823 with private insurance (0.026%) received elder mistreatment diagnosis. Transition from ICD-9 to ICD-10 was associated with a small increase in diagnosis rate, with "suspected" codes used in 45.3% of ICD-10 versus 9.7% of ICD-9 cases. Overall rates remained low. Rates, settings, and types of diagnosis differed between MA and private insurance patients.

Association of Health Conditions and Health Service Utilization With Intimate Partner Violence Identified via Routine Screening Among Middle-Aged and Older Women

IMPORTANCE

The US Preventive Services Task Force recently determined that there is insufficient evidence to recommend routine screening for intimate partner violence (IPV) in women who are middle-aged and older. Certain Veterans Health Administration (VHA) clinics have been routinely screening women of all ages for IPV since 2014.

OBJECTIVES

To examine the proportion of women older than childbearing age (ie, ≥45 years) who have positive results when routinely screened for past-year IPV at VHA clinics and to evaluate the associations of a positive screening result with health conditions and health service utilization.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 4481 women aged 45 years and older who were screened for past-year IPV in 13 VHA outpatient clinics in 11 states between April 2014 and April 2016. Data analysis was conducted from March 2019 to August 2019.

EXPOSURE

Positive screening result for past-year IPV.

MAIN OUTCOMES AND MEASURES

Mental and physical health conditions (identified using International Classification of Diseases, Ninth Edition [ICD-9] and ICD-10 codes from VHA medical record data) and VHA health services utilization (identified using inpatient and outpatient VHA encounter data) in the 20 months after screening.

RESULTS

In this study, 2937 of 4481 women (65.5%) were middle-aged (ie, aged 45 to 59 years), and 1544 (34.5%) were older (ie, aged ≥60 years), with 1955 (43.6%) black participants. A total of 255 middle-aged women (8.7%; mean [SD] age, 51 [4] years) and 79 older women (5.1%; mean [SD] age, 64 [5] years) screened positive for past-year IPV. In adjusted logistic regression models among middle-aged women, screening positive for IPV was associated with subsequent diagnoses of anxiety (adjusted odds ratio [aOR], 2.00; 95% CI, 1.50-2.70; P < .001), depression (aOR, 2.30; 95% CI, 1.80-3.00; P < .001), posttraumatic stress disorder (aOR, 2.30; 95% CI, 1.80-3.00; P < .001), suicidal ideation and/or behavior (aOR, 3.80; 95% CI, 2.10-6.90; P < .001), and substance use disorder (aOR, 2.50; 95% CI, 1.80-3.50; P < .001). Similar but attenuated associations were seen for older women (eg, substance use disorder: aOR, 2.20; 95% CI, 1.10-4.40; P = .04). In adjusted negative binomial regression models among middle-aged women, screening positive for IPV was associated with a higher rate of subsequent psychosocial (eg, mental health) visits (adjusted rate ratio [aRR], 2.40; 95% CI, 2.00-2.90; P < .001), primary care visits (aRR, 1.20; 95% CI, 1.10-1.30; P < .001), and emergency department visits (aRR, 1.50; 95% CI 1.20-1.80; P < .001). Older women screening positive for IPV had a higher rate of psychosocial visits (aRR, 1.90; 95% CI, 1.30-2.70; P < .001) but not of other visit types.

CONCLUSIONS AND RELEVANCE

To our knowledge, this study was the largest to evaluate routine screening for IPV among women aged 45 years and older, and it found that IPV remained prevalent and was associated with morbidity for these women. Screening for IPV in women older than 44 years may improve detection and provision of evidence-based services to this growing population.

Violence In Older Adults: Scope, Impact, Challenges, And Strategies For Prevention

Although often perceived to be a problem of the young, violence commonly affects older adults, a rapidly growing segment of the population. Violence can be directed toward older adults (elder abuse and intimate partner violence), self-directed (suicide), or perpetrated by older adults against others (intimate partner violence and violence in dementia). Across forms of violence, firearm access increases lethality, and veterans may be a particularly high-risk population. The forms of violence in older adults have some common risk factors (such as medical or psychiatric illness) and common challenges for prevention (such as balancing autonomy and well-being in vulnerable adults). The integration of prevention strategies across the life span, disciplines, and forms of violence offers promise for promoting older adult health and well-being. Looking forward, key areas for attention will include raising awareness about these topics and prioritizing funding for the implementation and evaluation of violence prevention interventions in health care settings and the community.

Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients

Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.

Late Transitions and Bereaved Family Member Perceptions of Quality of End-of-Life Care

OBJECTIVES

To examine associations between healthcare transitions at the end of life (EOL; late transitions) and bereaved family members' and friends' assessment of EOL quality of care (QOC).

DESIGN

National Health and Aging Trends Study (NHATS), a prospective cohort of Medicare enrollees aged 65 and older.

SETTING

United States, all sites of death.

PARTICIPANTS

Family members and close friends of decedents from NHATS Rounds 2 through 6 (N=1,653; weighted 6.0 million Medicare deaths).

MEASUREMENTS

Multivariable logistic regression with survey weights was used to examine the association between having a late transition and reports of perceived unmet needs for symptom management, spiritual support, concerns with communication, and overall QOC.

RESULTS

Seventeen percent of decedents had a late transition. Bereaved respondents for decedents experiencing late transitions were more likely to report that the decedent was treated without respect (21.3% vs 15.6%; adjusted odds ratio (AOR)=1.59, 95% confidence interval (CI)=1.09-2.33), had more unmet needs for spiritual support (67.4% v 55.2%; AOR=1.48, 95% CI=1.03-2.13), and were more likely to report they were not kept informed about the person's condition (31.0% vs 20.9%; AOR=1.54, 95% CI=1.07-2.23). Bereaved respondents were less likely to rate QOC as excellent when there was a late transition (43.6% vs 48.2%; AOR=0.79, 95% CI=0.58-1.06). Subgroup analyses of those experiencing a transition between a nursing home and hospital (13% of all late transitions) revealed such transitions to be associated with even worse QOC.

CONCLUSION

Transitions in the last 3 days of life are associated with more unmet needs, higher rate of concerns, and lower rating of QOC than when such late transitions are absent, especially when that transition is between a nursing home and hospital.

Specialty Care Access in the Safety Net-the Role of Public Hospitals and Health Systems

Access to specialty care in the United States safety net, already strained, is fac-ing increasing pressure with an influx of patients following the passage of the Affordable Care Act (ACA). We surveyed 18 public hospitals and health systems across the country to describe the current state of specialty care delivery in safety-net systems. We elicited information regarding challenges, provider models, metrics of access and productivity, and strategies for improving access. Based on our findings, we propose a framework for assessing and improving specialty care access with a focus on population health planning.

Veterans Experiencing Elder Abuse: Improving Care of a High-Risk Population About Which Little Is Known

At least 10% of older adults experience abuse, neglect, or exploitation annually in the United States, and this problem is expected to grow as our population ages. Little is known about the prevalence and characteristics of elder abuse of veterans, but it is likely that this population is at high risk based on established elder abuse risk factors. Veterans who receive their care through the Veterans Health Administration (VHA) have a higher prevalence of poor psychological health, poor physical health, functional impairment, cognitive impairment, and social isolation than the general population. As the largest integrated healthcare system in the United States, the VHA has long been a leader in the development of innovative, integrated care programs for older adults. The VHA has another opportunity to lead by promoting research, clinical care, and education on elder abuse, furthering their mission of serving those who served. This article outlines the rationale for developing a research agenda for elder abuse in the VHA, as well as potential first steps toward understanding more about this complex problem affecting veterans.

Wealth-Associated Disparities in Death and Disability in the United States and England

Importance

Low income has been associated with poor health outcomes. Owing to retirement, wealth may be a better marker of financial resources among older adults.

Objective

To determine the association of wealth with mortality and disability among older adults in the United States and England.

Design, Setting, and Participants

The US Health and Retirement Study (HRS) and English Longitudinal Study of Aging (ELSA) are nationally representative cohorts of community-dwelling older adults. We examined 12 173 participants enrolled in HRS and 7599 enrolled in ELSA in 2002. Analyses were stratified by age (54-64 years vs 66-76 years) because many safety-net programs commence around age 65 years. Participants were followed until 2012 for mortality and disability.

Exposures

Wealth quintile, based on total net worth in 2002.

Main Outcomes and Measures

Mortality and disability, defined as difficulty performing an activity of daily living.

Results

A total of 6233 US respondents and 4325 English respondents aged 54 to 64 years (younger cohort) and 5940 US respondents and 3274 English respondents aged 66 to 76 years (older cohort) were analyzed for the mortality outcome. Slightly over half of respondents were women (HRS: 6570, 54%; ELSA: 3974, 52%). A higher proportion of respondents from HRS were nonwhite compared with ELSA in both the younger (14% vs 3%) and the older (13% vs 3%) age cohorts. We found increased risk of death and disability as wealth decreased. In the United States, participants aged 54 to 64 years in the lowest wealth quintile (Q1) (≤$39 000) had a 17% mortality risk and 48% disability risk over 10 years, whereas in the highest wealth quintile (Q5) (>$560 000) participants had a 5% mortality risk and 15% disability risk (mortality hazard ratio [HR], 3.3; 95% CI, 2.0-5.6; P < .001; disability subhazard ratio [sHR], 4.0; 95% CI, 2.9-5.6; P < .001). In England, participants aged 54 to 64 years in Q1 (≤£34,000) had a 16% mortality risk and 42% disability risk over 10 years, whereas Q5 participants (>£310,550) had a 4% mortality risk and 17% disability risk (mortality HR, 4.4; 95% CI, 2.7-7.0; P < .001; disability sHR, 3.0; 95% CI, 2.1-4.2; P < .001). In 66- to 76-year-old participants, the absolute risks of mortality and disability were higher, but risk gradients across wealth quintiles were similar. When adjusted for sex, age, race, income, and education, HR for mortality and sHR for disability were attenuated but remained statistically significant.

Conclusions and Relevance

Low wealth was associated with death and disability in both the United States and England. This relationship was apparent from age 54 years and continued into later life. Access to health care may not attenuate wealth-associated disparities in older adults.

Older adults rate their mental health better than their general health

Background.

Self-rated health (SRH) shows strong associations with measures of health and well-being. Increasingly, studies have used self-rated mental health (SRMH) as a predictor of various outcomes, independently or together with SRH. Research has not firmly established if and how these two constructs differ. We sought to characterize the relationship between SRH and SRMH, and to determine how this relationship differed across subgroups defined by sociodemographic and health-related characteristics.

Design and methods.

We analyzed data from the 2012 CAHPS Medicare Advantage Survey. SRH and SRMH ratings were crosstabulated to determine the distribution of responses across response categories. The expected joint probability distribution was computed and compared to the observed distribution. A constructed variable indicated whether SRMH was better, the same, or worse than SRH. We analyzed the distribution of this variable across various subgroups defined by sociodemographic and health-related factors.

Results.

A total of 114,905 Medicare Advantage beneficiaries responded to both the SRH and SRMH questions. Both in general and within all subgroups, SRMH was usually rated as better than SRH, and rarely as worse.

Conclusions.

Within a large group of Medicare recipients, the overwhelming trend was for recipients to rate their mental health as at least as good as their overall health, regardless of any sociodemographic and health-related factors. This finding of a shifted distribution encourages caution in the analytic use of selfrated mental health, particularly the use of both SRH and SRMH for adjustment. Additional research is needed to help clarify the complex relationship between these variables.