[Hannover-Polytrauma-Longterm-Study HPLS]

From the period of September 2000 to March 2006 Hannover Reinsurance and the Department of Traumatology of the Hanover Medical School conducted a retrospective observational study of the long-term outcome of patients after polytrauma. The follow-up period was on average 17 +/- 5 years. The goal of the study was to determine the social, financial, medical and psychological long-term outcome after a severe accident. Of the 1560 enrolled patients 519 patients died in the observed period, 397 patients were followed up but could not be examined, 637 patients (female n = 158, male n = 479) were examined and answered detailed questionnaires concerning their social, financial medical and psychological situation. 6 patients did not fullfil the input criteria and one patient had two polytraumata. The average age at the time of accident was 26.5 years (+/- 12.3).

RESULTS

Financial losses were observed in 41.1% of all males and 44.4% of females. 21.7% of all male (female 18.4%) had no financial protection at all. Due to the accident 30.1% of all men were unemployed and 19.8% permanently disabled (women 27.4% and 27.6% respectively). Psychological treatment almost doubled after discharge from rehabilitation centres. Even 20 years after the accident extra-mortality was substantially increased by 79%.

CONCLUSION

Ten to twenty years after polytrauma significant financial, social and medical impairments are still present.

[Incapacity for work and disability pensions in persons with mental disorders]

The number of people suffering from mental disorders and receiving disability pensions is still increasing in Europe. Young persons in their working-age are receiving disability pensions more and more often. Among those who are incapable to work (due to both mental and somatic disorders), persons on benefits due to mental disorders are usually younger. The number of disability pensions depends on the sort of mental disorder. Persons suffering from affective and anxiety disorders are the most common group receiving benefits. An increase in the number of disability payments among people with several mental disorders or both, mental and somatic diseases is observed. Furthermore, research data shows Poland as the country with high costs relevant disability payments. Disability pensions assignment for persons suffering from mental disorders, as well as incapacity for work, is discussed in this article. The reason for a still increasing number of disability payments is explained, the characteristics of persons applying for disability pensions is introduced and the mental impaired persons' incapacity for work is described.

Substance abuse treatment and criminal justice involvement for SSI recipients: results from Washington state

This study examined the association between receiving substance abuse treatment and subsequent criminal justice involvement. The sample consisted of Supplemental Security Income (SSI) recipients in the state of Washington that were determined to be in need of treatment. Fifty-two percent of those clients entered substance abuse treatment during the study period, while 48% did not. Arrests, felony convictions and convictions for less serious crimes were tracked for 8343 adults for one year following the end of an index treatment episode. Results showed that entering treatment was associated with reduced risks for each outcome. In addition, further analyses were conducted just on those entering treatment. Among that subset of the study population, the completion of treatment and having an episode of treatment lasting at least 90 days were both associated with reduced criminal justice risks. These results suggest that efforts to provide substance abuse treatment for SSI recipients have the potential to provide substantial public benefits.

Health insurance and access to care among Social Security Disability Insurance beneficiaries during the Medicare waiting period

For most Social Security Disability Insurance (SSDI) beneficiaries, Medicare entitlement begins 24 months after the date of SSDI entitlement. Many may experience poor access to health care during the 24-month waiting period because of a lack of insurance. National Health Interview Survey data for the period 1994-1996 were linked to Social Security and Medicare administrative records to examine health insurance status and access to care during the Medicare waiting period. Twenty-six percent of SSDI beneficiaries reported having no health insurance, with the uninsured reporting many more problems with access to care than insured individuals. Access to health insurance is especially important for people during the waiting period because of their low incomes, poor health, and weak ties to the workforce.

Allocation of rehabilitation measures provided by the Social Insurance Institution in Finland: a register linkage study

OBJECTIVE

To study the allocation of rehabilitation measures provided by the Finnish Social Insurance Institution in relation to the characteristics and health status of rehabilitants.

DESIGN

A register linkage study.

SUBJECTS

A total of 67,106 full-time local government employees with a minimum of 10-month job contracts in 10 Finnish towns during the period 1994-2002.

METHODS

Data on the rehabilitation granted between 1994 and 2002, special medication reimbursements for chronic diseases, and disability retirement, were derived from the registers of the Social Insurance Institution as an indicator of chronic morbidity and linked to the employers' records on demographic characteristics and rates of sickness absence.

RESULTS

In comparison with non-rehabilitants, the rate of sickness absence (> 21 days) was 2.2-2.9-fold (95% confidence interval (CI) 2.0-3.0) higher, the odds ratios of special medication reimbursement 1.5-6.1-fold (95% CI 1.3-6.9) higher and disability retirement 3.1-7.5-fold (95% CI 2.7-9.3) higher among rehabilitants. Older women and employees in manual or lower-grade non-manual jobs predominated in the rehabilitation groups. The proportion of temporary employees receiving rehabilitation was low.

CONCLUSION

Permanently employed older women with an excess burden of health problems predominate in the receipt of rehabilitation provided by the Social Insurance Institution.

Trends in mortality differentials and life expectancy for male social security-covered workers, by socioeconomic status

This article presents an analysis of trends in mortality differentials and life expectancy by average relative earnings for male Social Security-covered workers aged 60 or older. Because average relative earnings are measured at the peak of the earnings distribution (ages 45-55), it is assumed that they act as a rough proxy for socioeconomic status. The historical literature reviewed in this analysis generally indicates that mortality differentials by socioeconomic status have not been constant over time. For this study, time trends are examined by observing how mortality differentials by average relative earnings have been changing over 29 years of successive birth cohorts that encompass roughly the first third of the 20th century. Deaths for these birth cohorts are observed at ages 60-89 from 1972 through 2001, encompassing roughly the last third of the 20th century. The large size and long span of death observations allow for disaggregation by age and year-of-birth groups in the estimation of mortality differentials by socioeconomic status. This study finds a difference in both the level and the rate of change in mortality improvement over time by socioeconomic status for male Social Security-covered workers. Average relative earnings (measured as the relative average positive earnings of an individual between ages 45 and 55) are used as a proxy for adult socioeconomic status. In general, for birth cohorts spanning the years 1912-1941 (or deaths spanning the years 1972-2001 at ages 60-89), the top half of the average relative earnings distribution has experienced faster mortality improvement than has the bottom half. Specifically, male Social Security-covered workers born in 1941 who had average relative earnings in the top half of the earnings distribution and who lived to age 60 would be expected to live 5.8 more years than their counterparts in the bottom half. In contrast, among male Social Security-covered workers born in 1912 who survived to age 60, those in the top half of the earnings distribution would be expected to live only 1.2 years more than those in the bottom half. The life expectancy estimates in this article represent one possible outcome under one set of assumptions. These projections should not be regarded as an accurate depiction of the future. Specifically, this study adopts a simple projection method in which differentials are assumed to follow the pattern observed over the last 30 years of the 20th century for the first 30 years of the 21st century. This assumption lacks theoretical underpinnings because the causes of the widening differentials observed over the past 30 years have not been determined. On the one hand, if the trend of widening mortality differentials by year of birth observed over the past 30 years does not continue, the projection method used in this analysis could lead to an overestimation of future differences in life expectancy between socioeconomic groups. On the other hand, if mortality differentials do not narrow by age as observed in the past, the projection method used could lead to an underestimation of the differences in life expectancy between socioeconomic groups aged 60 or older.

Benefit adequacy among elderly Social Security retired-worker beneficiaries and the SSI federal benefit rate

Both target effectiveness and administrative simplicity are desirable properties in the design of minimum benefit packages for public retirement programs. The federal benefit rate (FBR) of the Supplemental Security Income (SSI) program has been proposed by some analysts as a potentially attractive basis of establishing a new minimum benefit for Social Security on both of these grounds. This type of proposal is related to a broader array of minimum benefit proposals that would establish a Social Security benefit floor based on the poverty rate. In contrast to Social Security, the SSI program is means tested, including both an income and asset screen and also a categorical eligibility screen (the requirement to qualify as aged or disabled). The SSI FBR provides an inflation-adjusted, guaranteed income floor for aged and disabled people with low assets. The FBR has been perceived by proponents as a minimal measure of Social Security benefit adequacy because it represents a subpoverty income level for a family of one or two depending on marital status. For this same reason it has been seen as a target-effective tool of designing a minimum Social Security benefit. An FBR-based minimum benefit has also been viewed as administratively simple to implement; the benefit can be calculated from Social Security administrative records using a completely automated electronic process. Therefore-in contrast to the SSI program itself-an FBR-based minimum benefit would incur virtually no ongoing administrative costs, would not require a separate application for a means-tested program, and would avoid the perception of welfare stigma. While these ideas have been discussed in the literature and among policymakers in the United States over the years, and similar proposals have been considered or implemented in several foreign countries, there have been no previous analyses measuring the size of the potentially affected beneficiary population. Nor has there been any systematic assessment of the FBR as a measure of benefit adequacy or the tradeoffs between potential target effectiveness and administrative simplicity. Based on a series of simulations, we assess the FBR as a potential foundation for minimum Social Security benefits and we examine the tradeoffs between administrative simplicity and target effectiveness using microdata from the 1996 panel of the Survey of Income and Program Participation (SIPP). Our empirical analysis is limited to Social Security retired-worker beneficiaries aged 65 or older. We start with the assessment of the FBR as a measure of benefit adequacy. We are particularly concerned about two types of error: (1) incorrectly identifying some Social Security beneficiaries as "economically vulnerable," and (2) incorrectly identifying others as "not economically vulnerable." Operationally we measure economic vulnerability by two alternative standards. One of our measures considers beneficiaries with family income below the official poverty threshold as vulnerable. Our second measure is more restrictive; it uses a family income threshold equal to 75 percent of the official poverty threshold. We find that a substantial minority of retired workers have Social Security benefits below the FBR. The results also show that the FBR-based measure of Social Security benefit adequacy is very imprecise in terms of identifying economically vulnerable people. We estimate that the vast majority of beneficiaries with Social Security benefits below the FBR are not economically vulnerable. Conversely, an FBR-level Social Security benefit threshold fails to identify some beneficiaries who are economically vulnerable. Thus an FBR-level minimum benefit would be poorly targeted in terms of both types of errors we are concerned about. An FBR-level minimum benefit would provide minimum Social Security benefits to many people who are clearly not poor. Conversely, an FBR-level minimum benefit would not provide any income relief to some who are poor. The administrative simplicity behind these screening errors also results in additional program cost that may be perceived as substantial. We estimate that an FBR-level minimum benefit would increase aggregate program cost for retired workers aged 65 or older by roughly 2 percent. There are two fundamental reasons for these findings. First, the concept of an FBR-level minimum benefit looks at the individual or married couple in artificial isolation; however, the family is the main consumption unit in our society. The income of an unmarried partner or family members other than a married spouse is ignored. Second, individuals and couples may also have income from sources other than Social Security or SSI, which is also ignored by a simple FBR-based minimum benefit concept. The substantial empirical magnitude of measurement error arising from these conceptual simplifications naturally leads to the assessment of the tradeoff between target effectiveness and administrative simplicity. To facilitate this analysis, we simulate the potential effect of alternative screening methods designed to increase target effectiveness; while reducing program cost, such alternatives also may increase administrative complexity. For example, considering the combined Social Security benefit of a married couple (rather than looking at the husband and wife in isolation) might substantially increase target effectiveness with a relatively small increase in administrative complexity. Adding a family income screen might increase administrative complexity to a greater degree, but also would increase target effectiveness dramatically. The results also suggest that at some point adding new screens-such as a comprehensive asset test-may drastically increase administrative complexity with diminishing returns in terms of increased target effectiveness and reduced program cost. Whether a broad-based minimum benefit concept that is not tied to previous work experience is perceived by policymakers as desirable or not may depend on several factors not addressed in this article. However, to the extent that this type of minimum benefit design is regarded as potentially desirable, the tradeoffs between administrative simplicity and target effectiveness need to be considered.

Life, health, and disability insurance: understanding the relationships

Communitarian values are stronger in health insurance than in life or disability insurance. This correlates with increased tolerance for insurers' use of genetic information in disability insurance underwriting, which, in turn, is relevant to the scope and content of proposals to regulate such use.

Social Security cost-of-living adjustments and the Consumer Price Index

OASDI benefits are indexed for inflation to protect beneficiaries from the loss of purchasing power implied by inflation. In the absence of such indexing, the purchasing power of Social Security benefits would be eroded as rising prices raise the cost of living. By statute, cost-of-living adjustments (COLAs) for Social Security benefits are calculated using the Bureau of Labor Statistics (BLS) Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W). Some argue that this index does not accurately reflect the inflation experienced by the elderly population and should be changed to an elderly-specific price index such as the Experimental Consumer Price Index for Americans 62 Years of Age and Older, often referred to as the Consumer Price Index for the Elderly (CPI-E). Others argue that the measure of inflation underlying the COLA is technically biased, causing it to overestimate changes in the cost of living. This argument implies that current COLAs tend to increase, rather than merely maintain, the purchasing power of benefits over time. Potential bias in the CPI as a cost-of-living index arises from a number of sources, including incomplete accounting for the ability of consumers to substitute goods or change purchasing outlets in response to relative price changes. The BLS has constructed a new index called the Chained Consumer Price Index for All Urban Consumers (C-CPI-U) that better accounts for those consumer adjustments. Price indexes are not true cost-of-living indexes, but approximations of cost-of-living indexes (COLI). The Bureau of Labor Statistics (2006a) explains the difference between the two: As it pertains to the CPI, the COLI for the current month is based on the answer to the following question: "What is the cost, at this month ' market prices, of achieving the standard of living actually attained in the base period?" This cost is a hypothetical expenditure-the lowest expenditure level necessary at this month's prices to achieve the base-period's living standard.... Unfortunately, because the cost of achieving a living standard cannot be observed directly, in operational terms, a COLI can only be approximated. Although the CPI cannot be said to equal a cost-of-living index, the concept of the COLI provides the CPI's measurement objective and the standard by which we define any bias in the CPI. While all versions of the CPI only approximate the actual changes in the cost of living, the CPI-E has several additional technical limitations. First, the CPI-E may better account for the goods and services typically purchased by the elderly, but the expenditure weights for the elderly are the only difference between the CPI-E and CPI-W. These weights are based on a much smaller sample than the other two indices, making it less precise. Second, the CPI-E does not account for differences in retail outlets frequented by the aged population or the prices they pay. Finally, the purchasing population measured in the CPI-E is not necessarily identical to the Social Security beneficiary population, where more than one-fifth of OASDI beneficiaries are under age 62. Likewise, over one-fifth of persons aged 62 or older are not beneficiaries, but they are included in the CPI-E population. Finally, changes in the index used to calculate COLAs directly affect the amount of benefits paid, and as a result, projected solvency of the Social Security program. A switch to the CPI-E for the December 2006 COLA (received in January 2007) would have resulted in an average monthly benefit $0.90 higher than that received. If the December 2006 COLA had been adjusted by the Chained CPI-U instead, the average monthly benefit would have been $4.70 less than with current indexing. Any changes to the COLA that would cause faster growth in individual benefits would make the projected date of insolvency sooner, while slower growth would delay insolvency. Hobijn and Lagakos (2003) estimated that switching to the CPI-E for COLAs would move projected insolvency sooner by 3-5 years. A projection by SSA's Office of the Chief Actuary estimated that annual COLAs based on the Chained C-CPI-U beginning in 2006 would delay the date of OASDI insolvency by 4 years.

Hispanics, Social Security, and Supplemental Security Income

The U.S. Census Bureau reports that Hispanics are the country's largest and fastest growing minority, representing about 14.4 percent of the population in 2005 (Census Bureau 2006b). By 2050, Hispanics will account for an estimated 24.4 percent of the population--or 1 in every 4 persons in the United States (Census Bureau 2004, Table 1 a). The Hispanic population tends to be younger than the overall population and currently represents a relatively small but growing fraction of the Social Security beneficiary population. The representation of Hispanics in the Supplemental Security Income (SSI) program, however, approximates that of their representation in the overall population. This article compares the Hispanic population with the overall population along several dimensions, with a particular focus on the Social Security beneficiary and SSI recipient populations. Data are drawn mainly from the 2005 Public Use Microdata Sample of the American Community Survey (ACS PUMS), a relatively new data source with a rich set of economic and demographic variables. Fully implemented nationwide for the first time in 2005, the ACS became the largest household survey in the United States with a sample of almost 3 million addresses. The analysis using the ACS finds that the Hispanic population is significantly different from the general population, particularly in the areas of age distribution, educational attainment, and economic well-being. Compared with the general population, the Hispanic segment is younger and is characterized by lower levels of educational attainment and a higher rate of poverty. The Hispanic Social Security beneficiary population also differs significantly from the general beneficiary population in the same areas. In contrast, the Hispanic and general SSI populations are more comparable with regard to age and economic status and differ significantly only with regard to education.

[Prevalence of disability in Iceland in December 2005]

OBJECTIVE

To determine the size and main medical and social characteristics of the group of individuals receiving disability benefits in Iceland in December 2005.

MATERIAL AND METHODS

The study includes all those receiving disability benefits in Iceland on December 1st 2005 as ascertained by the disability register at the State Social Security Institute of Iceland classified by gender, age and place of residence. Similar information was obtained on the Icelandic population. The prevalence of disability pension was calculated.

RESULTS

On December 1st 2005 the prevalence of disability pension was 8.6% for females (8.0% for the higher and 0.6% for the lower pension level) and 5.5% for males (5.2% for the higher and 0.3% for the lower pension level). For females the prevalence of disability was lower in the capital region than in other regions, but this was not the case for males. The prevalence of disability increased with age. On the whole disability was more common among females than males. Mental and behavioural disorders and diseases of the musculoskeletal system and connective tissue were the most prevalent causes of disability.

CONCLUSION

The prevailing trend over the last decade of increasing disability in Iceland has continued. Iceland appears to lag behind the other Nordic countries in the use of vocational rehabilitation and labour marked activation to prevent disability. Ample opportunities to slow down this trend are therefore available by greater emphasis on such measures.

Ascertainment of Hispanic ethnicity on California death certificates: implications for the explanation of the Hispanic mortality advantage

OBJECTIVES

We determined the size and correlates of underascertainment of Hispanic ethnicity on California death certificates.

METHODS

We used 1999 to 2000 vital registration data. We compared Hispanic ethnicity reported on the death certificate to Hispanic ethnicity derived from birthplace for the foreign-born and an algorithm that used first and last name and percentage of Hispanics in the county of residence for the US-born. We validated death certificate nativity by comparing data with that in linked Social Security Administration records.

RESULTS

Ethnicity and birthplace information was concordant for foreign-born Hispanics, who have mortality rates that are 25% to 30% lower than those of non-Hispanic Whites. Death certificates likely underascertain deaths of US-born Hispanics, particularly at older ages, for persons with more education, and in census tracts with lower percentages of Hispanics. Conservative correction for under-ascertainment eliminates the Hispanic mortality advantage for US-born men.

CONCLUSIONS

Hispanic ethnicity is accurately ascertained on the California death certificate for immigrants. Immigrant Hispanics have lower age-adjusted mortality rates than do non-Hispanic Whites. For US-born Hispanics, the mortality advantage compared with non-Hispanic Whites is smaller and may be explained by underreporting of Hispanic ethnicity on the death certificate.

Acidentes de trabalho: custos previdenciários e dias de trabalho perdidos

OBJETIVO: Estimar a contribuição de benefícios concedidos por acidentes de trabalho dentre o total de benefícios relacionados com a saúde da Previdência Social, focalizando os custos conforme o tipo de benefício, e o impacto sobre a produtividade relativa a dias perdidos de trabalho. MÉTODOS: Utilizam-se registros dos despachos de benefícios do Sistema Único de Benefícios do Instituto Nacional de Seguridade Social da Bahia, em 2000. Acidentes de trabalho foram definidos com o diagnóstico clínico para Causas Externas, Lesões e Envenenamentos (SS-00 a T99) da Classificação Internacional de Doenças 10ª Revisão, e o tipo de benefício que distingue problemas de saúde ocupacionais e não ocupacionais. RESULTADOS: Foram estudados 31.096 benefícios concedidos por doenças ou agravos à saúde, dos quais 2.857 (7,3%) eram devidos a acidentes de trabalho. Maiores proporções foram estimadas entre os trabalhadores da indústria da transformação e construção/eletricidade/gás, 18% do total dos benefícios. Os custos com os benefícios para acidentes de trabalho foram estimados em R$8,5 milhões, com aproximadamente meio milhão de dias perdidos de trabalho no ano. CONCLUSÕES: Apesar do conhecimento de que esses dados são sub-enumerados, e restritos aos trabalhadores que conseguiram receber benefícios relacionados com a saúde, os achados revelam o grande impacto sobre a produtividade e o orçamento do Instituto Nacional de Previdência Social de agravos reconhecidos como evitáveis, reforçando a necessidade de sua prevenção.

Qualitative evaluation of a form for standardized information exchange between orthopedic surgeons and occupational physicians

Background

Both occupational physicians and orthopedic surgeons can be involved in the management of work relevant musculoskeletal disorders. These physicians hardly communicate with each other and this might lead to different advices to the patient. Therefore, we evaluated a standardized information exchange form for the exchange of relevant information between the orthopedic surgeon and the occupational physician. The main goals of this qualitative study are to evaluate whether the form improved information exchange, whether the form gave relevant information, and to generate ideas to further improve this information exchange.

Methods

The information exchange form was developed in two consensus meetings with five orthopedic surgeons and five occupational physicians. To evaluate the information exchange form, a qualitative evaluation was set up. Structured telephone interviews were undertaken with the patients, interviews with the physicians were face-to-face and semi-structured, based on a topic list. These interviews were recorded and literally transcribed. Each interview was analyzed separately in Atlas-Ti.

Results

The form was used for 8 patients, 7 patients agreed to participate in the qualitative evaluation. All three orthopedic surgeons involved and three of the six involved occupational physicians agreed to be interviewed. The form was transferred to 4 occupational physicians, the other 3 patients recovered before they visited the occupational physician. The information on the form was regarded to be useful. All orthopedic surgeons agreed that the occupational physician should take the initiative. Most physicians felt that the form should not be filled out for each patient visiting an orthopedic surgeon, but only for those patients who do not recover as expected. Orthopedic surgeons suggested that a copy of the medical information provided to the general practitioner could also be provided to occupational physicians.

Conclusion

The information exchange form was regarded to be useful and could be used in practice. The occupational physician should take the initiative for using this form and most physicians felt the information should only be exchanged for patients who do not recover as expected. That means that the advantage of giving information early in the treatment is lost.

The relations between psychosocial factors at work and health status among workers in home care organizations

A considerable proportion of sickness absence and disability pension is caused by subjective health complaints, especially low back pain (LBP). In recent years focus has been on psychosocial characteristics of work as potential risk factors. The aim of this study is to examine the relations between psychosocial work aspects and subjective health complaints, LBP, and need for recovery. A total of 779 employees working in home care participated in a cross-sectional study. Higher psychological demands were associated with subjective health complaints and need for recovery. However, decision authority, skill discretion, and the 2 aspects of social support did not seem to be important factors. Higher psychological demands do not seem to be associated with severity of LBP, but does show an association with sick leave.

[Prescription and drug expenditure in gynecology and obstetrics in Northwest medical units from IMSS]

BACKGROUND

Drug prescription is the most frequent medical intervention in Gynecology and Obstetrics; however, studies of prescription profile are limited. In this study, we analyzed differences of expense by drug prescription for gynecologic and obstetrics health problems.

PATIENTS AND METHOD

It was performed a cross sectional study for one year analysis in each medical area that shape IMSS western district. We calculated spending and consumption coefficients for each drug and therapeutic groups. User coefficients were ordered to compare consumption differences. Besides the statistical ratio of consumption between drugs groups, we described the differences found and analyzed the prescription profile among medical regions.

RESULTS

Data related to the expenses in each one of the regions show important differences in each one of the drugs and therapeutic groups. The most common expense for drugs is related to the treatment of osteoporosis, menopause and fertility problems. We also found differences in prescription drug preferences in each therapeutic subgroup.

DISCUSSION

Drug prescription studies are useful as a basis for further specific studies in each pharmacologic subgroup. There are few studies that analyze the drug prescription profile on Gynecology and Obstetrics. In this study it is possible to suppose that medical prescription was not based on known medical evidences; therefore, we must reconsider the need of a permanent actualization and systematic medical evaluation.

A population-based cohort study of the effect of common mental disorders on disability pension awards

OBJECTIVE

Mental illness is consistently underrecognized in general health care, which may lead to underestimation of its effects on awards for social security payments. The authors investigated empirically the contribution of psychiatric morbidity to the award of disability pensions, in particular those awarded for physical diagnoses.

METHOD

Using a historical cohort design, the authors utilized a unique link between a large epidemiological cohort study and a comprehensive national database. Baseline information on mental and physical health was gathered from a 1995-1997 population-based health study of those of working age (20-66 years) in Nord-Trøndelag County, Norway, who were not recipients of disability pension (N=45,782). The outcome assessed was the awarding of disability pensions ascribed to specific ICD-10 diagnoses within 6 to 30 months as registered in the National Insurance Administration.

RESULTS

Anxiety and depression were robust predictors of disability pension awards in general, even when disability pensions awarded for any mental disorder were excluded. These effects were only partly explained by baseline somatic symptoms and diagnoses and were stronger in individuals aged 20-44 than in those aged 45-66. Somatic symptoms accounted for far more disability pension awards than did somatic diagnoses.

CONCLUSIONS

The cost of common mental disorders in terms of disability pensions and lost productivity may have been considerably underestimated by official statistics, particularly for younger claimants. The results suggest this might be due both to overuse of physical diagnoses and underrecognition of common mental disorders in primary care.

Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service

We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.

Should uptake of state benefits be used as indicators of need and disadvantage?

Government requires indicators of disadvantage to guide programmes and allocate resources to those areas which are most in need. Proxy measures of relative disadvantage are often utilised for this task in the absence of ideal indicators of need. The recent availability of government administrative datasets, such as social security benefit uptake levels, are increasingly being used throughout the UK and have been hailed as a significant advance on previous measures of need. However, their suitability presupposes that the association between those in need of benefit and those actually in receipt of benefit is not confounded by non-needs-related factors. In the present study, the authors examine area-level factors associated with uptake of one health-related benefit and show that, while closely correlated with health status, it is also associated with factors which might be related to the propensity and ability to make a successful claim, as well as local adjudication practices. They conclude that, while the use of these government datasets has increased our ability to target resources, researchers and policy makers should be aware of these additional influences.

[Applicability, duration, and sociomedical course of rehabilitation of alcohol dependency. Current results and perspectives from the insurers' point of view]

Reducing the paucity of German studies on the rehabilitation of alcohol-dependent patients, this article presents current data of Germany's national Pension Insurance Federal Institution. Numbers of applications, grants and use of rehabilitation, length and duration of treatment, percentage of nonattendance, comorbidity, and sociomedical course after 2 years are discussed. There has been a constant increase in numbers of rehabilitative treatment, especially in the outpatient setting with decreased treatment length, a high rate of comorbidity, and improvements in the sociomedical course and vocational integration. Two years after rehabilitation, 87% of inpatients and 92% of outpatients were recontributing to the pension system continuously or sporadically. Despite the still marked deficits in the provision of rehabilitative treatment for addicted patients, rehabilitation plays an important and established role in this field and shows promising clinical results.

Implications of Welfare Reform on the Elderly

Whereas many studies of welfare reform have focused on effects on children and families, little research has examined the implications of welfare reform for the elderly. This case study incorporates interviews with service providers for the aging, members of advocacy organizations, and two focus groups of older consumers conducted in the multi-ethnic urban community of San Francisco. Study findings suggest that welfare reform has had both direct and indirect effects on the elderly and their services in the study community. Direct effects derive primarily from changes in the welfare reform legislation that had the effect of undermining both immigrants' eligibility for and claiming of public assistance benefits. Indirect effects on older persons include increased child-care demands upon grandparents. The case study data bear on a significant policy change within the broader trend of devolution at a historical point when anti-immigrant sentiment in the United States was running high.

Epidemiologic changes and economic burden of hypertension in Latin America: evidence from Mexico

BACKGROUND

Costs of health services for hypertension and the financial consequences of epidemiologic changes in this disease are important concerns for health systems in Latin America.

METHODS

We conducted longitudinal analyses of the economic impact of the epidemiologic changes on health care services for hypertension in the Mexican health care system. The cost evaluation method used was based on costing technique by production function and consensus techniques. To estimate the epidemiologic changes and financial consequences for the period 2005 to 2007, three probabilistic models were constructed according to the Box-Jenkins technique.

RESULTS

If changes are not implemented in prevention programs to reduce the effects of current risk factors, there will be increases in the number of patients with hypertension as well as in the financial burden to treat the disease. The amount allocated for hypertension in 2007, which will be 6% to 8% of the total health budget, is US$ 2,486,145,132. Of these, US$ 1,178,725,132 will be direct costs and US$ 1,307,420,000 will be indirect costs. Regarding epidemiologic changes for 2005 v 2007 (P < .05), an increase is expected, although results show a greater increase in insured populations.

CONCLUSIONS

If the risk factors and different health programs remain as they currently are, the economic impact of expected epidemiologic changes on the social security system will be particularly strong. Another relevant financial factor is the appearance of internal competition in the allocation of financial resources among the main providers of health services for hypertension; this factor becomes even more complicated within each provider.

Does enhanced information exchange between social insurance physicians and occupational physicians improve patient work resumption? A controlled intervention study

BACKGROUND

Patient work resumption after sickness absence varies even among patients with similar pathologies and characteristics. Explanations remain uncertain. One newly investigated field is "information asymmetry", a situation in which critical information is not appropriately exchanged between stakeholders in disability management. It is hypothesised that information asymmetry between social insurance physicians and occupational physicians prolongs sickness absence.

OBJECTIVES

To assess the influence of enhanced information exchange between these physicians on patient outcome.

METHODS

Non-randomised controlled intervention study. The setting was the work inability assessment consultation of social insurance physicians in Belgium. Inclusion criteria were: employee, age 18-50, and subacute (more than one month) sickness absence. The intervention was a structured information exchange (through the use of a communication form) between the patient's social insurance physician and occupational physician. The intervention started when the patient's sickness absence reached the subacute stage, and ended when the sickness absence benefit was ceased or the duration exceeded one year. The primary outcome measure was the sickness absence benefit status of the patient assessed one year after benefit onset.

RESULTS

Of the 1883 patients asked to enroll in the study, 1564 (84%) participated; 505 (32%) of 1564 patients were assigned to the intervention group and 1059 (68%) to the control group; 1553 (99%) of 1564 patients completed the study. In the intervention group, 86% received no sickness absence benefit at the end of the study, versus 84% in the control group (95% CI 0.91-1.15). No significant differences in other outcome parameters were obtained.

CONCLUSIONS

Information exchange between physicians may not be enough to influence work resumption among patients on sickness absence. Further research on stakeholders' information asymmetry and its effect on the outcome of patients are necessary. The complexity of information asymmetry in disability management cannot be underestimated.