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Evans E, Jacobs M. Diabetes and Financial Well-Being: Differential Hardship Among Vulnerable Populations. Sci Diabetes Self Manag Care 2024:26350106241256324. [PMID: 38853573 DOI: 10.1177/26350106241256324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
PURPOSE The purpose of the study was to examine financial well-being among a diverse population of individuals with and without diabetes. METHODS Data from the Understanding America Survey, a nationally representative, longitudinal panel, were utilized to identify adults with self-reported diabetes diagnoses between 2014 and 2020. We used longitudinal mixed effects regression models to assess the association between diabetes and financial well-being score (FWBS) among racial and ethnic population subgroups. Models included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, employment, and health insurance, incorporating individual- and household-level fixed effects. Racial and ethnic differentials were captured using group-condition interactions. RESULTS Black participants (17.06%) had the highest prevalence of diabetes, followed by White participants (12.2%), "other" racial groups (10.7%), and Hispanic participants (10.0%). In contrast, White participants (M = 67.66, SD = 22.63) and other racial groups (M = 67.99, SD = 18.45) had the highest FWBSs, followed by Hispanic participants (M = 59.31, SD = 22.78) and Black participants (M = 55.86, SD = 25.67). Compared to White participants, Black participants (β = -5.49, SE = 0.71) and Hispanic participants (β = -2.06, SE = 0.63) have significantly lower FWBSs. Compared to males, females (β = -3.25, SE = 0.41) had lower FWBSs among individuals with diabetes. FWBSs of individuals with diabetes was 2.71 points lower (SE = 0.52), on average, than those without diabetes. Education, household size, age, marital status, and income were also significantly associated with FWBSs. CONCLUSIONS Findings suggest potential disparities in the financial ramifications of diabetes among socially marginalized populations.
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Affiliation(s)
- Elizabeth Evans
- Communication Equity and Outcomes Laboratory, Department of Speech, Language and Hearing Sciences, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Molly Jacobs
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
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2
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Ko DT, Brophy JM, Mamas MA, McCrindle BW, Wijeysundera HC. Social Determinants of Health in Cardiovascular Disease: A Call to Action. Can J Cardiol 2024; 40:969-972. [PMID: 38663527 DOI: 10.1016/j.cjca.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
- Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Newcastle, United Kingdom
| | - Brian W McCrindle
- University of Toronto, Toronto, Ontario, Canada; Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
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Park YMM, Baek JH, Lee HS, Elfassy T, Brown CC, Schootman M, Narcisse MR, Ko SH, McElfish PA, Thomsen MR, Amick BC, Lee SS, Han K. Income variability and incident cardiovascular disease in diabetes: a population-based cohort study. Eur Heart J 2024; 45:1920-1933. [PMID: 38666368 DOI: 10.1093/eurheartj/ehae132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/07/2024] [Accepted: 02/19/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND AIMS Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D). METHODS Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders. RESULTS High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results. CONCLUSIONS Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.
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Affiliation(s)
- Yong-Moon Mark Park
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jong-Ha Baek
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, South Korea
| | - Hong Seok Lee
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Tali Elfassy
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Clare C Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mario Schootman
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | - Marie-Rachelle Narcisse
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Pearl A McElfish
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | - Michael R Thomsen
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Benjamin C Amick
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Seong-Su Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, 369 Sangdo-ro, Dongjak-gu, Seoul 06978, South Korea
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McWhorter K. Insights into the influence of income variability on cardiovascular risk in non-elderly adults with type 2 diabetes. Eur Heart J 2024; 45:1934-1936. [PMID: 38666364 DOI: 10.1093/eurheartj/ehae163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024] Open
Affiliation(s)
- Ketrell McWhorter
- Department of Epidemiology and Environmental Health, College of Public Health, University of Kentucky, Lexington, KY 40508, USA
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Shashikumar SA, Zheng Z, Joynt Maddox KE, Wadhera RK. Financial Burden of Health Care in the Privately Insured US Population. JAMA Intern Med 2024:2818898. [PMID: 38805205 PMCID: PMC11134276 DOI: 10.1001/jamainternmed.2024.1464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/15/2024] [Indexed: 05/29/2024]
Abstract
This cross-sectional study examines how changes in privately insured families’ contributions to insurance premiums and out-of-pocket spending have affected the financial burden of health care in recent decades.
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Affiliation(s)
- Sukruth A. Shashikumar
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - ZhaoNian Zheng
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Center for Advancing Health Services, Policy & Economics Research, Washington University, St Louis, Missouri
| | - Rishi K. Wadhera
- Section of Health Policy and Equity, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
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Brown CE, Jackson SY, Marshall AR, Pytel CC, Cueva KL, Doll KM, Young BA. Discriminatory Healthcare Experiences and Medical Mistrust in Patients With Serious Illness. J Pain Symptom Manage 2024; 67:317-326.e3. [PMID: 38218413 PMCID: PMC11000579 DOI: 10.1016/j.jpainsymman.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/03/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
CONTEXT Though discrimination in healthcare settings is increasingly recognized, the discriminatory experiences of patients with serious illness has not been well studied. OBJECTIVES Describe racial differences in patient-reported experiences with discrimination in the healthcare setting and examine its association with mistrust. METHODS We used surveys containing patient-reported frequency of discrimination using the Discrimination in Medical Setting (DMS) and Microaggressions in Health Care Settings (MHCS) scales, mistrust using the Group Based Medical Mistrust (GBMM) scale, and patient characteristics including patient-reported race, income, wealth, insurance status, and educational attainment. Univariable and multivariable linear regression models as well as risk ratios were used to examine associations between patient characteristics including self-reported race, and DMS, MHCS, and GBMM scores. RESULTS In 174 participants with serious illness, racially minoritized patients were more likely to report experiencing discrimination and microaggressions. In adjusted analyses, DMS scores were associated with elements of class and not with race. Black, Native American/Alaskan Native (NA/AN), and multiracial participants had higher MHCS scores compared to White participants with similar levels of income and education. Higher income was associated with lower GBMM scores in participants with similar DMS or MHCS scores, but Black and NA/AN participants still reported higher levels of mistrust. CONCLUSION In this cross-sectional study of patients with serious illness, discriminatory experiences were associated with worse mistrust in the medical system, particularly for Black and NA/AN participants. These findings suggest that race-conscious approaches are needed to address discrimination and mistrust in marginalized patients with serious illness and their families.
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Affiliation(s)
- Crystal E Brown
- Cambia Palliative Care Center of Excellence at UW Medicine (C.E.B., A.R.M.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine (C.E.B.), Department of Medicine, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities (C.E.B.), School of Medicine, University of Washington, Seattle, Washington, USA.
| | - Sandra Y Jackson
- United States Army (S.Y.J.), Center for Army Analysis, Fort Belvoir, Virginia, USA
| | - Arisa R Marshall
- Cambia Palliative Care Center of Excellence at UW Medicine (C.E.B., A.R.M.), Seattle, Washington, USA
| | - Christina C Pytel
- Department of Anesthesiology and Pain Medicine (C.C.P.), University of Washington, Seattle, Washington, USA
| | - Kristine L Cueva
- Department of Medicine (K.L.C.), University of Washington, Seattle, Washington, USA
| | - Kemi M Doll
- Division of Gynecologic Oncology (K.M.D.), Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Bessie A Young
- Division of Nephrology (B.A.Y.), Department of Medicine, University of Washington, Seattle, Washington, USA; Justice, Equity, Diversity, and Inclusion Center for Transformational Research (B.A.Y.), Office of Healthcare Equity, University of Washington, Seattle, Washington, USA
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Himmelstein KEW, Tsai AC, Venkataramani AS. Wealth Redistribution to Extend Longevity in the US. JAMA Intern Med 2024; 184:311-320. [PMID: 38285594 PMCID: PMC10825783 DOI: 10.1001/jamainternmed.2023.7975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/10/2023] [Indexed: 01/31/2024]
Abstract
Importance The US is unique among wealthy countries in its degree of wealth inequality and its poor health outcomes. Wealth is known to be positively associated with longevity, but little is known about whether wealth redistribution might extend longevity. Objective To examine the association between wealth and longevity and estimate the changes in longevity that could occur with simulated wealth distributions that were perfectly equal, similar to that observed in Japan (among the most equitable of Organisation for Economic Co-operation and Development [OECD] countries), generated by minimum inheritance proposals, and produced by baby bonds proposals. Design, Setting, and Participants This longitudinal cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study (1992-2018), a nationally representative panel study of middle-aged and older (≥50 years) community-dwelling, noninstitutionalized US adults. The data analysis was performed between November 15, 2022, and September 24, 2023. Exposure Household wealth on study entry, calculated as the sum of all assets minus the value of debts and classified into deciles. Main Outcomes and Measures Weibull survival models were used to estimate the association between per-person wealth decile and survival, adjusting for age, sex, marital status, household size, and race and ethnicity. Changes in longevity that might occur under alternative wealth distributions were then estimated. Results The sample included 35 164 participants (mean [SE] age at study entry, 59.1 [0.1] years; 50.1% female and 49.9% male [weighted]). The hazard of death generally decreased with increasing wealth, wherein participants in the highest wealth decile had a hazard ratio of 0.59 for death (95% CI, 0.53-0.66) compared with those in the lowest decile, corresponding to a 13.5-year difference in survival. A simulated wealth distribution of perfect equality would increase populationwide median longevity by 2.2 years (95% CI, 2.2-2.3 years), fully closing the mortality gap between the US and the OECD average. A simulated minimum inheritance proposal would increase populationwide median longevity by 1.7 years; a simulated wealth distribution similar to Japan's would increase populationwide median longevity by 1.2 years; and a simulated baby bonds proposal would increase populationwide median longevity by 1.0 year. Conclusions and Relevance These findings suggest that wealth inequality in the US is associated with significant inequities in survival. Wealth redistribution policies may substantially reduce those inequities and increase population longevity.
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Affiliation(s)
- Kathryn E. W. Himmelstein
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Alexander C. Tsai
- Harvard Medical School, Boston, Massachusetts
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Atheendar S. Venkataramani
- Division of Health Policy, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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8
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Westrick AC, Esiaka DK, Meier HCS, Rooks RN, Manning M, Tarraf W. Cognition and Wealth Changes in Mid-to-later Life: A Latent Class Trajectories Approach Using the Health and Retirement Study. J Aging Health 2024:8982643241232003. [PMID: 38356174 DOI: 10.1177/08982643241232003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
ObjectivesTo assess how cognitive trajectories from mid-to-later life relate to wealth change, overall and by mid-life income. Methods: Data were from participants (51-64 years) in the 2000-2018 U.S. Health and Retirement Study who were cognitively healthy at baseline (year 2000; unweighted n = 3821). Longitudinal latent class analyses generated cognitive and wealth trajectories, independently, and multinomial logistic regressions estimated the association between cognitive trajectories and wealth profiles, overall and by median income. Results: We identified three cognitive: cognitively healthy (CH), increasing cognitive impairment (ICI), and increasing dementia (ID) and four wealth profiles: stable wealth loss (SWL), delayed gradual wealth loss (DGWL), stable wealth gain (SWG), and gradual wealth gain (GWG). The ID group had higher probability of being in the SWL group and lower probability of SWG, which was more pronounced in respondents with greater median income. Discussion: Individuals with ID may be vulnerable to wealth loss, particularly for middle-class households.
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Affiliation(s)
- Ashly C Westrick
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Darlingtina K Esiaka
- Center for Health Equity Transformation, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Helen C S Meier
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Ronica N Rooks
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
| | - Mark Manning
- Department of Psychology, Oakland University, Rochester, MI, USA
| | - Wassim Tarraf
- Institute of Gerontology, Wayne State University, Detroit, MI, USA
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9
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Moniz MH, Stout MJ, Kolenic GE, Carlton EF, Scott JW, Miller MM, Becker NV. Association of Childbirth With Medical Debt. Obstet Gynecol 2024; 143:11-13. [PMID: 37769313 PMCID: PMC11014426 DOI: 10.1097/aog.0000000000005381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/20/2023] [Indexed: 09/30/2023]
Abstract
We evaluated the association between childbirth and having medical debt in collections and examined differences by neighborhood socioeconomic status. Among a statewide cohort of commercially insured pregnant (n=14,560) and postpartum (n=12,157) adults, having medical debt in collections was more likely among postpartum individuals compared with pregnant individuals (adjusted odds ratio [aOR] 1.36, 95% CI 1.27-1.46) and those in lowest-income neighborhoods compared with all others (aOR 2.18, 95% CI 2.02-2.35). Postpartum individuals in lowest-income neighborhoods had the highest predicted probabilities of having medical debt in collections (28.9%, 95% CI 27.5-30.3%), followed by pregnant individuals in lowest-income neighborhoods (23.2%, 95% CI 22.0-24.4%), followed by all other postpartum and pregnant people (16.1%, 95% CI 15.4-16.8% and 12.5%, 95% CI 11.9-13.0%, respectively). Our findings suggest that current peripartum out-of-pocket costs are objectively more than many commercially insured families can afford, leading to medical debt. Policies to reduce maternal-infant health care spending among commercially insured individuals may mitigate financial hardship and improve birth equity.
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Affiliation(s)
| | - Molly J. Stout
- University of Michigan Department of Obstetrics and Gynecology
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Pan L, Gao B, Zhu J, Guo J. Negative Wealth Shock and Cognitive Decline and Dementia in Middle-Aged and Older US Adults. JAMA Netw Open 2023; 6:e2349258. [PMID: 38147330 PMCID: PMC10751595 DOI: 10.1001/jamanetworkopen.2023.49258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/09/2023] [Indexed: 12/27/2023] Open
Abstract
Importance As a financial hardship, negative wealth shock has been implicated in some adverse health outcomes. However, associations between negative wealth shock and cognitive decline and dementia have not been examined. Objective To investigate whether negative wealth shock was associated with cognitive decline and incident dementia among middle-aged and older US adults. Design, Setting, and Participants The Health and Retirement Study (HRS) is a prospective cohort study conducted biennially among US adults older than 50 years. Data from the HRS from calendar years 1996 to 2020 were analyzed from July 1 to 31, 2023. The final sample included 8082 participants with complete data of interest. Exposures Wealth status was quantified with questionnaires. Negative wealth shock was defined as a loss of 75% or more in total wealth over a 2-year period. Asset poverty was defined as zero or less total net wealth. Main Outcomes and Measures Cognitive function was assessed with the modified Telephone Interview for Cognitive Status (TICS-m). Dementia status was determined with TICS-m scores and proxy assessment. Results Among 8082 participants included (mean [SD] age, 63.7 [5.7] years; 4179 women [51.7%] and 3903 men [48.3%]; 1111 Black [13.7%], 6689 White [82.7%], and 282 other [3.5%]), 1441 developed incident dementia over a median follow-up time of 14 (IQR, 7-20) years. Compared with participants who had positive wealth without shock, those with negative wealth shock had accelerated cognitive decline (β coefficient, -0.014 [95% CI, -0.027 to -0.001]; P = .03) and increased risks of dementia (hazard ratio [HR], 1.27 [95% CI, 1.11-1.46]; P < .001). Higher dementia risks were also found in participants with asset poverty at baseline (HR, 1.61 [95% CI, 1.30-2.00]; P < .001). Associations were found in White participants (HR, 1.34 [95% CI, 1.14-1.58]; P < .001) and participants younger than 65 years (HR, 1.38 [95% CI, 1.13-1.68]; P = .001) but not in other races and ethnicities or those 65 years or older. Conclusions and Relevance In this cohort study, negative wealth shock was associated with accelerated cognitive decline and elevated risks of dementia among middle-aged and older US adults, with modifications by age and ethnicity. These findings should be confirmed by further prospective and interventional studies.
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Affiliation(s)
- Liulu Pan
- Zhejiang University School of Medicine, Hangzhou, China
| | - Bin Gao
- Department of Psychiatry, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junpeng Zhu
- Center for Rehabilitation Medicine, Department of Psychiatry, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Jing Guo
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Prugger C, Perier MC, Gonzalez-Izquierdo A, Hemingway H, Denaxas S, Empana JP. Incidence of 12 common cardiovascular diseases and subsequent mortality risk in the general population. Eur J Prev Cardiol 2023; 30:1715-1722. [PMID: 37294923 DOI: 10.1093/eurjpc/zwad192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/25/2023] [Accepted: 06/03/2023] [Indexed: 06/11/2023]
Abstract
BACKGROUND Incident events of cardiovascular diseases (CVDs) are heterogenous and may result in different mortality risks. Such evidence may help inform patient and physician decisions in CVD prevention and risk factor management. AIMS This study aimed to determine the extent to which incident events of common CVD show heterogeneous associations with subsequent mortality risk in the general population. METHODS AND RESULTS Based on England-wide linked electronic health records, we established a cohort of 1 310 518 people ≥30 years of age initially free of CVD and followed up for non-fatal events of 12 common CVD and cause-specific mortality. The 12 CVDs were considered as time-varying exposures in Cox's proportional hazards models to estimate hazard rate ratios (HRRs) with 95% confidence intervals (CIs). Over the median follow-up of 4.2 years (2010-16), 81 516 non-fatal CVD, 10 906 cardiovascular deaths, and 40 843 non-cardiovascular deaths occurred. All 12 CVDs were associated with increased risk of cardiovascular mortality, with HRR (95% CI) ranging from 1.67 (1.47-1.89) for stable angina to 7.85 (6.62-9.31) for haemorrhagic stroke. All 12 CVDs were also associated with increased non-cardiovascular and all-cause mortality risk but to a lesser extent: HRR (95% CI) ranged from 1.10 (1.00-1.22) to 4.55 (4.03-5.13) and from 1.24 (1.13-1.35) to 4.92 (4.44-5.46) for transient ischaemic attack and sudden cardiac arrest, respectively. CONCLUSION Incident events of 12 common CVD show significant adverse and markedly differential associations with subsequent cardiovascular, non-cardiovascular, and all-cause mortality risk in the general population.
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Affiliation(s)
- Christof Prugger
- Institute of Public Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marie-Cécile Perier
- INSERM U970, Paris Cardiovascular Research Centre (PARCC), Integrative Epidemiology of Cardiovascular Diseases, Université Paris Cité, 56 rue Leblanc, 75015 Paris, France
| | - Arturo Gonzalez-Izquierdo
- Institute of Health Informatics, University College London, 222 Euston Road, NW1 2DA London, UK
- Health Data Research UK, 215 Euston Road, NW1 2DA London, UK
- UCL Hospitals Biomedical Research Centers (BRC), 270 Tottenham Court Road, 215 Euston Road, NW1 2BE London, UK
| | - Harry Hemingway
- Institute of Health Informatics, University College London, 222 Euston Road, NW1 2DA London, UK
- Health Data Research UK, 215 Euston Road, NW1 2DA London, UK
- UCL Hospitals Biomedical Research Centers (BRC), 270 Tottenham Court Road, 215 Euston Road, NW1 2BE London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, 222 Euston Road, NW1 2DA London, UK
- Health Data Research UK, 215 Euston Road, NW1 2DA London, UK
- UCL Hospitals Biomedical Research Centers (BRC), 270 Tottenham Court Road, 215 Euston Road, NW1 2BE London, UK
- British Heart Foundation Data Science Center, 215 Euston Road, NW1 2BE London, UK
| | - Jean-Philippe Empana
- INSERM U970, Paris Cardiovascular Research Centre (PARCC), Integrative Epidemiology of Cardiovascular Diseases, Université Paris Cité, 56 rue Leblanc, 75015 Paris, France
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Cho TC, Yu X, Gross AL, Zhang YS, Lee J, Langa KM, Kobayashi LC. Negative wealth shocks in later life and subsequent cognitive function in older adults in China, England, Mexico, and the USA, 2012-18: a population-based, cross-nationally harmonised, longitudinal study. THE LANCET. HEALTHY LONGEVITY 2023; 4:e461-e469. [PMID: 37544315 PMCID: PMC10529910 DOI: 10.1016/s2666-7568(23)00113-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Household wealth is positively related to cognitive health outcomes in later life. However, the association between negative wealth shocks and cognitive function in later life, and whether this association might differ across countries at different levels of economic development, is unclear. We aimed to investigate whether negative wealth shocks in later life are associated with cognitive function in older adults in China, England, Mexico, and the USA, and whether this association is modified by country income level. METHODS For this population-based, cross-nationally harmonised, longitudinal study, data were analysed from core interviews of the population-based US Health and Retirement Study (2012 and 2016) and its partner studies in China (the China Health and Retirement Longitudinal Study; 2015 and 2018), England (the English Longitudinal Study of Ageing; 2012 and 2016), and Mexico (Mexican Health and Aging Study; 2012 and 2015-16), and their respective Harmonized Cognitive Assessment Protocols (HCAPs). Negative wealth shocks over the follow-up periods of the respective cohorts were defined in two ways: an extreme loss of 75% or greater from the baseline amount of wealth, and a decline in within-population wealth quintile rank. The primary outcome was the harmonised general cognitive function (GCF) factor score, which was constructed with factor analysis on the HCAP neuropsychological assessments of memory, orientation, attention, executive function, and verbal fluency performance (mean 0; SD 1). We used sampling-weighted, multivariable-adjusted linear models to examine associations. FINDINGS Data from 9465 participants were included in this analysis: 3796 from China, 1184 from England, 1193 from Mexico, and 3292 from the USA. The mean baseline age of participants was 68·5 (SD 5·4) years in China (49·8% women), 72·0 (7·0) years in England (54·6% women), 70·6 (6·8) years in Mexico (55·1% women), and 72·7 (7·5) years in the USA (60·4% women). A wealth loss of 75% or greater was negatively associated with subsequent cognitive function in the USA (β -0·16 SD units; 95% CI -0·29 to -0·04) and China (-0·14; -0·21 to -0·07), but not in England (-0·01; -0·24 to 0·22) or Mexico (-0·11; -0·24 to 0·03). Similarly, within-population wealth quintile rank declines were negatively associated with subsequent cognitive function in the USA (β -0·07 per quintile rank decline; 95% CI -0·11 to -0·03) and China (β -0·07; -0·09 to -0·04), but not in England (-0·05; -0·11 to 0·01) or Mexico (-0·03; -0·07 to 0·01). INTERPRETATION The impact of wealth shocks in later life on subsequent lower level of cognitive function of older adults in China, England, Mexico, and the USA differed across macro-level socioeconomic structures. These findings suggest that government policies and social safety nets in countries with different levels of economic development might have a role in protecting older adults from adverse health effects of wealth losses in later life. FUNDING US National Institute on Aging, US National Institutes of Health.
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Affiliation(s)
- Tsai-Chin Cho
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Xuexin Yu
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins University Center on Aging and Health, Baltimore, MD, USA
| | - Yuan S Zhang
- Robert N. Butler Columbia Aging Center, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Jinkook Lee
- Center for Economic and Social Research and Department of Economics, University of Southern California, Los Angeles, CA, USA
| | - Kenneth M Langa
- Department of Internal Medicine, School of Medicine, University of Michigan Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Lindsay C Kobayashi
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.
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Wolfe JD, Thomeer MB, Reczek R. Age at first birth and women's midlife health: Cohort and race differences across the 20th century. Soc Sci Med 2023; 331:116097. [PMID: 37473543 PMCID: PMC10529505 DOI: 10.1016/j.socscimed.2023.116097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023]
Abstract
We test whether the negative association between socially "early" childbearing and poor health in later adulthood, well-established in prior research, differs across distinct historical contexts in the U.S.We further examine whether socioeconomic status explains this shift in the impact of childbearing timing and poor health and whether there are additional differences across racial groups. To address these questions, we pooled data from two nationally representative longitudinal surveys: the National Longitudinal Surveys' Mature Women (born 1922-1937) and Youth 1979 (born 1957-1964). Together, these NLS cohorts include women who entered adolescence before and after the major economic, political, and demographic changes in the latter half of the twentieth century that gave women access to socioeconomic structures previously limited to White men. These data thus provide a unique opportunity to test cohort and racial differences. Overall, findings suggest that the negative association of young childbearing, which included adolescent childbearing and childbearing in early 20s, with midlife health grew across the two cohorts, with this largely explained by differences in adult educational attainment. This cohort shift appeared especially large for White women compared to Black women. This study highlights the importance of sociopolitical context in shaping the health consequences of major life events like childbearing.
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14
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Park JC, Nam GE, Yu J, McWhorter KL, Liu J, Lee HS, Lee SS, Han K. Association of Sustained Low or High Income and Income Changes With Risk of Incident Type 2 Diabetes Among Individuals Aged 30 to 64 Years. JAMA Netw Open 2023; 6:e2330024. [PMID: 37603333 PMCID: PMC10442710 DOI: 10.1001/jamanetworkopen.2023.30024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Importance Evidence of the association between income fluctuation and risk of type 2 diabetes (T2D) is scarce. Objective To investigate whether sustained low or high income and income changes are associated with incidence of T2D. Design, Setting, and Participants In this population-based cohort study, more than 7.8 million adults without T2D aged 30 to 64 years from a nationally representative sample from the Korean Health Insurance Service database were enrolled in 2012 and followed up to 2019 (median follow-up, 6.3 years [IQR, 6.1-6.6 years]). Exposures Twenty quantiles of monthly health insurance premiums determined income levels. Income quartiles were annually analyzed from 2008 to 2012. Beneficiaries of the Medical Aid Program were regarded as those with very low income. A decrease in income was indicated as a reduction of 25% or more in income compared with income in the previous year. Main Outcomes and Measures The primary outcome was incident T2D based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes E11 to E14, 1 or more claims of antidiabetic medication, or a fasting glucose level of 126 mg/dL or higher. Multivariable Cox proportional hazards models were used to assess the association of low- or high-income status and income changes with incidence of T2D. Results Of 7 821 227 participants (mean [SD] age, 46.4 [9.3] years; 54.9% men), 359 931 (4.6%) developed T2D at least 1 year after enrollment. Individuals who repeatedly experienced low and very low income for 5 years showed 22% (hazard ratio [HR], 1.22 [95% CI, 1.21-1.23]) and 57% (1.57 [95% CI, 1.53-1.62]) higher T2D risk compared with those who never experienced low and very low income, respectively. In contrast, individuals who were repeatedly in high-income quartiles showed lower T2D risk compared with those who never experienced high income (HR, 0.86 [95% CI, 0.85-0.86]). The number of income decreases was associated with elevated T2D risk (≥2 vs 0 income decreases: HR, 1.08 [95% CI, 1.06-1.11]; P < .001 for trend). When income quartile status was compared between 2008 and 2012, individuals who experienced an income increase had lowered T2D risk, while those who experienced an income decrease had elevated T2D risk in each income quartile group. Conclusions and Relevance This cohort study found that individuals who experienced sustained low-income status or an income decrease had elevated T2D risk, while those who had sustained high-income status or an income increase had lowered T2D risk.
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Affiliation(s)
| | - Ga Eun Nam
- Department of Family Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jinna Yu
- Department of Nursing, Chung-Ang University, Seoul, South Korea
| | - Ketrell L. McWhorter
- Department of Epidemiology and Environmental Health, College of Public Health, University of Kentucky, Lexington
| | - Junxiu Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hong Seok Lee
- Division of Cardiology, Banner University Medical Group, Sarver Heart Center, University of Arizona, Tucson
| | - Seong-Su Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, South Korea
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15
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Turner K, Stover AM, Tometich DB, Geiss C, Mason A, Nguyen OT, Hume E, McCormick R, Powell S, Hallanger-Johnson J, Patel KB, Kirtane KS, Jammigumpula N, Moore C, Perkins R, Rollison DE, Jim HS, Oswald LB, Crowder S, Gonzalez BD, Robinson E, Tabriz AA, Islam JY, Gilbert SM. Oncology Providers' and Professionals' Experiences With Suicide Risk Screening Among Patients With Head and Neck Cancer: A Qualitative Study. JCO Oncol Pract 2023; 19:e892-e903. [PMID: 36395441 PMCID: PMC10337750 DOI: 10.1200/op.22.00433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/03/2022] [Accepted: 10/11/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE There has been limited study of the implementation of suicide risk screening for patients with head and neck cancer (HNC) as a part of routine care. To address this gap, this study assessed oncology providers' and professionals' perspectives about barriers and facilitators of implementing a suicide risk screening among patients with HNC. MATERIALS AND METHODS All patients with HNC with an in-person visit completed a suicide risk screening on an electronic tablet. Patients reporting passive death wish were then screened for active suicidal ideation and referred for appropriate intervention. Interviews were conducted with 25 oncology providers and professionals who played a key role in implementation including nurses, medical assistants, patient access representatives, advanced practice providers, physicians, social workers, and informatics staff. The interview guide was based on the Consolidated Framework for Implementation Research. Interviews were transcribed and analyzed for themes. RESULTS Participants identified multilevel implementation barriers, such as intervention level (eg, patient difficulty with using a tablet), process level (eg, limited nursing engagement), organizational level (eg, limited clinic Wi-Fi connectivity), and individual level (eg, low clinician self-efficacy for interpreting and acting upon patient-reported outcome scores). Participants noted facilitators, such as effective care coordination across nursing and social work staff and the opportunity for patients to be screened multiple times. Participants recommended strengthening patient and clinician education and providing patients with other modalities for data entry (eg, desktop computer in the waiting room). CONCLUSION Participants identified important intervention modifications that may be needed to optimize suicide risk screening in cancer care settings.
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Affiliation(s)
- Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Angela M. Stover
- Department of Health Policy and Management, UNC Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, UNC Chapel Hill, Chapel Hill, NC
| | | | - Carley Geiss
- Participant Research, Interventions, and Measurement Core, Moffitt Cancer Center, Tampa, FL
| | - Arianna Mason
- Participant Research, Interventions, and Measurement Core, Moffitt Cancer Center, Tampa, FL
| | - Oliver T. Nguyen
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Emma Hume
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Rachael McCormick
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
| | - Sean Powell
- Department of Social Work, Moffitt Cancer Center, Tampa, FL
| | | | - Krupal B. Patel
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, FL
| | - Kedar S. Kirtane
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, FL
| | - Neelima Jammigumpula
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL
| | - Colin Moore
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
| | - Randa Perkins
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL
| | - Dana E. Rollison
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL
| | - Heather S.L. Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Laura B. Oswald
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Sylvia Crowder
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Brian D. Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Edmondo Robinson
- Department of Clinical Informatics, Center for Digital Health, Moffitt Cancer Center, Tampa, FL
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida, Tampa, FL
| | - Jessica Y. Islam
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
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Troger A, Burns MM. Pharmaceutical Purchasing: a Review of the Landscape and Implications for Antidotal Therapies. J Med Toxicol 2023:10.1007/s13181-023-00943-5. [PMID: 37249803 DOI: 10.1007/s13181-023-00943-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/15/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
The management of the poisoned patient often requires the utilization of uncommonly used pharmaceutical interventions. These interventions can be associated with significant costs to both the patient and treating institution. Pharmaceutical supply shortages and issues with accessibility of antidotal therapies complicate the management of many toxic exposures. These challenges are an inherent property of the pharmaceutical purchasing infrastructure in the United States, which is a complicated network of public and private intra-institutional agreements. The cost and availability of any given therapy is dependent on the individual contracting agreements between the treating institution, payer, pharmacy benefit manager, manufacturer or wholesaler, and in some cases a specialty pharmacy. Small or remote hospitals may experience greater challenges related to insufficient patient volume to achieve predicable prescribing patterns of rare and expensive medications, necessitating consignment purchasing arrangements. Although pharmaceutical costs are the focus of recent legislative attention, these reforms are not expected to significantly alter the cost or availability of antidotal therapies.
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Affiliation(s)
- Andrew Troger
- Harvard Medical Toxicology Fellowship, Boston, MA, USA.
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
- Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, MA, USA.
| | - Michele M Burns
- Harvard Medical Toxicology Fellowship, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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17
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Mead MP, Vargas EA, Knutson KL. Racial Disparities in Sleep: Potential Mediation by Discrimination and Psychological Distress. J Racial Ethn Health Disparities 2023; 10:573-580. [PMID: 35106740 PMCID: PMC9548322 DOI: 10.1007/s40615-022-01247-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Abstract
Previous research has demonstrated that experiences of discrimination contribute to racial disparities in sleep, and that psychological distress mediates these relationships. However, previous research has not included race as part of the mediation pathway and has had limited dimensions of sleep health and psychological mediators. In the current study, we examine serial mediation pathways by which race and sleep health are mediated through discrimination and subsequently through psychological distress (i.e., depressive symptoms, chronic stress, and loneliness). Data were from the 2010 wave of the Health Retirement Study (HRS). The analytic sample (n = 7,749) included Black and White participants who were included in the enhanced face-to-face interview in 2010 and who completed the psychosocial questionnaire. Race was reported as either Black or White. Sleep health was assessed with a 4-item questionnaire. Depressive symptoms were assessed with the shortened CES-D, chronic stress via the ongoing chronic stressor scale, and loneliness via the UCLA loneliness scale. Covariates were included in all serial mediation models. Relative to White participants, Black participants reported increased experiences of discrimination, which was associated with increased psychological distress, and poorer sleep health. Findings demonstrate the significant adverse impact that discrimination has on both psychological well-being and sleep health.
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Affiliation(s)
- Michael P Mead
- Department of Neurology, Northwestern University Feinberg School of Medicine, 710 N Lake Shore Dr, Chicago, IL, 60611, USA.
| | - Emily A Vargas
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Suite 1400, Chicago, IL, 60611, USA
| | - Kristen L Knutson
- Department of Neurology, Northwestern University Feinberg School of Medicine, 710 N Lake Shore Dr, Chicago, IL, 60611, USA
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18
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Tran M, Gannon B, Rose C. The effect of housing wealth on older adults' health care utilization: Evidence from fluctuations in the U.S. housing market. JOURNAL OF HEALTH ECONOMICS 2023; 88:102737. [PMID: 36758392 DOI: 10.1016/j.jhealeco.2023.102737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 06/18/2023]
Abstract
Do wealthier individuals use more health care services than those less affluent? Our paper addresses this question by examining the relationship between housing wealth and health care utilization. Exploiting fluctuations in the U.S. housing market, we estimate the effect of unanticipated wealth shocks on older adults' health care utilization, using county-year variation in house prices to construct an instrumental variable. Using data from the 1996-2016 Health and Retirement Study, we find that an increase in wealth significantly increases numbers of doctor visits, prescription drugs, outpatient surgery, and dental services. Notably, an economic downturn like that in the Great Recession, when housing wealth declined by 16 percent on average, could reduce the utilization of prescription drugs by 0.4 percent, outpatient services by 0.5 percent, dental care by 0.6 percent, and numbers of doctor visits by 0.5 visits annually.
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Affiliation(s)
- My Tran
- School of Economics, University of Queensland, Australia; Department of Health Services Research & Policy, Australian National University, Australia; Centre for the Business and Economics of Health, University of Queensland, Australia.
| | - Brenda Gannon
- School of Economics, University of Queensland, Australia; Centre for the Business and Economics of Health, University of Queensland, Australia.
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19
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Li W, Chen J, He X, Wang J, Wei C, Tang X, Gao P. Stock volatility and hospital admissions for cardiovascular disease: results from the National Insurance Claims for Epidemiological Research (NICER) study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 31:100595. [PMID: 36879781 PMCID: PMC9985007 DOI: 10.1016/j.lanwpc.2022.100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND The association between stock volatility and cardiovascular diseases (CVD) was described during the 2008 Global Stock Market Crash; however, whether the finding in an occasional stock market crash is spurious remains unclear. METHODS A time-series design was used to evaluate the association between short-term exposure to daily returns of two major indices and daily hospital admissions for CVD and its subtypes based on claims data from the National Insurance Claims for Epidemiological Research (NICER) study covering 174 major cities in China. The average percentage change in daily hospital admissions for cause-specific CVD per 1% change in daily index returns was calculated because the Chinese stock market policy limits its change by 10% of the previous day's closing price. A Poisson regression in a generalised additive model was used to assess the city-specific association; then, overall national estimations were pooled by random-effects meta-analysis. FINDINGS Totally 8,234,164 hospital admissions for CVD were recorded during 2014-2017. Points of the Shanghai closing indices ranged from 1991·3 to 5166·4. A U-shaped association was observed between daily index returns and CVD admissions. Changes of 1% in daily returns of the Shanghai index corresponded to 1·28%(95%CI: 1·04%-1·53%), 1·25%(0·99%-1·51%), 1·42%(1·13%-1·72%), and 1·14%(0·39%-1·89%) increases in hospital admissions for total CVD, ischaemic heart disease, stroke, or heart failure on the same day, respectively. Similar results were observed for the Shenzhen index. INTERPRETATION Stock market volatility is associated with an increased CVD admission. FUNDING Chinese Ministry of Science and Technology (2020YFC2003503) and National Natural Science Foundation of China (81973132, 81961128006).
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Affiliation(s)
- Wei Li
- Department of Epidemiology and Biostatistics, Peking University Health Science Center, Beijing, China
| | - Jia Chen
- Peking University, Beijing, China
| | - Xianjie He
- School of Accountancy, Shanghai University of Finance and Economics, Shanghai, China
| | - Jinxi Wang
- Beijing HealthCom Data Technology, Beijing, China
| | - Chen Wei
- Beijing HealthCom Data Technology, Beijing, China
| | - Xun Tang
- Department of Epidemiology and Biostatistics, Peking University Health Science Center, Beijing, China
| | - Pei Gao
- Department of Epidemiology and Biostatistics, Peking University Health Science Center, Beijing, China
- Center for Real-world Evidence evaluation, Peking University Clinical Research Institute, Beijing, China
- Key Laboratory of Molecular Cardiovascular Sciences (Peking University), Ministry of Education, Beijing, China
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20
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Yu X, Westrick AC, Kobayashi LC. Cumulative loneliness and subsequent memory function and rate of decline among adults aged ≥50 in the United States, 1996 to 2016. Alzheimers Dement 2023; 19:578-588. [PMID: 35920364 PMCID: PMC9895124 DOI: 10.1002/alz.12734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The study objective was to investigate the association between loneliness duration and memory function over a 20-year period. METHODS Data were from 9032 adults aged ≥50 in the Health and Retirement Study. Loneliness status (yes vs. no) was assessed biennially from 1996 to 2004 and its duration was categorized as never, 1 time point, 2 time points, and ≥3 time points. Episodic memory was assessed from 2004 to 2016 as a composite of immediate and delayed recall trials combined with proxy-reported memory. Mixed-effects linear regression models were fitted. RESULTS A longer duration of loneliness was associated with lower memory scores (P < 0.001) and a faster rate of decline (P < 0.001). The association was stronger among adults aged ≥65 than those aged <65 (three-way interaction P = 0.013) and was stronger among women than men (three-way interaction P = 0.002). DISCUSSION Cumulative loneliness may be a salient risk factor for accelerated memory aging, especially among women aged ≥65. HIGHLIGHT A longer duration of loneliness was associated with accelerated memory aging. The association was stronger among women than men and among older adults than the younger. Reducing loneliness in mid- to late life may help maintain memory function.
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Affiliation(s)
- Xuexin Yu
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Ashly C Westrick
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Lindsay C Kobayashi
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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21
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Gibson-Davis C, Boen CE, Keister LA, Lowell W. Net worth poverty and adult health. Soc Sci Med 2023; 318:115614. [PMID: 36610245 PMCID: PMC10018316 DOI: 10.1016/j.socscimed.2022.115614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/09/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
This study broadens the traditional focus on income as the primary measure of economic deprivation by providing the first analysis of wealth deprivation, or net worth poverty (NWP), and adult health. Net worth poverty-having wealth (assets minus debts) less than one-fourth of the federal poverty line-likely exacerbates the negative effects of income poverty (IP). In 2019, one-third of US households were net worth poor, with substantially higher rates among Black (60%) relative to White (25%) households. We estimate longitudinal growth curve (i.e., linear mixed effects) models to test how NWP, IP, and the interaction of the two predict a diverse set of health measures. We also consider whether NWP resulting from either low assets or high debts is more predictive of health outcomes and test for heterogeneous associations by race. Data come from Panel Study of Income Dynamics on 8,962 individuals ages 25 to 64, observed between 2011 and 2019 (n = 26,776). Adjusting for income poverty, net worth poverty, relative to no poverty, was associated with a one-quarter to one-third increase in the likelihood of reporting poor self-rated health, psychological distress, and work limitations. Simultaneously experiencing both NWP and IP was associated with the largest deficits. Both asset-driven (low asset) and debt-driven (high debt) NWP reduced health, but asset-driven NWP had stronger associations (e.g., a 5-percentage point increase of being in poor health, twice that of debt-driven). White, relative to Black, adults exhibited statistically larger associations for psychological distress (4.3 vs 1.1 percentage points) and work limitations (3.7 vs. 1.5 percentage points). White and Black adults who were jointly net worth and income poor exhibited the most disadvantage. Findings underscore how wealth is a critical component of financial deprivation and that wealth deprivation, particularly the lack of assets, merits attention in socioeconomic studies of health inequalities.
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Affiliation(s)
- Christina Gibson-Davis
- Sanford School of Public Policy and Department of Sociology, Duke University, Durham, NC, 27708, USA
| | - Courtney E Boen
- Department of Sociology and Demography, Population Studies and Population Aging Research Centers, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Lisa A Keister
- Department of Sociology and Sanford School of Public Policy, Duke University, Durham, NC, 27708, USA.
| | - Warren Lowell
- Sanford School of Public Policy and Department of Sociology, Duke University, Durham, NC, 27708, USA
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Lee HS, Park JC, Chung I, Liu J, Lee SS, Han K. Sustained Low Income, Income Changes, and Risk of All-Cause Mortality in Individuals With Type 2 Diabetes: A Nationwide Population-Based Cohort Study. Diabetes Care 2023; 46:92-100. [PMID: 36367896 DOI: 10.2337/dc21-2305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 10/10/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE There is limited evidence on the association of sustained low-income status, income changes, and all-cause mortality risk in individuals with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS Using the Korean Health Insurance Service database, we studied 1,923,854 adults with T2D (aged ≥30 years) without cardiovascular disease and cancer, who were enrolled from 2009 through 2012 and followed to the end of 2020 (median 10.8 years of follow-up). We defined income levels based on the amount of health insurance premiums and categorized them into quartiles, the first being the low-income group, and assessed the income status annually in the preceding 5 years. Cox proportional hazards models were used to quantify the association of low-income status and income changes with mortality, with adjustment for sociodemographic factors, comorbidities, and diabetes duration and treatment. RESULTS Participants who consecutively had low income showed a higher risk of mortality (hazard ratio [HR] 1.19; 95% CI 1.16-1.22), compared with those who had never been in the low-income group. This association was much stronger for consecutive recipients of Medical Aid, reflecting very-low-income status (HR 2.26; 95% CI 2.16-2.36), compared with those who had never been Medical Aid beneficiaries. Sustained low- and very-low-income status was associated with increased risk of mortality, specifically for younger adults (aged <40 years) and males. Those who experienced declines in income between the first (preceding 5 years) and the last (baseline) time points had an increased risk of mortality, regardless of baseline income status. CONCLUSIONS Among Korean adults with T2D, sustained low-income status and declines in income were associated with increased risk of mortality.
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Affiliation(s)
- Hong Seok Lee
- Department of Medicine, University of Arizona, Tucson, AZ
| | | | - Inkwan Chung
- Department of Information Sociology, Soongsil University, Seoul, South Korea
| | - Junxiu Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Seong-Su Lee
- Division of Endocrinology and Metabolism, Bucheon St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, South Korea
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Kobayashi LC, O'Shea BQ, Joseph C, Finlay JM. Acute relationships between mental health and cognitive function during the COVID-19 pandemic: Longitudinal evidence from middle-aged and older US adults. SSM - MENTAL HEALTH 2022; 2:100097. [PMID: 35434675 PMCID: PMC8993427 DOI: 10.1016/j.ssmmh.2022.100097] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 02/08/2023] Open
Abstract
Background The acute impacts of COVID-19-related mental health concerns on cognitive function among middle-aged and older adults are unknown. We investigated whether between-person (BP) differences and within-person (WP) changes in loneliness, anxiety, and worry about COVID-19 were related to cognitive function and abilities in a longitudinal cohort of middle-aged and older United States (US) adults over a nine-month period during the COVID-19 pandemic. Methods Data were from bimonthly questionnaires in the nationwide COVID-19 Coping Study from August/September 2020 through April/May 2021 (N = 2262 adults aged ≥55). Loneliness was assessed with the 3-item UCLA Loneliness Scale, anxiety with the 5-item Beck Anxiety Inventory, and COVID-19 worry on a 5-point Likert-type scale. Cognitive outcomes were assessed with the 6-item Patient Reported Outcomes Measurement Information System (PROMIS®) Cognitive Function and Abilities scales. Marginal structural models incorporating inverse probability of treatment and attrition weights as well as sampling weights estimated the BP and WP relationships between the mental health predictors and PROMIS® cognitive scores over time. Results In any given month, experiencing a loneliness or anxiety symptom score higher than the sample mean (BP difference) or higher than one's personal mean across the nine-month period (WP change) was negatively associated with cognitive function and abilities in that month. The observed magnitudes of associations were stronger for BP differences than for WP changes and were the strongest for anxiety symptom scale scores. Conclusions Elevated loneliness and anxiety symptoms, both relative to other adults and to one's usual levels, were acutely associated with worse perceived cognitive function and abilities over a nine-month period during the COVID-19 pandemic in the United States. The long-term impacts of mental health symptoms experienced during the pandemic for population cognitive health should be explored.
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Affiliation(s)
- Lindsay C. Kobayashi
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA,MRC/Wits Rural Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa,Corresponding author. 1415 Washington Heights, SPH I, Ann Arbor, MI, 48109, USA
| | - Brendan Q. O'Shea
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Carly Joseph
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA,Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - Jessica M. Finlay
- Social Environment and Health Program, Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
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24
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Robertson C, Woolhandler S, Himmelstein DU. Arizona's debt collection reform-a small step towards health justice. BMJ 2022; 379:o2822. [PMID: 36418037 DOI: 10.1136/bmj.o2822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Christopher Robertson
- Boston University School of Law and School of Public Health, Boston, Massachusetts, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
| | - David U Himmelstein
- City University of New York at Hunter College, New York
- Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
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25
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Aggarwal R, Yeh RW, Dahabreh IJ, Robertson SE, Wadhera RK. Medicare eligibility and healthcare access, affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis. PLoS Med 2022; 19:e1004083. [PMID: 36194574 PMCID: PMC9531792 DOI: 10.1371/journal.pmed.1004083] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/02/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND US policymakers are debating whether to expand the Medicare program by lowering the age of eligibility. The goal of this study was to determine the association of Medicare eligibility and enrollment with healthcare access, affordability, and financial strain from medical bills in a contemporary population of low- and higher-income adults in the US. METHODS AND FINDINGS We used cross-sectional data from the National Health Interview Survey (2019) to examine the association of Medicare eligibility and enrollment with outcomes by income status using a local randomization-based regression discontinuity approach. After weighting to account for survey sampling, the low-income group consisted of 1,660,188 adults age 64 years and 1,488,875 adults age 66 years, with similar baseline characteristics, including distribution of sex (59.2% versus 59.7% female) and education (10.8% versus 12.5% with bachelor's degree or higher). The higher-income group consisted of 2,110,995 adults age 64 years and 2,167,676 adults age 66 years, with similar distribution of baseline characteristics, including sex (40.0% versus 49.4% female) and education (41.0% versus 41.6%). The share of adults age 64 versus 66 years enrolled in Medicare differed within low-income (27.6% versus 87.8%, p < 0.001) and higher-income groups (8.0% versus 85.9%, p < 0.001). Medicare eligibility at 65 years was associated with a decreases in the percentage of low-income adults who delayed (14.7% to 6.2%; -8.5% [95% CI, -14.7%, -2.4%], P = 0.007) or avoided medical care (15.5% to 5.9%; -9.6% [-15.9%, -3.2%], P = 0.003) due to costs, and a larger decrease in the percentage who were worried about (66.5% to 51.1%; -15.4% [-25.4%, -5.4%], P = 0.003) or had problems (33.9% to 20.6%; -13.3% [-23.0%, -3.6%], P = 0.007) paying medical bills. In contrast, there were no significant associations between Medicare eligibility and measures of cost-related barriers to medication use. For higher-income adults, there was a large decrease in worrying about paying medical bills (40.5% to 27.5%; -13.0% [-21.4%, -4.5%], P = 0.003), a more modest decrease in avoiding medical care due to cost (3.5% to 0.6%; -2.9% [-5.3%, -0.5%], P = 0.02), and no significant association between eligibility and other measures of healthcare access and affordability. All estimates were stronger when examining the association of Medicare enrollment with outcomes for low and higher-income adults. Additional analyses that adjusted for clinical comorbidities and employment status were largely consistent with the main findings, as were analyses stratified by levels of educational attainment. Study limitations include the assumption adults age 64 and 66 would have similar outcomes if both groups were eligible for Medicare or if eligibility were withheld from both. CONCLUSIONS Medicare eligibility and enrollment at age 65 years were associated with improvements in healthcare access, affordability, and financial strain in low-income adults and, to a lesser extent, in higher-income adults. Our findings provide evidence that lowering the age of eligibility for Medicare may improve health inequities in the US.
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Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Issa J. Dahabreh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sarah E. Robertson
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Becker NV, Scott JW, Moniz MH, Carlton EF, Ayanian JZ. Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults. JAMA Intern Med 2022; 182:1044-1051. [PMID: 35994265 PMCID: PMC9396471 DOI: 10.1001/jamainternmed.2022.3687] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/02/2022] [Indexed: 11/14/2022]
Abstract
Importance The bidirectional association between health and financial stability is increasingly recognized. Objective To describe the association between chronic disease burden and patients' adverse financial outcomes. Design, Setting, and Participants This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan. Exposures Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders). Main Outcomes and Measures Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt. Results The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions. Conclusions and Relevance This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.
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Affiliation(s)
- Nora V. Becker
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - John W. Scott
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Michelle H. Moniz
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor
| | - Erin F. Carlton
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Pediatric Critical Care Medicine, University of Michigan Medical School, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
| | - John Z. Ayanian
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Himmelstein DU, Dickman SL, McCormick D, Bor DH, Gaffney A, Woolhandler S. Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US. JAMA Netw Open 2022; 5:e2231898. [PMID: 36112374 PMCID: PMC9482049 DOI: 10.1001/jamanetworkopen.2022.31898] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH). OBJECTIVE To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years. EXPOSURES Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs. MAIN OUTCOMES AND MEASURES Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity. RESULTS Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, 51.6% were female, 16.8% Hispanic, 6.0% were non-Hispanic Asian, 11.9% non-Hispanic Black, 62.6% non-Hispanic White, and 2.18% other non-Hispanic. A total of 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates: 15.3%; (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]). In cross-sectional analyses, hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness; residing in a Medicaid-expansion state was protective (2019 odds ratio [OR], 0.76; 95% CI, 0.70-0.83). Prospective findings were similar, eg, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019 (OR, 1.63; 95% CI, 1.23-2.14), as was becoming newly disabled (OR, 2.42; 95% CI, 1.95-3.00) or newly hospitalized (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening SDOHs, with ORs of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019. CONCLUSIONS AND RELEVANCE In this cross-sectional and cohort study, medical indebtedness was common, even among insured individuals. Acquiring such debt may worsen SDOHs. Expanded and improved health coverage could ameliorate financial distress, and improve housing and food security.
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Affiliation(s)
- David U. Himmelstein
- The City University of New York at Hunter College, New York, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Public Citizen Health Research Group, Washington, DC
| | | | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David H. Bor
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- The City University of New York at Hunter College, New York, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Public Citizen Health Research Group, Washington, DC
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Smith GL, Banegas MP, Acquati C, Chang S, Chino F, Conti RM, Greenup RA, Kroll JL, Liang MI, Pisu M, Primm KM, Roth ME, Shankaran V, Yabroff KR. Navigating financial toxicity in patients with cancer: A multidisciplinary management approach. CA Cancer J Clin 2022; 72:437-453. [PMID: 35584404 DOI: 10.3322/caac.21730] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/15/2022] [Accepted: 04/13/2022] [Indexed: 12/21/2022] Open
Abstract
Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.
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Affiliation(s)
- Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew P Banegas
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Chiara Acquati
- Graduate College of Social Work, University of Houston, Houston, Texas
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shine Chang
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rena M Conti
- Department of Markets, Public Policy, and Law, Boston University School of Business, Boston, Massachusetts
| | - Rachel A Greenup
- Division of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Juliet L Kroll
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Maria Pisu
- Department of Internal Medicine, The University of Alabama, Birmingham, Alabama
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Veena Shankaran
- Seattle Cancer Care Alliance/University of Washington Medicine and Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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South E, Venkataramani A, Dalembert G. Building Black Wealth - The Role of Health Systems in Closing the Gap. N Engl J Med 2022; 387:844-849. [PMID: 36053512 DOI: 10.1056/nejmms2209521] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Eugenia South
- From the Penn Urban Health Lab (E.S.), and the Departments of Emergency Medicine (E.S.), Medical Ethics and Health Policy (A.V.), and Pediatrics (G.D.), Perelman School of Medicine, and the Leonard Davis Institute for Health Economics (E.S., A.V., G.D.), University of Pennsylvania, and the Possibilities Project, Children's Hospital of Philadelphia (G.D.) - both in Philadelphia
| | - Atheendar Venkataramani
- From the Penn Urban Health Lab (E.S.), and the Departments of Emergency Medicine (E.S.), Medical Ethics and Health Policy (A.V.), and Pediatrics (G.D.), Perelman School of Medicine, and the Leonard Davis Institute for Health Economics (E.S., A.V., G.D.), University of Pennsylvania, and the Possibilities Project, Children's Hospital of Philadelphia (G.D.) - both in Philadelphia
| | - George Dalembert
- From the Penn Urban Health Lab (E.S.), and the Departments of Emergency Medicine (E.S.), Medical Ethics and Health Policy (A.V.), and Pediatrics (G.D.), Perelman School of Medicine, and the Leonard Davis Institute for Health Economics (E.S., A.V., G.D.), University of Pennsylvania, and the Possibilities Project, Children's Hospital of Philadelphia (G.D.) - both in Philadelphia
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Wolfe JD. The Financial Correlates of Midlife Obesity. Am J Prev Med 2022; 63:S18-S27. [PMID: 35725137 PMCID: PMC9219113 DOI: 10.1016/j.amepre.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study explored the associations between midlife obesity and an array of common financial stressors related to wealth loss, debt, and bankruptcy. METHODS The analysis was conducted in 2022 with data from the National Longitudinal Survey of Youth 1979. The final sample included 36,122 observations on 8,059 respondents as they aged from ages 31‒39 years in 1996 to ages 51‒59 in 2016. Associations between obesity and financial stressors were estimated with logistic regression models adjusting for a comprehensive set of relevant control variables. RESULTS The analysis found significant relationships between obesity and multiple types of financial stressors, including property debt, unsecured debt, and bankruptcy. Property debt and unsecured debt increased the odds of obesity by 29% and 20%, respectively, and bankruptcy increased the odds of obesity by 43%. Average Marginal Effects (AMEs) in combination with model fit statistics confirmed that these stressors-unsecured debt, property debt, and bankruptcy-were important financial correlates of midlife obesity among the National Longitudinal Survey of Youth 1979 cohort. CONCLUSIONS The financial correlates of obesity included multiple financial stressors, but the magnitude of associations varied substantially across types of financial stressors. Results suggest that future interventions aimed at reducing obesity disparities should target populations with high levels of debt and bankruptcy.
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Affiliation(s)
- Joseph D Wolfe
- Department of Sociology, College of Arts and Sciences, The University of Alabama at Birmingham, Birmingham, Alabama.
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Gangaidzo T, von Fintel M, Schutte AE, Burger R. Stressful life events, neighbourhood characteristics, and systolic blood pressure in South Africa. J Hum Hypertens 2022; 37:405-411. [PMID: 35513441 DOI: 10.1038/s41371-022-00695-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/22/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022]
Abstract
The relationship between negative events, neighbourhood characteristics, and systolic blood pressure in developing countries is not well-documented, particularly using longitudinal data. To explore this relationship, we analysed panel data from the first three waves of the South African National Income Dynamics Study using a correlated random effects model adjusted for confounding risk factors. Our sample comprised of 15,631 respondents in 2008, 14,443 respondents in 2010/2011, and 14,418 respondents in 2012, all aged above 15 years. The prevalence of at least one negative household event across the three waves was approximately 30%. In any of the three waves, the adjusted prevalence of hypertension was 23.84%. This share was 21.75% in 2008 (95% CI 18.06-25.44), 23.16% in 2010/11 (95% CI 19.18-27.14), and 18.39% in 2012 (95% CI 16.03-20.75). In our adjusted correlated random effects model, we found that systolic blood pressure was significantly higher among respondents from households that reported death of a household member (0.85 mmHg; p = 0.02) and a reduction in grant income and remittances (2.14 mm Hg; p = 0.01). We also found no significant association between systolic blood pressure and neighbourhood income level. In a country with social and economic challenges, our results indicate that grief and negative financial events are adversely associated with blood pressure, which may explain in part the significant burden of hypertension in low- and middle-income countries.
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Affiliation(s)
- Trust Gangaidzo
- Department of Economics, Stellenbosch University, Stellenbosch, South Africa.
| | - Marisa von Fintel
- Department of Economics, Stellenbosch University, Stellenbosch, South Africa
| | - Aletta Elisabeth Schutte
- School of Population Health, University of New South Wales; The George Institute for Global Health, Sydney, NSW, Australia.,Hypertension in Africa Research Team (HART); MRC Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Stellenbosch, South Africa
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Connors K, Flores-Torres MH, Cortés-Valencia A, Barrientos-Gutiérrez T, Cantú-Brito C, Rodriguez B, Lajous M, Valdimarsdóttir U, Catzin-Kuhlmann A. Serious Financial Difficulties, Psychological Stress, and Subclinical Cardiovascular Disease in Mexican Women. Ann Epidemiol 2022; 71:38-43. [DOI: 10.1016/j.annepidem.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 02/06/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022]
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OUP accepted manuscript. THE GERONTOLOGIST 2022; 63:783-794. [PMID: 35617139 PMCID: PMC10167764 DOI: 10.1093/geront/gnac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite evidence linking financial challenges to poor health among older adults, effective interventions are lacking. This study examined the experience of living with financial challenges, useful strategies to handle them, and social norms that may constrain options and decision-making. RESEARCH DESIGN AND METHODS This two-staged qualitative study recruited low-income older adults from the United States Baltimore City area. First, semistructured individual interviews examined older adults' experiences and strategies used to handle financial challenges. Then, vignette-based focus groups examined relevant social norms. Transcripts were coded, and hierarchical themes were described using thematic analysis. RESULTS Two themes were generated. First, the social norms relevant to financial challenges share a common underlying assumption of personal responsibility. Second, social norms about personal responsibility are inconsistent with the experiences of older adults facing financial challenges, who typically lack control over their situation and face structural barriers to preventing and handling financial challenges. Differences between statements related to norms and personal responsibility were found across six subthemes, including how finances should be handled to prevent financial challenges, the causes of financial challenges, asking for help from community resources, navigating community resources, getting help from family, and cutting back to handle financial challenges. DISCUSSION AND IMPLICATIONS The disconnect between social norms and the reality of financial challenges among older adults may explain why so many older adults cut back to the point of foregoing necessities. There is an urgent need to strengthen the social safety net and remove normative barriers to services.
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Mueller JT. The Poverty Balancing Equation: Expressing Poverty of Place as a Population Process. Demography 2021; 58:2065-2088. [PMID: 34596211 DOI: 10.1215/00703370-9530075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The accurate measurement of poverty is essential for the development of effective poverty policy. Unfortunately, approaches that use poverty rates to assess the causes and consequences of poverty do not fully capture the components of change in the poverty population because changes in the conventional poverty rate can occur owing to processes of natural increase, migration, or transitions in and out of poverty. This article presents an accounting framework for changes in poverty within and between places. The framework, termed the poverty balancing equation, generates a series of summary statistics that can be used in place of the conventional poverty rate in future research. The approach is demonstrated using the 2014 panel of the Survey of Income and Program Participation to generate state-level estimates of the poverty components of change for three states in the American South between January and December of 2013. Results show that even when poverty rates remain constant, there is significant dynamism within poor and nonpoor populations. By applying this approach, either completely or in part, researchers can provide more specific and actionable evidence for poverty alleviation policy.
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Affiliation(s)
- J Tom Mueller
- Department of Geography and Environmental Sustainability, University of Oklahoma, Norman, OK, USA
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Brenner MH. Unemployment, Bankruptcies, and Deaths From Multiple Causes in the COVID-19 Recession Compared With the 2000‒2018 Great Recession Impact. Am J Public Health 2021; 111:1950-1959. [PMID: 34709850 PMCID: PMC8630493 DOI: 10.2105/ajph.2021.306490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/04/2022]
Abstract
Objectives. To determine whether unemployment and bankruptcy rates are related to increased excess deaths during the COVID-19 recession and to examine whether the current recession-based mortality rate not only is dependent on COVID-19 but also continues the pattern of recessions, especially the Great Recession, in relation to chronic disease mortality rates and mental health disturbances (e.g., including suicide) from 2000 to 2018. Methods. This study used pooled cross-sectional time series analysis to determine the impact of unemployment and bankruptcy rates on excess deaths from February to November 2020 for US states. The study used a second pooled cross-sectional time series analysis to determine whether the COVID-19‒ era recessional mortality continues the impact of prepandemic recessions (2000-2018) on multiple causes of mortality. Results. Ten percent unemployment was associated with approximately 48[thin space]149 excess deaths, while, jointly with bankruptcies, their combined effect produced 35 700 and 144 483 excess deaths, for unemployment and bankruptcies, respectively. These health-damaging COVID-19‒recessional findings suggest a reiteration of the significantly increased major cause‒specific mortality during 2000 to 2018, mitigated by the size of the health care workforce. Conclusions. Minimization of deaths attributable to the COVID-19 recession requires ample funding for the unemployed and underemployed, especially Black and Hispanic communities, along with significant investments in the health workforce. (Am J Public Health. 2021;111(11):1950-1959. https://doi.org/10.2105/AJPH.2021.306490).
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Affiliation(s)
- M Harvey Brenner
- M. Harvey Brenner is with the Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. He is also with the Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth
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36
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Smith GL, Mendoza TR, Lowenstein LM, Shih YCT. Financial Hardship in Survivorship Care Delivery. J Natl Cancer Inst Monogr 2021; 2021:10-14. [PMID: 34478512 PMCID: PMC8415532 DOI: 10.1093/jncimonographs/lgaa012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Cancer-related financial hardship is highly prevalent and affects individuals in the setting of cancer care delivery across the survivorship trajectory. Mitigating financial hardship requires multi-level solutions at the policy, payer, health-care system, provider, and individual patient levels. At the highest level, strategies for intervention include enacting policies to improve price transparency and expand insurance coverage. Also needed are implementing systematic screening and financial navigation in cancer care delivery; improving cost communication by provider care teams; developing patient-reported measures that incorporate the multiple, complex dimensions of financial hardship, as reflected in the Economic Strain and Resilience in Cancer tool; and advancing electronic medical record infrastructure to manage data on patient financial hardship. For individual patients, activating their social networks, community resources, and employers provides patient-level support resources to enhance coping. The proposed multi-level approach is needed to overcome financial hardship in the setting of high-quality, high-value cancer care delivery.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tito R Mendoza
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisa M Lowenstein
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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37
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Kim DJ, Yoo JW, Chang JW, Yamashita T, Park EC, Han KT, Kim SJ, Kim SJ. Does low income effects 5-year mortality of hepatocellular carcinoma patients? Int J Equity Health 2021; 20:151. [PMID: 34465351 PMCID: PMC8408948 DOI: 10.1186/s12939-021-01498-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 06/11/2021] [Indexed: 12/15/2022] Open
Abstract
Background In Korea, the universal health system offers coverage to all members of society. Despite this, it is unclear whether risk of death from hepatocellular carcinoma (HCC) varies depending on income. We evaluated the impact of low income on HCC mortality. Methods The Korean National Health Insurance sampling cohort was used to identify new HCC cases (n = 7325) diagnosed between 2004 and 2008, and the Korean Community Health Survey data were used to investigate community-level effects. The main outcome was 5-year all-cause mortality risk, and Cox proportional hazard models were applied to investigate the individual- and community-level factors associated with the survival probability of HCC patients. Results From 2004 to 2008, there were 4658 new HCC cases among males and 2667 new cases among females. The 5-year survival proportion of males was 68%, and the incidence per person-year was 0.768; the female survival proportion was 78%, and the incidence per person-year was 0.819. Lower income was associated with higher hazard ratio (HR), and HCC patients with hepatitis B (HBV), alcoholic liver cirrhosis, and other types of liver cirrhosis had higher HRs than those without these conditions. Subgroup analyses showed that middle-aged men were most vulnerable to the effects of low income on 5-year mortality, and community-level characteristics were associated with survival of HCC patients. Conclusion Having a low income significantly affected the overall 5-year mortality of Korean adults who were newly diagnosed with HCC from 2004 to 2008. Middle-aged men were the most vulnerable. We believe our findings will be useful to healthcare policymakers in Korea as well as to healthcare leaders in countries with NHI programs who need to make important decisions about allocation of limited healthcare resources according to a consensually accepted and rational framework.
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Affiliation(s)
- Dong Jun Kim
- Department of Health Administration and Management, Soonchunhyang University Graduate School, Asan, Republic of Korea.,Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - Jong Wha Chang
- Department of Health Administration, College of Business, Texas Women's University, Denton, TX, USA
| | - Takashi Yamashita
- Department of Sociology, Anthropology, and Health Administration and Policy, University of Maryland, Baltimore, MD, USA
| | - Eun-Cheol Park
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Tae Han
- Division of Cancer Management Policy, National Cancer Center, Goyang, Republic of Korea
| | - Seung Ju Kim
- College of Nursing, Catholic University of Korea, Seoul, Republic of Korea
| | - Sun Jung Kim
- Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea. .,Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, 22 Soonchunhyang-ro, Asan, 31538, Republic of Korea. .,Department of Software Convergence, Soonchunhyang University, Asan, Republic of Korea.
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38
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Avanceña ALV, DeLuca EK, Iott B, Mauri A, Miller N, Eisenberg D, Hutton DW. Income and Income Inequality Are a Matter of Life and Death. What Can Policymakers Do About It? Am J Public Health 2021; 111:1404-1408. [PMID: 34464177 DOI: 10.2105/ajph.2021.306301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anton L V Avanceña
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Ellen Kim DeLuca
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Bradley Iott
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Amanda Mauri
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Nicholas Miller
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Daniel Eisenberg
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - David W Hutton
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
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Wagner AL, Rajamoorthy Y, Taib NM. Impact of economic disruptions and disease experiences on COVID-19 vaccination uptake in Asia: A study in Malaysia. NARRA J 2021; 1:e42. [PMID: 38449462 PMCID: PMC10914033 DOI: 10.52225/narraj.v1i2.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 03/08/2024]
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, individuals have had a variety of experiences with the disease and economic disruptions in Asia. We assessed how these experiences could impact COVID-19 vaccination intent and uptake in one of the Asian country, Malaysia. Two opt-in internet-based cross-sectional samples were collected: a March wave (26 March - 7 April 2021) and a June wave (22 June - 10 July 2021). Individuals were asked about their vaccination status, their employment status, and their experience with COVID-19 cases. The impact of economic disruptions and experiences with COVID-19 on COVID-19 vaccination was assessed through a multivariable, multinomial logistic regression model. Among 1,493 participants (735 in March and 758 in June wave), 26% were already vaccinated, 57% planned to vaccinate, and 17% had no plan to vaccinate. The number who had lost a job or earned less because of the pandemic was 30% in March and 36% in June. Across both waves, 5%-6% had a personal, very serious experience of COVID-19, 13%-16% knew of a family member or friend with a very serious experience of COVID-19, and 43%-61% knew of a very serious COVID-19 case through media. Notably, compared to those who worked the same amount throughout the pandemic, those who lost their job had lower odds of already being vaccinated (OR: 0.37; 95%CI: 0.23, 0.59), but similar odds of planning to become vaccinated. Personal, family/friend, and media experiences were also all related to increased odds of planning to vaccinated or being already vaccinated. The COVID-19 pandemic has led to large disruptions in people's lives. People's experiences during the pandemic impact their likelihood of being vaccinated or planning to vaccinate against COVID-19. Equitable allocation of COVID-19 vaccines will require outreach to groups with less stable employment and can leverage people's experiences with disease during the pandemic.
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Affiliation(s)
- Abram L. Wagner
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Yogambigai Rajamoorthy
- Department of Economics, Faculty of Accountancy and Management, Universiti Tunku Abdul Rahman, Sungai Long Campus, Cheras, Selangor, Malaysia
| | - Niazlin M. Taib
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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40
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Finegood ED, Briley DA, Turiano NA, Freedman A, South SC, Krueger RF, Chen E, Mroczek DK, Miller GE. Association of Wealth With Longevity in US Adults at Midlife. JAMA HEALTH FORUM 2021; 2:e211652. [PMID: 35977209 PMCID: PMC8796893 DOI: 10.1001/jamahealthforum.2021.1652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/24/2021] [Indexed: 01/20/2023] Open
Affiliation(s)
- Eric D. Finegood
- Institute for Policy Research, Northwestern University, Evanston, Illinois
- Department of Psychology, Northwestern University, Evanston, Illinois
| | - Daniel A. Briley
- Department of Psychology, University of Illinois Urbana-Champaign, Urbana
| | | | - Alexa Freedman
- Institute for Policy Research, Northwestern University, Evanston, Illinois
- Department of Psychology, Northwestern University, Evanston, Illinois
| | - Susan C. South
- Department of Psychological Sciences, Purdue University, West Lafayette, Indiana
| | | | - Edith Chen
- Institute for Policy Research, Northwestern University, Evanston, Illinois
- Department of Psychology, Northwestern University, Evanston, Illinois
| | - Daniel K. Mroczek
- Department of Psychology, Northwestern University, Evanston, Illinois
- Department of Medical Social Sciences, Northwestern University, Evanston, Illinois
| | - Gregory E. Miller
- Institute for Policy Research, Northwestern University, Evanston, Illinois
- Department of Psychology, Northwestern University, Evanston, Illinois
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Affiliation(s)
| | - Jennifer J Griggs
- Division of Hematology/Oncology, Department of Medicine, School of Medicine, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
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42
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Abstract
Importance The association of socioeconomic status and cardiovascular outcomes has been well described, but little is known about whether longitudinal changes in wealth are associated with cardiovascular health status. Objective To evaluate the association between midlife wealth mobility and risk of cardiovascular events. Design, Setting, and Participants This longitudinal, retrospective cohort study included US adults 50 years or older who participated in the Health and Retirement Study. Participants in the primary analysis had no history of cardiovascular disease and had observations in at least two of three 5-year age intervals (50-54, 55-59, and 60-64 years) and follow-up after 65 years of age. Data were collected from January 1, 1992, to December 31, 2016, and analyzed from November 10, 2020, to April 26, 2021. Exposures Quintiles of wealth (reflecting total nonhousing assets) were defined within each of 4 birth cohorts (1931-1935, 1936-1940, 1941-1945, and 1946-1950). Wealth mobility was defined as an increase or a decrease of 1 or more wealth quintiles and was compared with wealth stability (same quintile over time) using covariate-adjusted Cox proportional hazards regression models. Main Outcomes and Measures Composite outcome of nonfatal cardiovascular event (myocardial infarction, heart failure, cardiac arrhythmia, or stroke) or cardiovascular death. Results A total of 5579 participants were included in the primary analysis (mean [SD] age, 54.2 [2.6] years; 3078 women [55.2%]). During a mean (SD) follow-up of 16.9 (5.8) years, 1336 participants (24.0%) experienced a primary end point of nonfatal cardiovascular event or cardiovascular death (14.4 [95% CI, 13.6-15.2] per 1000 patient-years). Higher initial wealth (per quintile) was associated with lower cardiovascular risk (adjusted hazard ratio [aHR] per quintile, 0.89 [95% CI, 0.84-0.95]; P = .001). When compared with stable wealth, participants who experienced upward wealth mobility (by at least 1 quintile) had independently lower hazards of a subsequent nonfatal cardiovascular event or cardiovascular death (aHR, 0.84 [95% CI, 0.73-0.97]; P = .02), and participants who experienced downward wealth mobility had higher risks (aHR, 1.15 [95% CI, 1.00-1.32]; P = .046). Conclusions and Relevance These findings suggest that upward wealth mobility relative to peers in late middle age is associated with lower risks of cardiovascular events or death after 65 years of age.
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Affiliation(s)
- Sara Machado
- Department of Health Policy, London School of Economics, London, United Kingdom
| | - Andrew Sumarsono
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas.,Division of Hospital Medicine, Parkland Memorial Hospital, Dallas, Texas
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
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Smith GL, Shih YCT, Frank SJ. Financial Toxicity in Head and Neck Cancer Patients Treated With Proton Therapy. Int J Part Ther 2021; 8:366-373. [PMID: 34285962 PMCID: PMC8270089 DOI: 10.14338/ijpt-20-00054.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/29/2020] [Indexed: 11/21/2022] Open
Abstract
Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy-dimensions of "financial toxicity"-need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Sbarra DA, Whisman MA. Divorce, health, and socioeconomic status: An agenda for psychological science. Curr Opin Psychol 2021; 43:75-78. [PMID: 34298203 DOI: 10.1016/j.copsyc.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/03/2022]
Abstract
This brief review article discusses marital dissolution and health with a focus on two specific themes. First, we introduce and discuss the search for plausible causal pathways that link the end of marriage to distal health outcomes. Second, we suggest that the socioeconomic status disruptions that follow divorce represent a plausible causal pathway and emphasize the need for more psychological science in this area of study. Although there is substantial literature that demonstrates that divorced adults, especially divorced women, experience significant financial disruptions, the research in this area remains broad and largely the province of family sociology and demography. Research is needed to better understand adults' psychological and behavioral responses to changes in their financial situation after the end of marriage.
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Affiliation(s)
- David A Sbarra
- Department of Psychology, University of Arizona, Tucson, AZ, USA.
| | - Mark A Whisman
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
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45
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Wolfe JD, Baker EH, Uddin J, Kirkland S. Varieties of Financial Stressors and Midlife Health Problems. J Gerontol B Psychol Sci Soc Sci 2021; 77:gbab108. [PMID: 34137839 DOI: 10.1093/geronb/gbab108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Financial stressors such as wealth loss, indebtedness, and bankruptcy have gained the attention of public health scholars since the Great Recession. In this study, we extend this area of research by comparing the mental and physical impact of multiple financial stressors during midlife, a pivotal period in the life course for wealth accumulation and disease onset. METHODS With data from the National Longitudinal Survey of Youth 1979 (www.nlsinfo.org), an ongoing survey of adult men and women in the U.S., we used logistic regression to estimate the associations between financial stressors and the risk of a psychiatric disorder or high blood pressure diagnosis from ages 31-39 in 1996 to ages 50-59 in 2016 (N = 7,143). Financial stressors include multiple types of wealth loss, debt, and bankruptcy. RESULTS Even after adjusting for a comprehensive set of confounders, many of the financial stressors we considered had similar associations with the risk of a psychiatric disorder, whereas only debt and bankruptcy were associated with the risk of high blood pressure. The best fitting models for both health outcomes included a simple indicator of indebtedness. Stock losses were not significantly associated with either health outcome. DISCUSSION Given the recent volatility in the U.S. economy, our results highlight the potential loss of health that may occur if nothing is done to prevent economically vulnerable populations from sliding into financial crisis. Our results also emphasize the need for additional research to develop individual-level interventions to improve health among those already experiencing financial difficulties.
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Affiliation(s)
- Joseph D Wolfe
- University of Alabama at Birmingham, Department of Sociology, Birmingham, AL
| | - Elizabeth H Baker
- University of Alabama at Birmingham, Department of Sociology, Birmingham, AL
| | - Jalal Uddin
- University of Alabama at Birmingham, Department of Epidemiology, Birmingham, AL
| | - Stephanie Kirkland
- University of Alabama at Birmingham, Department of Sociology, Birmingham, AL
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46
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Yu X, Zhang W, Kobayashi LC. Duration of Poverty and Subsequent Cognitive Function and Decline Among Older Adults in China, 2005-2018. Neurology 2021; 97:e739-e746. [PMID: 34099525 DOI: 10.1212/wnl.0000000000012343] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/13/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To investigate the relationship between late-life duration of poverty exposure and cognitive function and decline among older adults in China. METHODS Data were from 3,209 participants ≥64 years of age in the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Duration of poverty, defined according to urban and rural regional standards from the China Statistical Yearbook, was assessed according to annual household income from 2005 to 2011 (never in poverty; one-third of the period in poverty; two-thirds or more of the period in poverty). Cognitive function was measured by the Chinese Mini-Mental State Examination (CMMSE) from 2011 to 2018. We used attrition-weighted, multivariable mixed-effects Tobit regression to examine the association of duration of poverty with cognitive function and rate of decline. RESULTS A total of 1,162 individuals (36.21%) were never in poverty over the period from 2005 to 2011; 1,172 (36.52%) were in poverty one-third of the period; and 875 (27.27%) were in poverty two-thirds or more of the period. A longer poverty duration was associated with lower subsequent CMMSE scores with a dose-response relationship (one-third vs never in poverty: β = -0.98; 95% confidence interval -1.61 to -0.35; two-thirds or more vs never in poverty: β = -1.55; 95% confidence interval -2.29 to -0.81). However, a longer duration of poverty was associated with a slower rate of CMMSE score decline over time from 2011 to 2018. CONCLUSION These findings provide valuable evidence for the role of cumulative late-life poverty in relation to cognitive health among older adults in a rapidly urbanizing and aging middle-income country. Our findings may support a compensation hypothesis for cognitive reserve in this setting.
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Affiliation(s)
- Xuexin Yu
- From the West China Biomedical Big Data Center (X.Y., W.Z.), West China Hospital, Sichuan University; and Department of Epidemiology (X.Y., L.C.K.), University of Michigan School of Public Health, Ann Arbor
| | - Wei Zhang
- From the West China Biomedical Big Data Center (X.Y., W.Z.), West China Hospital, Sichuan University; and Department of Epidemiology (X.Y., L.C.K.), University of Michigan School of Public Health, Ann Arbor
| | - Lindsay C Kobayashi
- From the West China Biomedical Big Data Center (X.Y., W.Z.), West China Hospital, Sichuan University; and Department of Epidemiology (X.Y., L.C.K.), University of Michigan School of Public Health, Ann Arbor.
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47
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Community-dwelling older adults who are low-income and disabled weathering financial challenges. Geriatr Nurs 2021; 42:901-907. [PMID: 34098443 DOI: 10.1016/j.gerinurse.2021.04.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/20/2022]
Abstract
Despite interventions aiming to improve outcomes among older adults experiencing financial challenges, the challenges and strategies employed to handle them are poorly understood. This study examined the experiences of financial challenges among low-income adults aged ≥65 years. Eleven semi-structured interviews were analyzed using thematic analyses. An overarching theme was "I guess it balances", capturing attempts to maintain hope and proactively address challenges despite stress, uncertainty and limitations. Balancing was demonstrated within four domains, including cognitive bandwidth ("think a lot" versus "I don't dwell on that"), emotional experience ("depressing" versus "be thankful"), learned resilience ("that was a shock" versus "there's always a way"), and meeting daily needs ("we learned to do without" versus "take a dollar and stretch it"). Participants described being weathered by challenges and using predominately high-effort coping strategies to weather the challenges. These findings call for strengthening the safety net for older adults facing financial challenges.
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48
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Wang SY, Valero-Elizondo J, Ali HJ, Pandey A, Cainzos-Achirica M, Krumholz HM, Nasir K, Khera R. Out-of-Pocket Annual Health Expenditures and Financial Toxicity From Healthcare Costs in Patients With Heart Failure in the United States. J Am Heart Assoc 2021; 10:e022164. [PMID: 33998273 PMCID: PMC8483501 DOI: 10.1161/jaha.121.022164] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out‐of‐pocket healthcare costs on patients with HF and their families. Methods and Results In the Medical Expenditure Panel Survey, we identified all families with ≥1 adult member with HF during 2014 to 2018. Total out‐of‐pocket healthcare expenditures included yearly care‐specific costs and insurance premiums. We evaluated 2 outcomes of financial toxicity: (1) high financial burden—total out‐of‐pocket healthcare expense to postsubsistence income ratio of >20%, and (2) catastrophic financial burden with the ratio of >40%—a bankrupting expense defined by the World Health Organization. There were 788 families in the Medical Expenditure Panel Survey with a member with HF representing 0.54% (95% CI, 0.48%–0.60%) of all families nationally. The overall mean annual out‐of‐pocket healthcare expenses were $4423 (95% CI, $3908–$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%–18%) of families experienced a high burden and 5% (95% CI, 3%–6%) experienced a catastrophic burden. Among the two‐fifths of families considered low income, 24% (95% CI, 18%–30%) experienced a high financial burden, whereas 10% (95% CI, 6%–14%) experienced a catastrophic burden. Low‐income families had 4‐fold greater risk‐adjusted odds of high financial burden (odds ratio [OR] , 3.9; 95% CI, 2.3–6.6), and 14‐fold greater risk‐adjusted odds of catastrophic financial burden (OR, 14.2; 95% CI, 5.1–39.5) compared with middle/high‐income families. Conclusions Patients with HF and their families experience large out‐of‐pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low‐income families.
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Affiliation(s)
- Stephen Y Wang
- Department of Internal Medicine Yale-New Haven Hospital New Haven CT
| | | | - Hyeon-Ju Ali
- Department of Cardiology Houston Methodist Houston TX
| | - Ambarish Pandey
- Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | | | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Khurram Nasir
- Department of Cardiology Houston Methodist Houston TX
| | - Rohan Khera
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
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49
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Tan YV, Flannagan CAC, Pool LR, Elliott MR. Accounting for selection bias due to death in estimating the effect of wealth shock on cognition for the Health and Retirement Study. Stat Med 2021; 40:2613-2625. [PMID: 33665879 DOI: 10.1002/sim.8921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 12/23/2020] [Accepted: 02/03/2021] [Indexed: 11/11/2022]
Abstract
The Health and Retirement Study (HRS) is a longitudinal study of U.S. adults enrolled at age 50 and older. We were interested in investigating the effect of a sudden large decline in wealth on the cognitive ability of subjects measured using a dataset provided composite score. However, our analysis was complicated by the lack of randomization, time-dependent confounding, and a substantial fraction of the sample and population will die during follow-up leading to some of our outcomes being censored. The common method to handle this type of problem is marginal structural models (MSM). Although MSM produces valid estimates, this may not be the most appropriate method to reflect a useful real-world situation because MSM upweights subjects who are more likely to die to obtain a hypothetical population that over time, resembles that would have been obtained in the absence of death. A more refined and practical framework, principal stratification (PS), would be to restrict analysis to the strata of the population that would survive regardless of negative wealth shock experience. In this work, we propose a new algorithm for the estimation of the treatment effect under PS by imputing the counterfactual survival status and outcomes. Simulation studies suggest that our algorithm works well in various scenarios. We found no evidence that a negative wealth shock experience would affect the cognitive score of HRS subjects.
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Affiliation(s)
| | - Carol A C Flannagan
- Transportation Research Institute, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay R Pool
- Preventive Medicine (Epidemiology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael R Elliott
- Biostatistics Department, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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50
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Mäcken J, Riley AR, Glymour MM. Cross-national Differences in the Association Between Retirement and Memory Decline. J Gerontol B Psychol Sci Soc Sci 2021; 76:620-631. [PMID: 33301002 PMCID: PMC7887730 DOI: 10.1093/geronb/gbaa223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Retirement is a potential trigger for cognitive aging as it may be a stressful life event accompanied by changes in everyday activities. However, the consequences of retirement may differ across institutional contexts which shape retirement options. Comparing memory trajectories before and after retirement in 17 European countries, this study aims to identify cross-national differences in the association between retirement and memory decline. METHOD Respondents to the longitudinal Survey of Health, Aging, and Retirement in Europe (SHARE; N = 8,646) aged 50+ who were in paid work at baseline and retired during the observation period completed up to 6 memory assessments (immediate and delayed word recall) over 13 years. Three-level (time points, individuals, and countries) linear mixed models with country-level random slopes for retirement were estimated to evaluate whether memory decline accelerated after retirement and if this association differed between countries. RESULTS On average, retirement was associated with a moderate decrement in word recall (b = -0.273, 95% CI -0.441, -0.104) and memory decline accelerated after retirement (b = -0.044, 95% CI -0.070, -0.018). Significant between-country heterogeneity in memory decline after retirement existed (variance = 0.047, 95% CI (0.013, 0.168). Memory decline after retirement was more rapid in Italy, Greece, Czech Republic, Poland, Portugal, and Estonia compared to Northern and Central European countries. DISCUSSION Memory decline postretirement was faster in Mediterranean and eastern European countries, which are characterized by less generous welfare systems with comparatively low pension benefits. Evaluation of resources that could protect retirees from memory decline would be valuable.
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Affiliation(s)
- Jana Mäcken
- Institute of Sociology and Social Psychology, University of Cologne, Albertus-Magnus-Platz, Germany
| | - Alicia R Riley
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
| | - Maria M Glymour
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
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