The Effect of Disability on Personal Quality of Primary Care Received by Older Adults

1. The Effect of Disability on Personal Quality of Primary Care Received by Older Adults Chun-Ju Hsiao, PhD, MHS AcademyHealth Disability Research Interest Group Meeting June 10, 2008

2. Objective • To examine the relationship between community-dwelling older persons’ disabilities and their reported personal quality of primary care looking back over a one-year period

3. Background • More than 40% of medical expenditures are spent on people aged 65 and over • Two-thirds of Medicare beneficiaries have two or more chronic conditions • The growing need of primary care for older persons

4. Disability in the Older Population • Community-dwelling adults aged 75 and older • 10% require help with ADL • 19% require help with IADL • Unmet needs in health care • Resulted in more office visits, ED visits, and hospitalizations

5. Study Population • “Choice & Quality in Senior Health care” study (1998-1999) • Medicare beneficiaries enrolled in FFS and HMO in 13 states (MA, NY, PA, FL, IL, MN, TX, NM, AZ, CO, CA, OR, WA) • Analytic sample in this study excluded respondents without a regular personal doctor

6. Measurement of the Personal Quality of Primary Care • Scales used in the Primary Care Assessment Survey (PCAS) • Communication (3 items) • Integration (2 items) • Interpersonal treatment (2 items) • Patient trust (4 items) • Visit-based continuity (1 item) • Relationship duration (1 item)

7. Methods • Missing data imputation • For variables with more than 10% missing values • Factor analysis on the personal quality of care scales • Generated standardized factor score based on five scales that had a high factor loading • Higher score indicates higher quality of care • One unit change in the factor score represented one SD change in the study population • All analyses were adjusted for sampling weight

8. Statistical Analysis • Linear regression • Dependent variable: personal quality of care (continuous factor score) • Main independent variable of interest: disability status • Disability (having difficulty in any 1 ADL or any 2 IADLs) • 4 disability statuses (no disability was the reference group) • Adjusted for sociodemographic characteristics, health insurance plan, number of chronic conditions, and length of relationship with primary care physician

9. Disability statuses

10. Results * p<0.05

11. Limitations and Strengths • Limitations • No data on cause and total length of disability • Limited generalizability to older persons living in institutions • Attrition of study participants • Strengths • Novel approach to study disability in a persistent manner • First study to use a composite to measure the personal aspects of quality • Large sample of community-dwelling Medicare beneficiaries in the U.S.

12. Conclusions • Previous disability appears to have a negative effect on the personal quality of care while incident and persistent disability do not. • Findings for previous and incident disability may suggest a lag in the perception of quality of care. • A ‘response shift’ phenomenon may explain the lack of an observed association between persistent disability and personal quality of care.