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 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 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 Two-thirds of Medicare beneficiaries have two or more chronic conditions The growing need of primary care for older persons The growing need of primary care for older persons

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

5. Study Population Choice & Quality in Senior Health care study (1998-1999) 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) 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 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) Scales used in the Primary Care Assessment Survey (PCAS) Communication (3 items) Communication (3 items) Integration (2 items) Integration (2 items) Interpersonal treatment (2 items) Interpersonal treatment (2 items) Patient trust (4 items) Patient trust (4 items) Visit-based continuity (1 item) Visit-based continuity (1 item) Relationship duration (1 item) Relationship duration (1 item)

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

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

9. Disability statuses Having disabilities Disability status 19981999 No disability NoNo Persistent disability YesYes Incident disability NoYes Previous disability YesNo

10. Respondent Characteristics Coefficient (Std Errors) Disability status from 1998 to 1999 (no disability: ref) Persistent disability -0.165 (0.132) Incident disability 0.016 (0.084) Previous disability -0.497 (0.152)* Age -0.013 (0.004)* Male 0.005 (0.039) Non-white 0.021 (0.057) Health insurance (FFS: ref) Open-model HMO Open-model HMO -0.084 (0.038)* Closed-model HMO Closed-model HMO -0.241 (0.042)* High school education 0.052(0.056) Number of chronic conditions 0.003 (0.018) Length of relationship with primary care physician (<1 year: ref) 1-2 years 1-2 years 0.080 (0.067) 3-5 years 3-5 years 0.188 (0.073)* >5 years >5 years 0.471 (0.060)* Results * p<0.05

11. Limitations and Strengths Limitations Limitations No data on cause and total length of disability No data on cause and total length of disability Limited generalizability to older persons living in institutions Limited generalizability to older persons living in institutions Attrition of study participants Attrition of study participants Strengths Strengths Novel approach to study disability in a persistent manner Novel approach to study disability in a persistent manner First study to use a composite to measure the personal aspects of quality First study to use a composite to measure the personal aspects of quality Large sample of community-dwelling Medicare beneficiaries in the U.S. 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. 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. 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. A response shift phenomenon may explain the lack of an observed association between persistent disability and personal quality of care.