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The purpose of this study is to determine whether patient activation is a changing or changeable characteristic and to assess whether changes in activation also are accompanied by changes in health behavior.To obtain variability in activation and self-management behavior, a controlled trial with chronic disease patients randomized into either intervention or control conditions was employed. In addition, changes in activation that occurred in the total sample were also examined for the study period. Using Mplus growth models, activation latent growth classes were identified and used in the analysis to predict changes in health behaviors and health outcomes.Survey data from the 479 participants were collected at baseline, 6 weeks, and 6 months.Positive change in activation is related to positive change in a variety of self-management behaviors. This is true even when the behavior in question is not being performed at baseline. When the behavior is already being performed at baseline, an increase in activation is related to maintaining a relatively high level of the behavior over time. The impact of the intervention, however, was less clear, as the increase in activation in the intervention group was matched by nearly equal increases in the control group.Results suggest that if activation is increased, a variety of improved behaviors will follow. The question still remains, however, as to what interventions will improve activation. more...

Race and ethnicity have been shown to be associated with medical diagnosis and treatment (Mayberry, Mili, and Ofili 2000). The contemporary medical literature uses “race” as a social construct because previous research has accumulated evidence against the biological differences between human races (Stolley 1999). Allocation to a specific racial group is associated with the level of social stress that individuals are subjected to and the medical care they receive (Krieger 2000; Laws 2001). In contrast to race, ethnicity refers to a group that people belong to due to shared languages, cultural traditions, etc. (Bhopal 1997). According to the Institute of Medicine 2003 report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” both racial and ethnic minorities tend to receive health care of lower quality and/or quantity than majority populations (Smedley, Stith, and Nelson 2003). These disparities have significant economic and sociological implications. First, racial and ethnic disparities raise concerns about whether health care is being provided in a consistent and appropriate manner (Smedley, Stith, and Nelson 2003). Additionally, from an economic viewpoint, overall health care expenditures may increase as a result of inconsistent or inappropriate treatment (Smedley, Stith, and Nelson 2003). For example, a study using the Medical Expenditure Panel Survey showed that using newer drugs reduced nondrug medical costs and overall treatment costs (Lichtenberg 2001). Disparities in the use of new prescription drugs may thus be related to increased health care costs. The aforementioned negative effects of racial and ethnic disparities on quality and health care expenditures may be exacerbated because the proportion of minorities in the United States is increasing (U.S. Census Bureau 2004). Because of the impact of racial and ethnic disparities in the United States, there has been an intensive effort to document disparities in health services utilization and identify their causes, in preparation for effective interventions. Such studies, however, have not addressed the use of prescription drugs in a comprehensive manner. Particularly, the use of new prescription drugs has not been compared across racial and ethnic groups. New drugs are usually priced higher than the older medications, but they may offer the potential benefits of fewer side effects and higher effectiveness (Lichtenberg 2001; Mullins et al. 2001). Therefore, racial and ethnic disparities in the use of new prescription drugs deserve examination. This study was undertaken to examine the question as to whether there are racial and ethnic disparities in new prescription use among non-Hispanic whites, non-Hispanic blacks, and Hispanic whites. more...

Mammography is an imperfect test, and false-positive mammograms, where the mammogram is read as abnormal in a woman who does not have breast cancer, happen frequently. On average, in the United States, about 10 percent of mammograms are read as abnormal (Brown, Houn et al. 1995). The cumulative probability of a false-positive mammogram after 10 screening mammograms may reach 49 percent (Elmore, Barton et al. 1998). Women who are told that their mammograms are abnormal often remain anxious beyond the period of additional testing (Ellman, Angeli et al. 1989; Gram, Lund et al. 1990; Bull and Campbell 1991; Lerman, Rimer, and Engstrom 1991; Lerman, Trock, Rimer, Boyce et al. 1991; Lerman, Trock, Rimer, Jepson et al. 1991; Gram and Slenker 1992; Brown, Houn et al. 1995; Paskett and Rimer 1995; Sutton, Saidi et al. 1995; Lidbrink, Elfving et al. 1996; Lowe, Balanda et al. 1999; Cullen, Schwartz et al. 2004). Women with false-positive mammograms also seek more medical attention for breast-related concerns and other medical issues than women with normal mammograms (Barton, Moore et al. 2001). These adverse effects are important, given the large volume of women undergoing screening mammography each year and the sizeable number who are given false-positive results (Cullen, Schwartz et al. 2004). Small increases in anxiety at the individual level due to false-positive mammograms may have a large impact on overall anxiety in the community, as well as an adverse effect on health care costs. Developing ways to decrease anxiety after an abnormal mammogram might improve patient care. We recently reported that among women with false-positive mammograms, those whose mammograms were read by a radiologist while the woman was still in the radiology suite (“immediate reading”) had lower levels of anxiety at 3 weeks compared with women whose mammograms were read in the usual manner, in batches after the woman had left the radiology suite. A majority of women with immediate readings did not realize they had had abnormal readings, indicating that immediate completion of follow-up testing minimized the effect of a false-positive mammogram on anxiety (Barton, Morley et al. 2004). We therefore undertook the current study to determine the cost of lowering anxiety with immediate mammogram reading. We had two goals: first, we wanted to estimate the additional cost associated with immediate reading compared with batch reading based on all women undergoing screening mammography, i.e., both those with normal and false-positive results. Second, we wanted to evaluate the net impact of immediate reading on downstream health care utilization and costs among women with false-positive mammograms. We hypothesized that women with false-positive mammograms who had immediate mammogram readings and decreased anxiety would have lower downstream utilization for discretionary medical care, compared with women who had batch reading and higher anxiety. If medical care utilization and costs were lower, we wanted to determine whether these lower costs offset some of the increased costs associated with immediate reading. We evaluated all 12-month medical care costs borne by the health plan and costs such as time, travel, and copayments borne by the patients. more...

In Canada's publicly funded health care system, policy is governed by the Canada Health Act whose primary objective is to “protect, promote, and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health care services without financial or other barriers” (Canada Health Act 1984, c.6, s.3). “Reasonable access,” while not explicitly defined by the Act, is generally assumed to have been achieved by the removal of the direct cost of health care at the point of delivery (Birch and Abelson 1993; Birch, Eyles, and Newbold 1993; Newbold, Eyles, and Birch 1995). A number of Canadian studies have examined access to general practitioner (GP) services in relation to income with conflicting results. While most conclude that there is no association between income and incidence of GP utilization when assessed over a 1-year period (Broyles et al. 1983; Birch, Eyles, and Newbold 1993; McIsaac, Goel, and Naylor 1997; Dunlop, Coyte, and McIsaac 2000; Finkelstein 2001), the association between income and volume of GP utilization is less clear. Several studies have reported an inverse association even after adjustment for need (Broyles et al. 1983; McIsaac, Goel, and Naylor 1997; Dunlop, Coyte, and McIsaac 2000), while others have reported no differential utilization by income level (Birch, Eyles, and Newbold 1993; Finkelstein 2001). In general, most studies that were unable to use direct measures to control for medical need found an expected inverse association between income and utilization of GP services (Roos and Mustard 1997; Kephart, Thomas, and MacLean 1998; Veugelers and Yip 2003); however, a recent study by Roos et al. (2004) observed lower than expected use of physician services among individuals from poorer neighborhoods. While the literature examining equity of access to GP services in Canada contains many studies of the relationship between income and access to physician services, comparatively little attention has been given to other potential barriers to access (Birch and Abelson 1993; Birch, Eyles, and Newbold 1993). It has been suggested that opportunity costs associated with attending medical appointments may render some individuals less likely to access care than others (Broyles et al. 1983; Birch, Eyles, and Newbold 1993). There are reasons to believe that employment-related opportunity costs may influence an individual's ability to access GP services. Because the ability to attend ambulatory medical appointments is time dependent, “time crunch” imposed by work may operate as a barrier to utilization (Boaz and Muller 1989) in that it reduces opportunities to access medical appointments (Nishiyama and Johnson 1997). Lost wages for time off work may also deter some workers from accessing care (Broyles et al. 1983; Boaz and Muller 1989). Studies of work hours and health have largely focused on the effect of long work hours on illness, injury, and health behavior (Caruso et al. 2004); however, the relationship between work hours and use of health care services has not been well studied. Only one qualitative study (Wellstood, Wilson, and Eyles 2006), and no quantitative studies were identified that have specifically assessed whether work hours act as a barrier to accessing GP services. The purpose of this study, therefore, was to examine the relationship between work hours and utilization of ambulatory GP services in order to assess the extent to which work hours may act as a barrier to access. more...