@article {11815, title = {No association between rheumatoid arthritis and cognitive impairment in a cross-sectional national sample of older U.S. adults.}, journal = {BMC Rheumatology}, volume = {5}, year = {2021}, pages = {24}, abstract = {

BACKGROUND: Studies suggest an increased prevalence of cognitive impairment (CI) among people with rheumatoid arthritis (RA). However, most prior studies have used convenience samples which are subject to selection biases or have failed to adjust for key confounding variables. We thus examined the association between CI and RA in a large national probability sample of older US adults.

METHODS: Data were from interviews with 4462 participants in the 2016 wave of the nationally representative U.S. Health and Retirement Study with linked Medicare claims. RA diagnoses were identified via a minimum of two ICD-9CM or ICD-10 codes in Medicare billing records during the prior 2 years. The Langa-Weir Classification was used to classify cognitive status as normal, cognitively impaired non-dementia (CIND), or dementia based on a brief neuropsychological battery for self-respondents and informant reports for proxy respondents. We compared the odds of CI between older adults with and without RA using logistic regression, adjusted for age, education, gender, and race.

RESULTS: Medicare records identified a 3.36\% prevalence of RA (150/4462). While age, gender, education, and race independently predicted CI status, controlling for these covariates we found no difference in CI prevalence according to RA status (prevalent CI in 36.7\% of older adults with RA vs. 34.0\% without RA; adjusted OR = 1.08, 95\% CI 0.74-1.59, p~= .69).

CONCLUSION: There was no association between RA and CI in this national sample of older U.S. adults.

}, keywords = {cognitive impairment, Epidemiology, National health survey, rheumatoid arthritis}, issn = {2520-1026}, doi = {10.1186/s41927-021-00198-z}, author = {Booth, Michael J and Mary R Janevic and Lindsay C Kobayashi and Daniel Clauw and John D Piette} } @article {11993, title = {No increased risk of Alzheimer{\textquoteright}s disease among people with immune-mediated inflammatory diseases: findings from a longitudinal cohort study of U.S. older adults.}, journal = {BMC Rheumatology}, volume = {5}, year = {2021}, pages = {48}, abstract = {

OBJECTIVE: Immune-mediated inflammatory diseases (IMID) are characterized by systemic inflammation affecting the joints and bodily organs. Studies examining the association between individual IMIDs and the risk of Alzheimer{\textquoteright}s disease (AD) have yielded inconsistent findings. This study examines AD risk across a group of IMIDs in a large population-based sample of older adults.

METHODS: Data on a national sample of US adults over age 50 was drawn from the Health and Retirement Study (HRS) and linked Medicare claims from 2006 to 2014. IMIDs include rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn{\textquoteright}s disease, ulcerative colitis, and related conditions. We identified IMIDs from 2006 to 2009 Medicare claims using International Classification of Diseases (ICD9-CM) codes. The date of incident AD was derived from Chronic Conditions Warehouse (CCW) identifiers. We examined the risk of AD from 2009 to 2014 using Cox proportional hazards models, both unadjusted and adjusted for age, gender, education, race, and the genetic risk factor APOE-e4.

RESULTS: One hundred seventy-one (6.02\%) of the 2842 total HRS respondents with Medicare coverage and genetic data were classified with IMIDs. Over the subsequent 6 years, 9.36\% of IMID patients developed AD compared to 8.57\% of controls (unadjusted hazard ratio (HR): 1.09, 95\% CI .66-1.81, p = 0.74). Adjusted HR 1.27 (95\% CI 0.76-2.12, p = 0.35). Age (HR for 10-year increment 3.56, p < .001), less than high school education (HR 1.70, p = .007), and APOE-e4 (HR 2.61, p < .001 for one or two copies), were also statistically significant predictors of AD.

CONCLUSION: HRS respondents with common IMIDs do not have increased risk of Alzheimer{\textquoteright}s disease over a 6-year period.

}, keywords = {Alzheimer, immune-mediated inflammatory disease, Medicare claims data}, issn = {2520-1026}, doi = {10.1186/s41927-021-00219-x}, author = {Booth, Michael J and Lindsay C Kobayashi and Mary R Janevic and Daniel Clauw and John D Piette} } @article {11466, title = {Validation of Self-Reported Rheumatoid Arthritis Using Medicare Claims: A Nationally Representative Longitudinal Study of Older Adults.}, journal = {ACR Open Rheumatology}, volume = {3}, year = {2021}, pages = {239-249}, abstract = {

OBJECTIVE: To determine the validity of self-reported physician diagnosis of rheumatoid arthritis (RA) using multiple gold-standard measures based on Medicare claims in a nationally representative sample of older adults and to verify whether additional questions about taking medication and having seen a physician in the past two years for arthritis can improve the positive predictive value (PPV) and other measures of the validity of self-reported RA.

METHODS: A total of 3768 Medicare-eligible respondents with and without incident self-reported RA were identified from the 2004, 2008, and 2012 waves of the United States Health and Retirement Study. Self-reported RA was validated using the following three claims-based algorithms: 1) a single International Classification of Diseases, ninth edition, Clinical Modification claim for RA, 2) two or more claims no greater than 2 years apart, and 3) two or more claims with at least one diagnosis by a rheumatologist. Additional self-report questions of medication use and having seen a doctor for arthritis in the past two years were validated against the same criteria.

RESULTS: A total of 345 respondents self-reported a physician diagnosis of RA. Across all three RA algorithms, the PPV of self-report ranged from 0.05 to 0.16., the sensitivity ranged from 0.23 to 0.55., and the κ statistic ranged from 0.07 to 0.15. Additional self-report data regarding arthritis care improved the PPV and other validity measures of self-report; however, the values remained low.

CONCLUSION: Most older adults who self-report RA do not have a Medicare claims history consistent with that diagnosis. Revisions to current self-reported RA questions may yield more valid identification of RA in national health surveys.

}, keywords = {Medicare claims, rheumatoid arthritis, self reported}, issn = {2578-5745}, doi = {10.1002/acr2.11229}, author = {Booth, Michael J and Daniel Clauw and Mary R Janevic and Lindsay C Kobayashi and John D Piette} } @article {9249, title = {Racial and socioeconomic disparities in disabling chronic pain: Findings from the Health and Retirement Study.}, journal = {The Journal of Pain: Official Journal of the American Pain Society}, volume = {18}, year = {2017}, pages = {1459-1467}, abstract = {The U.S. National Pain Strategy calls for increased population research on "high impact chronic pain," i.e., longstanding pain that substantially limits participation in daily activities. Using data from the nationally-representative Health and Retirement Study (HRS), we investigated the prevalence of high-impact chronic pain in U.S. adults over age 50 overall and within population subgroups. We also explored sociodemographic variation in pain-related disability within specific activity domains. Data are from a subsample of HRS respondents (n=1,925) who were randomly selected for a supplementary pain module in 2010. Our outcome was operationalized as pain duration of >7 months and a disability rating of >7 (0 to 10 scale) in at least one domain: family/home, leisure, social activities, work, or basic activities. Overall, 8.2\% (95\% C.I. = 6.7 to 10.1\%) of adults over age 50 met criteria for high-impact chronic pain. This proportion rose to 17.1\% (95\% C.I. = 12.3 to 23.4\%) among individuals in the lowest wealth quartile. Prevalence differences by education, race/ethnicity and age were not significant. Arthritis and depression were significantly associated with high-impact pain in multivariable analysis. Among adults with any chronic pain, African Americans and individuals in the lowest wealth quartile reported more pain-related disability across activity domains.

PERSPECTIVE: High-impact chronic pain is unequally distributed among midlife and older U.S. adults. Efforts to reduce the burden of disabling chronic pain should prioritize socioeconomically vulnerable groups, who may have the least access to multi-modal pain treatment to improve function.}, keywords = {Chronic pain, Racial/ethnic differences, Socioeconomic factors}, issn = {1528-8447}, doi = {10.1016/j.jpain.2017.07.005}, author = {Mary R Janevic and Sara J McLaughlin and Alicia A Heapy and Thacker, Casey and John D Piette} } @article {6466, title = {Advance directive completion by elderly americans: A decade of change}, journal = {Journal of the American Geriatrics Society}, volume = {62}, year = {2014}, note = {Export Date: 21 April 2014 Source: Scopus Article in Press}, pages = {706-710}, abstract = {Objectives: To describe trends in advance directive (AD) completion from 2000 to 2010 and to explore the relationship between AD and hospitalization and hospital death at the end of life. Design: Retrospective cohort study. Setting: Health and Retirement Study (HRS). Participants: HRS participants who died between 2000 and 2010 and were aged 60 and older at death (N = 6,122). Measurements: Trends over time in rates of AD completion, hospitalization before death, and death in hospital are described. The association between trends in AD completion and hospital death was then assessed by comparing nested, multivariable logistic regression models predicting the odds of hospital death over time with and without adjusting for AD status and sociodemographic characteristics. The complex sampling design was accounted for in all analyses. Results: The proportion of decedents with an AD increased from 47 in 2000 to 72 in 2010. At the same time, the proportion of decedents with at least one hospitalization in the last 2 years of life increased from 52 to 71 , and the proportion dying in the hospital decreased from 45 to 35 . After adjusting for confounding by sociodemographic characteristics, the trend in declining hospital death over the decade was negligibly associated with the greater use of ADs. Conclusion: There has been a significant increase in rates of AD completion over the last decade, but this trend has had little effect upon hospitalization and hospital death, suggesting that AD completion is unlikely to stem hospitalization before death. 2014, The American Geriatrics Society.}, keywords = {End of life decisions, Retirement Planning and Satisfaction}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84897346861andpartnerID=40andmd5=6c3047d8b5bb80860463fea1777abea9}, author = {Maria J Silveira and Wiitala, W. and John D Piette} } @article {7806, title = {Adults with cardiovascular disease who help others: a prospective study of health outcomes.}, journal = {J Behav Med}, volume = {36}, year = {2013}, note = {Copyright - Springer Science Business Media New York 2013 Last updated - 2013-04-30 DOI - 2922261571; 76454332; 69709; BVMD; 22481214; SPVLBVMD108653629414}, month = {2013 Apr}, pages = {199-211}, publisher = {36}, abstract = {

Little is known about the health impact of helping behaviors among individuals with high-risk chronic diseases such as cardiovascular disease (CVD). Using a nationally representative, longitudinal survey, we examined the subsequent health of adults with CVD (n~=~4,491) who spent time providing non-paid assistance to family and friends outside of their households compared with those who had provided no assistance. After both adjusting for baseline characteristics and using propensity score matching methods, spending up to 200~h over the prior 12~months helping others was associated with lower odds of experiencing a new CVD event or dying in the subsequent 2~years. Providing up to 100~h of assistance was associated with reporting fewer depressive symptoms. This threshold effect raises the question of whether assistance beyond a certain number of hours may impose a burden that mitigates health benefits from helping others. Health care providers could play an important role exploring ways that patients with CVD can provide beneficial levels of assistance to others in their own social networks or communities, thereby possibly also improving their own health.

}, keywords = {Activities of Daily Living, Aged, Cardiovascular Diseases, depression, Female, Health Status, Helping Behavior, Humans, Longitudinal Studies, Male, Middle Aged, Prospective Studies, Time Factors}, issn = {1573-3521}, doi = {10.1007/s10865-012-9414-4}, url = {http://search.proquest.com.proxy.lib.umich.edu/docview/1318045378?accountid=14667}, author = {Michele M Heisler and Choi, Hwajung and John D Piette and Ann Marie Rosland and Kenneth M. Langa and Stephanie Brown} } @article {7799, title = {Functional limitations in older adults who have cognitive impairment without dementia.}, journal = {J Geriatr Psychiatry Neurol}, volume = {26}, year = {2013}, note = {NLM Title Abbreviation: J Geriatr Psychiatry Neurol}, month = {2013 Jun}, pages = {78-85}, abstract = {

OBJECTIVE: To characterize the prevalence of functional limitations among older adults with cognitive impairment without dementia (CIND).

METHODS: Secondary data analysis was performed using the Aging, Demographics, and Memory Study data set. A total of 856 individuals aged >= 71 years were assigned to 3 diagnostic cognitive categories. A questionnaire was completed by a proxy informant regarding functional limitations for 744 of the 856 respondents.

RESULTS: Of the 744 patients, 263 (13.9\%) had dementia, 201 (21.3\%) had CIND, and 280 (64.8\%) had normal cognition. Informants reported >=1 instrumental activities of daily living (ADLs) limitation in 45\% of the patients with CIND compared to 13\% of the patients with normal cognition and 85\% of the patients with dementia (P < .001). The ADL impairments among individuals with CIND were primarily attributed to physical health problems (n = 41; 40\%).

CONCLUSIONS: Many individuals with CIND have impairment in a range of complex and basic daily activities, largely due to physical health problems.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Cognitive Dysfunction, Dementia, Female, Humans, Male, Neuropsychological tests, Severity of Illness Index, Surveys and Questionnaires}, issn = {0891-9887}, doi = {10.1177/0891988713481264}, author = {Tanya R Gure and Kenneth M. Langa and Gwenith G Fisher and John D Piette and Brenda L Plassman} } @article {7683, title = {Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study.}, journal = {Hepatology}, volume = {55}, year = {2012}, month = {2012 Jan}, pages = {184-91}, publisher = {55}, abstract = {

UNLABELLED: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients{\textquoteright} health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person.

CONCLUSION: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.

}, keywords = {Aged, Black People, Caregivers, Comorbidity, Cost of Illness, Databases, Factual, Disability Evaluation, Female, Health Care Costs, Health Status, Hispanic or Latino, Humans, Incidence, Liver Cirrhosis, Male, Medicaid, Medicare, Prevalence, Prospective Studies, Retirement, United States, White People}, issn = {1527-3350}, doi = {10.1002/hep.24616}, author = {M. O. Rakoski and Ryan J McCammon and John D Piette and Theodore J Iwashyna and J. A. Marrero and Lok, Anna S and Kenneth M. Langa and Volk, Michael L} } @article {7530, title = {The case for involving adult children outside of the household in the self-management support of older adults with chronic illnesses.}, journal = {Chronic Illn}, volume = {6}, year = {2010}, month = {2010 Mar}, pages = {34-45}, publisher = {6}, abstract = {

OBJECTIVES: This study sought to (1) identify barriers to spousal support for chronic illness self-care among community-dwelling older adults; and (2) describe the potential availability of self-care support from adult children living outside of the household.

METHODS: Nationally representative US sample of chronically ill adults aged 51+ were interviewed as part of the Health and Retirement Study (N = 14,862). Both participants and their spouses (when available) reported information about their health and functioning. Participants also reported information about their contact with adult children and the quality of those relationships.

RESULTS: More than one-third (38\%) of chronically ill older adults in the US are unmarried; and when spouses are available, the majority of them have multiple chronic diseases and functional limitations. However, the vast majority of chronically ill older adults (93\%, representing roughly 60 million Americans) have adult children, with half having children living over 10 miles away. Most respondents with children (78\%) reported at least weekly telephone contact and that these relationships were positive. Roughly 19 million older chronically ill Americans have adult children living at a distance but none nearby; these children are in frequent telephone contact and respondents (including those with multiple chronic diseases) report that the relationships are positive.

DISCUSSION: As the gap between available health services for disease management and the need among community-dwelling patients continues to grow, adult children-including those living at a distance-represent an important resource for improving self-care support for people with chronic diseases.

}, keywords = {Adult, Chronic disease, Family Relations, Female, Humans, Male, Middle Aged, Self Care, Social Support}, issn = {1745-9206}, doi = {10.1177/1742395309347804}, author = {John D Piette and Ann Marie Rosland and Maria J Silveira and Mohammed U Kabeto and Kenneth M. Langa} } @article {7464, title = {Differences in functional impairment across subtypes of dementia.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {65}, year = {2010}, month = {2010 Apr}, pages = {434-41}, publisher = {65A}, abstract = {

BACKGROUND: Dementia is a cause of disability in later life. Despite the importance of functional status to the diagnosis of dementia, limited information exists on differences in functional limitations by dementia subtype. We conducted a cross-sectional analysis using the Aging, Demographics, and Memory Study (ADAMS) to determine the extent of functional impairment among older adults with dementia due to different etiologies.

METHODS: The ADAMS sample consisted of 856 individuals aged 71 years and older originally surveyed as part of the Health and Retirement Study. Based on a comprehensive in-person cognitive evaluation, respondents were assigned to diagnostic categories of normal cognition, cognitive impairment not demented, and demented. Dementia subtypes were grouped into three categories: vascular dementia (VaD), Alzheimer{\textquoteright}s dementia (AD), and dementia due to other etiologies. For 744 of the 856 respondents, a proxy informant completed a questionnaire asking whether the respondent had difficulty completing instrumental activities of daily living and activities of daily living (ADLs).

RESULTS: Of 744 ADAMS participants, 263 had dementia: 199 (70.5\%) with AD, 42 (16.9\%) with VaD, and 22 (12.6\%) were demented due to other etiologies. After adjustment for demographics, chronic illnesses, and dementia severity, participants with VaD (odds ratio [OR] 5.74; 95\% confidence interval [CI] 2.60-12.69) and other etiologies of dementia (OR 21.23; 95\% CI 7.25-62.16) were more likely to have greater than or equal to four ADL limitations compared with those with AD.

CONCLUSIONS: VaD is associated with significantly more ADL limitations than AD. These physical limitations should be considered when designing adult day care programs, which adequately accommodate the needs of non-AD patients.

}, keywords = {Activities of Daily Living, Aged, Alzheimer disease, Dementia, Dementia, Vascular, Humans}, issn = {1758-535X}, doi = {10.1093/gerona/glp197}, author = {Tanya R Gure and Mohammed U Kabeto and Brenda L Plassman and John D Piette and Kenneth M. Langa} } @article {7476, title = {Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach.}, journal = {Value Health}, volume = {13}, year = {2010}, month = {2010 Jun-Jul}, pages = {338-45}, publisher = {13}, abstract = {

OBJECTIVE: Although multiple noncost factors likely influence a patient{\textquoteright}s propensity to forego treatment in the face of cost pressures, little is known about how patients{\textquoteright} sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults.

METHODS: We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone{\textquoteright}s risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005.

RESULTS: Of the 3071 respondents who met study criteria, 20\% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN.

CONCLUSIONS: Noncost factors influenced patients{\textquoteright} propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients{\textquoteright} cost pressures.

}, keywords = {Aged, Aged, 80 and over, Chronic disease, Female, Financing, Personal, Health Status, Humans, Logistic Models, Male, Medication Adherence, Models, Econometric, Multivariate Analysis, Prescription Fees, Risk Factors, Socioeconomic factors, United States}, issn = {1524-4733}, doi = {10.1111/j.1524-4733.2009.00679.x}, author = {Zivin, Kara and Scott M Ratliff and Michele M Heisler and Kenneth M. Langa and John D Piette} } @article {7450, title = {Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.}, journal = {Med Care}, volume = {48}, year = {2010}, note = {Using Smart Source Parsing Feb Comment In: Med Care. 2010 Feb;48(2):85-6 20057326 Index Medicus}, month = {2010 Feb}, pages = {87-94}, publisher = {48}, abstract = {

CONTEXT: It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths.

OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47\% compared with 38\%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54\% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42\% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

}, keywords = {Aged, Aged, 80 and over, Cardiovascular Diseases, Female, Financing, Personal, Health Care Costs, Health Services Accessibility, Health Status Disparities, Hospitalization, Humans, Logistic Models, Longitudinal Studies, Male, Medication Adherence, Middle Aged, Multivariate Analysis, Risk Factors, United States}, issn = {1537-1948}, doi = {10.1097/MLR.0b013e3181c12e53}, author = {Michele M Heisler and Choi, Hwajung and Allison B Rosen and Sandeep Vijan and Mohammed U Kabeto and Kenneth M. Langa and John D Piette} } @article {7173, title = {Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients{\textquoteright} treatment priorities and self-management?}, journal = {J Gen Intern Med}, volume = {22}, year = {2007}, month = {2007 Dec}, pages = {1635-40}, publisher = {22}, abstract = {

BACKGROUND: The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40\% have at least three.

OBJECTIVE: We sought to understand how the number, type, and severity of comorbidities influence diabetes patients{\textquoteright} self-management and treatment priorities.

DESIGN: Cross-sectional observation study.

PATIENTS: A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.

MEASUREMENTS: We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).

RESULTS: 40\% of respondents had at least 1 microvascular comorbidity, 79\% at least 1 macrovascular comorbidity, and 61\% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.

CONCLUSIONS: The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients{\textquoteright} self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

}, keywords = {Aged, Attitude to Health, Cohort Studies, Comorbidity, Cross-Sectional Studies, Diabetes Mellitus, Female, Health Priorities, Heart Failure, Humans, Male, Middle Aged, Self Care, Severity of Illness Index, United States}, issn = {1525-1497}, doi = {10.1007/s11606-007-0313-2}, author = {Eve A Kerr and Michele M Heisler and Sarah L. Krein and Mohammed U Kabeto and Kenneth M. Langa and David R Weir and John D Piette} } @article {6920, title = {The health effects of restricting prescription medication use because of cost.}, journal = {Med Care}, volume = {42}, year = {2004}, note = {Comment in: Med Care. 2004 Jul;42(7):623-5 AN=15213485}, month = {2004 Jul}, pages = {626-34}, publisher = {42}, abstract = {

BACKGROUND: High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS: We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS: In adjusted analyses, 32.1\% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2\% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9\% vs. 8.2\%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8\% vs. 5.3\%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS: Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

}, keywords = {Aged, Chronic disease, Female, Financing, Personal, Health Services Accessibility, Health Status, Humans, Male, Middle Aged, Multivariate Analysis, Patient Compliance, Prospective Studies, Risk, United States}, issn = {0025-7079}, doi = {10.1097/01.mlr.0000129352.36733.cc}, author = {Michele M Heisler and Kenneth M. Langa and Eby, Elizabeth L. and A. Mark Fendrick and Mohammed U Kabeto and John D Piette} }