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The association between chronic disease and physical disability among female Medicaid beneficiaries 18–64 years of age
Disability and Health Journal 6 (2013) 141e148 www.disabilityandhealthjnl.com
Research Paper
The association between chronic disease and physical disability among female Medicaid beneficiaries 18e64 years of age Amal J. Khoury, Ph.D., M.P.H.a,*, Allyson Hall, Ph.D.b, Elena Andresen, Ph.D.c, Jianyi Zhang, Ph.D.b, Rachel Ward, M.P.H.d, and Chad Jarjoura, M.D.e a
Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Box 70623, Johnson City, TN 37614, USA b Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA c Institute on Development & Disability, Oregon Health & Science University, Portland, OR, USA d Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN, USA e Holston Medical Group, Kingsport, TN, USA
Abstract Background: Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. Objective: This study described the prevalence of chronic disease among adult (18e64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005. Methods: Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability. Results: Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts. Discussion: Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the longrun. Ó 2013 Elsevier Inc. All rights reserved. Keywords: Disability; Women’s health; Medicaid; Access to health care
According to a comprehensive report from the U.S. Census Bureau, about 56.7 million people (19 percent of the civilian, non-institutionalized population) had a disability in 2010, based on a broad definition of disability, with more than half of them reporting the disability was severe. This estimate includes 41.5 million adults who had disabilities in the physical domain.1 The prevalence of disability remained relatively unchanged since 1999, likely due to Financial support information: This study was funded by the Florida Agency for Health Care Administration, through the Florida Center for Medicaid and the Uninsured. * Corresponding author. Tel.: þ1 423 439 4937. E-mail address: [email protected] (A.J. Khoury). 1936-6574/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.11.006
competing trends. While progress has been made on some fronts, which might have decreased disability (e.g. a better educated public, improved medical interventions, increased use of assistive technology, and increased public health focus on appropriate behavior modifications), trends, such as the obesity epidemic and the increasing lifespan in the last decade, may have increased disability, hence countering this progress.2e4 While the prevalence of disability in the U.S. has remained stable in the past decade, the absolute number of people living with disability has increased, representing a major policy concern. The unmet needs of the growing number of people living with disability are highlighted by the creation of the new Health and Human Service (HHS)
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agency, Administration for Community Living, which combines efforts of the Administration on Aging, the Office on Disability, and the Administration on Developmental Disabilities in a single agency. Globally, disability is becoming a greater concern due to aging populations and the global increase in chronic diseases, as stated in The Toronto Declaration on Bridging Knowledge, Policy and Practice in Aging and Disability, issued in March 2012.4 The variation in disability rates by population group represents yet another public health policy concern. Women, African Americans, and individuals with low-income and low educational attainment are at greater risk for disability than men, Caucasians, and individuals with higher incomes and educational attainment, respectively.5e8 In addition, length of life with disease and mobility functioning loss has increased, indicating a need to prevent disability and improve quality of life in later years.9 And while aging with disability is a concern for both sexes, women live longer than men, and older women experience higher rates of disability than older men,10 making them a particularly vulnerable group. While health and disability are different concepts, chronic health conditions increase the risk of disability. Disability and functioning can be viewed as outcomes of the interaction between health conditions and contextual factors, including environmental and personal factors. This interaction leads persons with chronic health conditions to experience varied levels of disability, including no disability, impairment, activity limitation, or participation restriction.11 In the U.S. today, chronic disease, including heart disease, cancer, and stroke, accounts for greater than 50% of all deaths annually and affects more than 133 million Americans.12,13 Chronic disease is often the cause of functional limitations and disabilities, especially in older ages, or the cause of medical and mental health complications that can lead to disability.13 For example, estimates are that 40% of the increase in disability prevalence in working-aged adults can be attributed to obesity.14 It seems that every individual can experience a decrement in health and therefore some disability, making disability an experience that can be impacted by all health conditions, especially in the absence of supportive social and personal environments.11 In addition, people with disability experience some added risks of secondary conditions including chronic disease. For example, physical disability may contribute to chronic lung disease, depression, and anxiety, or trigger the development of some health conditions at a younger age leading to additional health complications.15e17 Regardless of the causal pathway, there is a strong association between disability and chronic disease. In crosssectional observations, the presence of disability has been found to be significantly associated with all chronic diseases (diabetes, hypertension, coronary heart disease, stroke, arthritis, and asthma) among adults ages 50e65 years, and the odds of having a disability were higher in women relative
to men.18 Among older adults, although the relationships between chronic disease and disability were largely unchanged in the past decade (between 1998 and 2008), disability became less associated with hypertension and more associated with diabetes and lung disease.19 Within the working-age population, there is a strong association between chronic disease and disability that can be attributed, at least in part, to obesity.14 And, among women, the prevalence of hypertension appears to increase with the number of functional limitations: hypertension was present in 34% of women with 3 or more functional limitations, compared to 27% of women with 1 or 2 limitations, and 15% of women with no limitations in a national sample.6 Zhao and colleagues (2009) suggest a linear relationship between chronic disease rates and disability, where the odds of reporting a disability increase with each additional chronic disease.12 Understanding the rates of certain chronic illnesses among populations living with disability is necessary for appropriate public health planning. Further, understanding the burden of multimorbidity can inform health care planning, as the co-existence of chronic conditions has implications for health system design and for care coordination and management approaches for such patients.19,20 To our knowledge, few studies have explored the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. Yet, nationally, over 21 million lowincome women (69% of adult Medicaid beneficiaries) were enrolled in Medicaid in 2008.21 Medicaid is a critical source of health care financing for women living with disabilities and provides assistance both with medical services and supportive living arrangements. Half of all women in the United States ages 21 to 64 living with a disability are covered by Medicaid.21 This study describes and compares the prevalence of chronic disease among women living with a physical disability who are Florida Medicaid beneficiaries. We define our physical disability study groups based on medical diagnoses of mobility-limiting conditions (diseases of the central and peripheral nervous systems and of the musculoskeletal systems, injury, congenital anomalies) and use of mobility-assistive devices. We examine the distribution of ten chronic diseases across the physical disability study groups, including asthma, hypertension, diabetes, depression, chronic pulmonary disease, heart failure, HIV/AIDS, breast cancer, lung cancer, and End Stage Renal Disease. Previous studies have largely depended on self-report data and were limited by sampling bias due to relying on phone surveying, recall bias, and/or on another household member responding on behalf of the person with disability. Additionally, the means by which individuals cope with disability may not be equivalent, and these differences may influence self-reports of disability in surveys.22 Further, some studies did not differentiate between types of disability while others treated disability as an ‘‘all or
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none’’ phenomenon. This study augments findings from previous work by using Medicaid claims data to describe physical disability and to compare the prevalence of certain chronic diseases across women with two levels of physical disability, with women who live without disability. While there are certain limitations associated with the use of administrative data, these data represent an entire population and reflect recorded clinical diagnoses and actual utilization and therefore provide a viable alternative to surveys.23 The data are typical of health plans and represent a source of new information and methodology to examine access to care, health care utilization and potential health disparities of women with physical disability.18,24 Further, using Medicaid data to describe health and physical disability among beneficiaries is important to inform Medicaid policy and for planning and prevention purposes at the state level. Using Florida Medicaid data is particularly helpful given the large size of the state and the heterogeneity of its population. Florida provides an interesting case study due to its substantial diversity including racial (e.g. 16% African American), ethnic (22% Hispanic), elderly and veteran (17% over 65) and rural (16% live in non-metropolitan areas) populations.25,26
Methods Study population Our study population included all adult (18e64 years of age) female beneficiaries of the Florida Medicaid program who were continuously enrolled in the program and had at least one outpatient visit during the study period. Our study period was defined by the four and half (4.5) most recent years of data (May 2001eOctober 2005) at the time of study. We excluded women who had not been continuously enrolled in the Medicaid program during the study period, i.e., who had one or more lapses in coverage, because we could not capture the services that they might have received during periods of lapses in coverage. Also, continuous coverage better captures women with long-term (not temporary) disability. We excluded women who were dually eligible for Medicaid and Medicare, because we lacked access to Medicare claims and therefore could not capture Medicare-covered services. We also excluded beneficiaries with limited benefits, including Medically Needy, Family Planning Waiver, and Part B Medicare Only (PBMO). Medically Needy includes individuals whose income is too high to qualify for other Medicaid programs but who have large monthly medical bills. For those individuals, the Medicaid benefit consists of coverage only for the month or partial month when share of cost was met. The Family Planning Waiver only covers family planning services and related ancillary services, treatment for sexually transmitted diseases, sterilization, and colposcopy. QI 1 (Qualifying individualsdformerly PBMO) pays for Medicare Part B premium only.
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Data sources Data were extracted from the Florida Medicaid eligibility and claims files. The eligibility file includes the beneficiaries’ age, gender, race, zip code, social security number, Medicaid identification number, and eligibility criteria (e.g. Social Security Income [SSI], Temporary Assistance to Needy Families [TANF]). We merged this file with facility inpatient/outpatient, medical/physician, and pharmacy claims files, which included the beneficiaries’ identification, date of service, primary and secondary diagnosis codes, CPT (Current Procedure Terminology) or ICD (International Classification of Disease) procedure codes, payment amount, provider information (identification number, specialty, zip code), discharge status, length of stay, drug code (NDC), therapeutic class, and days of supply. Analytic file Each individual’s records from the eligibility file or various claims files (facility, medical/physician, and pharmacy) were aggregated/collapsed into per person per record. Based on the information in the respective claims files, each record was flagged for different levels of physical mobility, various types of mobility-assistive devices, and 10 different chronic conditions, including asthma, breast cancer, lung cancer, end stage renal disease (ESRD), diabetes, HIV/ AIDS, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), depression, and congestive heart failure. A person-level analytic file was therefore created by merging the records for adult females 18e64 years of age. Study groups We used ICD-9 codes for physically-disabling conditions and CPT codes for mobility-assistive devices (such as cane, walker, or wheelchair) to define physical disability categories. We identified and included ICD-9 codes for the following physically-disabling conditions: hereditary and degenerative diseases of the central nervous system (such as Parkinson’s Disease and spinocerebellar disease); other diseases of the central nervous system (including multiple sclerosis, cerebral palsy, paralytic syndromes, and brain conditions); disorders of the peripheral nervous system, (including mononeuritis of the upper and lower limbs, neuropathy, and muscular dystrophy); diseases of the musculoskeletal system and connective tissue (such as rheumatoid arthritis and disorders of the back, muscle, and cervix); injury (including spinal cord injury, fractures of the skull, vertebral column, pelvis, and lower limb, and late effects of injury to the musculoskeletal and nervous systems); and congenital anomalies (including spina bifida and congenital anomalies of the musculoskeletal and nervous systems). Two experts, including a disability epidemiologist and a physician, reviewed the ICD-9 codes and corresponding diagnoses for face validity. The reviews
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were highly consistent and produced a total of 41 physically-disabling conditions (Table 1). With assistance from the Florida Center for Medicaid and the Uninsured, we identified local CPT codes for mobilityassistive devices, including canes, crutches, walkers and accessories, wheelchairs and accessories, and hospital beds and accessories (The list of CPT codes and corresponding devices is available from the authors). We then created three ordinal levels of physical disability: 1) No Physically-Disabling Condition, No Device, i.e., women who had NOT been diagnosed with a physicallydisabling condition AND did NOT use a mobility-assistive device; 2) Physically-Disabling Condition, No Device, i.e., women who had been diagnosed with one or more physically-disabling conditions but did NOT use a mobilityassistive device; and 3) Physically-Disabling Condition, Device User, i.e., women who had been diagnosed with a physically-disabling condition AND used a mobilityassistive device, such as cane, walker, or wheelchair. A variable that distinguished among the three groups was created and added to the analytic file. Since administrative data do not capture body functions, activity, and participation as described in the ICF, our definition of disability used a ‘‘medical model’’ view, based on medical diagnosis, rather than an ICF-based view. Our classification does not assume that physical disability is an all-or-nothing phenomenon, but that levels of severity of disability are important. As such, we constructed an ordinal scale of levels of physical disability, where levels are not assumed to be equidistant from each other. Similar definitions have been used by disability researchers.6,17,18 While less common, mobility devices have also been used as part of defining levels of disability in the general population, among women with multiple sclerosis, and to measure Health-Related Quality of Life for persons with mobility impairments.24,27,28 Study variables We included a number of measures that described our study population, including age at the beginning of the study, race/ethnicity, and State Assistance Category Group. We also independently examined each of the following chronic diseases from claims associated with these diseases at any time during the study period: asthma, breast cancer, lung cancer, end stage renal disease (ESRD), diabetes, HIV/ AIDS, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), depression, and congestive heart failure. Those diseases were selected for the following reasons. They represent a major public health and health care burden due to their chronic nature and high prevalence rates. They are associated with a decline in health-related quality of life. They have modifiable risk factors that are amenable to change, as well as evidencebased disease management programs. And they tend to be well-documented in administrative databases.
Analysis We examined the age, racial/ethnic distribution, and state assistance category groups of women overall and by level of physical disability. We computed the proportion of women who had been diagnosed with each of the 10 chronic diseases and compared the prevalence of disease among the study groups. The study protocol was approved by the University of Florida Institutional Review Board.
Results A total of 650,163 women were continuously enrolled in Medicaid during the study period. After removing women with no claims, dual eligibility, and those who fell into one of the other exclusion criteria, 74,851 women were included in the analysis. Of these, 39,381 women (52.61%) were defined as level 1 (No Physically-Disabling Condition, No Device); 31,527 women (42.12 %) were defined as level 2 (Physically-Disabling Condition, No Device); and 3,943 (5.27%) as level 3 (Physically-Disabling Condition, Device User). Thus, close to half of the study population experienced one or more physically-disabling conditions. Table 2 presents the characteristics of the three physical disability groups and the analytic sample overall. The average age of women was 38 years. We examined the distribution of women across five age groups (18e25, 26e35, 36e45, 46e55, and 56e64). There were approximately equal proportions of women in each age group, with the exception of women 56e64 years of age who represented only 11% of the study population. With regard to race/ ethnicity, 36% of women were White, non-Hispanic, 39% were Black, 15% were Hispanic, and the remaining 10% belonged to Oriental, American Indian, and other groups. Almost seven out of 10 women had SSI (Social Security Income), and one in four were TANF (Temporary Assistance to Needy Families) recipients. The average age of Level 3 women (Physically-Disabling Condition, Device User) was 45.5 years and was higher than the average age of other women. The association between age and level of physical disability was consistent regardless of whether we analyzed age as a continuous or categorical variable. Relatively larger proportions of Level 2 women (Physically-Disabling Condition, No Device) and Level 3 women (Physically-Disabling Condition, Device User) were White, non-Hispanic, whereas a larger proportion of Level 1 women (No Limiting Condition, No Device) were Black. The proportions of Hispanic and Other women were relatively similar across the physical disability groups. As expected, almost all Level 3 women (93%) received SSI, and this proportion was significantly higher than the proportions of women in the other disability groups who received SSI. More than one-third of Level 1 women were TANF recipients. We examined the prevalence of each of 10 chronic diseases across levels of physical disability. The
A.J. Khoury et al. / Disability and Health Journal 6 (2013) 141e148 Table 1 Conditions associated with physical mobility Hereditary and degenerative diseases of the central nervous system Parkinson’s disease Other extrapyramidal disease and abnormal movement disorders Spinocerebellar disease Disorders of the autonomic nervous system Other disorders of the central nervous system Multiple sclerosis Other demyelinating diseases of CNS Hemiplegia and hemiparesis Infantile cerebral palsy Other paralytic syndromes Other conditions of the brain (cerebral cysts, anoxic brain damage) Other and unspecified disorders of the nervous system Disorders of the peripheral nervous system Nerve root and plexus disorders Mononeuritis of upper limb (e.g. carpal tunnel) Mononeuritis of lower limb Hereditary and idiopathic peripheral neuropathy Inflammatory and toxic neuropathy Muscular dystrophies and other myopathies Diseases of the musculoskeletal system and connective tissue Rheumatoid arthritis Osteoarthrosis Internal derangement of the knee Ankylosing spondylitis and other inflammatory spondylopathies Spondylosis and allied disorders Disc disorders Other disorders of the cervical region Other disorders of the back Polymyalgia rheumatica Disorders of the muscle, ligament and fascia Osteochondropathies Injury Fractures of the vault of the skull Fractures of the base of the skull Fracture of the vertebral column without spinal cord injury Fracture of the vertebral column with spinal cord injury Fracture of the pelvis Late effect of musculoskeletal and connective tissue injuries Late effect of injury to the nervous system Crushing injury of the lower limb Spinal cord injury Congenital anomalies Anencephalus and similar anomalies Spina bifida Other congenital anomalies of the nervous system Other congenital musculoskeletal anomalies
proportions of women who had been diagnosed with each of those chronic diseases are presented in Table 3. The most frequently occurring diseases were hypertension, which affected one in three women overall, followed by depression (19.5%), diabetes (15.7%), chronic obstructive pulmonary disease (13.2%), HIV/AIDS (9.0%), and congestive heart failure (6.7%). Other chronic diseases, including asthma, breast cancer, lung cancer, end stage renal disease, and hemophilia affected less than 3% of women (Table 3). The prevalence of chronic diseases significantly and consistently increased with the level of physical disability. For example, hypertension affected 14% of women with No
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Physically-Disabling Condition/No Device compared to 52% of women with a Physically-Disabling Condition/No Device and a high of 72% of women with PhysicallyDisabling Condition/Device User. Diabetes afflicted 7% of women with No Disabling Condition/No Device compared to 24% of women with a Disabling Condition/ No Device and 40% of women with Disabling Condition/ Device User. A similar trend was observed for all of the other chronic diseases.
Discussion Overall, study participants appeared to be at high risk for both physical disability and co-morbid chronic disease. Close to half of the women had one or more physicallydisabling conditions and 5.3% used mobility-assistive devices, such as canes, crutches, walkers, and wheelchairs. In addition, one-third of the women had hypertension and sizeable proportions had other chronic diseases, such as diabetes, pulmonary disease, and depression. Our findings were consistent with the literature regarding the health risks that Medicaid beneficiaries face and their increased need for preventive and primary care, as well as chronic disease management.8,29,30 Study participants with physical disability were more likely to have co-morbid chronic diseases than their ablebodied counterparts. This is consistent with the literature on the increased incidence of secondary conditions among persons with disability31 and emphasizes the need for prevention of secondary conditions often experienced by persons with disabilities. A study of 2,075 Washington state residents found that secondary conditions were two to three times higher in individuals with disabilities than those without functional limitations.32 In another study, Kinne and colleagues found that 87% of BRFSS respondents with disability in Washington State also reported a secondary condition.33 In a community based sample of women, those with disability were significantly more likely to report a range of secondary conditions, including a 13.6% higher prevalence of obesity than non-disabled women.34 While physical disability can contribute to the incidence of secondary conditions, it is also possible that chronic diseases contributed to physical disability in our study population. For example, untreated diabetes could lead to leg amputations and limitation in physical mobility. The extent to which one health problem contributed to another could not be assessed given the cross-sectional research design of the study. As with any claims-based study, findings are limited by the overall accuracy of claims data, which may not always capture segments of the population that underutilize preventative services (e.g. women without transportation). Further, administrative data do not lend themselves to a definition of disability based on function, activities, environment, and participation as in the International Classification of Functioning, Disability and Health (ICF); therefore, we used
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Table 2 Demographic characteristics of women by disability level Level 1 (no physicallydisabling condition, no Level 2 (physically-disabling assistive device) condition, no assistive (N 5 39,381), women device) (N 5 31,527), with characteristic, women with characteristic n (column %) n (column %) Age (mean, standard deviation) Age group 18e25 26e35 36e45 46e55 56e64 Race/ethnicity White Black Hispanic Otherb State assistance category group SSI Elderly Disabled TANF PMAc SOBRA
34.5 6 12.31
Level 3 (physically-disabling condition, device user) (N 5 3943), women with characteristic n (column %)
Total (N 5 74,851), women with characteristic n (column %)
p-valuea
45.5 6 10.91
37.8 6 12.7
!.0001
(15.7%) (18.2) (26.1) (26.3) (13.7)
267 468 973 1425 810
(31.9%) (11.9) (24.7) (36.1) (20.5)
17,785 16,039 17,420 15,540 8067
(23.8) (21.4) (23.3) (20.8) (10.8)
(42.1) (27.1) (19.6) (11.2)
1702 1082 568 591
(43.2) (27.4) (14.4) (15.0)
26,689 29,024 11,593 7545
(35.7) (38.8) (15.5) (10.1)
40.8 6 12.25
!.0001 12,563 9831 8221 5832 2934
(6.8%) (25.0) (20.9) (14.8) (7.4)
11,721 19,411 4842 3407
(29.8) (49.3) (12.3) (8.6)
4955 5740 8226 8283 4323
!.0001 13,266 8531 6183 3547
!.0001 23,839 210 13,775 1205 350 2
(60.5) (0.5) (35.0) (3.1) (0.9) (0.01)
24,360 380 5920 713 152 2
(77.3) (1.2) (18.8) (2.3) (0.5) (0.01)
3676 51 195 19 2 0
(93.2) (1.3) (5.0) (0.5) (0.05) (0.00)
51,875 641 19,890 1937 504 4
(69.3) (0.86) (26.6) (2.6) (0.7) (0.01)
SSI 5 Supplemental Security Income; TANF 5 Temporary Aid to Needy Families; PMA 5 Public Medical Assistance; SOBRA 5 Sixth Omnibus Budget Reconciliation Act. a p-values based on t-test of independence for the continuous variable ‘‘age’’ and 2 2 tables and Chi-square for all other variables. b ‘‘Other’’ race/ethnicity includes American Indians, oriental, and other groups. c Includes ‘‘Unemployed Parents’’ and ‘‘Public Medical Assistance’’.
a ‘‘medical model’’ definition of disability, based on medical diagnoses, rather than an ICF-based definition. Yet, the use of administrative data has a number of advantages including access to a relatively large and heterogeneous population, the ability to define disability based on objective diagnosis and procedure codes as well as pharmacy claims and durable medical equipment claims, and the ability to examine a wide Table 3 Prevalence of chronic diseases by disability level Level 1 (no physicallydisabling condition, no assistive device) (N 5 39,381), women with disease, n (column %) Had asthma Had breast cancer Had lung cancer Had end stage renal disease Had diabetes Had HIV/AIDS Had chronic obstructive pulmonary disease Had hypertension Had depression Had congestive heart failure a
351 125 30 365 2754 1908 1362
(0.9) (0.3) (0.1) (0.9) (7.0) (4.8) (3.5)
5451 (13.8) 3480 (8.8) 820 (2.1)
p-value based on 2 x 2 tables and Chi-square tests.
range of co-morbid conditions.35 Future research should continue to examine the use of administrative data with augmented information to validate our approach and the robustness of our findings. Administrative data augmented with clinical information or direct patient interviews could also be used to examine the association between physical disability and reproductive
Level 2 (physically-disabling condition, no assistive device) (N 5 31,527), women with disease, n (column %) 1489 465 120 1202 7446 4173 6960
(4.7) (1.5) (0.4) (3.8) (23.6) (13.2) (22.1)
16,264 (51.6) 9713 (30.8) 3170 (10.0)
Level 3 (physically-disabling condition, device user) Total (N 5 74,851), (N 5 3943), women women with disease, with disease, n (column %) n (column %) p-valuea 346 74 28 380 1583 623 1569
(8.8) (1.9) (0.7) (9.6) (40.2) (15.8) (39.8)
2825 (71.6) 1371 (34.8) 998 (25.3)
(2.9) (0.9) (0.2) (2.6) (15.7) (9.0) (13.2)
!.0001 !.0001 !.0001 !.0001 !.0001 !.0001 !.0001
24,540 (32.8) 14,564 (19.5) 4988 (6.7)
!.0001 !.0001 !.0001
2186 664 178 1947 11,783 6704 9891
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health and health care among Medicaid beneficiaries. There is a gap in our knowledge of the impact of disability on pregnancy outcomes, such as premature birth, menstrual problems, and contraceptive use, and a need for future research to address those questions. Overall, our findings support the need for improved chronic disease prevention in younger female Medicaid beneficiaries, and particularly those with physical disability. Medicaid women represent a particularly disadvantaged group, with the majority (84%) having incomes below 200% of the federal poverty level and 58% having incomes below the poverty level.21,23 Poverty is an overarching determinant of health and increases the susceptibility of the Medicaid population to risky behaviors and chronic disease. Socio-economic and educational policies may mitigate the impact of poverty on the health status of Medicaid women. In addition, since the risk factors responsible for the onset of many chronic diseases are modifiable (e.g. tobacco use, insufficient physical activity, poor nutrition and excessive alcohol use),35 many chronic diseases are largely preventable. Strategies to improve prevention, screening and treatment in the younger adult population may mitigate the trends toward higher disability rates in the working-age population and may also prevent high Medicare and Medicaid costs in the long-run. For example, programs to prevent obesity in chronically ill individuals may produce declines in disability in the working-aged population.16 Understanding prevalence rates of chronic disease among Medicaid women with physical disability will allow states to appropriately identify those conditions for which individuals are most at risk. States can then develop disease management programs that either work toward preventing disease or reducing the severity of such disease among people living with disabilities. Such a focus is responsive to the Healthy People 2020 goal of promoting the health and well-being of people with disabilities and ensures that these individuals are included in public health activities and receive well-timed interventions and services.36 Women with disabilities constitute a substantial segment of the Medicaid population and are long-term users of the program. Recommendations for facilitating access to care for these women include increasing the number of participating providers, providing culturally-sensitive services, addressing the language barrier, and supplying transportation in rural areas. There are also missed opportunities for delivering preventive services to women who have contact with the health care system. The Medicaid program could work with providers to better take advantage of outpatient visits to deliver screening and other primary care services through innovative models of care delivery and evidence-based practice support systems. Innovative models, such as the patient-centered medical home, promise to significantly improve the delivery of coordinated and continuous primary care.37e39 Similarly, evidence-based practice systems can effectively increase
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the delivery of preventive and primary care. Such systems may include electronic health records, client-based interventions (such as client reminders, small media, one-onone education), and provider-based interventions (such as provider reminders of when clients are due for screening and provider assessment and feedback).40e46 Finally, there is a need for community-based health education and promotion programs to raise awareness of women of the value of health maintenance and early detection of disease. Such efforts would contribute to the quality of life of beneficiaries and potentially to lower health care spending.
Acknowledgments We thank the Florida Agency for Health Care Administration’s officials for providing access to the Medicaid files and for assistance in identifying CPT codes for mobility devices. References 1. Brault MW. ‘‘American with Disabilities: 2010, ’’ Current Population Reports. Washington, DC: U.S. Census Bureau; 2012. pp. 70e131. 2. Field MJ, Jette AM, eds. The Future of Disability in America. Washington DC: National Academies Press, http://www.nap.edu/catalog. php?record_id511898; 2007. 3. Institute of Medicine. Workshop on Disability in America: A New Look. Washington, DC: The National Academies Press. Papers in Appendices E, F, http://www.nap.edu/catalog.php?record_id511579; 2005. 4. Bickenbach J, Bigby C, Salvador-Carulla L, et al. The Toronto Declaration on Bridging Knowledge, Policy and Practice in Aging and Disability, http://www.marchofdimes.ca/dimes/images/emails/FICCDAT/Toronto_ Declaration.pdf; 2012. 5. Wolf MS, Gazmararian JA, Baker DW. Health literacy and health risk behaviors among older adults. Am J Prev Med. 2007;32:19e24. 6. Chevarley FM, Thierry JM, Gill CJ, Ryerson AB, Nosek MA. Health, preventive health care, and health care access among women with disabilities in the 1994e1995 National Health Interview Survey, Supplement on Disability. Womens Health Issues. 2006;16:297e312. 7. Seeman T, Merkin S, Crimmins E, Karlamangla A. Disability trends among older Americans: National Health and Nutrition Examination Surveys, 1988e1994 and 1999e2004. Am J Public Health. 2010; 100(1):100e107. 8. Plantinga LC, Johansen KL, Schillinger D, Powe NR. Lower socioeconomic status and disability among US adults with chronic kidney disease, 1999e2008. Prev Chronic Dis. 2012;9:E12. 9. Crimmins E, Beltrez-Sanchez H. Mortality and morbidity trends: is there compression of morbidity? J Gerontol B Psychol Sci Soc Sci. 2011;66B(1):75e86. 10. Newman A, Brach J. Gender gap in longevity and disability in older persons. Epidemiol Rev. 2001;23(2):343e350. 11. World Health Organization (WHO). International Statistical Classification of Diseases and Related Health Problems. 10th ed., http://www. who.int/classifications/icd/ICD10Volume2_en_2010.pdf; 2010. Accessed October 2012. 12. Zhao G, Ford ES, Li C, Crews JE, Mokdad AH. Disability and its correlates with chronic morbidities among U.S. adults aged 50-!65 years. Prev Med. 2009;48:117e121. 13. Florida Office on Disability and Health. Adult Disability Prevalence: 2010 Florida Behavioral Risk Factor Surveillance System. Gainesville, Florida: University of Florida; 2011 September.
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14. Kung HS, Hoyert DL, Xu J, Murphy SL. Deaths: final data for 2005. Natl Vital Stat Rep. 2008;561(10). 15. Institute of Medicine. Living Well with Chronic Illness: A Call for Public Health Action. Washington, D.C: The National Academies Press; 2012. 16. Battacharya J, Choudhry K, Lakwawalla D. Chronic disease and trends in severe disability in working-age populations. In: Workshop on Disability in America: A New Look e Summary and Background Papers. Washington, D.C: National Academies Press; 2006. 17. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services. Arch Phys Med Rehabil. 2004;85(5):749e757. 18. Iezzoni LI, McCarthy EP, Davis RB, Harris-David L, O’Day B. Use of screening and preventive services among women with disabilities. Am J Med Qual. 2001;16:135e144. 19. Boyd CM, Fortin M. Future of multimorbidity research: how should understanding of multimorbidity inform health system design? Public Health Reviews. 2010;32:451e474. 20. Mercer SW, Smith SM, Wyke S, O’Dowd T, Watt GCM. Multimorbidity in primary care: developing the research agenda. Fam Pract. 2009;26(2):79e80. 21. The Henry J Kaiser Family Foundation. Issue Brief: An Update on Women’s Health Policy: Medicaid’s Role for Women across the Lifespan. Available at, http://www.kff.org/womenshealth/upload/ 7213-03.pdf; January 2012. 22. Agree EM. The influence of personal care and assistive devices on the measurement of disability. Soc Sci Med. 1999;48(4):427e443. 23. The Henry J. Kaiser Family Foundation. Medicaid’s Role for Women across the Lifespan: Current Issues and the Impact of the Affordable care Act; January 2012. Washington, D.C. 24. Iezzoni LI, McCarthy EP, Davis RB, Siebens H. Mobility impairments and use of screening and preventive services. Am J Public Health. 2000;90(6):955e961. 25. Centers for Disease Control and Prevention. Chronic Disease. The Power to Prevent, the Call to Control: At a Glance, 2009. Atlanta, GA; 2012. December 17, 2009. 26. U.S. Department of Health and Human Services. Healthy People 2020. Disability and Health. Overview and Objectives. Washington, D.C.; 2012 27. Cheng E, Myers L, Wolf S, et al. Mobility impairments and use of preventive services in women with multiple sclerosis: observational study. BMJ. 2001;323:968e969. 28. Froehlich-Grobe K, Andresen EM, Caburnay C, White GW. Measuring health related quality of life for persons with mobility impairments: an enabled version of the short form 36 (SF-36E). Qual Life Res. 2008;17(5):751e770. 29. Billings J, Mijanovich T. Improving the management of care for high cost Medicaid patients. Health Aff. 2007;26(6):1643e1654. 30. Sommers A, Cohen M. Medicaid’s High Cost Enrollees: How Much Do They Drive Programming?. Kaiser Commission, http://www.kff. org/medicaid/upload/7490.pdf; 2006. 31. Meyers AR, Mitra M, Klein-Walker D, Wilber N, Allen D. Predictors of secondary conditions in a sample of independently living adults
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with high level spinal cord injury. Top Spinal Cord Inj Rehabil. 2000;9:1e8. Kinne S. Distribution of secondary medical problems, impairments, and participation limitations among adults with disabilities and their relationship to health and other outcomes. Disabil Health J. 2007; 1(1):42e50. Kinne S, Donald P, Lochner D. Prevalence of secondary conditions among people with disabilities. Am J Public Health. 2004;94(3): 443e445. Nosek M, Hughes R, Petersen N, et al. Secondary conditions in a community-based sample of women with physical disabilities over a 1-year period. Arch Phys Med Rehabil. 2006;87:320e327. Iezzoni LI. Using administrative data to study persons with disabilities. Milbank Q. 2002;80:347e379. Centers for Disease Control and Prevention (CDC). Healthy People 2010: Understanding and Improving Health. Washington, DC: US Government Printing Office; 2000. Davis K, Schoenbaum SC, Audet A. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953e957. Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19): 2038e2040. Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008;21(5): 427e440. Friedberg MW, Coltin KL, Safran DG, Dresser M, Zaslavsky AM, Schneider EC. Associations between structural capabilities of primary care practices and performance on selected quality measures. Ann Intern Med. 2009;151(7):456e463. Hudson SV, Ohman-Strickland P, Cunningham R, Ferrante JM, Hahn K, Crabtree BF. The effects of teamwork and system support on colorectal cancer screening in primary care practices. Cancer Detect Prev. 2007;31(5):417e423. Roetzheim RG, Christman LK, Jacobsen PB, et al. A randomized controlled trial to increase cancer screening among attendees of community health centers. Ann Fam Med. 2004;2(4):294e300. Sarfaty M, Wender R. How to increase colorectal cancer screening rates in practice. CA Cancer J Clin. 2007;57(6):354e366. Baron RC, Rimer BK, Breslow RA, et al; Task Force on Community Preventive Services. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening: a systematic review. Am J Prev Med. 2008 Jul;35(suppl 1):S34eS55. Baron RC, Melillo S, Rimer BK, et al; Task Force on Community Preventive Services. Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: a systematic review of provider reminders. Am J Prev Med. 2010 Jan;38(1):110e117. Sabatino SA, Habarta N, Baron RC, et al; Task Force on Community Preventive Services. Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: Systematic reviews of provider assessment and feedback and provider incentives. Am J Prev Med. 2008 Jul;35(suppl 1):S67eS74.
Research Paper
The association between chronic disease and physical disability among female Medicaid beneficiaries 18e64 years of age Amal J. Khoury, Ph.D., M.P.H.a,*, Allyson Hall, Ph.D.b, Elena Andresen, Ph.D.c, Jianyi Zhang, Ph.D.b, Rachel Ward, M.P.H.d, and Chad Jarjoura, M.D.e a
Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Box 70623, Johnson City, TN 37614, USA b Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA c Institute on Development & Disability, Oregon Health & Science University, Portland, OR, USA d Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN, USA e Holston Medical Group, Kingsport, TN, USA
Abstract Background: Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. Objective: This study described the prevalence of chronic disease among adult (18e64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005. Methods: Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability. Results: Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts. Discussion: Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the longrun. Ó 2013 Elsevier Inc. All rights reserved. Keywords: Disability; Women’s health; Medicaid; Access to health care
According to a comprehensive report from the U.S. Census Bureau, about 56.7 million people (19 percent of the civilian, non-institutionalized population) had a disability in 2010, based on a broad definition of disability, with more than half of them reporting the disability was severe. This estimate includes 41.5 million adults who had disabilities in the physical domain.1 The prevalence of disability remained relatively unchanged since 1999, likely due to Financial support information: This study was funded by the Florida Agency for Health Care Administration, through the Florida Center for Medicaid and the Uninsured. * Corresponding author. Tel.: þ1 423 439 4937. E-mail address: [email protected] (A.J. Khoury). 1936-6574/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.11.006
competing trends. While progress has been made on some fronts, which might have decreased disability (e.g. a better educated public, improved medical interventions, increased use of assistive technology, and increased public health focus on appropriate behavior modifications), trends, such as the obesity epidemic and the increasing lifespan in the last decade, may have increased disability, hence countering this progress.2e4 While the prevalence of disability in the U.S. has remained stable in the past decade, the absolute number of people living with disability has increased, representing a major policy concern. The unmet needs of the growing number of people living with disability are highlighted by the creation of the new Health and Human Service (HHS)
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agency, Administration for Community Living, which combines efforts of the Administration on Aging, the Office on Disability, and the Administration on Developmental Disabilities in a single agency. Globally, disability is becoming a greater concern due to aging populations and the global increase in chronic diseases, as stated in The Toronto Declaration on Bridging Knowledge, Policy and Practice in Aging and Disability, issued in March 2012.4 The variation in disability rates by population group represents yet another public health policy concern. Women, African Americans, and individuals with low-income and low educational attainment are at greater risk for disability than men, Caucasians, and individuals with higher incomes and educational attainment, respectively.5e8 In addition, length of life with disease and mobility functioning loss has increased, indicating a need to prevent disability and improve quality of life in later years.9 And while aging with disability is a concern for both sexes, women live longer than men, and older women experience higher rates of disability than older men,10 making them a particularly vulnerable group. While health and disability are different concepts, chronic health conditions increase the risk of disability. Disability and functioning can be viewed as outcomes of the interaction between health conditions and contextual factors, including environmental and personal factors. This interaction leads persons with chronic health conditions to experience varied levels of disability, including no disability, impairment, activity limitation, or participation restriction.11 In the U.S. today, chronic disease, including heart disease, cancer, and stroke, accounts for greater than 50% of all deaths annually and affects more than 133 million Americans.12,13 Chronic disease is often the cause of functional limitations and disabilities, especially in older ages, or the cause of medical and mental health complications that can lead to disability.13 For example, estimates are that 40% of the increase in disability prevalence in working-aged adults can be attributed to obesity.14 It seems that every individual can experience a decrement in health and therefore some disability, making disability an experience that can be impacted by all health conditions, especially in the absence of supportive social and personal environments.11 In addition, people with disability experience some added risks of secondary conditions including chronic disease. For example, physical disability may contribute to chronic lung disease, depression, and anxiety, or trigger the development of some health conditions at a younger age leading to additional health complications.15e17 Regardless of the causal pathway, there is a strong association between disability and chronic disease. In crosssectional observations, the presence of disability has been found to be significantly associated with all chronic diseases (diabetes, hypertension, coronary heart disease, stroke, arthritis, and asthma) among adults ages 50e65 years, and the odds of having a disability were higher in women relative
to men.18 Among older adults, although the relationships between chronic disease and disability were largely unchanged in the past decade (between 1998 and 2008), disability became less associated with hypertension and more associated with diabetes and lung disease.19 Within the working-age population, there is a strong association between chronic disease and disability that can be attributed, at least in part, to obesity.14 And, among women, the prevalence of hypertension appears to increase with the number of functional limitations: hypertension was present in 34% of women with 3 or more functional limitations, compared to 27% of women with 1 or 2 limitations, and 15% of women with no limitations in a national sample.6 Zhao and colleagues (2009) suggest a linear relationship between chronic disease rates and disability, where the odds of reporting a disability increase with each additional chronic disease.12 Understanding the rates of certain chronic illnesses among populations living with disability is necessary for appropriate public health planning. Further, understanding the burden of multimorbidity can inform health care planning, as the co-existence of chronic conditions has implications for health system design and for care coordination and management approaches for such patients.19,20 To our knowledge, few studies have explored the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. Yet, nationally, over 21 million lowincome women (69% of adult Medicaid beneficiaries) were enrolled in Medicaid in 2008.21 Medicaid is a critical source of health care financing for women living with disabilities and provides assistance both with medical services and supportive living arrangements. Half of all women in the United States ages 21 to 64 living with a disability are covered by Medicaid.21 This study describes and compares the prevalence of chronic disease among women living with a physical disability who are Florida Medicaid beneficiaries. We define our physical disability study groups based on medical diagnoses of mobility-limiting conditions (diseases of the central and peripheral nervous systems and of the musculoskeletal systems, injury, congenital anomalies) and use of mobility-assistive devices. We examine the distribution of ten chronic diseases across the physical disability study groups, including asthma, hypertension, diabetes, depression, chronic pulmonary disease, heart failure, HIV/AIDS, breast cancer, lung cancer, and End Stage Renal Disease. Previous studies have largely depended on self-report data and were limited by sampling bias due to relying on phone surveying, recall bias, and/or on another household member responding on behalf of the person with disability. Additionally, the means by which individuals cope with disability may not be equivalent, and these differences may influence self-reports of disability in surveys.22 Further, some studies did not differentiate between types of disability while others treated disability as an ‘‘all or
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none’’ phenomenon. This study augments findings from previous work by using Medicaid claims data to describe physical disability and to compare the prevalence of certain chronic diseases across women with two levels of physical disability, with women who live without disability. While there are certain limitations associated with the use of administrative data, these data represent an entire population and reflect recorded clinical diagnoses and actual utilization and therefore provide a viable alternative to surveys.23 The data are typical of health plans and represent a source of new information and methodology to examine access to care, health care utilization and potential health disparities of women with physical disability.18,24 Further, using Medicaid data to describe health and physical disability among beneficiaries is important to inform Medicaid policy and for planning and prevention purposes at the state level. Using Florida Medicaid data is particularly helpful given the large size of the state and the heterogeneity of its population. Florida provides an interesting case study due to its substantial diversity including racial (e.g. 16% African American), ethnic (22% Hispanic), elderly and veteran (17% over 65) and rural (16% live in non-metropolitan areas) populations.25,26
Methods Study population Our study population included all adult (18e64 years of age) female beneficiaries of the Florida Medicaid program who were continuously enrolled in the program and had at least one outpatient visit during the study period. Our study period was defined by the four and half (4.5) most recent years of data (May 2001eOctober 2005) at the time of study. We excluded women who had not been continuously enrolled in the Medicaid program during the study period, i.e., who had one or more lapses in coverage, because we could not capture the services that they might have received during periods of lapses in coverage. Also, continuous coverage better captures women with long-term (not temporary) disability. We excluded women who were dually eligible for Medicaid and Medicare, because we lacked access to Medicare claims and therefore could not capture Medicare-covered services. We also excluded beneficiaries with limited benefits, including Medically Needy, Family Planning Waiver, and Part B Medicare Only (PBMO). Medically Needy includes individuals whose income is too high to qualify for other Medicaid programs but who have large monthly medical bills. For those individuals, the Medicaid benefit consists of coverage only for the month or partial month when share of cost was met. The Family Planning Waiver only covers family planning services and related ancillary services, treatment for sexually transmitted diseases, sterilization, and colposcopy. QI 1 (Qualifying individualsdformerly PBMO) pays for Medicare Part B premium only.
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Data sources Data were extracted from the Florida Medicaid eligibility and claims files. The eligibility file includes the beneficiaries’ age, gender, race, zip code, social security number, Medicaid identification number, and eligibility criteria (e.g. Social Security Income [SSI], Temporary Assistance to Needy Families [TANF]). We merged this file with facility inpatient/outpatient, medical/physician, and pharmacy claims files, which included the beneficiaries’ identification, date of service, primary and secondary diagnosis codes, CPT (Current Procedure Terminology) or ICD (International Classification of Disease) procedure codes, payment amount, provider information (identification number, specialty, zip code), discharge status, length of stay, drug code (NDC), therapeutic class, and days of supply. Analytic file Each individual’s records from the eligibility file or various claims files (facility, medical/physician, and pharmacy) were aggregated/collapsed into per person per record. Based on the information in the respective claims files, each record was flagged for different levels of physical mobility, various types of mobility-assistive devices, and 10 different chronic conditions, including asthma, breast cancer, lung cancer, end stage renal disease (ESRD), diabetes, HIV/ AIDS, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), depression, and congestive heart failure. A person-level analytic file was therefore created by merging the records for adult females 18e64 years of age. Study groups We used ICD-9 codes for physically-disabling conditions and CPT codes for mobility-assistive devices (such as cane, walker, or wheelchair) to define physical disability categories. We identified and included ICD-9 codes for the following physically-disabling conditions: hereditary and degenerative diseases of the central nervous system (such as Parkinson’s Disease and spinocerebellar disease); other diseases of the central nervous system (including multiple sclerosis, cerebral palsy, paralytic syndromes, and brain conditions); disorders of the peripheral nervous system, (including mononeuritis of the upper and lower limbs, neuropathy, and muscular dystrophy); diseases of the musculoskeletal system and connective tissue (such as rheumatoid arthritis and disorders of the back, muscle, and cervix); injury (including spinal cord injury, fractures of the skull, vertebral column, pelvis, and lower limb, and late effects of injury to the musculoskeletal and nervous systems); and congenital anomalies (including spina bifida and congenital anomalies of the musculoskeletal and nervous systems). Two experts, including a disability epidemiologist and a physician, reviewed the ICD-9 codes and corresponding diagnoses for face validity. The reviews
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were highly consistent and produced a total of 41 physically-disabling conditions (Table 1). With assistance from the Florida Center for Medicaid and the Uninsured, we identified local CPT codes for mobilityassistive devices, including canes, crutches, walkers and accessories, wheelchairs and accessories, and hospital beds and accessories (The list of CPT codes and corresponding devices is available from the authors). We then created three ordinal levels of physical disability: 1) No Physically-Disabling Condition, No Device, i.e., women who had NOT been diagnosed with a physicallydisabling condition AND did NOT use a mobility-assistive device; 2) Physically-Disabling Condition, No Device, i.e., women who had been diagnosed with one or more physically-disabling conditions but did NOT use a mobilityassistive device; and 3) Physically-Disabling Condition, Device User, i.e., women who had been diagnosed with a physically-disabling condition AND used a mobilityassistive device, such as cane, walker, or wheelchair. A variable that distinguished among the three groups was created and added to the analytic file. Since administrative data do not capture body functions, activity, and participation as described in the ICF, our definition of disability used a ‘‘medical model’’ view, based on medical diagnosis, rather than an ICF-based view. Our classification does not assume that physical disability is an all-or-nothing phenomenon, but that levels of severity of disability are important. As such, we constructed an ordinal scale of levels of physical disability, where levels are not assumed to be equidistant from each other. Similar definitions have been used by disability researchers.6,17,18 While less common, mobility devices have also been used as part of defining levels of disability in the general population, among women with multiple sclerosis, and to measure Health-Related Quality of Life for persons with mobility impairments.24,27,28 Study variables We included a number of measures that described our study population, including age at the beginning of the study, race/ethnicity, and State Assistance Category Group. We also independently examined each of the following chronic diseases from claims associated with these diseases at any time during the study period: asthma, breast cancer, lung cancer, end stage renal disease (ESRD), diabetes, HIV/ AIDS, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), depression, and congestive heart failure. Those diseases were selected for the following reasons. They represent a major public health and health care burden due to their chronic nature and high prevalence rates. They are associated with a decline in health-related quality of life. They have modifiable risk factors that are amenable to change, as well as evidencebased disease management programs. And they tend to be well-documented in administrative databases.
Analysis We examined the age, racial/ethnic distribution, and state assistance category groups of women overall and by level of physical disability. We computed the proportion of women who had been diagnosed with each of the 10 chronic diseases and compared the prevalence of disease among the study groups. The study protocol was approved by the University of Florida Institutional Review Board.
Results A total of 650,163 women were continuously enrolled in Medicaid during the study period. After removing women with no claims, dual eligibility, and those who fell into one of the other exclusion criteria, 74,851 women were included in the analysis. Of these, 39,381 women (52.61%) were defined as level 1 (No Physically-Disabling Condition, No Device); 31,527 women (42.12 %) were defined as level 2 (Physically-Disabling Condition, No Device); and 3,943 (5.27%) as level 3 (Physically-Disabling Condition, Device User). Thus, close to half of the study population experienced one or more physically-disabling conditions. Table 2 presents the characteristics of the three physical disability groups and the analytic sample overall. The average age of women was 38 years. We examined the distribution of women across five age groups (18e25, 26e35, 36e45, 46e55, and 56e64). There were approximately equal proportions of women in each age group, with the exception of women 56e64 years of age who represented only 11% of the study population. With regard to race/ ethnicity, 36% of women were White, non-Hispanic, 39% were Black, 15% were Hispanic, and the remaining 10% belonged to Oriental, American Indian, and other groups. Almost seven out of 10 women had SSI (Social Security Income), and one in four were TANF (Temporary Assistance to Needy Families) recipients. The average age of Level 3 women (Physically-Disabling Condition, Device User) was 45.5 years and was higher than the average age of other women. The association between age and level of physical disability was consistent regardless of whether we analyzed age as a continuous or categorical variable. Relatively larger proportions of Level 2 women (Physically-Disabling Condition, No Device) and Level 3 women (Physically-Disabling Condition, Device User) were White, non-Hispanic, whereas a larger proportion of Level 1 women (No Limiting Condition, No Device) were Black. The proportions of Hispanic and Other women were relatively similar across the physical disability groups. As expected, almost all Level 3 women (93%) received SSI, and this proportion was significantly higher than the proportions of women in the other disability groups who received SSI. More than one-third of Level 1 women were TANF recipients. We examined the prevalence of each of 10 chronic diseases across levels of physical disability. The
A.J. Khoury et al. / Disability and Health Journal 6 (2013) 141e148 Table 1 Conditions associated with physical mobility Hereditary and degenerative diseases of the central nervous system Parkinson’s disease Other extrapyramidal disease and abnormal movement disorders Spinocerebellar disease Disorders of the autonomic nervous system Other disorders of the central nervous system Multiple sclerosis Other demyelinating diseases of CNS Hemiplegia and hemiparesis Infantile cerebral palsy Other paralytic syndromes Other conditions of the brain (cerebral cysts, anoxic brain damage) Other and unspecified disorders of the nervous system Disorders of the peripheral nervous system Nerve root and plexus disorders Mononeuritis of upper limb (e.g. carpal tunnel) Mononeuritis of lower limb Hereditary and idiopathic peripheral neuropathy Inflammatory and toxic neuropathy Muscular dystrophies and other myopathies Diseases of the musculoskeletal system and connective tissue Rheumatoid arthritis Osteoarthrosis Internal derangement of the knee Ankylosing spondylitis and other inflammatory spondylopathies Spondylosis and allied disorders Disc disorders Other disorders of the cervical region Other disorders of the back Polymyalgia rheumatica Disorders of the muscle, ligament and fascia Osteochondropathies Injury Fractures of the vault of the skull Fractures of the base of the skull Fracture of the vertebral column without spinal cord injury Fracture of the vertebral column with spinal cord injury Fracture of the pelvis Late effect of musculoskeletal and connective tissue injuries Late effect of injury to the nervous system Crushing injury of the lower limb Spinal cord injury Congenital anomalies Anencephalus and similar anomalies Spina bifida Other congenital anomalies of the nervous system Other congenital musculoskeletal anomalies
proportions of women who had been diagnosed with each of those chronic diseases are presented in Table 3. The most frequently occurring diseases were hypertension, which affected one in three women overall, followed by depression (19.5%), diabetes (15.7%), chronic obstructive pulmonary disease (13.2%), HIV/AIDS (9.0%), and congestive heart failure (6.7%). Other chronic diseases, including asthma, breast cancer, lung cancer, end stage renal disease, and hemophilia affected less than 3% of women (Table 3). The prevalence of chronic diseases significantly and consistently increased with the level of physical disability. For example, hypertension affected 14% of women with No
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Physically-Disabling Condition/No Device compared to 52% of women with a Physically-Disabling Condition/No Device and a high of 72% of women with PhysicallyDisabling Condition/Device User. Diabetes afflicted 7% of women with No Disabling Condition/No Device compared to 24% of women with a Disabling Condition/ No Device and 40% of women with Disabling Condition/ Device User. A similar trend was observed for all of the other chronic diseases.
Discussion Overall, study participants appeared to be at high risk for both physical disability and co-morbid chronic disease. Close to half of the women had one or more physicallydisabling conditions and 5.3% used mobility-assistive devices, such as canes, crutches, walkers, and wheelchairs. In addition, one-third of the women had hypertension and sizeable proportions had other chronic diseases, such as diabetes, pulmonary disease, and depression. Our findings were consistent with the literature regarding the health risks that Medicaid beneficiaries face and their increased need for preventive and primary care, as well as chronic disease management.8,29,30 Study participants with physical disability were more likely to have co-morbid chronic diseases than their ablebodied counterparts. This is consistent with the literature on the increased incidence of secondary conditions among persons with disability31 and emphasizes the need for prevention of secondary conditions often experienced by persons with disabilities. A study of 2,075 Washington state residents found that secondary conditions were two to three times higher in individuals with disabilities than those without functional limitations.32 In another study, Kinne and colleagues found that 87% of BRFSS respondents with disability in Washington State also reported a secondary condition.33 In a community based sample of women, those with disability were significantly more likely to report a range of secondary conditions, including a 13.6% higher prevalence of obesity than non-disabled women.34 While physical disability can contribute to the incidence of secondary conditions, it is also possible that chronic diseases contributed to physical disability in our study population. For example, untreated diabetes could lead to leg amputations and limitation in physical mobility. The extent to which one health problem contributed to another could not be assessed given the cross-sectional research design of the study. As with any claims-based study, findings are limited by the overall accuracy of claims data, which may not always capture segments of the population that underutilize preventative services (e.g. women without transportation). Further, administrative data do not lend themselves to a definition of disability based on function, activities, environment, and participation as in the International Classification of Functioning, Disability and Health (ICF); therefore, we used
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Table 2 Demographic characteristics of women by disability level Level 1 (no physicallydisabling condition, no Level 2 (physically-disabling assistive device) condition, no assistive (N 5 39,381), women device) (N 5 31,527), with characteristic, women with characteristic n (column %) n (column %) Age (mean, standard deviation) Age group 18e25 26e35 36e45 46e55 56e64 Race/ethnicity White Black Hispanic Otherb State assistance category group SSI Elderly Disabled TANF PMAc SOBRA
34.5 6 12.31
Level 3 (physically-disabling condition, device user) (N 5 3943), women with characteristic n (column %)
Total (N 5 74,851), women with characteristic n (column %)
p-valuea
45.5 6 10.91
37.8 6 12.7
!.0001
(15.7%) (18.2) (26.1) (26.3) (13.7)
267 468 973 1425 810
(31.9%) (11.9) (24.7) (36.1) (20.5)
17,785 16,039 17,420 15,540 8067
(23.8) (21.4) (23.3) (20.8) (10.8)
(42.1) (27.1) (19.6) (11.2)
1702 1082 568 591
(43.2) (27.4) (14.4) (15.0)
26,689 29,024 11,593 7545
(35.7) (38.8) (15.5) (10.1)
40.8 6 12.25
!.0001 12,563 9831 8221 5832 2934
(6.8%) (25.0) (20.9) (14.8) (7.4)
11,721 19,411 4842 3407
(29.8) (49.3) (12.3) (8.6)
4955 5740 8226 8283 4323
!.0001 13,266 8531 6183 3547
!.0001 23,839 210 13,775 1205 350 2
(60.5) (0.5) (35.0) (3.1) (0.9) (0.01)
24,360 380 5920 713 152 2
(77.3) (1.2) (18.8) (2.3) (0.5) (0.01)
3676 51 195 19 2 0
(93.2) (1.3) (5.0) (0.5) (0.05) (0.00)
51,875 641 19,890 1937 504 4
(69.3) (0.86) (26.6) (2.6) (0.7) (0.01)
SSI 5 Supplemental Security Income; TANF 5 Temporary Aid to Needy Families; PMA 5 Public Medical Assistance; SOBRA 5 Sixth Omnibus Budget Reconciliation Act. a p-values based on t-test of independence for the continuous variable ‘‘age’’ and 2 2 tables and Chi-square for all other variables. b ‘‘Other’’ race/ethnicity includes American Indians, oriental, and other groups. c Includes ‘‘Unemployed Parents’’ and ‘‘Public Medical Assistance’’.
a ‘‘medical model’’ definition of disability, based on medical diagnoses, rather than an ICF-based definition. Yet, the use of administrative data has a number of advantages including access to a relatively large and heterogeneous population, the ability to define disability based on objective diagnosis and procedure codes as well as pharmacy claims and durable medical equipment claims, and the ability to examine a wide Table 3 Prevalence of chronic diseases by disability level Level 1 (no physicallydisabling condition, no assistive device) (N 5 39,381), women with disease, n (column %) Had asthma Had breast cancer Had lung cancer Had end stage renal disease Had diabetes Had HIV/AIDS Had chronic obstructive pulmonary disease Had hypertension Had depression Had congestive heart failure a
351 125 30 365 2754 1908 1362
(0.9) (0.3) (0.1) (0.9) (7.0) (4.8) (3.5)
5451 (13.8) 3480 (8.8) 820 (2.1)
p-value based on 2 x 2 tables and Chi-square tests.
range of co-morbid conditions.35 Future research should continue to examine the use of administrative data with augmented information to validate our approach and the robustness of our findings. Administrative data augmented with clinical information or direct patient interviews could also be used to examine the association between physical disability and reproductive
Level 2 (physically-disabling condition, no assistive device) (N 5 31,527), women with disease, n (column %) 1489 465 120 1202 7446 4173 6960
(4.7) (1.5) (0.4) (3.8) (23.6) (13.2) (22.1)
16,264 (51.6) 9713 (30.8) 3170 (10.0)
Level 3 (physically-disabling condition, device user) Total (N 5 74,851), (N 5 3943), women women with disease, with disease, n (column %) n (column %) p-valuea 346 74 28 380 1583 623 1569
(8.8) (1.9) (0.7) (9.6) (40.2) (15.8) (39.8)
2825 (71.6) 1371 (34.8) 998 (25.3)
(2.9) (0.9) (0.2) (2.6) (15.7) (9.0) (13.2)
!.0001 !.0001 !.0001 !.0001 !.0001 !.0001 !.0001
24,540 (32.8) 14,564 (19.5) 4988 (6.7)
!.0001 !.0001 !.0001
2186 664 178 1947 11,783 6704 9891
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health and health care among Medicaid beneficiaries. There is a gap in our knowledge of the impact of disability on pregnancy outcomes, such as premature birth, menstrual problems, and contraceptive use, and a need for future research to address those questions. Overall, our findings support the need for improved chronic disease prevention in younger female Medicaid beneficiaries, and particularly those with physical disability. Medicaid women represent a particularly disadvantaged group, with the majority (84%) having incomes below 200% of the federal poverty level and 58% having incomes below the poverty level.21,23 Poverty is an overarching determinant of health and increases the susceptibility of the Medicaid population to risky behaviors and chronic disease. Socio-economic and educational policies may mitigate the impact of poverty on the health status of Medicaid women. In addition, since the risk factors responsible for the onset of many chronic diseases are modifiable (e.g. tobacco use, insufficient physical activity, poor nutrition and excessive alcohol use),35 many chronic diseases are largely preventable. Strategies to improve prevention, screening and treatment in the younger adult population may mitigate the trends toward higher disability rates in the working-age population and may also prevent high Medicare and Medicaid costs in the long-run. For example, programs to prevent obesity in chronically ill individuals may produce declines in disability in the working-aged population.16 Understanding prevalence rates of chronic disease among Medicaid women with physical disability will allow states to appropriately identify those conditions for which individuals are most at risk. States can then develop disease management programs that either work toward preventing disease or reducing the severity of such disease among people living with disabilities. Such a focus is responsive to the Healthy People 2020 goal of promoting the health and well-being of people with disabilities and ensures that these individuals are included in public health activities and receive well-timed interventions and services.36 Women with disabilities constitute a substantial segment of the Medicaid population and are long-term users of the program. Recommendations for facilitating access to care for these women include increasing the number of participating providers, providing culturally-sensitive services, addressing the language barrier, and supplying transportation in rural areas. There are also missed opportunities for delivering preventive services to women who have contact with the health care system. The Medicaid program could work with providers to better take advantage of outpatient visits to deliver screening and other primary care services through innovative models of care delivery and evidence-based practice support systems. Innovative models, such as the patient-centered medical home, promise to significantly improve the delivery of coordinated and continuous primary care.37e39 Similarly, evidence-based practice systems can effectively increase
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the delivery of preventive and primary care. Such systems may include electronic health records, client-based interventions (such as client reminders, small media, one-onone education), and provider-based interventions (such as provider reminders of when clients are due for screening and provider assessment and feedback).40e46 Finally, there is a need for community-based health education and promotion programs to raise awareness of women of the value of health maintenance and early detection of disease. Such efforts would contribute to the quality of life of beneficiaries and potentially to lower health care spending.
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