Disability Policy Research: Population Estimates

History, implementation, and current status of the National Spinal Cord Injury Database.

Stover SL, DeVivo MJ, Go BK. Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, USA. Arch Phys Med Rehabil 1999 Nov;80(11):1365-71

Objective: To summarize a 25-year history of the Model Spinal Cord Injury Program and the coexistent National Spinal Cord Injury Database and provide the status of the Database with a discussion of the strengths and weaknesses.
p. Design: Inception cohort.
p. Setting: Model spinal cord injury systems throughout the United States.
p. Results: As of September 1998, the National Spinal Cord Injury Database included abbreviated registry records on 6,085 new patients, more complete initial injury and hospitalization records on 18,969 new patients, and 78,627 annual follow up records on those persons. Although stability and continuity of the Database has been a priority since it was started, some changes were needed to meet the changes in health care, health care policy, and new technology.
p. Conclusion: This large database can now provide a wealth of information about short- and long-term outcomes, provide data on which future health care policies can be evaluated, and act as a source for answers to future research questions.


Improved disability population estimates of functional limitation among American children aged 5-17.

Hogan DP, Msall ME, Rogers ML, Avery RC. Population Studies and Training Center, Brown University, Providence, Rhode Island 02912, USA. Dennis_Hogan@brown.edu Matern Child Health J 1997 Dec;1(4):203-16

Objective: This paper (a) creates and validates measures for population survey data to assess functional limitation in mobility, self-care, communication, and learning ability for school-age American children; (b) calculates rates of functional limitation using these measures, and provides population estimates of the number of children with limitations; and © examines these limitations as a function of socioeconomic factors.
p. Methods: The study is based on data for children aged 5-17 collected in the 1994 National Health Interview Survey on Disability. Ordinal values are assigned to survey items in the four functional areas and analyzed to produce scales of high reliability. These measures are used to identify within a 95% confidence interval the number of children with these limitations. Ordered logistic regression models measure the effects of functional limitations on disability and societal limitation. Socioeconomic differences are measured with an ordered logistic regression model that predicts severity and comorbidity.
p. Results: Limitations in learning ability (10.6%) and communication (5.5%) are the most common, with mobility (1.3%) and self-care (0.9%) occurring less often. Six percent of children have one serious functional limitation and 2.0% have two or more serious functional limitations. This corresponds to 4.0 million school-age American children with serious functional limitations. Functional limitation is strongly linked to socioeconomic disadvantage and to residence in single-mother households.
p. Conclusion: Future population research should use multiple-item scales for four distinct areas of functional limitation, and a summary that takes into account both severity and comorbidity. The improved estimates of the number of school-age children with functional limitation in this paper may help contribute to a more informed scientific and policy discussion of functional limitation and disability among American school-age children. Future research on the disability process among children must consider the role of socioeconomic disadvantage and family structure.


Issues surrounding age: vascular disease in the elderly.

Shepherd J. Institute of Biochemistry, Royal Infirmary, Glasgow, Scotland, UK. JShepherd@gri-biochem.org.uk Curr Opin Lipidol 2001 Dec;12(6):601-9

One-fifth of all humans who have survived beyond the age of 65 are alive today, and in the industrialized world the elderly segment of the population is expanding most rapidly. In biological terms, these survivors are healthier than the elderly of previous generations. However ‘there are no diseases peculiar to old age and very few from which it is exempt’ (Alfred Worcester, 1855-1951), and so society will inevitably accumulate a significant share of degenerative diseases within the ranks of its senior citizens. In the last two decades, the prevalence of stroke, diabetes mellitus, arthritis and heart disease has increased significantly as a tangible index of ageing in the population, and these diseases have been accompanied by degenerating cognitive function and physical disability, both of which are adding increasing stress to community healthcare and social services. Policy-makers need to understand and monitor these trends in order to make informed and cogent decisions about the management of this growing problem. This review highlights some of the key health issues facing the elderly in regard to coronary artery disease, insulin resistance, redox status, and statin therapy, in the hope that enlightened debate will inform decision making on resource allocation for this important and growing segment of society.


Metropolitan versus nonmetropolitan differences in functional status and self-care practice: findings from a national sample of community-dwelling older adults.

Rabiner DJ, Konrad TR, DeFriese GH, Kincade J, Bernard SL, Woomert A, Arcury T, Ory MG. National Center for Health Promotion, VA Medical Center, Durham, NC 27705, USA. J Rural Health 1997 Winter;13(1):14-28

The objective of this study was to use a recent national probability survey of the noninstitutionalized older adult population to compare the functional status and self-care practices of older adults residing in metropolitan and nonmetropolitan communities and to identify differences associated with residential location. The survey used in this study was the National Survey of Self-care and Aging (NSSCA). A cross-sectional design was employed using weighted bivariate and multivariate logistic regression analyses to examine the relationship between metropolitan and nonmetropolitan residential location and self-reported ability to perform basic, mobility, and instrumental activities of daily living (ADLs), as well as to assess the degree to which the levels and types of functional limitations affect metropolitan versus nonmetropolitan older adults’ performance of self-care activities. The bivariate logistic analyses pointed to modest, often insignificant metropolitan versus nonmetropolitan differences in the ability to perform functional tasks. However, larger positive effects of nonmetropolitan residence were generally observed once other factors likely to account for some of these differences were taken into account. Older adults from nonmetropolitan areas were more likely to report being able to perform functional activities but also were more likely to report performing self-care activities both in the presence and absence of disability. This study, therefore, concluded that nonmetropolitan older adults may discount the significance of declining functional status, thus normalizing the trajectory of aging in a different way than do their metropolitan counterparts. If this process occurs, it may affect how nonmetropolitan persons use primary health care and/or long-term care services, challenging the economists’ concept of demand, the clinicians’ concept of need, and the policy analysts’ concept of equity. Additional work is required to assess whether such a normalization process actually occurs and, if so, to explore its distribution, causes, correlates, and consequences.


Mortality and morbidity among older adults with intellectual disability: health services considerations.

Janicki MP, Dalton AJ, Henderson CM, Davidson PW. New York State Office of Mental Retardation and Developmental Disabilities, Staten Island, USA. mpjzj@aol.com Disabil Rehabil 1999 May-Jun;21(5-6):284-94

Purpose: Described is a study of the mortality and morbidity characteristics of 2752 adults with intellectual disability, age 40 and older, who died over a 10 year period in one American state.
p. Results: The main finding was that although individuals in the current generation of older adults with intellectual disability still generally die at an earlier age than do adults in the general population (average age at death: 66.1 years), many adults with intellectual disability live as long as their age peers in the general population. The results suggest that the longevity of adults with intellectual disability, whose aetiology is not attributable to organic causes, is progressively increasing. The results also confirm an increased longevity for adults with Down syndrome (average age at death: 55.8 years). Findings also showed that the causes of death for the study cohort were similar to those of the general older population, with cardiovascular, respiratory and neoplastic diseases among the most prominent causes of death.
p. Conclusion: It was proposed that clinical and prophylactic health practices could have significant social and health care consequences for delaying the onset or minimizing the occurrence of life threatening diseases (and thus prolonging life) in adults with intellectual disability. It was suggested that clinical practices could be implemented that deter the onset and lessen the impact and burden of older age-related diseases and secondary conditions and that greater attention needs to be given to training of health care professionals in the area of geriatric medicine and intellectual disability.


Prevalence of disabilities and associated health conditions among adults–United States, 1999.

MMWR Morb Mortal Wkly Rep 2001 Feb 23;50(7):120-5 Erratum in: MMWR Morb Mortal Wkly Rep 2001 Mar 2;50(8):149

In the United States, the number of persons reporting disabling conditions increased from 49 million during 1991-1992 to 54 million during 1994-1995. During 1996, direct medical costs for persons with disability were $260 billion. Surveillance of disability prevalence and associated health conditions is useful in setting policy, anticipating the service needs of health systems, assisting state programs, directing health promotion and disease prevention efforts, and monitoring national health objectives. The U.S. Bureau of the Census and CDC analyzed data from the Survey of Income and Program Participation (SIPP) to determine national prevalence estimates of adults with disabilities and associated health conditions. This report summarizes findings of that analysis, which indicate that disability continues to be an important public health problem, even among working adults, and arthritis or rheumatism, back or spine problems, and heart trouble/hardening of the arteries remain the leading causes. Better health promotion and disease prevention may reduce the prevalence of disability-associated health conditions.


Regional assessment of elderly disability in the U.S.

Lin G. Centre on Aging, University of Victoria, BC, Canada. glin@uvic.ca Soc Sci Med 2000 Apr;50(7-8):1015-24

This study examines regional variation of elderly disability in the United States. Elderly disability measurements are derived from two newly available questions on mobility and self-care limitations in the 1990 census. Substantial regional differences in elderly disability rates exist, with a higher prevalence of disability in the Southeast. These differences persist after controlling for age and socioeconomic status (SES). The study findings suggest that some public health policy should be regionally formulated and some government actions should be devoted to reduce the excessive elderly disability in the South.


State-specific prevalence of disability among adults–11 states and the District of Columbia, 1998.

MMWR Morb Mortal Wkly Rep 2000 Aug 11;49(31):711-4

Disability is a large public health problem in the United States (1), affecting an estimated 54 million persons who report disabling conditions (2). One of the national health goals for 2010 is to eliminate health disparities among different segments of the population, including among persons with disabilities (3). Although the development and implementation of public health policy and services relating to disability would be aided by public health surveillance (4), the lack of a brief case definition of disability limits efforts to obtain state-level prevalence to define the magnitude of disability. To assess state-level prevalence based on uniform criteria, CDC analyzed data from the Disability Module of the 1998 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of the analyses, which indicated an overall prevalence consistent with national surveys and demonstrated wide variation in disability prevalence in states.


The Missouri Disability Epidemiology and Health Project.

Andresen EM, Prince-Caldwell A, Akinci F, Brownson CA, Hagglund K, Jackson-Thompson J, Crocker R. Department of Community Health, Saint Louis University School of Public Health, MO 63108, USA. Am J Prev Med 1999 Apr;16(3 Suppl):63-71

Introduction: Estimates of disability in this country are as high as 20%. State health departments need to provide the core activities to deal with this public health problem including assessment, policy development, and assurance. A collaboration among academic institutions and the Missouri Department of Health (MDOH) is a model for providing this core.

Methods: A disability workgroup was established among bureaus of the MDOH and three universities. This group selected the disability domain of mobility impairments for initial work. Existing data from the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS) in Missouri and data from the 1990 Census were analyzed. Dissemination of the findings involved community and consumer participation via an advisory group and a public health-sponsored conference on disability. In addition, new data collection efforts are underway using the BRFSS. Education and training activities include both public health students and public health practitioners in learning the content and methodology associated with disability epidemiology.

Results: Data analyses have identified rural geographic areas of the State with high levels of disability and a trend of increasing work disability since 1993. A selected key condition, arthritis, has been confirmed as having a high prevalence (28%) in Missouri. These data also demonstrate that there is a strong risk of limitations associated with arthritis [adjusted odds ratio (OR) 3.57; 95% confidence intervals 3.0, 4.2]. These results will be applied to program planning.

Conclusion: The Missouri program is succeeding in providing both academic and public health practice partners with a productive experience that meets the needs of each.


Understanding disability in mental and general medical conditions.

Druss BG, Marcus SC, Rosenheck RA, Olfson M, Tanielian T, Pincus HA. benjamin.druss@yale.edu Am J Psychiatry 2000 Sep;157(9):1485-91

Objective: This study characterized the prevalence, characteristics, and impact of mental and general medical disabilities in the United States.

Methods: The 1994-1995 National Health Interview Survey of Disability was the largest disability survey ever conducted in the United States. A national sample was Screened for disability, defined as limitation or inability to participate in a major life activity. Analyses compared cohorts who attributed their disability to physical, mental, or combined conditions.

Results: Of 106,573 adults, 1.1% reported functional disability from mental conditions, 4.8% from general medical conditions, and 1.2% from combined mental and general medical conditions. Disabilities attributed to a mental condition were predominantly associated with social and cognitive difficulties, those attributed to general medical conditions with physical limitations, and combined disabilities with deficits spanning multiple domains. In multivariate models, comorbid medical and mental conditions were associated with a twofold increase in odds of unemployment and a two-thirds increase in odds of support on disability payments compared to respondents with a single form of disability. More than half the nonworking disabled reported that economic, social, and job-based barriers contributed to their inability to work. One-fourth of working disabled people reported discrimination on the basis of their disability during the past 5 years.

Conclusion: An estimated three million Americans (one-third of disabled people) reported that a mental condition contributes to their disability. Mental, general medical, and combined conditions are associated with unique patterns of functional impairment. Social and economic factors and job discrimination may exacerbate the functional impairments resulting from clinical syndromes.