Health-Care Utilization Among Mid-Aged Womena NANCY E. AVIS AND SONJA M. McKINLAY New England Research Institute 9 Galen Street Watertown, Massachusetts 02172 It is well established that women are higher utilizers of health-care services than are men.'" It is often thought that during mid-life, and in particular at the time of menopause, women evidence signs of increased clinical depression, present with a broad range of accompanying symptoms, are even higher utilizers of physicians' services, and generally consume a disproportionate share of medical resources. Studies of health status and health-service utilization in adult populations, however, show no evidence of increased morbidity or health-service use in this midaged population beyond expected increases with Most of the work to date that focuses on the menopause tends to be based on hospitallclinic populations or general-practice settings, which, by definition, represent patients presenting complaints (see for example, McKinlay and McKinlay8). The Massachusetts Women's Health Study (MWHS) is a large (N = 2570) prospective study of women aged 45-55 years randomly sampled throughout Massachusetts. Previously reported data from this study have shown that ( I ) natural changes associated with the onset of menopause have no impact on measures of subsequent health-service utilization; and (2) a surgical menopause increases the probability of subsequent consultation with a health-care professional, both as a result of the surgery and because of a higher rate of chronic conditions that tend to predate the surgery.I0 This paper examines the relative impact of menopause on health-service utilization in this sample from the MWHS and addresses the following specific questions: I . What are the patterns of overall health-care utilization among middle-aged women and what variables (including menopausal status) are related to utilizing health-care services? 2. What variables (including menopausal status) are related to specific types of utilization?
METHODS Sample The data for this paper were obtained from five years of follow-up of 2,570 mid-aged women in Massachusetts who were aged 45-55 years as of January 1, 1982. The study began with a baseline cross-sectional survey that employed a two-stage cluster sampling design. A total of 8,050 completed responses were obtained from women randomly selected from annually compiled census lists. This research was supported by Grant AGO31 11 from the National Institute on Aging. 228
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These responses were obtained by mailed questionnaires, or telephone interviews of women who did not respond to mailings. The overall response rate was 77%. From this cross-sectional sample a cohort of approximately 2,570 women was identified, consisting of women who had menstruated in the preceding 3 months and who had not experienced a removal of the uterus and/or ovaries. Prospective study of the cohort consisted of six telephone contacts every 9 months. Retention of the cohort was excellent, with response rates of 94% to 99% over the six contacts. At each contact an interview was conducted which included questions relating to current health status, health-service utilization, employment, and changes in selected sociodemographic characteristics. To limit interview length to approximately 30 minutes, questions were divided into four instruments. A core instrument (administered at each follow-up) included the questions related to menstrual status, physical health, and health-care utilization. The remaining three instruments, which covered social support networks, lifestyle (including depression and health-related behavior), and helpseeking behavior, were administered in rotation. Assignments were rotated so that after three interviews each woman had been questioned with each of these three instruments once. Thus, during the course of the study, each respondent completed each supplemental instrument twice, 27 months apart.
Description of Variables Self-report data were obtained on a range of sociodemographic, health, and psychosocial variables using in all cases the most reliable methodologies available. The sociodemographic variables included age, education (in three categories), employment status (employed, housewife, other), and marital status (nevermarried, married, separated, divorced, and widowed). Seven measures of utilization of formal and informal health-care resources were included. Respondents were asked whether they had consulted either a health-care professional (nurse, nurse practitioner, physician’s assistant, physician) and/or relative or friend concerning a problem with their health in the prior 2 weeks. Consultation with one or more health professionals indicated formal health-service use, while consultation with a friend or relative indicated use of informal or lay helping resources. Prescribed and over-the-counter (OTC) medications reportedly taken in the prior 2 weeks were classified separately. The use of a 2-week time frame for these four variables has been shown by the National Center for Health Statistics (NCHS) to ensure reliable recall. Reported operations or procedures (other than surgical menopause) in the last 9 months was another indicator of formal health-service use. Finally, two other utilization variables were undergoing breast examination in the past 9 months by a health professional or a pap smear in the prior 9 months. Currently receiving treatment for any of the following common chronic conditions was also considered a measure of utilization: diabetes, high blood pressure, asthma, allergies, heart disease, ulcer, arthritis or rheumatism, and cancer. Five measures of health status were included. Self-assessed health in relation to one’s peers has been shown to be a reliable indicator of actual health status.“ Another variable was restricted activity in the prior 2 weeks due to some aspect of the respondent’s health. This measure is comparable to that used in the National Center for Health Statistics’ ongoing Health Interview Study. Finally, respondents were asked to indicate whether or not each of a list of common SymptOMS
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had been experienced in the previous 2 weeks. These symptoms were divided into two groups: (1) common physical symptoms, which included diarrhea andlor constipation, persistent cough, upset stomach, backaches, headaches, sore throat and aches/stiffness in the joints; and (2) psychological symptoms, which included dizzy spells, lack of energy, irritability, feeling blue or depressed, trouble sleeping, and loss of appetite. TABLE 1.
Summary of Variables Included in Analysis Scale or Range
Variable (by group) Sociodemographic characteristics Age Education Employment status Marital status Health Status Self-assessed health Physical symptoms Psychological symptoms Restricted activity Utilization Lay consultation Health professional New surgeries or procedures (other than surgical menopause) Prescribed medications Over-the-counter medications Treatment for chronic conditions Pap smear Breast exam by health professional Depression Stress Health-related behaviors Body-mass index Cigarette-smoking Exercise Prior use of oral contraceptives Menopauselmenstrual symptoms Menopause status Menopause transition
Based on year of birth
METHODS Sample The data for this paper were obtained from five years of follow-up of 2,570 mid-aged women in Massachusetts who were aged 45-55 years as of January 1, 1982. The study began with a baseline cross-sectional survey that employed a two-stage cluster sampling design. A total of 8,050 completed responses were obtained from women randomly selected from annually compiled census lists. This research was supported by Grant AGO31 11 from the National Institute on Aging. 228
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These responses were obtained by mailed questionnaires, or telephone interviews of women who did not respond to mailings. The overall response rate was 77%. From this cross-sectional sample a cohort of approximately 2,570 women was identified, consisting of women who had menstruated in the preceding 3 months and who had not experienced a removal of the uterus and/or ovaries. Prospective study of the cohort consisted of six telephone contacts every 9 months. Retention of the cohort was excellent, with response rates of 94% to 99% over the six contacts. At each contact an interview was conducted which included questions relating to current health status, health-service utilization, employment, and changes in selected sociodemographic characteristics. To limit interview length to approximately 30 minutes, questions were divided into four instruments. A core instrument (administered at each follow-up) included the questions related to menstrual status, physical health, and health-care utilization. The remaining three instruments, which covered social support networks, lifestyle (including depression and health-related behavior), and helpseeking behavior, were administered in rotation. Assignments were rotated so that after three interviews each woman had been questioned with each of these three instruments once. Thus, during the course of the study, each respondent completed each supplemental instrument twice, 27 months apart.
Description of Variables Self-report data were obtained on a range of sociodemographic, health, and psychosocial variables using in all cases the most reliable methodologies available. The sociodemographic variables included age, education (in three categories), employment status (employed, housewife, other), and marital status (nevermarried, married, separated, divorced, and widowed). Seven measures of utilization of formal and informal health-care resources were included. Respondents were asked whether they had consulted either a health-care professional (nurse, nurse practitioner, physician’s assistant, physician) and/or relative or friend concerning a problem with their health in the prior 2 weeks. Consultation with one or more health professionals indicated formal health-service use, while consultation with a friend or relative indicated use of informal or lay helping resources. Prescribed and over-the-counter (OTC) medications reportedly taken in the prior 2 weeks were classified separately. The use of a 2-week time frame for these four variables has been shown by the National Center for Health Statistics (NCHS) to ensure reliable recall. Reported operations or procedures (other than surgical menopause) in the last 9 months was another indicator of formal health-service use. Finally, two other utilization variables were undergoing breast examination in the past 9 months by a health professional or a pap smear in the prior 9 months. Currently receiving treatment for any of the following common chronic conditions was also considered a measure of utilization: diabetes, high blood pressure, asthma, allergies, heart disease, ulcer, arthritis or rheumatism, and cancer. Five measures of health status were included. Self-assessed health in relation to one’s peers has been shown to be a reliable indicator of actual health status.“ Another variable was restricted activity in the prior 2 weeks due to some aspect of the respondent’s health. This measure is comparable to that used in the National Center for Health Statistics’ ongoing Health Interview Study. Finally, respondents were asked to indicate whether or not each of a list of common SymptOMS
ANNALS NEW YORK ACADEMY OF SCIENCES
230
had been experienced in the previous 2 weeks. These symptoms were divided into two groups: (1) common physical symptoms, which included diarrhea andlor constipation, persistent cough, upset stomach, backaches, headaches, sore throat and aches/stiffness in the joints; and (2) psychological symptoms, which included dizzy spells, lack of energy, irritability, feeling blue or depressed, trouble sleeping, and loss of appetite. TABLE 1.
Summary of Variables Included in Analysis Scale or Range
Variable (by group) Sociodemographic characteristics Age Education Employment status Marital status Health Status Self-assessed health Physical symptoms Psychological symptoms Restricted activity Utilization Lay consultation Health professional New surgeries or procedures (other than surgical menopause) Prescribed medications Over-the-counter medications Treatment for chronic conditions Pap smear Breast exam by health professional Depression Stress Health-related behaviors Body-mass index Cigarette-smoking Exercise Prior use of oral contraceptives Menopauselmenstrual symptoms Menopause status Menopause transition
Based on year of birth
