Successful Aging into the 21st Century: The Social and Built Environment as Facilitators or Barriers for Individuals Aging with Disability

Abstract

Up to 21% of Americans are aging with a disability acquired at birth or within the first 4-5 decades of life. Their disability trajectory and life course experiences make them a distinct group of older adults with a disability. They have higher risk of age-related chronic diseases and secondary conditions stemming from their disability, and face barriers to navigating their communities. Their limited mobility means they may be more reliant on their environments to facilitate good health. However, little is known about the role of the environment in successful aging for this population. This dissertation addressed this gap by examining the relationship between features of the environment and quality of care and health outcomes for individuals aging with a physical disability. The cohort was identified using claims data from a national private health insurance database and linked to neighborhood data from the National Neighborhood Data Archive (NaNDA). The first Aim examined specific features of the built environment pertinent to this population, and their association with incident cardiometabolic disease. Residence in neighborhoods with a high density of recreational establishments, parks, broadband internet connections, and transit stops was associated with lower risk of any cardiometabolic disease. Neighborhoods with a high density of “health promoting” resources were protective for cardiometabolic health but no significant findings were observed for “health harming” establishments. Density of healthcare establishments was not independently associated with cardiometabolic health, suggesting that other factors such as quality of care experiences, not the presence of healthcare establishments per se, may be important to consider. The second Aim of this dissertation characterized quality of care, measured using Bice-Boxerman continuity of care (COC) index, and identified the associated individual and community-level factors. This population had low COC scores, indicative of more fragmented care, and saw a variety of provider specialties. Those with high COC had a greater proportion of visits concentrated amongst two specialties (Family & Internal Medicine). Living in less affluent communities, and having less access to transit, broadband internet and health care providers (e.g., Medical Specialists) was associated with more concentrated care patterns. Residence in neighborhoods with fewer healthcare establishments was associated with lower odds of continuous care. Environments that facilitate access to many health care providers afford readily available opportunities to seek care from different sources to meet health preferences and needs; though it may lead to more fragmented care patterns. Examination of health outcomes is required to better understand the effect of these care patterns. Aim three examined the association between COC and diagnosis of chronic health conditions and receipt of preventive screening. After adjusting for individual and community-level confounders, high continuity was associated with lower odds of pain diagnosis and receipt of preventive screening. Effects were more salient in younger adults (<40 years). In concert, these dissertation Aims highlight the role of the neighborhood environment in understanding quality of care patterns and health outcomes for individuals aging with a physical disability. Neighborhood-level interventions should focus on investment in health-promoting resources. Innovative policies that consider factors outside the healthcare system are required to avert fragmented care in this population, with important implications for supporting appropriate screening and early disease detection for younger adults aging with disability. This work has the potential to support neighborhood designs, policies and programs that facilitate the ability of this population to age successfully in place.