Pathways to Illness, Pathways to Health

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Selecting which interventions to prioritize can be difficult, however. The pathways are organized by the stages of care from prevention and primary care to acute care and rehabilitation and include the full range of interventions that may be offered at each stage. Some pathways focus on specific diseases, such as diabetes or coronary heart disease CHD ; these pathways include all treatments, from primary prevention to rehabilitative services, that may be offered to patients with those diseases.

However, a care pathway can also cover a group of conditions with similar treatment requirements, such as chronic diseases, or even a phase of life e. The pediatric care pathway, for example, includes routine vaccinations and other well-child services, primary and community care services for sick children, specialist care for more severely ill children, and palliative care for the terminally ill. Both types of care pathways rely heavily on clinical evidence. As a result, clinicians tend to find them intuitive to use. In this article, we focus on the use of disease-specific care pathways.

We describe why these pathways can be so valuable and outline how they are developed. In addition, we provide several case examples of how health systems have used disease-specific pathways to improve care quality, reduce costs, or both. McKinsey uses cookies to improve site functionality, provide you with a better browsing experience, and to enable our partners to advertise to you. Detailed information on the use of cookies on this Site, and how you can decline them, is provided in our cookie policy.

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No Downloads. Views Total views. Perceived social support typically refers to the perceived availability of social support if and when support is needed Thoits, Accordingly, older adults who receive adequate social support generally report lower psychological distress, depression, and anxiety see Taylor for a review.

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Social support may enhance mental health by providing a sense of stability and positive affect. Beyond its main effects, perceived social support may relate to well-being through self-esteem. Having a supportive spouse, friends, and family members can make people feel better about themselves i. Alternatively, a lack of support may influence how much individuals appreciate themselves, affecting their mental abilities to deal more effectively with stressful circumstances.

Indeed, Symister and Friend found that self-esteem mediates the relationship between social support and distress. Later Uchino proposed a conceptual model of social support, psychological, and biological processes, highlighting bidirectional effects. Using cross-sectional data or ignoring such bidirectionality may lead to an overestimation of social support benefits on mental health outcomes.

The absence of mental health problems, such as depression or anxiety, does not necessarily indicate mental well-being. The current study attempts to extend the models by focusing on mental health benefits of social support using nationally representative, longitudinal data of community-dwelling older adults, accounting for potential bidirectionality. If the pathway from social support, self-esteem, and mental health is operant, it provides evidence for our conceptual models in general older adults population, regardless of major life stressors.

A body of work suggests that perceived social support from family, spouse, and friends is associated with lower risk of cardiovascular mortality Rizzuto et al. Cohen ; recommended that simultaneous tests of psychological and cardiovascular risk factors are preferable, since social support influences health both through psychological states and through triggering physiological processes.

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Uchino explicates that among key cardiovascular health outcomes, research on inflammation provides a potentially integrative approach on how social support gets under the skin and affects physiological harbingers of CVD, which is accountable for one in four deaths in the United States Centers for Disease Control and Prevention, However, studies do not systematically examine the possibility that social support may operate on chronic inflammation through indirect pathways.

Responding to this call for further research, the current study examines whether social support affects chronic inflammation through mental health. There are multiple hypotheses regarding links between biological processes and social support. Individuals who are deprived of support may lack relevant psychosocial resources, which translate into a dysregulated inflammatory process Cobb, ; Hermes et al. Studies show that social support is related to pro-inflammatory and anti-inflammatory markers both directly Yang et al.

Das shows that CRP predicts subsequent anxiety and depression, but not vice versa. Another study states that chronic inflammation may also alter how individuals perceive support, albeit with cross-sectional data Nowakowski, , thus running the risk of overestimating the effects of inflammation on support. The competing vulnerability and scar hypotheses suggest potential bidirectional relationships between social support, mental health, and chronic inflammation. Based on the aforementioned models as well as the empirical evidence regarding social support and health discussed, the current paper contributes to the literature by considering both direct and indirect processes by which social support may benefit health outcomes.

We hypothesize that greater social support at Wave 1 W1 is associated with higher self-esteem, better mental health, and lower CRP at W1, all of which, in turn, predict subsequent mental health and CRP at Wave 2 W2. We also test multiple potential indirect effects including a social support W1 affecting mental health W2 through self-esteem W1 and b social support W1 predicting CRP W2 through mental health W1 and W2. By doing so, we strive to provide a clearer model of direct and indirect pathways in support-health relationships.

The model also tests potential bidirectionality, explicating whether social support predicts subsequent mental health and CRP, or vice versa. The first wave of the NSHAP, collected in —, included 3, respondents aged 57—85 years with a response rate of By Wave 2, fielded in —, respondents had died; 85 were in poor health; and 97 respondents were not reinterviewed for various reasons including refusal, yielding a sample size of 1, An additional 37 cases with missing information for control variables were eliminated.


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The final analytic sample size is 1, During the interview at both waves, a blood sample was collected via a finger stick and disposable lancet and applied to filter paper for transport and storage. Higher levels of CRP indicate a more chronic inflammatory state i. We use an item capturing self-rated mental health.

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Self-esteem is only available at W1. For perceived social support from family, respondents were asked how often a they could open up to their family if they need to talk about their worries; and b rely on their family for help if they have a problem. These two items were then repeated for spouse and friends. This results in a total of six items for the social support measure. The response for each question ranged from hardly ever or never 0 , sometimes 1 , and often 2. Individuals who lacked a support relationship or source of support were coded as 0.

The items were then averaged i. Covariates include demographics, health lifestyle factors, and chronic conditions because of their associations with chronic inflammation Herd et al. Age is coded in years and sex is dichotomized with 1 indicating female. Race includes the categories of non-Hispanic White reference category , African American Black , hereafter , and individuals of other races Hispanic, Native American, Asian or Pacific Islander, and those who identified as multiracial.

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Education consisted of four categories less than high school, high school, some college, and college graduate or more. For lifestyle factors, we use self-reported information. The analysis also adjusts for chronic conditions that may be related to CRP that are commonly considered in the literature see Herd et al. Finally, the analysis takes into account initial CRP level. Supplementary analyses considered additional covariates such as income, wealth, stroke, cancer, antihypertensive medication use, statin use, antidepressants, and regular NSAIDs use.

These variables either had too few cases or did not change the pattern of results, so they were omitted from the final analyses for a more parsimonious model. We estimated cross-lagged panel models in order to account for possible bidirectionality Finkel, As displayed in Figure 1 , we used W1 social support to predict W2 C-reactive protein CRP both directly and indirectly through W1 self-esteem and W1 mental health, controlling for all other covariates.

Since mental health and self-esteem are both measured at an ordinal level, we estimated ordered logistic regression models for these outcomes. Due to the highly skewed distribution of CRP few individuals reporting high CRP levels , values were natural log transformed for the statistical analyses. Our analysis included only those who were interviewed at both waves. Although reinterview rates were high in the follow-up study This approach consisted of modeling mortality between W1 and W2 using a probit model with relevant W1 predictors.

Then, endogenous variables were modeled as a function of independent variables as well as the estimated probabilities of dying between waves. Thus, the final estimates were adjusted for probability of dying. Finally, a series of sensitivity analyses were conducted in order to test the robustness of the final analytic model. We discuss the findings from supplementary analyses in the results section. Table 1 shows the descriptive statistics and the coding schemes of the study variables.

Pathway to Health

The mean level log CRP at W1 is 0. The respondents reported fairly high levels of mental health overall 3. They also reported high levels of self-esteem on average 4. At both waves, most respondents reported having supportive relationships 1. In a supplementary analysis with direct pathways only, W1 social support was significantly and directly associated with W2 mental health and W2 CRP model not shown. Although not shown in Table 2 , correlations among W1 and W2 variables are included. Testing indirect pathways, results show that W1 social support operates through several indirect pathways.

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