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a Connecticut Mental Health Center, New Haven, CT
b The Mental Illness Research, Education and Clinical Center and the Northeast Program Evaluation Center, Veterans Affairs Medical Center, West Haven, CT
c Department of Psychiatry, Yale University School of Medicine, New Haven, CT
d The Donaghue Women's Health Investigator Program, Yale University School of Medicine
e Department of Epidemiology and Public Health, Yale University School of Medicine
Correspondence: Holly G. Prigerson, PhD, Connecticut Mental Health Center, Room 522, 34 Park Street, New Haven, CT 06519. E-mail: Holly.Prigerson{at}Yale.edu.
Decision Editor: Vernon L. Greene, PhD
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Key Words: Bereavement • Marital quality • Health costs
Although 800,000 people become widowed each year (Osterweis, Solomon, and Green 1984
), little is known about the impact of widowhood on health service use or health care costs. According to the U.S. Census, 10,551,000 of the 13,546,000 (78%) widowed individuals in 1996 were 65 years of age or over (U.S. Bureau of the Census 1997). Given the aging of the U.S. population, there will be a continuing growth in the number and proportion of the population that is widowed.
Not only are the numbers of late-life widows and widowers rising, but elderly Americans are consuming an increasing amount of health care resources. In 1995, per capita health care expenditures for Americans over 65 years of age were $7,038—nearly four times that for people age 65 and under (Agency for Health Care Policy and Research, Center for Costs and Financing Studies 1997). As the elderly population consumes a growing proportion of national health care expenditures, there will be mounting interest in determining the factors that contribute to their use of health services. This study examined the extent to which widowhood, an event most common in later life, contributes to an increase in the use of health services, and the costs with which they are associated.
Because bereavement poses a substantial risk for mental and physical health impairments, it seems reasonable to expect that widowhood might result in increased health service use and health care costs. The loss of a loved one has been found to heighten the survivor's vulnerability to depressive symptoms and episodes of major depression (Bruce, Kim, Leaf, and Jacobs 1990; Clayton 1974; Lund, Dimond, and Caserta 1985). Bereavement also has been shown to be a risk factor for impaired immune function (Bartrop, Luckhurst, Lazarus, Kiloh, and Penny 1977; Irwin, Daniels, and Weiner 1987; Schleifer, Keller, Camerino, Thornton, and Stein 1983), neuroendocrine changes (Irwin et al. 1987; Kim and Jacobs 1993), sleep disruptions (McDermott et al. 1997), increased use of substances such as tobacco, alcohol, and tranquilizers (Glass, Prigerson, Kasl, and Mendes de Leon 1995; Maddison and Viola 1968; Martin and Dean 1993), suicidality (Bunch 1972; Kaprio, Koskenvuo, and Rita 1987; MacMahon and Pugh 1965), and mortality (Helsing and Szklo 1981; Schaefer, Quesenberry, and Wi 1995; Jagger and Sutton 1991). Because the growing number of widows and widowers with compromised health have the potential to place considerable demands on the health care system, it is important to evaluate the increase in health costs that might be associated with widowhood.
In contrast with the wealth of information that has emerged about the morbidity and mortality associated with widowhood, surprisingly little is known about the effects of widowhood on health service utilization and costs, and the limited number of studies show mixed results. Parkes 1964 found widows to consult their general practitioner more than three times as frequently during the 6 months after bereavement than they had prior to bereavement. Clayton 1974 and Wolinsky and Johnson 1992, however, concluded that becoming widowed did not significantly influence patterns of physician or hospital utilization. Contrasting rates of health service use among those bereaved 4 months with national averages, Mor, McHorney and Sherwood 1986 found that physician visit rates were somewhat higher but that hospitalization rates were lower among the bereaved in their study than age- and sex-adjusted national norms. We were unable to locate a single study that estimated the health costs associated with widowhood, much less one that prospectively examined the effects of widowhood on changes in health care utilization and costs, while adjusting for important confounding influences such as age, sex, health insurance coverage, pre-loss mental and physical health status, socioeconomic status, and health service use.
While marital harmony has consistently demonstrated positive effects on health and well-being (Burman and Margolin 1992; Ewart, Burnett, and Taylor 1983; Goering, Lancee, and Freeman 1992; Hibbard and Pope 1993; Medalie and Goldbourt 1976; Ren 1997; Waltz, Badura, Pfaff, and Schott 1988; Wickrama, Conger, and Lorenz 1995), results of studies that have examined the influence of marital harmony on adjustment to widowhood have been inconsistent. There appear to be two schools of thought concerning the type of relationship to the deceased that portends the greatest problems with adjustment to bereavement. Freud 1957, and later Marris 1958, proposed that ambivalent feelings toward the deceased would result in a pathological form of grief that Freud referred to as "obsessive reproaches"—a form of self-denigration predicated on conflicting feelings about the deceased. Similarly, Parkes and Weiss 1983 found that widowed subjects who retrospectively reported a high degree of conflict with their spouses had considerably higher levels of anxiety, depression, guilt, and yearning than those who reported less conflict in their marriages.
By contrast, several studies suggest that marriages with low degrees of conflict and high degrees of closeness, consensus, and support are predisposed to more problematic bereavement reactions. Research suggests that complicated, or what we now call "traumatic," grief reactions are most strongly associated with marriages rated as close, supportive, and security-increasing (Prigerson et al. 1997b; Prigerson, Shear, Frank, Silberman, and Reynolds 1997c; van Doorn, Kasl, Beery, Jacobs, and Prigerson 1998). Because traumatic grief has been shown to predict mental and physical health impairments as well as adverse health behaviors (Prigerson et al. 1995a, Prigerson et al. 1995b, Prigerson et al. 1996, Prigerson et al. 1997a, Prigerson et al. 1999), it seems reasonable to hypothesize that death in a marriage that was harmonious might result in greater emotional and physical distress for the surviving spouse, and that this would translate into an increase in the widowed person's use of health services. McHorney and Mor 1988 demonstrated increased health care utilization among the depressed bereaved (though no differences were observed in service utilization between depressed and nondepressed subjects who were not bereaved), suggesting that the emotional distress associated with widowhood may play a mediating role in increased service use. Based on prior studies of traumatic grief, we would expect that widowed individuals who had harmonious marriages would be more emotionally distressed than either people who were not widowed or those widowed after discordant marriages, and that this would result in poorer health, and increased health service use and health costs.
The present study tests this hypothesis using data from a two-wave, national probability sampling of community-dwelling respondents—the Americans Changing Lives (ACL) dataset (House et al. 1990). The ACL survey provided a dataset that minimized many of the methodological limitations common to bereavement research (e.g., inadequate sampling, low response rates, failure to include a representative control group, retrospective assessments of pre-loss information such as quality of the marriage, health and health service use; Futterman, Gallagher, Thompson, Lovett, and Gilewski 1990; Gentry and Shulman 1985; Lopata 1981; Schlernitzauer, Bierhals, Houck, Prigerson, and Reynolds 1998; Stroebe and Stroebe 1989). The longitudinal design allowed for a prospective study of respondents who lost a spouse between waves, provided a control group of married respondents, as well as pre-loss assessments of functioning and the quality of the marriage. Details of the sample are in the following sections.
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Methods |
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). Further information about the ACL study is provided elsewhere (House et al. 1990).
The present report focuses only on those who were married and living with their spouse, who had not been widowed previously, and who were age 50 years or above at baseline (N = 968). Of this group, 755 (78.0%) were retained in the analyses, 183 (18.9%) did not participate in the follow-up interview [133 (13.7%) were living nonrespondents and 50 (5.2%) had died], 5 (0.5%) had changes in marital status other than widowhood between waves, and 25 (2.6%) had missing data. Those meeting baseline inclusion criteria who did not participate in the follow-up assessment (n = 183) were significantly older, more likely to be male, and of lower socioeconomic status than those who were retained in the analyses (n = 755). They also had significantly higher levels of depressive symptoms, worse functional health, more chronic conditions, and lower life-satisfaction than those retained in the analyses. In order to adjust for these differences between analyzed subjects and those lost to follow-up, a term that corrected for sample selection biases was included in each multivariate model, using the procedure that has been described by Heckman 1979. (See Analyses section.)
Measures
Marital Harmony
The ACL contained a "marital satisfaction and harmony" index composed of items from scales constructed by Parkes and Weiss 1983 and Pearlin and Schooler 1978. We modified this scale to include baseline assessments of the degree of marital satisfaction, love, and affection; frequency of thoughts of separation/divorce, disagreements, feeling upset by the marriage; extent of agreement with statements that they would "feel lost without ..." and that "no one could replace" their spouse; frequency with which the spouse pushed, slapped, or hit the respondent. The refined measure, compared to the ACL-provided marital quality index, fit better with contemporary recommendations for such measures (e.g., Sabatelli 1988) because it contained "objective characteristics of adjustment such as ... absence of conflict ... combined with the ... degree of satisfaction with the relationship ..." (Sabatelli 1988; 894). Internal consistency (Cronbach's 
) for the refined marital harmony measure was 0.67. A median-split of the baseline score for marital harmony was used to divide respondents into a marital harmony group (n = 366) and a marital discord group (n = 389). The statistical power afforded by a median-split was advantageous for analyses that examined the effects of a Marital Harmony x Widowhood status interaction term. It is worth noting that analyses employing a continuous measure of marital harmony produced similar effects on health costs to analyses employing the marital harmony–marital discord dichotomy, as will be reported below. We chose to present the results for the dichotomous measure of marital quality rather than the continuous measure because they appear easier to interpret.
Health Service Utilization
The ACL contained self-reported assessments of the number of nights spent in a hospital in the past 6 months, the number of days spent in a nursing home over the past 6 months, the number of visits to a medical doctor, and the number of visits to a psychiatrist over the past 3 months. Visits to a physician were doubled to reflect use for a period consistent with that specified for the number of nights spent in a hospital (i.e., 6 months). "Outpatient" services refer to psychiatrist and other medical visits; "inpatient" services refer to the number of days spent in a hospital and nursing home.
Health Costs
Health care costs were estimated by multiplying the number of units of each service used by the estimated unit costs for each type of service. Unit costs for 1989 were derived from national data in the Statistical Abstracts of the U.S. (U.S. Bureau of the Census, 1991). Based on these data, we assigned $767 as the cost of a night spent in the hospital, $100 as the cost for a day spent in a nursing home, $130 as the cost for a visit to a physician, and $97 for the cost of a visit to a psychiatrist. Total costs were the summation of the costs for each self-reported psychiatrist visit, other medical doctor visit, nursing home day, and hospital night up to a maximum of 8 nights. The costs associated with hospital stays were limited to 8 nights in order to eliminate the influence of extreme outlying values on estimates of mean inpatient costs. Only 19 of 694 (2.7%) of the group who remained married and 2 of 61 (3.3%) of the group who became widowed had hospital stays of 8 or more nights at follow-up (
2 = 0.1, df = 1, NS).
Control Variables
Age, sex, socioeconomic status, life-satisfaction, depressive symptoms, number of chronic conditions, functional health status, health service use and costs at baseline, and follow-up health insurance coverage were included as control variables because they were significantly associated with widowhood, marital harmony, and/or follow-up health service use/costs. We describe briefly the control variables that require definition.
Using information obtained on levels of income and education, the ACL provided a 4-category measure of socioeconomic status (SES): low, lower-middle, upper-middle, and high SES. When used as a control variable, the SES measure was dichotomized to reflect whether or not the respondent was of low SES. The dichotomous measure was deemed more desirable because nearly one half of those who became widowed (30 of 61) fell into the low SES group, and only a few (3 of 61) fell into the high SES group. Thus, the modified low versus not low SES measure yielded a more even distribution across SES categories. Life-satisfaction was assessed using an index comprising 4 Likert-scaled items that asked respondents the extent to which they agreed with statements about their happiness, satisfaction, and lack of regrets. Higher scores on this standardized index correspond to lower levels of life-satisfaction. An 11-item short form of the Center for Epidemiological Studies Depression scale (CES-D; Radloff 1977) was used to assess severity of depressive symptoms. The short form, developed by Kohut, Berkman, Evans, and Cornoni-Huntley 1993, had sound psychometric properties (e.g., Cronbach's = .81). Standardized scores were provided. The number of major chronic conditions experienced in the last year included the number of the following 10 chronic conditions endorsed by the respondent: arthritis/rheumatism, lung disease, hypertension, heart attack or heart trouble, diabetes, cancer/malignant tumor, foot problems, stroke, fractures or broken bones, and urinary incontinence. An index of functional health status was used to rate respondents on a scale ranging from a score of 1, indicating confinement to a bed or chair, to a score of 4, indicating ability to do heavy housework without difficulty. Health insurance coverage at the 1989 assessment was determined by an affirmative response to a question asking whether or not the respondent had health insurance at that time.
Analyses
First, between-group t tests for continuous measures and 2 statistics for categorical measures were used to test for significant differences in baseline characteristics between married respondents and those who would become widowed. We then conducted a one-way analysis of covariance (ANCOVA) to estimate the main effect of widowhood on health status and health service use at follow-up. The ANCOVAs that estimated the effects of widowhood on 1989 health status adjusted for age, sex, SES, life-satisfaction, depressive symptoms, number of chronic conditions, functional health status at baseline, follow-up health insurance coverage, and a term that corrected for sample selection biases using a technique proposed by Heckman 1979. The ANCOVAs estimating the effect of widowhood on health service use in 1989 adjusted for age, sex, SES, life-satisfaction, depressive symptoms, number of chronic conditions, functional health status, and health service use at baseline, follow-up health insurance coverage, and sample selection biases.
Next, we conducted a one-way ANCOVA to estimate the main effects of becoming widowed versus remaining married, and the main effects of marital harmony versus marital discord, on 1989 health costs. These ANCOVAs adjusted for age, sex, SES, life-satisfaction, depressive symptoms, number of chronic conditions, functional health status, and health care costs at baseline, follow-up health insurance coverage, and sample selection biases.
We then entered the interaction between marital harmony and widowhood status into the ANCOVA for 1989 health costs, adjusting for the main effects of widowhood and marital harmony, age, sex, SES, life-satisfaction, depressive symptoms, number of chronic conditions, functional health status, and health care costs at baseline, follow-up health insurance coverage, and sample selection biases.
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With respect to the effects of widowhood status on health costs at follow-up (Table 3 ), the means for total health costs in 1989 were significantly higher for respondents who became widowed between the 1986 and 1989 assessments than for those who remained married during that interval (estimated annually: $2,384 vs $1,498, respectively; F = 4.72, df = 1,742, p = .03), adjusting for the full set of control variables mentioned above, but substituting baseline health care costs for baseline health service use. The widowed group had significantly higher adjusted mean outpatient (i.e., psychiatric and other medical visit) costs than those who remained married (estimated annually: $1,156 vs $748, respectively; F = 5.73, df = 1,742, p = .02). Although the annual adjusted mean inpatient costs at follow-up were 1.6 times higher for the widowed respondents than they were for the married respondents, the difference in inpatient costs between these two groups did not reach a level of statistical significance (estimated annually: $1,222 vs $744, respectively; F = 1.85, df = 1,742, NS).
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Interactive Effects of Widowhood and Marital Harmony on Health Care Costs
We then compared the means for health costs in 1989 among the four groups resulting from the interaction between the dichotomous marital status (married/became widowed) and marital quality (harmony/discord) variables, adjusting for the main effects of marital status and marital quality, and the full set of control variables (Table 4 ). In contrast with the significantly lower total health care costs in 1989 associated with having a harmonious marriage versus a discordant marriage (Table 3 ), respondents who became widowed in the context of a harmonious marriage had the highest average total costs in 1989 (annual estimate: $2,766). Their total adjusted mean health costs in 1989 were 32% higher than those for widowed respondents who had discordant marriages (annual estimate: $2,100).
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Before discussing the results in greater detail, several methodological limitations of this study deserve mention. First, a relatively small number of respondents were widowed between the baseline and follow-up assessments (n = 61), indicating a need to replicate the results found in this study in datasets that contain a larger sample of widows and widowers. The limited number of widowers, in particular, made it difficult to stratify by sex, although sex was entered as a control variable in each of the multivariate models. The size of the widowed sample also inhibited our ability to divide the sample into more narrowly defined age groups (e.g., the oldest-old, middle-old, youngest-old). In an attempt to adjust for the age bias in the effects of widowhood on health, we included only respondents age 50 years and above, and controlled for age by including it as a model covariate. The limited number of widowed respondents also made it difficult to compare the health costs of widowed persons in lower socioeconomic strata with those in upper socioeconomic strata, although baseline (the only time SES was assessed) low SES, follow-up health insurance coverage, and the sample selection correction allowed us to adjust our estimates for financial disincentives that might influence health costs for widowed versus married respondents.
In addition, the available data did not allow for an examination or comparison of health outcomes between recently widowed respondents and respondents who had been widowed for longer periods of time. Because only 4 of the 61 widowed subjects were widowed within 3 months of the follow-up assessment, we could not reliably estimate or compare more immediate with longer term effects of widowhood on health. We did examine the 15 subjects who reported being widowed in the 3 months prior to the baseline assessment with 607 others who were widowed longer than that duration at baseline. The 6-month mean total health costs, adjusted for age, sex, and SES, were $1,652 among the recently widowed group compared with $946 among those widowed longer than 3 months at baseline (this difference was not statistically significant, probably due to a lack of statistical power). These results suggest that, compared to those widowed longer than 3 months, health costs were higher at baseline for the more recently widowed.
Despite the fact that over 90% of the widowed respondents in this study were widowed beyond the time of greatest health risk (i.e., the first few months post-loss), we still find large effects of widowhood on health and health costs among persons widowed any time within a 3-year period. Furthermore, these effects of widowhood remain even after adjusting for a comprehensive set of confounding influences. Several studies (Parkes 1964; Prigerson et al. 1997a; Zisook, Shuchter, and Lyons 1987) suggest that the negative impact of widowhood on health is greatest in the first 6 months post-loss. Consequently, if we had compared a group of married respondents with a group of widowed respondents who had all been widowed 6 months or less, we might expect to find even greater discrepancies between these groups with respect to health impairments, health service use, and health care costs. Additionally, while the inclusion of the Heckman sample selection correction adjusted for the loss of many of the sickest subjects to follow-up, the actual health costs accrued by subjects who died between waves were not included in the cost estimates. Given that the last year of life is the most expensive, with 25%–35% of Medicare expenditures going to enrollees who will die in that year (Lubitz and Prihoda 1984), omitting these costs implies that costs probably would have been considerably higher had we been able to account for the services used by widowed subjects who themselves died between baseline and follow-up.
Another limitation was that the health costs were a direct function of the units of services used (i.e., costs = quantity of services used x the average unit cost of that service). Although it would have been preferable to use the actual costs of health services each respondent had used, information on individual costs was not available. Nevertheless, we believe the value of monetizing service use is that it provides a more intuitive understanding of the magnitude of the group differences and the public health consequences associated with widowhood. Because it is not reasonable to combine inpatient and outpatient units of service, dollar figures also provide a uniform metric for presenting costs of total service use.
Another limitation is that the assessments of health service utilization were based on self-report data rather than administrative data that document actual service use. Studies suggest, however, that self-report utilization data are reasonably accurate; if anything, the tendency is for respondents to underreport service use (Brown and Adams 1992; National Center for Health Statistics 1965). For example, the National Health Interview Survey (National Center for Health Statistics 1965) found the underreporting of information about hospitalizations to be less than 10%. The health cost estimates are also conservative because they do not include the expense of medications, fees for laboratory and other diagnostic services, disability days, transportation, and the like.
In spite of the overall conservative nature of the cost estimates, the costs found to be associated with widowhood were sizable. If we multiply the difference in annual adjusted mean total health costs found between the widowed group and the married group (adjusted annual estimated difference: $886) by the 800,000 newly widowed individuals in the United States each year, the annual difference between these two groups would be $708,800,000 in 1989 dollars, or nearly $1 billion in 2000 dollars. With the rising number of widowed persons, a more complete accounting of health costs, growing rates of health insurance coverage [particularly in light of the Surgeon General's recommendation for expanded coverage for mental health care (Pear 1999)], and rapidly rising health costs, the health expenses associated with widowhood are likely to be markedly higher in years to come.
Effects of Widowhood on Health Service Use and Costs
The results of this study demonstrate that widowed respondents have a greater number of physician visits and days spent in a nursing home than do married respondents. Despite the higher levels of depressive symptoms among the widowed group, widowed subjects were not significantly more likely to visit a psychiatrist or other mental health professional compared to nonwidowed subjects at follow-up. Widowhood appeared to have no significant influence on the number of days spent in a hospital.
With respect to health costs, the widowed group had significantly higher mean total costs than did the married group. This result appears to be a function of increases in physician visits rather than an increase in hospital lengths of stay. Although no comparative figures exist for health care costs associated with widowhood, prior studies have examined the influence of widowhood on health service use. Our results are consistent with studies that have found widowhood to be associated with increased use of physician visits (Parkes 1964; Mor et al. 1986), and the absence of a "widowhood" effect on hospital use (Clayton 1974; Mor et al. 1986; Wolinsky and Johnson 1992). The results of this study, together with prior research, indicate that widowed individuals, at least within 3 years following the spouse's death, are likely to have higher health costs relative to married individuals, primarily because of their greater number of physician visits.
Effects of Marital Quality on the Impact of Widowhood
Although a number of studies document the health benefits of a satisfying, nonconflictive marriage (Burman and Margolin 1992; Ewart et al. 1983; Goering et al. 1992; Hibbard and Pope 1993; Medalie and Goldbourt 1976; Ren 1997; Waltz et al. 1988; Wickrama et al. 1995), little is known about the effects of marital quality on health service utilization and health costs. The results of this study appear to confirm these prior reports by extending them to demonstrate the lower costs for physician visits associated with marital harmony in contrast to marital discord. Furthermore, because we controlled for potentially confounding influences such as severity of depressive symptoms and life-satisfaction (social support was not found to have a significant confounding effect), the influence of marital discord on higher physician costs cannot be attributed to these other factors. Similar to the effects of widowhood, marital harmony did not significantly influence inpatient costs.
When the effects of marital harmony are examined in interaction with the effects of widowhood, we find that the quality of the relationship to the deceased significantly influences the health costs of the surviving partner. Counter to those who have claimed that widowed individuals who had conflictive marriages are more adversely affected by the loss (Freud, 1917/Freud 1957; Marris 1958; Parkes and Weiss 1983), our results suggest that widowed individuals who had harmonious marriages are the group with the poorest health, and that this translates into increased health service utilization and health costs. These findings concur with studies by Futterman and colleagues 1990 and Vachon and colleagues 1982, that suggest that individuals with good marital quality exhibit greater dysfunction when they become widowed. They are also in agreement with our studies of traumatic grief in which we have found marriages high in marital quality to be associated with more severe traumatic grief symptomatology (Prigerson et al. 1997c; van Doorn et al. 1998) which, in turn, has been proven to be predictive of subsequent decline in health as well as adverse health behaviors (Prigerson et al. 1995a, Prigerson et al. 1995b, Prigerson et al. 1996, Prigerson et al. 1997b, Prigerson et al. 1999). Thus, prior work demonstrating the connection between positive marital quality and greater severity of traumatic grief symptoms suggests that the influence of marital harmony on health, health service utilization, and health care costs may be mediated through symptoms of pathological, or complicated, grief. Because the ACL survey did not contain specific assessments of traumatic grief symptomatology, we were unable to test this hypothesis explicitly. Future research is needed to test whether traumatic grief symptomatology mediates the relationship between being widowed after a harmonious marriage and poor health. To the extent we are able to identify and, ultimately, modify the effects that loss of a congenial marriage has on health (e.g., by ameliorating traumatic grief symptoms), we may be able to reduce the health costs associated with widowhood. Efficacious interventions would assist in reducing the burden of spousal loss both for the individual survivor and for society as a whole through the reduction of demand on an already strained health care system.
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Acknowledgments |
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Received for publication May 27, 1999. Accepted for publication January 7, 2000.
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This article has been cited by other articles:
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  H. G. Prigerson and S. C. Jacobs Caring for Bereaved Patients: "All the Doctors Just Suddenly Go" JAMA, September 19, 2001; 286(11): 1369 - 1376. [Abstract] [Full Text] [PDF]
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