Functional difficulty, cardiovascular dispensing continuity and healthcare utilisation in US counties
Published 27 October 2026. This edition separates the public explanation from the scientific record. No estimates were refitted and no new analyses or external validation were performed for release. Source periods, analytical methods, uncertainty, limitations and full results are retained from the prepared edition. The release review checked consistency with archived results; it is not an independent reanalysis.
Relationship to existing research
Functional limitations, medication support and adherence are established research topics. Whaley and colleagues (2015) studied functional limitations and medication support in Medicare Advantage survey participants. That study does not validate the county-level estimates reported here.
This brief presents the specific exploratory integration of corrected older-resident county functional-difficulty measures with separate dispensing and clinical-use indicators. It does not claim that the general association, the value of support or the methods are new. A focused publication-time search is not a systematic review and cannot establish absolute novelty.
Design, estimands and statistical instruments
Design and statistical instruments
Ecological analysis linking county ACS functional-difficulty estimates for civilian noninstitutionalised residents aged 65+ with separate Part D dispensing and CMS outcome populations. Spearman correlations and covariate-adjusted models use state-clustered uncertainty; Benjamini–Hochberg correction covers 28 primary adherence comparisons (seven difficulty measures × four drug classes). Clinical outcomes use separate correction families.
Definitions, corrections and missingness
Dispensing non-adherence is proportion of days covered below 80%, not observed medicine ingestion. The age 65+ denominators were corrected and independently reconciled with with/without-difficulty leaf sums in all seven tables before this draft. The archived denominator audit and all primary results remain downloadable.
Scope and limitations
Models adjust income, education, Medicare beneficiary age, Medicare Advantage share, categorical RUCC and state. No second direct age-standardisation is applied to already adjusted outcomes. Overlapping difficulty measures are not independent replications. Residual confounding, reverse causation, source-year differences and spatial dependence remain.
01 / OVERVIEW
Autonomy is part of continuity.
Across US counties, greater functional difficulty among older residents is associated with less continuous cardiovascular medication dispensing and greater use of some hospital services.
These territorial observations identify questions about accessible medication support and coordinated care. They do not measure the adherence of individual people with disabilities.
02 / KEY FINDINGS
Support the next step in care.
1. A continuity signal across functional needs
Greater cognitive difficulty among residents 65+ is associated with antihypertensive non-adherence: ρ=0.515. The adjusted difference is +0.91 percentage points per +10 points of cognitive difficulty (95% CI 0.41–1.40; BH q=0.00080).
Independent-living difficulty shows an adjusted difference of +1.19 points (0.71–1.67); visual difficulty, +1.17 (0.69–1.66); self-care difficulty, +1.45 (0.89–2.01). The hearing-difficulty association is not clear. These overlapping measures are not independent replications.
2. Clinical need and service use
Independent-living difficulty is associated with +1.19 heart-related emergency visits per 1,000 FFS beneficiaries per +10 points of difficulty (95% CI0.25–2.12; BH q=0.038). This outcome combines heart failure and non-ischaemic heart disease.
Self-care difficulty is associated with +19.99 general hospital stays per 1,000 beneficiaries (13.86–26.12) and+1.08 percentage points of general readmissions (0.44–1.73). Greater need, comorbidity and reverse causation are plausible contributors.
3. An opportunity for accessible medication support
Investigate readable and accessible instructions, dispensing arrangements, medication reconciliation, supported decision-making and coordination with caregivers where wanted. The data do not establish intervention effectiveness.
03 / METHODOLOGY
Connected data, explicit denominators.
ACS2019–2023 functional difficulty among civilian noninstitutionalised residents 65+ is linked by county FIPS to CDC Atlas2019 Medicare Part D 65+ non-adherence and CMS2023 outcomes. Seven difficulty measures and four medication classes yield28 primary adherence comparisons; all-age sensitivities are separate.
Non-adherence means proportion of days covered(PDC) <80% from dispensing. Models adjust income, education, Medicare mean age, MA share, categorical RUCC and state; uncertainty is clustered by state. Clinical families use separate BH corrections. No direct second age-standardisation is applied to already adjusted outcomes.
Age65+ denominators were corrected during audit and independently reconciled with with/without-difficulty leaf sums in all seven tables. This publication uses only corrected results.
04 / LIMITATIONS
Historical continuity. Territorial associations.
The dispensing indicator is from 2019 and functional estimates cover2019–2023. These are historical, partly asynchronous observations. PDC does not confirm ingestion; no dose or prescription quality is measured.
Exposure describes county residents, while medication and clinical populations differ. The results are not disability-specific patient risks. Illness may contribute to disability, and greater healthcare use may reflect appropriate response to greater needs. Residual confounding and spatial dependence remain.
Cognitive difficulty does not identify autism or ADHD. No causal impact or preventable-event count is estimated.
05 / CONCLUSION
Make continuity easier to maintain.
The consistency of the medication-continuity signal across several functional difficulties supports a focused research agenda on accessible support. Clinical-use associations add context about need, without proving that dispensing gaps cause hospital events.
Prioritise local assessment and more recent patient-specific data before choosing interventions.
06 / SOURCES
Traceable sources.
- Census ACS disability definitions: B18101–B18107.
- CDC Heart Disease and Stroke Atlas sources: MedicarePartD dispensing continuity.
- CMS Mapping Medicare Disparities.
- CMS Geographic Variation.
07 / CITE & DOWNLOAD
Published report and analytical supplements
Published 27 October 2026. Analysis draft prepared 13 October 2026; public and technical separation prepared 20 October 2026. This release does not introduce new estimates.
Machine-readable analytical record
The following appendices reproduce existing result, method, dictionary and quality records without recalculation. Large map datasets and ZIP supplements are listed in the provenance table and remain in the evidence package. Field names and original language are retained to avoid changing analytical definitions.
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]Availability, provenance and reproducibility limits
Figures are embedded in this HTML so they remain available after download. Links to source data and legacy supplements use the public website; the evidence ZIP preserves the available local supplements.
These materials document the analyses already carried out; this editorial conversion does not certify that an independent researcher has reproduced every result. Where the original package does not contain executable analysis code or all source inputs, that limitation remains. No missing methods, software versions or validation results have been invented.
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Citation for this technical edition
The Smart Mole Institute. Functional difficulty, cardiovascular dispensing continuity and healthcare utilisation in US counties. Research 005. Technical report version 1.2. 27 October 2026. Exploratory ecological research; not peer reviewed. Underlying analyses unchanged from the prepared edition.
Version history: draft prepared 13 October 2026; technical version 1.1 prepared 20 October 2026; publication version 1.2 released 27 October 2026.