Prevention Prevention Guidelines and the Guidelines and the

Risk of Nursing Risk of Nursing Home AdmissionHome Admission

Elmira Valiyeva, Ph.D., RutgersElmira Valiyeva, Ph.D., RutgersLouise Russell, Ph.D., RutgersLouise Russell, Ph.D., Rutgers

Jane Miller, Ph.D., RutgersJane Miller, Ph.D., RutgersMonika Safford, M.D., U Monika Safford, M.D., U

Alabama/BirminghamAlabama/Birmingham

Funded in part by AHRQ grant HS11477Funded in part by AHRQ grant HS11477

Prevention GuidelinesPrevention Guidelines

Clinical preventive services are “a Clinical preventive services are “a ubiquitous part of primary care ubiquitous part of primary care practice”. practice”.

Berg AO, Allan JD. Berg AO, Allan JD. Am J Prev MedAm J Prev Med 2001;20 (3 Suppl):3-4. 2001;20 (3 Suppl):3-4.

GuidelinesGuidelines US Preventive Services Task ForceUS Preventive Services Task Force National High Blood Pressure Education National High Blood Pressure Education

Program Program National Cholesterol Education ProgramNational Cholesterol Education Program Other national groupsOther national groups

Lifestyle-related risk Lifestyle-related risk factorsfactors

PrimaryPrimary: Smoking, inactivity, obesity: Smoking, inactivity, obesity IntermediateIntermediate: blood pressure, : blood pressure,

cholesterol, diabetescholesterol, diabetes Impact on death and disease well studiedImpact on death and disease well studied Impact on hospitalization: Impact on hospitalization: JE Miller, LB Russell, JE Miller, LB Russell,

DM Davis, DM Davis, et al. et al. Med CareMed Care. 1998;36:411-421. 1998;36:411-421

Impact on nursing home admission Impact on nursing home admission likely, but not studied in likely, but not studied in representative populations that representative populations that include the middle-agedinclude the middle-aged

NHANES I Epidemiologic NHANES I Epidemiologic Followup StudyFollowup Study

NHANES INHANES I Large nationally representative sample Large nationally representative sample Community-dwelling adults aged 45-74Community-dwelling adults aged 45-74 Baseline (1971-1975) largely predated Baseline (1971-1975) largely predated

current prevention campaignscurrent prevention campaigns Comprehensive risk factors by Comprehensive risk factors by

interview, physician exam interview, physician exam NHEFS tracked outcomes, including NHEFS tracked outcomes, including

nursing home admission, through nursing home admission, through 1992 1992

Analysis strategyAnalysis strategy

Cox proportional hazards regression Cox proportional hazards regression analysis of analysis of periods of time (spells) at periods of time (spells) at riskrisk of nursing home admission of nursing home admission

Middle-aged adults (45-64 at baseline) Middle-aged adults (45-64 at baseline) and elderly (65-74) analyzed separatelyand elderly (65-74) analyzed separately

Linked to lifestyle-related risk factors Linked to lifestyle-related risk factors and control variables present at and control variables present at baselinebaseline

Sample SizeSample SizeAge at baseline

45-64 65-74

Respondents 3,526 2,936

Respondents with 1+ admission 230 (6.5%)

728 (24.7%)

Spells at risk 3,660 3,303

Spells ending in admission 282 900

Person-years of observation 58,027 37,420

Lifestyle-related risk Lifestyle-related risk factorsfactors

Thresholds taken from national guidelines:Thresholds taken from national guidelines: SmokingSmoking: current: current InactivityInactivity: < very active in : < very active in usualusual day day

and/or recreationand/or recreation ObesityObesity: Body Mass Index (BMI) ≥ 30 : Body Mass Index (BMI) ≥ 30

kg/mkg/m22

Blood pressureBlood pressure: systolic BP ≥ 140 mm : systolic BP ≥ 140 mm HgHg

CholesterolCholesterol: ≥ 240 mg/dl: ≥ 240 mg/dl DiabetesDiabetes: ever diagnosed by doctor: ever diagnosed by doctor

Risk factor

Age at baseline

45-64 65-74

Current smoker 38.6 19.2

Inactive 51.0 64.4

Body mass index 30+ 17.8 18.0

Systolic blood pressure 140+ mm Hg 42.2 65.5

Total cholesterol 240+ mg/dl 41.6 48.1

Diabetes 4.6 8.8

Lifestyle-related risk factor Lifestyle-related risk factor prevalence, %prevalence, %

Risk factor

Age at baseline

45-64 65-74

Age in years 54.0 68.9

Female 52.3 57.4

Underweight (BMI <19) 4.0 3.5

Heart attack/heart failure 6.4 13.4

Stroke 3.0 4.9

Cancer 3.0 5.0

Arthritis

33.3 48.9

Chronic lung disease 21.5 24.4

Fracture 7.9 10.4

Prevalence of control variablesPrevalence of control variables (% except age)(% except age)

Relative risks of nursing home admission ( P<0.05, 95% CIs)

45-64 years 65-74 years

Smoker 1.56 (1.23, 1.99) 1.32 (1.08, 1.61)

Inactive 1.40 (1.05, 1.87) 1.14 (0.92, 1.42)

Body mass index 30+ 1.35 (0.96, 1.89) 1.31 (1.07, 1.60)

Systolic blood pressure 140+ 1.35 (1.06, 1.73) 1.29 (1.06, 1.56)

Total cholesterol 240+ 1.14 (0.89, 1.44) 0.90 (0.77, 1.06)

Diabetes 3.25 (2.04, 5.19) 1.50 (1.07, 2.11)

Attributable Fractions(based on NHANES III prevalences)

024681012141618

Perc

en

t 45-64

65-74

Policy and Clinical Policy and Clinical SignificanceSignificance

Prevention guidelines have identified Prevention guidelines have identified risk factors, and risk factor levels, that risk factors, and risk factor levels, that have major impacts on the risk of have major impacts on the risk of nursing home admission.nursing home admission.

Prevention could reduce that riskPrevention could reduce that risk Better quality of life.Better quality of life. Lower costs for families and third-party Lower costs for families and third-party

payers.payers.

Authors’ affiliationsAuthors’ affiliations

Elmira Valiyeva, Elmira Valiyeva, Ph.D.Ph.D.

Jane Miller, Jane Miller, Ph.D.Ph.D.

Louise Russell, Louise Russell, Ph.D.Ph.D.

Monika Safford, Monika Safford, M.D.M.D.

Institute for Health, Institute for Health, Rutgers University, Rutgers University, New Brunswick NJNew Brunswick NJ

Deep South Center on Deep South Center on Effectiveness at the Effectiveness at the Birmingham VA Medical Birmingham VA Medical Center and University of Center and University of Alabama at Birmingham, Alabama at Birmingham, ALAL