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