1. Prevention Guidelines and the Risk of Nursing Home Admission Elmira Valiyeva, Ph.D., Rutgers Louise Russell, Ph.D., Rutgers Jane Miller, Ph.D., Rutgers Monika Safford, M.D., U Alabama/Birmingham Funded in part by AHRQ grant HS11477

2. Prevention Guidelines Clinical preventive services are “a ubiquitous part of primary care practice”. Clinical preventive services are “a ubiquitous part of primary care practice”. Berg AO, Allan JD. Am J Prev Med 2001;20 (3 Suppl):3-4. Guidelines Guidelines US Preventive Services Task Force US Preventive Services Task Force National High Blood Pressure Education Program National High Blood Pressure Education Program National Cholesterol Education Program National Cholesterol Education Program Other national groups Other national groups

3. Lifestyle-related risk factors Primary: Smoking, inactivity, obesity Primary: Smoking, inactivity, obesity Intermediate: blood pressure, cholesterol, diabetes Intermediate: blood pressure, cholesterol, diabetes Impact on death and disease well studied Impact on death and disease well studied Impact on hospitalization: JE Miller, LB Russell, DM Davis, Impact on hospitalization: JE Miller, LB Russell, DM Davis, et al. Med Care. 1998;36:411-421 Impact on nursing home admission likely, but not studied in representative populations that include the middle-aged Impact on nursing home admission likely, but not studied in representative populations that include the middle-aged

4. NHANES I Epidemiologic Followup Study NHANES I NHANES I Large nationally representative sample Large nationally representative sample Community-dwelling adults aged 45-74 Community-dwelling adults aged 45-74 Baseline (1971-1975) largely predated current prevention campaigns Baseline (1971-1975) largely predated current prevention campaigns Comprehensive risk factors by interview, physician exam Comprehensive risk factors by interview, physician exam NHEFS tracked outcomes, including nursing home admission, through 1992 NHEFS tracked outcomes, including nursing home admission, through 1992

5. Analysis strategy Cox proportional hazards regression analysis of periods of time (spells) at risk of nursing home admission Cox proportional hazards regression analysis of periods of time (spells) at risk of nursing home admission Middle-aged adults (45-64 at baseline) and elderly (65-74) analyzed separately Middle-aged adults (45-64 at baseline) and elderly (65-74) analyzed separately Linked to lifestyle-related risk factors and control variables present at baseline Linked to lifestyle-related risk factors and control variables present at baseline

6. Sample Size Age at baseline 45-6465-74 Respondents3,5262,936 Respondents with 1+ admission230 (6.5%) 728 (24.7%) Spells at risk3,6603,303 Spells ending in admission282900 Person-years of observation58,02737,420

7. Lifestyle-related risk factors Thresholds taken from national guidelines: Thresholds taken from national guidelines: Smoking: current Smoking: current Inactivity: < very active in usual day and/or recreation Inactivity: < very active in usual day and/or recreation Obesity: Body Mass Index (BMI) ≥ 30 kg/m 2 Obesity: Body Mass Index (BMI) ≥ 30 kg/m 2 Blood pressure: systolic BP ≥ 140 mm Hg Blood pressure: systolic BP ≥ 140 mm Hg Cholesterol: ≥ 240 mg/dl Cholesterol: ≥ 240 mg/dl Diabetes: ever diagnosed by doctor Diabetes: ever diagnosed by doctor

8. Risk factor Age at baseline 45-6465-74 Current smoker38.619.2 Inactive51.064.4 Body mass index 30+17.818.0 Systolic blood pressure 140+ mm Hg42.265.5 Total cholesterol 240+ mg/dl41.648.1 Diabetes4.68.8 Lifestyle-related risk factor prevalence, %

9. Risk factor Age at baseline 45-6465-74 Age in years54.068.9 Female52.357.4 Underweight (BMI <19)4.03.5 Heart attack/heart failure6.413.4 Stroke3.04.9 Cancer3.05.0 Arthritis33.348.9 Chronic lung disease21.524.4 Fracture7.910.4 Prevalence of control variables (% except age)

10. Relative risks of nursing home admission ( P<0.05, 95% CIs) 45-64 years65-74 years Smoker1.56 (1.23, 1.99)1.32 (1.08, 1.61) Inactive1.40 (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) Diabetes3.25 (2.04, 5.19)1.50 (1.07, 2.11)

12. Policy and Clinical Significance Prevention guidelines have identified risk factors, and risk factor levels, that have major impacts on the risk of nursing home admission. Prevention guidelines have identified risk factors, and risk factor levels, that have major impacts on the risk of nursing home admission. Prevention could reduce that risk Prevention could reduce that risk Better quality of life. Better quality of life. Lower costs for families and third-party payers. Lower costs for families and third-party payers.

13. Authors’ affiliations Elmira Valiyeva, Ph.D. Jane Miller, Ph.D. Louise Russell, Ph.D. Monika Safford, M.D. Institute for Health, Rutgers University, New Brunswick NJ Deep South Center on Effectiveness at the Birmingham VA Medical Center and University of Alabama at Birmingham, AL