Public housing, public health: health needs of public housing tenants

OBJECTIVES: To determine the health needs of public housing tenants, measured in terms of self-reported health status, health risk factors and expressed need for health risk reduction intervention. METHOD: Face-to-face interviews were conducted with a randomly selected sample of public housing tenants in the Hunter Region of New South Wales. RESULTS: Of 463 contactable tenants, 329 consented to participate in the study. Participants were 2.5 times more likely to rate their health as fair or poor relative to the community generally, and visited a doctor twice as often. The prevalence of smoking was more than twice that of the community generally, and the prevalence of falls was approximately three times greater. Risk of injury due to domestic violence was approximately six times greater, and the risk of injury due to violence in other locations was more than double that in the community. Between a quarter and a half of the participants requested support to reduce their health risks. CONCLUSIONS: The findings suggest that public housing tenants are one of the more severely health-compromised groups in the Australian community. IMPLICATIONS: An urgent need exists for public health initiatives that are directed at improving not only the current markedly poorer health status of public housing tenants, but also the greater prevalence of health risk factors that predict a likely continuation of such differentials into the future.     

Self-rated health: a predictor of mortality among the elderly.

Data from the Manitoba Longitudinal Study on Aging (MLSA) were used to test the hypothesis that self-rated health (SRH) is a predictor of mortality independent of "objective health status" (OHS). Subjects were a random sample of non-institutionalized residents of Manitoba aged 65+ in 1971 (n = 3,128). A single item measure of SRH was obtained during a survey conducted in 1971; a baseline measure of OHS was derived from physician and self-reported conditions and health service utilization data. Occurrence and date of death during the years 1971-1977 were known. Analyses of the data revealed that, controlling for OHS, age, sex, life satisfaction, income and urban/rural residence, the risk of early mortality (1971-1973) and late mortality (1974-1977) for persons whose SRH was poor was 2.92 and 2.77 times that of those whose SRH was excellent. This increased risk of death associated with poor self-rated health was greater than that associated with poor OHS, poor life satisfaction, low income and being male. These findings provide empirical support for the long held, but inadequately substantiated, belief that the way a person views his health is importantly related to subsequent health outcomes.     

Predictors of hospital length of stay and nursing home placement in an elderly medical population

OBJECTIVE: To identify predictors of adverse outcomes (nursing home placement and hospital length of stay) in a cohort of older hospitalized patients. DESIGN: Prospective cohort study. SETTING: A suburban medical center in the New York City metropolitan area. PARTICIPANTS: Patients aged 65 years and older admitted from the emergency department to medical services who could be seen within 24 hours. Patients with terminal illness, planned stays < 2 days, and admission to other than medicine were excluded. MEASUREMENTS: Sociodemographic data, mobility, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), mental status, length of stay (LOS), discharge diagnosis, and disposition (nursing home vs. other). RESULTS: Of 681 patients screened, 322 were eligible and assessed at admission,206 were reassessed at discharge. Using multiple regression, greater dependency in IADL, more household help, and impaired mental status at admission predicted hospital LOS significantly (P = 0.0001). Compared with those discharged home, the nursing home (NH) group had lower scores on mean mobility and mean ADLs and IADLs and was more likely to exhibit a decline in at least one ADL. Stepwise discriminant analysis was performed using admission, discharge, and combined variables. In our final model of the predictors of discharge disposition, the use of admission functional variables, age, and sex correctly classified 100% of the NH group and 91% of the other group, with IADL, ADL, and mobility defining the function that discriminated the groups. CONCLUSIONS: Our data indicate the value of cognitive and physical function at admission as predictors of adverse outcomes and support early assessment of the elderly for discharge planning for long-term care.     

Sleep problems in the community elderly as predictors of death and nursing home placement

In 1984–85, 1855 elderly residents of an urban community responded to a comprehensive baseline interview that included questions regarding an extensive set of sleep characteristics and problems. During the subsequent 3 1/2 years of follow-up, 16.7% of the respondents died and 3.5% were placed in nursing homes. The predictive significance of each sleep characteristic for mortality and for nursing home placement was determined separately for males and females, using Cox proportional hazards models. Selected demographic and psychosocial variables were also entered into the models. Age, problems with activities of daily living (ADL), self-assessed health, income, cognitive impairment, depression and whether respondents were living alone were controlled for statistically.Of the many variables analyzed, in males insomnia was the strongest predictor of both mortality and nursing home placement. For mortality, the relative hazard associated with insomnia exceeded the hazards associated with age, ADL problems, fair-poor health and low income. For nursing home placement, the hazard associated with insomnia exceeded that associated with cognitive impairment. The relationships of insomnia to mortality and nursing home placement were U-shaped, with a worse outcome if insomnia complaints over the preceding 2 weeks were either prominent (numerous or frequent) or absent. For females, insomnia was a borderline predictor of mortality and did not predict nursing home placement at all. Symptoms of the restless legs syndrome predicted mortality for females in some Cox regression models. Reported sleep duration, symptoms of sleep apnea and frequent use of hypnotic drugs did not predict mortality or nursing home placement in either sex.Charles P. Pollak, M.D. is Director Institute of Chronobiology Department of Psychiatry New York Hospital-Cornell Medical Center White Plains, New York; Deborah Perlick, Ph.D. is Supervising Psychologist in Neuropsychology Department of Psychiatry Montefiore Hospital and Medical Center New York, New York; Jerome P. Linsner, Ph.D. is Research Associate Institute of Chronobiology Department of Psychiatry New York Hospital-Cornell Medical Center White Plains, New York; John Wenston, M.A. is Research Associate Department of Epidemiology and Social Medicine Montefiore Hospital and Medical Center New York, New York; Frank Hsieh, Ph.D. is Assistant Clinical Professor Department of Epidemiology and Social Medicine Albert Einstein College of Medicine New York, New YorkThis research was supported by grant numbers PO1 AG03424 and RO1 AG08125 from the National Institute on Aging.     

Predictors of nursing home admission in a biracial population.

Racial differences in predictors of institutionalization were studied in a biracial North Carolina cohort (n = 4074). During 3 years of follow-up, 8.5% of Whites and 6.4% of African Americans were admitted to nursing homes. African Americans were one half as likely as Whites to be institutionalized after adjustment for other risk factors. Among Whites, impaired activities of daily living and cognition were the strongest predictors; among African Americans, impaired instrumental activities of daily living and prior history of nursing home use were strongest. Racial differences in nursing home use were not explained by financial and social support or physical and cognitive impairment.     

The public health issues in nursing home care

Characteristics of patients in nursing homes and the nursing homes in the United States are reviewed. Issues concerning the selection of right nursing home for the right patient are discussed in the context of measuring the needs of the patient, describing the environment of the home, and involving the patient and family in the selection process so that the best patient-environment mix can be obtained. The major issues after nursing home placement relate to quality and cost of care. The problems in measuring quality of care in the nursing home are addressed, and a goal-attainment model is proposed for both quality assessment and cost containment. Examining alternatives to nursing home care and encouraging research into diseases that lead to placement in nursing homes are seen as high priority goals in the field.     

Medicare home health utilization as a function of nursing home market factors.

Rapid increases in the size and costs of the home health market, unknown impacts of Medicare's DRG hospital reimbursement on the posthospital market, and general lack of knowledge about factors that explain interstate variation in home health utilization all suggest the importance of developing and testing models of Medicare home health use. This article proposes and tests a model of state home health utilization as a function of the nursing home market. This model proposes that home health utilization is a function of nursing home bed capacity, of the utilization of nursing home beds by Medicaid patients, of other demand factors, and of supply factors. This model is supported by the data. Specifically, Medicare home health use in the 1978-1984 period was found to be negatively related to nursing home bed stock, positively related to Medicaid nursing home utilization, and related to several other supply and demand factors, as hypothesized by the model. The further model assumption that home health utilization does not affect the nursing home market could not be tested in this analysis, but will be addressed in future research by the authors.     

Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction

Self-rated health (SRH) is a useful summary measure of people's general health and was found to predict future health outcomes. Self-rated oral health (SROH) is a similarly useful summary measure of people's oral health. Both are related to quality of life, especially at old age. The objectives of the study were: (1) to assess the independent contribution of SROH to concurrent and future SRH of elderly people, controlling for sociodemographics and health measures, and, (2) to assess whether SROH adds unique information not captured by SRH by testing their independent associations with self-esteem and life satisfaction. Participants were 850 residents of a retirement community (mean age 73) interviewed in their homes at baseline and 5 years later. The interview included single-item self-ratings of general and oral health, self-reports of medical history, recent chronic diseases, medication usage, functional disability, self-esteem and life satisfaction. Multiple regression analyses showed that SROH had an independent effect on concurrent and future SRH, controlling for age and other measures of health status. Both SRH and SROH independently explained a significant amount of variance in concurrent ratings of self-esteem and life satisfaction. SROH has a unique role in people's perceptions of their overall health yet is not fully captured by SRH. Therefore, it should be considered by general health care providers in their assessments of the health status of older adults.     

Depression as a risk factor for nursing home admission among older individuals

OBJECTIVES: Depression is common among those aged 65 and older and has been associated with increased morbidity and mortality. This study investigated whether individuals enrolled in Medicare+Choice with symptoms of depression as measured using the mental health scale from the SF-36 were at increased risk of using nursing home services. DESIGN: A Cox proportional hazards model was used. SETTING: The study investigated community-based adults aged 65 and older. PARTICIPANTS: Participants were individuals aged 65 years and older enrolled in Medicare+Choice who responded to the Health Outcomes Survey and were not institutionalized or incapable of responding for themselves at the time of survey administration. MEASUREMENTS: The purpose of the study was to predict the risk of admission to a nursing home over time, controlling for variables related to demographics, comorbidity, age, and functional status. RESULTS: The results indicated that, even after controlling for physical health, functional status, age, demographics, and socioeconomic status, Medicare+Choice enrollees over the age of 65 experiencing symptoms of depression as identified by the SF-36 are at increased risk of using nursing home services. CONCLUSIONS: These results have implications for payers of nursing home services such as Medicare and Medicaid as well as for providers and the families of older individuals. While the results do not prove that prevention is possible, they do suggest that better identification and treatment of depression reduce the risk of nursing home admission. Even if nursing home placement cannot be avoided, it is possible that the individual's quality of life could be significantly enhanced by better diagnosis and treatment of depression. These findings have implications beyond the Medicare+Choice population.     

Self-rated health as a predictor of mid-term and long-term mortality in older Afro-Caribbeans hospitalised via the emergency department

Purpose

To determine whether self-rated health (SRH) is an independent predictor for mortality in older Afro-Caribbean patients hospitalised for an acute condition.

Methods

Prospective cohort of patients recruited from the University Hospitals of Martinique Acute Care for Elders unit. Patients aged 75 or older and hospitalised for an acute condition were eligible. The outcome was time to death within the 36-week follow-up. SRH was the explanatory variable of interest. Cox’s Proportional Hazards model was used to estimate the relationship between SRH and mortality.

Results

The 223 patients included in the study were aged 85.1 ± 5.5 years. In total, 123 patients reported “very good to good” health, and 100 “medium to very poor” health. Crude mortality rates at six months, 1, 2, and 3 years were 30.5, 34.8, 48.4, and 57.0%, respectively. By multivariate analysis, SRH reached significant relationship for all mortality timepoints. The adjusted hazard ratios for subjects who perceived their health as medium, poor or very poor was 1.6–2.7 times greater than that of subjects who reported good or very good health.

Conclusion

Assessment of SRH could have implications for clinical practice, particularly in helping practitioners to better estimate prognosis in the acute care settings.

     

Self-rated health and survival: a 7-year follow-up study of Australian elderly.

OBJECTIVES. This study tested the hypothesis, from North American findings, that global self-ratings of health predict survival for older Australians. METHODS. A stratified sample of Australians 60 years of age and older surveyed in 1981 was resurveyed in 1988. Cox proportional hazard general linear models were constructed separately for men and women to predict survival over 7 years. RESULTS. Better self-ratings of health had an incremental association with survival for women, but only men with poor ratings had significantly worse survival than others. After major illnesses, comorbidities, disability, depression, and social support were controlled for, poor ratings of health for both men and women were not significantly different from excellent ratings in predicting survival. Only women's good and fair health ratings remained significant predictors. CONCLUSIONS. People rate their health as poor on the objective basis of illness and disability. Australian findings show gender differences relative to North American results; methodological differences and site and gender variability in health profiles are discussed as reasons for the varying results.     

Self-rated health as a comprehensive indicator of lifestyle-related health status

Objectives

To evaluate the usefulness of self-rated health (SRH) as a comprehensive indicator of lifestyle-related health status by examining the relationships between SRH and: (1) history of cancer and cardiovascular disease; (2) treatment of hypertension, diabetes, and dyslipidemia; (3) abnormalities in clinical parameters including blood pressure, fasting glucose, and lipids; and (4) lifestyle habits.

Methods

3744 health-check examinees at Tokai University Hachioji Hospital seen between April 2009 and March 2010 were enrolled. SRH was graded as “good,” “relatively good,” “relatively poor,” or “poor.” For statistical comparison, the differences among “healthy” (=good), “relatively healthy” (=relatively good), and “unhealthy” (=relatively poor plus poor) groups were examined. Mantel–Haenszel odds ratios were calculated to remove the confounding effect of age, using the healthy group as the reference. The Mantel-extension method was used as a trend test.

Results

1049 subjects rated their health as good, 2194 as relatively good, 428 as relatively poor, and 73 as poor. The prevalence of all diseases showed significant odds ratios and trends as SRH deteriorated. Obesity, blood pressure, glucose metabolism, and lipids deteriorated significantly as SRH became poorer, and a trend was observed in all parameters. Weight change, exercise, smoking, and rest showed significant odds ratios and trends as SRH deteriorated.

Conclusion

SRH appears useful as a comprehensive indicator of lifestyle-related health status.

Electronic supplementary material

The online version of this article (doi:10.1007/s12199-012-0274-x) contains supplementary material, which is available to authorized users.     

Interactions between hospital and nursing home use.

National estimates are provided, for the first time, of the number of hospitalizations in a year for elderly persons who also experience some nursing home use, and patterns for this interaction are described. In 1987, 816,000 persons were transferred from nursing homes to hospitals, constituting 8.5 percent of all Medicare hospital admissions for persons ages 65 and older. Another 347,000 hospital stays involved people admitted from the community and discharged to a nursing home. The reporting of discharge destination on Medicare hospital bill data in 1987 also is analyzed. It was found that these data may have underreported a nursing home as the destination by between 15 and 20 percent. The magnitude of hospitalizations of nursing home residents suggests that programs aimed at improving nursing home care might have an important impact on total days of hospital care, and that it is important to learn more about the optimal use of expensive hospital care.