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National Center for Chronic Disease Prevention and Health Promotion
Chronic Disease Prevention
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National Center for Chronic Disease Prevention and Health Promotion Chronic Disease Prevention Home | Contact Us |
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CENTERS FOR DISEASE
CONTROL AND PREVENTION HRQOL Measures Can Help Track Health as Population Ages Life expectancies increased dramatically during the last 100 years and are projected to continue rising into the 21st century. Although longer life spans indicate success in many areas, including public health, they also bring new challenges. If a greater proportion of a country’s population is 65 or older, greater demands are placed on public health, medical, and social service systems. Adult rates of chronic diseases, which affect older adults disproportionately, also are likely to increase—contributing to greater disability, diminished quality of life, and increased health care costs. Thus, the new challenge for the public health community is to help people live healthier lives, not just longer ones, despite the cumulative effects associated with normal aging or disease progression. Fortunately, health care practitioners and policy makers can now use health-related quality of life (HRQOL) measures to identify and track the health status and service needs of older adults, particularly vulnerable subgroups. Then, they can develop and support programs that minimize the effects of chronic disease and disability, maintain the ability of older adults to live independently, and improve quality of life. “It’s the most important outcome to measure for any kind of health-related program involving older populations,” said David Moriarty, BS, a program analyst and aging studies specialist who coordinates CDC’s HRQOL assessment program. “If people say that they’re not feeling well in a population survey, it can be useful to planners because it indicates demand for health services and possible opportunities for prevention.” “And older people are very interested in the issue of quality of life,” he added. “They don’t want to live forever, but they want to feel healthy and able to function.” HRQOL is a broad and complex concept that encompasses both physical and mental health. In 1993, CDC’s Behavioral Risk Factor Surveillance System (BRFSS) added four HRQOL questions designed to measure selfperceived health and the number of recent days of poor physical health, poor mental health, and activity limitations (see Special Focus for complete list of questions).
These questions have since been added to several other national, state, and local surveys, including the physical examination portion of CDC’s National Health and Nutrition Examination Survey (NHANES) and the Medicare Health Outcomes Survey (HOS) component of HEDIS 2003. HEDIS (Health Plan Employer Data and Information Set) is the most widely used set of performance measures in the managed care industry; it is supported by the National Committee for Quality Assurance. “It’s very significant that the CDC measures were added to HEDIS because it’s generally regarded as the standard for measuring health care quality,” Mr. Moriarty said. “Because managed care plans change so much, it’s important to understand the community context for population health. Now, the Centers for Medicare and Medicaid Services, which uses HOS extensively to assess the effectiveness of Medicare managed care plans, will be able to compare data from this survey with populationwide data on health-related quality of life.” Self-Rated Health
Supports Other Disease Measures For example, arthritis and chronic joint symptoms are the leading cause of disability in the United States, affecting 70 million adults in 2001.2 Prevalence increases with age, affecting approximately 60% of people 65 years and older. “People don’t die of arthritis, but it’s a very prevalent condition that has a substantial effect on people’s health,” Mr. Moriarty said. “HRQOL measures are a very good way to measure the perceived burden—both physical and mental—of conditions like arthritis. They can also help identify high-risk groups for targeted interventions.” Health care officials in Missouri who helped pilot test the HRQOL measures in the early 1990s—including an optional survey module with questions specific to arthritis—have continued to use them in state, regional, and county surveys. They also have used a 10-question module created by CDC in 1995 that asks additional questions on activity limitation and recent days of pain, depression, anxiety, sleeplessness, and vitality. (In 2000, half of all states had used the optional module.) “We found that the questions worked and that people liked them,” said Jeannette Jackson-Thompson, PhD, MSPH, operations director for the Missouri BRFSS program. “The average person can’t always understand why we’re asking some of the questions that we ask, or they have no interest in them. But, ‘How’s your health?’ That’s something everybody can relate to.” Mr. Moriarty and Dr. Jackson-Thompson agree that the HRQOL measures are not meant to stand alone but to complement other health indicators. And because self-rated health is subjective, results must be validated against more objective data such as physician visits, hospital records, and mortality data. In 1998, CDC conducted a study in Missouri that validated the core HRQOL questions and the optional 10-question module against the widely used Medical Outcomes Study Short Form 36 (SF-36).3 Dr. Jackson-Thompson said this study was important because it showed that the HRQOL measures can be used in place of the longer SF-36, which is widely used by hospitals. In 1999, researchers contacted a sample of BRFSS participants in Missouri about 2 weeks after the initial survey and asked them to retake the four HRQOL questions.4 The reliability of the measures was rated as moderate to excellent overall, but slightly lower for older adults. Because health can change over time and because older adults often have more chronic conditions and variable health, researchers were not surprised by the lower reliability for this population. A recent Pennsylvania study showed that HRQOL measures can predict short-term and long-term physician visits, hospitalization, and mortality among older adults, even after controlling for demographic factors and comorbidity.5 “This study shows the importance of these measures as predictors of future health events, which makes them useful for planning, for identifying potentially unmet health needs, and for identifying disparities within populations,” Mr. Moriarty said. HRQOL measures also have been adopted in other countries (e.g., Norway, Sweden, South Africa, China), and a recent Canadian study noted their ability to identify health trends, high-risk groups, and relationships between health and its determinants.6 The study supported inclusion of these measures in both national and local health surveys in Canada. Lower Income and
Education Linked to More Unhealthy Days For example, a CDC analysis of 1993–1997 BRFSS data found that the number of U.S. adults aged 55 or older who reported fair or poor health (as opposed to good, very good, or excellent) increased as people aged (Table 1).1 Older adults also reported more recent unhealthy days, from a mean of 5.0 days for men aged 55–64 years to 7.2 days for women older than 75. This study also showed that people with lower socioeconomic status tended to report more unhealthy days. Groups that consistently rated their health as fair or poor included black or Hispanic adults and people who had less than a high school education, earned less than $15,000 a year, were unable to work, did not have health care coverage, lived in the South, reported diabetes or consistently high blood pressure, were underweight or overweight, were current smokers, or did not participate in leisure-time activities.1 Unexpectedly, people in their pre-retirement years (aged 55–64) who were unemployed and had lower levels of income and education reported more unhealthy days than their peers aged 65–74.1 In contrast, people with the highest socioeconomic status reported more unhealthy days as they aged. These findings indicate that HRQOL disparities become less pronounced with age, possibly because people’s access to health and social services improves when they become eligible for Medicare, social security, and other retirement benefits. “One explanation is that a number of low-income people are developing health problems that might benefit from treatment and full access to care that they aren’t getting now,” Mr. Moriarty said. “This could be an example of how the HRQOL measures reflect the benefit of some of our health and social programs.” Mr. Moriarty said the high numbers of unhealthy days (both mental and physical) for people aged 55–64 were a surprise, so a research fellow was asked to reanalyze the numbers. Targeting this subpopulation and identifying the factors contributing to the health status of its members could help address unmet health needs. Table 1. Percentage of older adults who reported fair or poor health—United States, Behavioral Risk Factor Surveillance System, 1993–1997
The reanalysis performed by Hatice Zahran, MD, MPH, an Association of Teachers of Preventive Medicine fellow, confirmed the initial findings. Dr. Zahran noted that the number of unhealthy days also was high for people aged 45–54 who earned less than $15,000 a year. Her initial findings indicated that two key factors appeared to contribute to the high numbers of unhealthy days—unemployment and limitation of activity because of impairment or health problems. Several state studies have also identified disparities in the self-reported health of certain populations. In North Carolina, researchers combined mortality data and HRQOL data to calculate healthy life expectancy (i.e., the number of years of life remaining in good perceived health) for a sample of the population.7 For minority populations in the state—mainly African Americans—life expectancies were shorter (from 79.6 years for white females to 68.0 years for minority males), and the number of years spent with health problems or activity limitations was much higher (from 10.6 for white males to 16.5 for minority females). Data such as these are vital to identifying and eliminating disparities among populations, which is one of the two overarching goals of Healthy People 2010. “Besides being a good overall measure of health, HRQOL allows you to look at the health of subpopulations and compare it with information on access to care, unmet service needs, income, and a variety of other factors,” Dr. Jackson-Thompson said. “So, for example, if people with low incomes have more unhealthy days, politicians and planners and policy makers can understand that and, in turn, support appropriate interventions to address this problem.” Addressing Mental
Health and Institutionalized Populations “Traditionally, less attention has been paid to the importance of stress, anxiety, and pain than on well-being in the general population,” Dr. Jackson-Thompson said. “HRQOL can increase recognition of the importance of measuring mental health.” Analysis of 1993–1997 BRFSS data indicates that nearly one-third of Americans reported problems with their mental or emotional health, including 11% who said their mental health was not good more than 7 days a month.8 As with the other HRQOL measures, socioeconomic status plays a major role. People who are unemployed, unable to work because of disabilities, or without health insurance suffer the most days of poor mental health. On a positive note, mental health appears to improve with age: people 75 or older report fewer days of poor mental health than younger adults (1.9 compared with 3.4 for those aged 18–24).8 Mr. Moriarty said he believes that older people often have better coping skills because of their past experiences, as well as stronger social and spiritual supports, all of which improve their mental health. But researchers and analysts must watch for “frequent mental distress,” defined as 14 or more days during the previous 30 days when mental health was not good. When people report numbers this high, more serious problems, such as depression, are suspected. Identifying depression in older populations can be more difficult, in part because of patient denial and inexperienced screeners in primary care settings. One area where health status data are lacking, however, is for people who reside in nursing homes or assisted living facilities. This is because the BRFSS surveys only noninstitutionalized adults. The best source of current data is the Minimum Data Set (MDS), a questionnaire that routinely assesses the functional needs of residents in nursing homes and community care programs that receive Medicare or Medicaid funding. The MDS includes a question on self-rated health, which allows researchers to make some inferences about these populations and how they might answer the other three BRFSS questions. States can add their own questions to the MDS, and the HRQOL measures could be added as well. “It would be the easiest survey to attach our questions to because it goes to all nursing home populations,” said Matthew M. Zack, MD, MPH, a CDC medical epidemiologist who specializes in HRQOL assessment and aging studies. “We’d start out small with a few states and see how well it worked.” Other ways to collect data on institutionalized populations include analyzing nursing home records and allowing family members or other caregivers to rate the health of people who cannot answer questions for themselves. The need for such data will increase as life expectancies continue to rise and the “baby-boom” generation ages, potentially increasing the demand for nursing home services and other types of long-term care. Projections for 2030 indicate that nearly 70 million U.S. residents will be 65 years or older and that about 8.5 million will be 85 years or older.9 If existing rates of nursing home use continue, 3 million people will be living in such facilities in 2030—nearly double the current number. People living in nursing homes are increasingly older and in worse health than previous nursing home populations and have high rates of mental and cognitive disorders and increased need for help with activities of daily living (e.g., bathing, dressing, eating).9 “We would presume that this population is worse off than people living at home,” Dr. Zack said. “Right now, about 15% of the total adult population living in the community reports fair to poor health. I would expect that maybe 75% of people living in nursing homes would rate their health as fair to poor. But we aren’t capturing these people, which means that our rates for community adults underestimate how bad the health-related quality of life may be in the overall adult population.” Fortunately, studies indicate that more people are staying healthier longer, which improves their quality of life and allows them to stay in the community longer. Many states are supporting programs that provide services to people in their homes, which is much cheaper than the skilled nursing care required in nursing homes. Other options include group homes and assisted living facilities. Despite these positive trends, future challenges await, as growing numbers of older adults put more and more pressure on existing services. Accurate information on this population will be critical, and HRQOL measures already have proven to be a valuable tool. “The aging network, state health departments, and national health and aging organizations need critical surveillance data on older adult health to better target their programmatic efforts,” said James S. Marks, MD, MPH, Director of CDC’s chronic disease center. “CDC is committed to developing better measures of older adult health and quality of life, providing critically needed data analyses and reports to states and communities, and better delineating existing and projected health disparities.” References
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Privacy
Policy | Accessibility This page last reviewed August 17, 2004 United
States Department of Health and Human Services |
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