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
Prevention Guidelines

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
US Preventive Services Task Force
 National High Blood Pressure Education Program
 National Cholesterol Education Program
 Other national groups

Lifestyle-related risk factors


Primary: Smoking, inactivity, obesity
Intermediate: blood pressure, cholesterol,
diabetes
Impact on death and disease well studied
 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
NHANES I Epidemiologic Followup
Study

NHANES I
Large nationally representative sample
 Community-dwelling adults aged 45-74
 Baseline (1971-1975) largely predated current
prevention campaigns
 Comprehensive risk factors by interview, physician
exam


NHEFS tracked outcomes, including nursing
home admission, through 1992
Analysis strategy

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

Linked to lifestyle-related risk factors and
control variables present at baseline
Sample Size
Age at baseline
45-64
Respondents
Respondents with 1+ admission
Spells at risk
Spells ending in admission
Person-years of observation
65-74
3,526
2,936
230
728
(6.5%)
(24.7%)
3,660
3,303
282
900
58,027
37,420
Lifestyle-related risk factors

Thresholds taken from national guidelines:
 Smoking: current
 Inactivity: < very active in usual day and/or
recreation
 Obesity: Body Mass Index (BMI) ≥ 30 kg/m2
 Blood pressure: systolic BP ≥ 140 mm Hg
 Cholesterol: ≥ 240 mg/dl
 Diabetes: ever diagnosed by doctor
Lifestyle-related risk factor prevalence, %
Risk factor
Current smoker
Inactive
Body mass index 30+
Systolic blood pressure 140+ mm Hg
Total cholesterol 240+ mg/dl
Diabetes
Age at baseline
45-64
65-74
38.6
19.2
51.0
64.4
17.8
18.0
42.2
65.5
41.6
48.1
4.6
8.8
Prevalence of control variables
(% except age)
Risk factor
Age in years
Age at baseline
45-64
65-74
54.0
68.9
Female
Underweight (BMI <19)
Heart attack/heart failure
52.3
4.0
6.4
57.4
3.5
13.4
Stroke
Cancer
Arthritis
3.0
3.0
33.3
4.9
5.0
48.9
Chronic lung disease
Fracture
21.5
7.9
24.4
10.4
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)
18
16
14
12
10
8
6
4
2
0
45-64
es
et
l2
te
ro
le
s
C
ho
D
ia
b
40
+
+
14
0
BP
BM
I3
e
In
ac
ti v
er
ok
0+
65-74
Sm
Percent
Attributable Fractions
(based on NHANES III prevalences)
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 could reduce that risk
Better quality of life.
 Lower costs for families and third-party payers.

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