[Senate Report 110-527]
[From the U.S. Government Publishing Office]
110th Congress Report
SENATE
2d Session 110-527
_______________________________________________________________________
RECOGNITION OF EXCELLENCE IN AGING RESEARCH COMMITTEE REPORT
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R E P O R T
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 89, SEC. 17(d), FEBRUARY 28, 2007
Resolution Authorizing a Study of the Problems of the Aged and Aging
December 10, 2008.--Ordered to be printed
RECOGNITION OF EXCELLENCE IN AGING RESEARCH COMMITTEE REPORT
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110th Congress
2d Session SENATE Report
110-527
_______________________________________________________________________
RECOGNITION OF EXCELLENCE IN AGING
RESEARCH COMMITTEE REPORT
__________
R E P O R T
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 89, SEC. 17(d), FEBRUARY 28, 2007
Resolution Authorizing a Study of the Problems of the Aged and Aging
December 10, 2008.--Ordered to be printed
SPECIAL COMMITTEE ON AGING
HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas RICHARD SHELBY, Alabama
EVAN BAYH, Indiana SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware MEL MARTINEZ, Florida
BILL NELSON, Florida LARRY CRAIG, Idaho
HILLARY RODHAM CLINTON, New York ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado DAVID VITTER, Louisiana
ROBERT P. CASEY, Jr., Pennsylvania BOB CORKER, Tennessee
CLAIRE McCASKILL, Missouri ARLEN SPECTER, Pennsylvania
SHELDON WHITEHOUSE, Rhode Island
Debra Whitman, Majority Staff Director
Catherine Finley, Ranking Member Staff Director
110th Congress Report
SENATE
2d Session 110-527
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RECOGNITION OF EXCELLENCE IN AGING RESEARCH COMMITTEE REPORT
_______
December 10, 2008.--Ordered to be printed
_______
Mr. Kohl, from the Committee on Aging,
submitted the following
R E P O R T
I. Executive Summary
The aging of the U.S. population is becoming an
increasingly urgent issue for Congress to address. During the
110th Congress, the oldest members of the baby boom reached the
age of 62 and became eligible for Social Security benefits. By
2029, the youngest baby boomers will have reached age 65 and
will be eligible for Medicare. America's older population will
double in the coming three decades, and even after the
demographic impact of the baby boom has passed, the share of
the population age 65 and over will grow due to longer life
expectancies and declines in fertility. After remaining fairly
constant for most of human history, average life expectancy has
nearly doubled in the past century. Older Americans are able to
spend these additional years working or by providing society
with the benefit of their knowledge and experience through
volunteerism or caregiving. As the nation's population ages,
Congress will have the opportunity to help the growing number
of older Americans contribute to and enrich the lives of their
communities, and it will face the challenge of meeting the
needs of the elderly who are poor, frail, or socially isolated.
In fields as diverse as biomedical sciences, housing, and
environmental protection, federal agencies are making important
contributions to the body of aging-related knowledge and
science. Collecting data about older people and conducting
research on their health, economic status, and social support
systems substantially improves the ability of community
leaders, program administrators, and the Congress to develop,
implement, and monitor public policies that are effective,
efficient, and equitable. Aging-related research conducted by
federal agencies has led to significant breakthroughs in
science and medicine and to the development of public policies
that help older Americans lead healthier and more productive
lives. By continuing to support aging-related research, the
Congress is committing the federal government to supporting
public policies that enrich the lives of all Americans by
improving the quality of life of older Americans.
RECOGNITION OF EXCELLENCE IN AGING RESEARCH
The U.S. Senate Special Committee on Aging (Committee) was
established in 1961 to serve as a focal point in the Senate for
discussion pertaining to the opportunities and challenges
facing older Americans. The Committee has historically sought
to recognize and promote the importance of aging research.
Accordingly, this report describes federally-funded research
that addresses the well-being of older adults in a wide range
of areas, such as maintaining health, assuring adequate income,
finding employment, engaging in productive and rewarding
activity, securing proper housing, and obtaining long-term care
services. The report demonstrates that the public sector is
dedicated to improving the quality of life for older adults and
their families and serves as a catalyst for continued progress
in addressing the most pressing concerns of the nation's older
population.
In May 2008, the Committee asked all federal departments
and agencies to identify federally-funded research projects
that address the well-being of older adults. Agencies were
asked to submit to the Committee examples of research projects
that contributed significantly to policymakers' knowledge and
understanding of social, economic, and medical issues related
to aging. Agencies were asked to describe how each research
project was deemed to be exceptional, relevant, effective, and
innovative. Agencies responded by identifying a wide range of
research projects, including efforts to promote interagency
collaboration in aging-related research, strengthen research
infrastructure, initiate or advance data collection efforts,
and carry out demonstration projects that are testing new
methods of resolving aging-related policy issues. All research
projects submitted for inclusion in the report were conducted,
administered, or sponsored by a federal department or agency
within the past four years. Research submissions included both
intramural and extramural research and research co-funded by
multiple federal agencies and by federal agencies and
nongovernmental organizations. The following is a summary of
aging-related research findings submitted by federal agencies.
II. Scope of Federal Aging-Related Research
A LARGE NUMBER OF AGENCIES CONDUCT AGING-RELATED RESEARCH
Twenty-seven agencies, ranging from the National Institutes
of Health and the Department of Veterans Affairs to the
Environmental Protection Agency and NASA, submitted over two
hundred research projects to be included in this report.\1\ The
research these agencies sponsor and conduct draws on the
knowledge and expertise of individuals representing a broad
range of disciplines and professions who are advancing our
understanding of the aging process and developing improved
strategies for providing services to older Americans.
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\1\See Appendix I for a full list of agencies.
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While many federal departments and agencies provide
services to older Americans, four agencies focus on the needs
of this population to a greater extent than most: the National
Institute on Aging, the Administration on Aging, the Centers
for Medicare and Medicaid Services, and the Social Security
Administration. While the size, budget, and mission of each of
these agencies differs substantially from that of the others,
each conducts, administers, or sponsors aging-related research
as part of its responsibilities to the public. For example:
The National Institute on Aging (NIA) sponsors and
conducts more aging-related research than any other agency of
the federal government. NIA-sponsored research has contributed
significantly to advancing scientific and medical understanding
of the aging process and diseases of old age, including the
identification of genes associated with a high risk of late-
onset Alzheimer's disease.
The Administration on Aging (AoA) provides
supportive services to older Americans, including nutrition
services, preventive health services, and home and community-
based long-term care services. Recently, the AoA conducted an
evaluation of supportive services provided under the Older
Americans Act, including their role in planning, coordinating,
and providing community services for older people.
The Centers for Medicare and Medicaid Services
(CMS) administers Medicare, Medicaid, and the State Children's
Health Insurance Program. CMS research highlights the need for
older Americans with multiple chronic diseases to receive
recommended screening and preventive care services. Researchers
have found that these services not only reduce mortality by one
half, they may also reduce significant Medicare expenditures.
The Social Security Administration (SSA)
administers both Social Security and the Supplemental Security
Income (SSI) program. Research conducted and sponsored by SSA
has contributed greatly to our knowledge of the economic
security of older Americans. Research findings from one recent
SSA research project, for example, demonstrate how automatic
enrollment in employer-sponsored 401(k) plans can boost
participation in these plans increase workers' future
retirement savings.
In addition to these examples, many federal agencies that
do not focus exclusively on the needs of older adults conduct
research on issues of importance to older Americans and their
families. Some federal agencies have undertaken research
specifically targeted at issues related to aging and the needs
of older persons, while others have incorporated aging-related
issues into other research projects. For example:
The Department of Transportation (DOT) examines
the driving safety of older adults who take multiple
medications by comparing the driving assessments of
occupational therapists with in-vehicle video recordings of
daily driving by older individuals.
The Environmental Protection Agency (EPA)
estimates the exposure of older persons to air pollution
through tools that can be used to evaluate whether air
pollution is associated with greater risk of heart attack,
stroke, chronic obstructive pulmonary disease, and asthma.
The National Aeronautics and Space
Administration's (NASA) Human Research Program is undertaking
biomedical research on human health, safety and performance
during space exploration missions. Because some of the effects
of space flight on astronauts have similarities to the effects
of human aging, such as loss of bone mass, impaired nutrition,
and reduced immunological response, NASA's research offers
insights into improving medical treatment of older persons.
The Substance Abuse and Mental Health Services
Administration (SAMHSA) is comparing the effectiveness for
older adults of an integrated primary health care approach to
specialty mental health and substance abuse services.
Several federal agencies that do not typically conduct
research are undertaking projects that have added to our
knowledge of the process of aging and the particular needs of
older citizens. For example, the National Endowment for the
Arts is evaluating the effects of active involvement in the
arts on the physical and mental health and social functioning
of older adults through a Creativity and Aging in America
study. The Smithsonian Institution's Department of Anthropology
is measuring bone density in 17th and 18th century human
skeletons to determine whether low bone mass occurred in that
era. The Appalachian Regional Commission, a federal-state
partnership that works to create self-sustaining economic
development and improved quality of life for people in
Appalachia, is studying potential economic development
opportunities for older persons in that area of the country.
A WIDE RANGE OF AGING ISSUES ARE ADDRESSED THROUGH RESEARCH
A majority of aging-related research currently being
conducted by the federal government is focused on health care.
The National Institutes of Health (NIH) conducts or sponsors
most of the clinical research undertaken by the federal
government, such as research on diseases and health conditions
associated with the aging process. (Some of this research is
described in following sections of this report). In addition to
NIH; however, other federal agencies are involved in health
care research on issues of importance for older adults. For
example, the Agency for Healthcare Research and Quality (AHRQ)
funds the Falls Prevention in Long Term Care Program that
focuses on the prevention of injurious falls and related
injuries and disabilities in nursing home and residential care
settings and the Health Resources and Services Administration
(HRSA) is examining access to home health care services among
older people in rural areas. The Department of Veterans Affairs
(VA) is working to improve end-of-life care through the Safe
Harbor Palliative Care clinical demonstration project which
strives to transfer the best practices of traditionally home-
based hospice and palliative care into VA inpatient settings.
In addition to health care, federal aging-related research
is also addressing social and economic concerns. For many older
Americans their economic well-being depends greatly on their
ability to continue working as they age. In addition to
providing additional income, work at older ages can be a source
of important social relationships. Older persons who continue
to interact with others through work and volunteer activities
tend to be healthier, both physically and mentally, than those
who become socially isolated. Federal agencies are evaluating
the benefits of volunteerism for older adults, the investment
and management of technology to better assist older people
living independently in their homes, and the availability and
accessibility of transportation options for older adults and
people with disabilities. Examples of these types of research
projects include:
The Department of Labor (DoL) uses data from the
Health and Retirement Study, to examine the economic
consequences for retirees of exiting the workforce gradually in
stages. The analysis focuses on the types of ``bridge'' jobs
that people choose, the reasons behind their choices, and their
socioeconomic outcomes.
The Corporation for National and Community Service
(CNCS) uses data from the Census Bureau's Current Population
Survey to trace the volunteer habits of the ``baby boom''
generation to help volunteer program administrators develop
strategies that will attract and retain greater numbers of
volunteers.
Researchers at the National Science Foundation
(NSF) are developing an integrated monitoring system called
``smart home'' that will capture data in a noninvasive manner
about elderly residents and their home environments in order to
assess their changing needs and capabilities as they age.
The National Council on Disability (NCD) utilizes
a ``livable communities'' framework to enable older citizens to
continue living in their homes, regardless of age or
disability. The project assessed the needs of older community
residents for safe and affordable housing, access to
transportation, access to the political process, and access to
services, programs, and activities offered by public and
private entities.
III. Models of Federal Aging Research
INVESTMENTS IN BASIC SCIENCE ARE LEADING TO SIGNIFICANT BREAKTHROUGHS
ON DISEASES THAT AFFECT OLDER AMERICANS
With more than half of its funding allocated to basic
research, the National Institutes of Health (NIH) conducts and
sponsors more research on aging-related diseases and disorders
than any other federal agency.\2\ While it is the mission of
the National Institutes of Aging to provide leadership in
aging-related research, the NIH Office of the Director and the
other 26 NIH Institutes and Centers also invest heavily in
research that contributes to greater understanding of the
physical, mental, and sociological aspects of the aging
process. For example, through NIH-sponsored research:
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\2\In fiscal year 2007, aging research accounted for almost nine
percent of all spending on health research by agencies in the
Department of Health and Human Services, including NIH. Data derived
from HHS Budget Office cross-cutting table on aging-related programs,
March 2008, and table on ``Federal Obligations for Health Research and
Development by Federal Agency, FY 1997-2007, ``NIH Office of Extramural
Research, available at: http://report.nih.gov/award/Research/
Fed_Obligations_By_Allocation_Agency_2007.xls.
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Investigators have demonstrated that restricting
caloric intake may improve the body's metabolic efficiency, an
effect that could contribute to the slowing of adverse changes
that often accompany aging.
Researchers have studied the ability of cells to
repair damage to DNA caused by exposure to environmental
toxins, which are a major cause of diseases associated with
aging, such as cancer.
A digital brain atlas of Alzheimer's disease was
developed that correlates observations from many images to a
single brain model. The research has led to novel methods to
characterize and track Alzheimer's disease that are used at
imaging centers worldwide.
Investigators found that a daily, high-dose
combination of antioxidant vitamins C, E, and beta-carotene and
the trace element zinc reduced the risk of developing advanced
age-related macular degeneration by 25 percent over a five-year
period.
Other federal agencies also conduct scientific research
that contributes to improving the lives of older persons. The
Department of Agriculture, for example, has studied the effects
of improved nutrition on reducing the risk of heart disease,
bone fractures, eye disease, and dementia in old age. The Food
and Drug Administration's (FDA) has used a combination of
experimental approaches to understand the growth and repair of
tissues in the joints, which are particularly susceptible to
injury among older persons. In addition, the Department of
Commerce is collaborating with other government scientists at
the National Institute of Standards and Technology, the FDA,
and the National Cancer Institute to develop standards for
benchmarking medical imaging algorithms used in the detection
and measurement of disease.
DATA COLLECTION EFFORTS PROVIDE VALUABLE INFORMATION ABOUT OLDER
AMERICANS
Many federal agencies conduct surveys and maintain data
registries that are used to inform policymakers and planners
about aging-related trends, including population projections,
labor force participation, and the incidence and prevalence of
specific health conditions among older people. Several federal
agencies collect data through surveys of households, employers,
hospitals, and nursing homes. Surveys of nationally
representative samples of the population, conducted on a
regular basis, are essential to enable researchers to monitor
trends in the health, functional capacity, family status, and
income of older Americans. National surveys of households and
institutions conducted and sponsored by federal agencies are
often the only surveys large enough to allow analysts to study
the most vulnerable populations, such as racial and ethnic
minority populations, residents of institutions, low-income
households, and people aged 85 and older. Examples of important
federal data collection efforts include:
The Social Security Administration and the
National Institute on Aging collaboratively conduct the Health
and Retirement Study, which is the most comprehensive source of
longitudinal data for research on health, income, wealth and
well-being for older Americans.
The Census Bureau's Current Population Survey
(CPS) and Survey of Income and Program Participation (SIPP)
collect data on employment, income, health insurance coverage,
household wealth, and other economic and demographic
characteristics of individuals, allowing researchers to measure
these variables in the elderly population relative to the non-
elderly population.
The National Science Foundation's (NSF) Panel
Study of Income Dynamics (PSID) has collected data on a
representative group of American families since 1968, allowing
researchers to study the economic and social well-being of
older Americans over time.
The Agency for Healthcare Research and Quality
(AHRQ) developed the Consumer Assessment of Health Providers
and Services Hospital Survey to allow consumers to compare the
experiences of adult inpatients' hospital care and services.
The Office of the Assistant Secretary for Planning
and Evaluation (ASPE) of the Department of Health and Human
Services is conducting the first National Survey of Residential
Care Facilities which will provide nationally representative
data on residential care facilities and their residents.
RESEARCH PROVIDES AN IMPORTANT LINK TO POLICY
Data collected through surveys conducted or sponsored by
federal agencies helps to inform Congress during the process of
developing legislation, and guides executive branch agencies in
implementing programs and policies. Federally-sponsored
research also plays a crucial role in evaluating the
effectiveness of federal programs and policies in achieving
their stated goals. Objective analysis, guided by scientific
methods and principles, is essential to ensuring that the
public's needs are measured accurately, that the policies
adopted by Congress to address those needs are executed
effectively, and that the funds appropriated to implement these
policies are expended efficiently.
Examples of how research conducted by federal agencies can
inform public policy include:
The Assistant Secretary for Planning and
Evaluation (ASPE) of the Department of Health and Human
Services is studying the potential for reverse mortgages to
play a greater role in financing long-term care. In addition,
ASPE is studying factors that influence the purchase of private
long-term care insurance, including the effect of tax
incentives.
The Congressional Budget Office (CBO) examined the
potential effectiveness of identifying high-cost Medicare
beneficiaries and focusing on early intervention strategies for
these individuals as a way to reduce the program's costs.
The Congressional Research Service (CRS) analyzed
the effect of possible benefit reductions under Social Security
reform proposals on poverty among the elderly and assessed the
effectiveness of options to mitigate these effects.
The Social Security Administration (SSA) estimated
how much longer a typical worker aged 65 in 2030 would have to
work for the same financial resources under a scenario of high
taxes and high health costs compared to one of lower taxes and
health costs.
IV. New Directions
BUILDING NEW INFRASTRUCTURE FOR AGING RESEARCH IN FEDERAL AGENCIES
In response to the growth of our nation's aging population,
some federal agencies have recognized a need to change or
restructure the programs that they lead to address the special
circumstances facing an aging society. The examples listed
below are indicative of how agencies have adapted their
research agendas to address the needs of an aging population:
The Department of Transportation is developing a
system that will correlate driver performance to age-related
functional deficits and use of medications, providing new
insights into risk factors for older drivers. DOT will also
conduct evaluations of changes to behavior that reduce the risk
of accidents among older drivers.
The Environmental Protection Agency developed the
Aging Initiative to give the agency and the public the ability
to anticipate, accommodate, and manage the environmental risks
associated with an aging society. The program is generating
data, models, and guidance to incorporate the older population
into health promotion and intervention strategies and to reduce
risks from environmental exposures.
The National Institute on Aging's Edward R. Roybal
Centers for Translational Research in the Social and Behavioral
Sciences are designed to improve the health, quality of life,
and productivity of middle-aged and older people by
facilitating the translation of knowledge learned in the social
and behavioral sciences into practical outcomes to benefit the
health and well being of older Americans.
INTERAGENCY COLLABORATION IS STRENGTHENING RESEARCH POTENTIAL
Federal agencies work together and with state and local
governments, community-based organizations, and private-sector
businesses to integrate their research projects with each
other. Federal agencies and other organizations collaborate on
research projects and share the knowledge and expertise of
their staffs and affiliated researchers. Collaboration allows
agencies to share resources and prevent duplication of effort
across agencies. Although agencies have diverse
responsibilities and goals, working collaboratively allows them
to use scarce resources efficiently and contributes to high-
quality research. The examples of interagency collaboration
listed below show some of the ways federal agencies are working
together to improve the lives of older Americans.
The Agency for Healthcare Research and Quality
(AHRQ) sponsors the Healthcare Cost and Utilization Project, a
unique federal-state-industry partnership that brings together
the data collection efforts of state data organizations,
hospital associations, private data organizations, and the
federal government to create a national information resource of
patient-level health care data.
The Administration on Aging (AoA), in
collaboration with AHRQ, CDC, CMS, NIA and several national
foundations, is promoting behavioral interventions that have
been proven to reduce the risk of disease, disability and
injury among the elderly.
As part of a larger consortium, the Center for
Disease Control's (CDC) National Center for Health Statistics
operates the Federal Interagency Forum on Aging-Related
Statistics (Forum) which brings together federal agencies that
share a common interest in improving aging-related data. The
Forum provides agencies with a venue to discuss data issues
that cut across agency boundaries.
The Centers for Medicare and Medicaid Services
(CMS) collaborates with the National Cancer Institute to
sponsor the Surveillance, Epidemiology, and End Results
database to provide detailed information about older cancer
patients.
The National Institutes of Health's (NIH)
Interdisciplinary Research Consortium in Geroscience fosters
collaboration among biologists, biochemists, geneticists,
physicians, physiologists, statisticians, and chemists that
will help scientists to better understand age-related diseases
and disorders. Examples include studies of the effects of diet
on aging and why the aging brain recovers less easily from
traumatic brain injury.
FUTURE FEDERAL AGING RESEARCH
Never has it been more important to have knowledge about
the aging process, including the characteristics and needs of
the current and future older populations. In the decades to
come, Congress and the executive branch will be responsible for
developing policies to improve the nation's methods of
financing and delivering health care and long-term care
systems. This may include not just reforms to the Medicare and
Medicaid programs, but possibly a comprehensive redesign and
reform of the private health insurance market and the means by
which long-term care services are provided and how they are
funded. Additionally, as the first baby boomers reach
retirement age and begin to rely on Social Security and pension
benefits, policymakers must ensure that the systems created to
support the economic well-being of older adults are secure. Now
is the time for Congress to direct federal agencies to review
their agendas for research on aging-related policy issues and
to set priorities for their research that will most effectively
aid the Congress as it develops legislation to address the
needs of older Americans today and in the future.
V. Appendix I: Agency Submissions
Administration on Aging
Agency for Healthcare Research and Quality
Appalachian Regional Commission
Assistant Secretary for Planning and Evaluation
Census Bureau
Centers for Disease Control and Prevention
Centers for Medicare and Medicaid Services
Corporation for National and Community Service
Department of Agriculture
Department of Commerce
Department of Labor
Department of Transportation
Department of Veterans Affairs
Environmental Protection Agency
Food and Drug Administration
Health Resources and Services Administration
Library of Congress/Congressional Research Service
National Aeronautics and Space Administration
National Council on Disability
National Endowment for the Arts
National Institute of Justice
National Institutes of Health/National Institute on Aging
National Science Foundation
Smithsonian Institution
Social Security Administration
Substance Abuse and Mental Health Services Administration
The Administration on Aging: Translating Disease and Disability
Prevention Research into State and Community Evidence-Based Service
Systems
AoA's Evidence-based Prevention Demonstration Initiative
documented that community aging service organizations can
successfully translate evidence-based interventions into
practical, attractive, low cost programs that improve the
health of older adults and are likely to reduce health care
costs. The best of these programs are being replicated across
the nation.
Lead Agency: Administration on Aging.
Agency Mission: The mission of the Administration on Aging
(AoA) is to help elderly individuals maintain their dignity and
independence in their homes and communities for as long as
possible. AoA does this by serving as the Federal agency
responsible for advancing the concerns and interests of older
people, and by working with and through a nationwide network of
29,000 community-based organizations, known as the Aging
Services Network, to promote the development of comprehensive
and coordinated systems of care at the community-level that
respond to the needs and preferences of older people and their
family caregivers.
Principal Investigator: Donald Grantt, Director, Evidence-
Based Disease and Disability Prevention Program, U.S.
Administration on Aging, Office of Planning and Policy
Development, One Massachusetts Avenue, NW., Washington, D.C.
20001.
Partner Agencies: Agency for Healthcare Research and
Quality (AHRQ), Centers for Disease Control and Prevention
(CDC), National Institute of Health (NIH), Atlantic
Philanthropies, Health Foundation of South Florida, Robert Wood
Johnson Foundation, and John H. Hartford Foundation.
General Description: In 2003, the Administration on Aging
(AoA) launched a $6 million demonstration program, in
collaboration with CDC, AHRQ, CMS, NIA and several national
foundations, to promote the translation of science-based
interventions into practice at the community-level that have
proven effective in helping older individuals to make
behavioral changes that reduce the risk of disease, disability
and injury among the elderly.
Chronic conditions currently limit activities for 12
million older persons living in communities. These conditions
collectively account for seven out of every 10 deaths, and more
than three-quarters of all health expenditures in the United
States. To address this growing chronic disease epidemic,
federal and philanthropic investments have generated a body of
scientific evidence on the efficacy of specific interventions
that can help older people to improve their health and well-
bring by better managing their chronic diseases, being more
physically active, avoiding falls, managing medications and
improving nutrition and diet. In many cases, these tested
interventions reached older adults in community, not clinical,
settings. This is a critical point--if we can reach older
adults with effective healthy aging programs without relying
solely upon clinicians, we will save billions of dollars and
reach many more people--especially those who are most
vulnerable and lack access to medical care.
The AoA demonstration was designed to test the
effectiveness of delivering these ``evidence-based prevention
programs'' though AoA's nationwide network of community-based
aging service provider organizations. The evidence-based
programs used for this demonstration include low-cost
interventions, such as chronic-disease self-management
training, fall prevention and exercise programs, that can be
delivered by staff and volunteers who are not clinicians but
are trained in specific tools and techniques that help people
to modify unhealthy behaviors. Examples of organizations in
AoA's network that provide sites for the delivery of such
programs include senior centers, adult day care programs,
congregate meal sites, senior housing projects and faith-based
organizations. These organizations make up an existing nation-
wide infrastructure that the federal government can use to
rapidly deploy new programs and services that have proven
effective in helping seniors to remain healthy and independent
in their homes and community. These organizations reach into
every community in the county and each year provide a wide
range of social and supportive services to nearly 10,000,000
elderly individuals.
In 2003, AoA awarded twelve demonstration grants to
communities across the nation supporting local partnerships
involving aging service providers, area agencies on aging,
local health entities and research organizations, such as
university research centers. A strong emphasis was placed on
coordination with the CDC and NIA funded Academic Research
Centers around the country. Over a four-year period, the
community grant programs reached more than 4,000 older adults.
Over half were members of minority groups and one in eight was
non-English speaking. The community programs' success has since
led to a strengthened collaboration between AoA and its
partners to create statewide programs in 27 states across the
country.
Beyond the participation numbers, analysis of surveys
conducted at baseline and then again 4-6 months after the
program ended demonstrated that participants in these
community-based demonstration projects achieved the same
benefits as subjects in the randomized trials in much more
controlled settings. Findings were especially powerful for the
Matter of Balance fear of falling program, the Healthy IDEAS
depression program, the Medication Management Program and the
Stanford Chronic Disease Self-management Program. The programs
reached diverse older adults and produced measurable and
meaningful improvements in health and function. The attached
list of references includes citations for relevant articles
that detail the findings on these programs. (See Healy et al.,
Quijano et al., Casado et al., Alkema et al., and Gitlin et
al.)
All of the grantees worked to ensure that their programs
faithfully replicated the intervention from the original
research. Four of them worked with an academic expert to
analyze various dimensions of ``fidelity'' (the label for
faithful replication) in their projects and the results were
also published. (See Frank et al.)
Based on the success of these community-level grants, in
2006 AoA launched a $14 million grants program designed to
encourage state governments to play a leadership role in
promoting the deployment of evidence-based programs for older
adults within their states as part of their overall prevention
agenda. This program that involves partnerships between the
state aging and health departments is currently supporting 350
community-level projects and has already provided evidence-
based prevention programs to an additional 8,600 older adults.
States and local agencies have matched the 2003 and 2006
federal investment with at least $6.5 million in non-federal
funds. Additionally, federal agencies such as AHRQ, CDC, CMS,
HRSA, NIA and others have contributed expertise and funds to
this demonstration initiative. Nine prestigious universities in
the CDC's Healthy Aging Research Network are contributing
expertise in research, evaluation and training to support
success at both the local and national levels.
This collective effort has been bolstered by $8.4 million
in grants from The Atlantic Philanthropies to the National
Council on Aging (NCOA), AoA's National Technical Assistance
Center and a leader in healthy aging. These funds are being
used to further advance replication of the Stanford Chronic
Disease Self-management Program in at least 27 states (24
funded by AoA and 3 by NCOA) and to build sustainable systems
for statewide access in at least eight states. Together, the
Robert Wood Johnson Foundation and The John A. Hartford
Foundation have provided over $3.5 million to NCOA to promote
healthy aging programming in the aging services network.
Additionally, The John A. Hartford Foundation awarded $1.7
million to the Partners in Care Foundation to fund national
expansion of the Medication Management Program developed under
the 2003 AoA demonstration grant. And in May 2008, the Health
Foundation of South Florida committed $7.5 million over five
years to embed evidence-based programming for older adults into
community care systems in three counties.
Excellence: What makes this project exceptional?
This demonstration initiative is exceptional because it
creates a practical, low-cost way to translate the best science
from NIH and other federal agencies into attractive, effective
programs that improve the health and function of older adults
and reduce costs. It promotes collaboration and partnerships at
the federal and local levels that leverage expertise, resources
and funding from multiple public and private organizations. And
it provides an important, value-added role for community-based
social services agencies in deploying interventions that can
keep older people healthy and also reduce health care costs.
Significance: How is this evidence-based demonstration
relevant to older persons, populations and/or an aging society?
Four out of five older adults have a chronic condition and
many experience limitations in activities due to such
conditions. Minority and disadvantaged elders are at greater
risk for chronic illnesses and accompanying disability. Nearly
40% of older adults living in the community reported
limitations in function due to chronic conditions. Two-thirds
of Medicare dollars are spent on people with 5 or more chronic
conditions. The aging of the population alone is projected to
increase health care costs by 25 percent between 2000 and 2030.
Falls are the leading cause of both fatal and nonfatal injuries
for those 65 and over. In 2005, over 1.8 million older adults
were treated in emergency departments for injuries from falls,
more than 433,000 were hospitalized, and nearly 16,000 died.
Poor health is not an inevitable consequence of aging.
Given the medical nature of these chronic illnesses, the search
for interventions has been heavily medical, but an often
overlooked set of programs is best delivered outside of the
medical care system. These programs relate primarily to
supporting healthy lifestyle choices including self-management
of chronic conditions, increasing physical activity, reducing
falls, improving eating habits, and managing depressive
symptoms.
Older adults--like everyone else--need support in making
healthier choices. They often face unique challenges to
engaging in preventive activities, such as having to endure
arthritic pain that makes exercising difficult, or being
discouraged about having so many chronic conditions, or not
having good peer support. Proven chronic disease self-
management workshops help older adults to address the barriers
to making healthier choices and build skills to effectively
manage their conditions. Community aging service providers,
working collaboratively with health care providers and other
local prevention experts, are highly suited to address the
prevention needs of the elderly.
Effectiveness: What is the impact and/or application of
this evidence-based demonstration to older persons?
Every program that was replicated under this demonstration
initiative was based upon an intervention that had proven
efficacy in a rigorous scientific study. For example, the
Stanford Chronic Disease Self-management Program, a six week
workshop led by trained lay facilitators, has repeatedly
produced powerful outcomes for people with chronic conditions.
In the original trial, six months after the end of the
intervention, participants reported significant:
Improvement in self-rated health, disability,
social and role activities;
More energy and less fatigue;
Decreased disability;
Increased exercise;
Greater skill in coping strategies and symptom
management;
Better communication with their physicians;
and,
Fewer physician visits and hospitalizations.
In the AoA demonstration projects offering the Chronic
Disease Self-management Program in Western Michigan and
Philadelphia, most of these findings were replicated when the
program was offered to diverse populations, including Hispanics
and African-Americans, by Area Agencies on Aging working with
senior centers and other local sites.
This program and many others in the AoA demonstration
produced significant improvements in health that have been
published in peer-reviewed journals. If taken to scale, these
programs hold the promise of making dramatic improvements in
the health and well-being of our older citizens.
Innovativeness: Why is this evidence-based demonstration
exciting or newsworthy?
This AoA demonstration initiative is exciting and
newsworthy because it did what is rarely done: It drew upon the
billions of federal investment in high quality research to test
practical, low-cost attractive programs that can reach millions
of diverse elders and produce meaningful improvements in health
and health care costs. It organized multiple public and private
organizations into an effective results-focused collaborative.
Streamlining Access to Long Term Care: The Aging and Disability
Resource Center Initiative
The vision of the ADRC program is to have Resource Centers
in every community serving as highly visible and trusted places
where people can turn for information on the full range of
long-term support options. The goal is to empower individuals
to make informed choices and to streamline access to long-term
support. Long-term support refers to a wide range of in-home,
community-based, and institutional services and programs that
are designed to help individuals with disabilities.
Lead Agency: Administration on Aging (AoA).
Agency Mission: The mission of the Administration on Aging
(AoA) is to help elderly individuals maintain their dignity and
independence in their homes and communities for as long as
possible. AoA does this by serving as the Federal agency
responsible for advancing the concerns and interests of older
people, and by working with and through a nationwide network of
29,000 community-based organizations, known as the Aging
Services Network, to promote the development of comprehensive
and coordinated systems of care at the community-level that
respond to the needs and preferences of older people and their
family caregivers.
Principal Investigator: Greg Case, U.S. Administration on
Aging, Office of Planning and Policy Development, on
Massachusetts Avenue, NW., Washington, D.C. 2001.
Partner Agency: Centers for Medicare and Medicaid Services
(CMS).
General Description: The Aging and Disability Resource
Center Program (ADRC), a collaborative effort of the
Administration on Aging (AoA) and the Centers for Medicare &
Medicaid Services (CMS), is designed to streamline access to
long-term care.
The ADRC initiative supports state efforts to develop
``one-stop shop'' programs at the community level that will
help people make informed decisions about their service and
support options and serve as the entry point to the long-term
support system. States are using ADRC funds to better
coordinate and/or redesign their existing systems of
information, assistance and access and are doing so by forming
strong state and local partnerships.
Resource Center programs provide information and assistance
to individuals needing either public or private resources,
professionals seeking assistance on behalf of their clients,
and individuals planning for their future long-term care needs.
Resource Center programs also serve as the entry point to
publicly administered long term supports including those funded
under Medicaid, the Older Americans Act and state revenue
programs.
Key Functions of an ADRC:
Awareness & Information
Information on Options
Assistance
Options Counseling
Benefits Counseling
Employment Options Counseling
Referral
Crisis Intervention
Planning for Future Needs
Access
Eligibility Screening
Private Pay Services
Comprehensive Assessment
Programmatic Eligibility Determination
Medicaid Financial Eligibility Determination
One-Stop Assessment to all public programs
ADRC demonstration grantee states target Resource Center
services to the elderly and at least one additional population
of people with disabilities (i.e., individuals with physical
disabilities, serious mental illness, and/or mental
retardation/developmental disabilities). Many ADRCs serve
people with all disabilities regardless of their age and others
are working towards this goal.
In many communities, long-term services are administered by
multiple agencies and have complex, fragmented, and often
duplicative intake, assessment, and eligibility functions.
Figuring out how to obtain services is difficult. A single,
coordinated system of information and access for all persons
seeking long-term support minimizes confusion, enhances
individual choice and supports informed decision-making. It
also improves the ability of state and local governments to
manage resources and to monitor program quality through
centralized data collection and evaluation.
AoA and CMS launched the ADRC initiative in the fall of
2003 through the funding of 12 grants to states to develop
pilot programs. Additional grants were awarded in 2004 and 2005
bringing the total number of states funded through the federal
ADRC initiative to 43. Additional states have implemented. ADRC
projects without federal funding.
To support ADRC grant projects, AoA and CMS fund technical
assistance providers. The AoA funded ADRC Technical Assistance
Exchange (TAE) coordinates technical assistance efforts and
collaborates closely with the CMS funded Community Living
Exchange Collaborative. Technical assistance is provided
through individual assistance to grantees, national meetings,
monthly teleconferences, a weekly newsletter, the ADRC-TAE
website and in other ways. Many of the technical assistance
products developed for grantees are available to the public on
the website www.adrc-tae.org.
Excellence: What makes this project exceptional?
Since its inception in 2003, states have embraced the ADRC
initiative as they have come to understand the significant role
single point of entry programs can play in helping consumers
with disabilities remain in their homes and communities. Today,
just four years since the first AoA and CMS funded ADRC opened
its doors, there are 173 ADRC program sites serving nearly 30%
of the U.S. population. Over half of the 43 states with
federally funded ADRC programs have passed legislation,
developed executive guidance, and/or contributed state funds to
enhance and expand ADRCs. State investments in ADRCs/single
entry point systems, independent of the federal initiative, now
total over $45,000,000. A number of states including Alaska,
Indiana, Kentucky, Louisiana, New Hampshire, and West Virginia
have achieved statewide coverage with their ADRCs.
On the Federal level, the ADRC initiative has also received
significant support. With the 2006 reauthorization of the Older
Americans Act, Congress directed the Assistant Secretary for
Aging to implement ADRC programs in all states to serve as
visible and trusted sources of information on the full range of
long-term care options.
Significance: How is this demonstration relevant to older
persons, populations and/or on aging society?
The American public has an overwhelming preference for care
at home, but all too often must deal with a long term care
system that is fragmented, confusing and often biased in favor
of more expensive institutional care. A fragmented system with
no easy point hinders informed decision-making on the part of
people with disabilities and their families and may result in
the unnecessary use of expensive forms of care and spend-down
to Medicaid. About half of the elderly people who enter a
nursing home as private pay end up exhausting their assets and
spending down to Medicaid. The ADRC initiative is designed to
reduce the confusion experienced by consumers and instead
empower them with the information and assistance they need to
make informed choices and, for those that need publicly funded
services, to streamline the eligibility determination process
to make it easier to access needed supports.
One of the most significant outcomes of the ADRC initiative
relates to the new partnerships that have formed as states and
communities have developed single point of entry systems. One
key example are the new partnerships that are forming across
aging and disability networks as they work together to develop
and implement ADRCs. While the aging network has always been a
service network serving older adults, the disability network
has developed primarily as an advocacy network assisting people
with disabilities of all ages gain basic civil rights. In
joining together to streamline access to long-term care, each
of these networks bring unique skill sets to the table and the
end result is that older adults and non-elderly adults with
disabilities now gain benefit from the skill sets of both
networks.
Effectivness: What is the impact and/or application of this
demonstration to older persons?
The ADRC program impact on people with disabilities,
including older people, is immeasurable as the program strives
to simplify state systems for long-term care to make them more
accessible. As ADRC projects become more visible in the
community, sites are seeing an increase in the number of
contacts they receive. From March 2004 to March 2008, the
average number of contacts per month per site have increased
20% from 929 to 1,118. By investing in IT and management
information systems that support ADRC functions and building
strong partnerships across aging and disability networks, ADRC
program sites have been able to respond to this increase in
service volume without significant increases in number of
staff. ADRCs will be well positioned to respond efficiently and
effectively to the needs of older adults even as demand for
services increases over the next two decades.
One important goal of the ADRC initiative is to get to
consumers as they go through the most critical pathways to long
term care: hospitals, physician's offices, and community health
clinics. By getting to a consumer at that critical point when
they are making decisions about long term care, the ADRC can
help to ensure they have access to comprehensive information
about the full range of supports available. Based on the most
recent ADRC reports from March 2008, 36.7% of referrals to
ADRCs were from these ``critical pathways.''
Several characteristics differentiate ADRCs from other
long-term care organizations and establish them as leaders in
rebalancing systems of care historically oriented toward
institutional care. These include:
Delivery of efficient, simplified access to
a wide range of information and supports about
community-based options for an array of consumer groups
seeking information or access into the long-term care
system through diverse entry points;
Commitment to providing resources based on
the values of consumer direction, person-centered
planning, and individual choice and autonomy,
particularly through options counseling;
Capacity to facilitate effective linkages at
multiple junctures involving diverse stakeholders along
the long-term care continuum; and
Ability to prevent institutional placement
by maximizing access to comprehensive, updated and
credible information about alternate resources in the
community including access to HCBS waiver services.
Innovativeness: Why is this demonstration exciting or
newsworthy?
The ADRC program is exciting and newsworthy because it is
being embraced by professional, consumers, and advocates alike
as an initiative that helps to ensure that people with
disabilities, regardless of income, in need of long-term
supports and services have access to the full range of
information to assist them in making informed decisions
regarding the care they need. Any public hearing that has been
held over the last decade to get consumer input on long-term
care issues has been inundated by pleas from consumers to
streamline the existing fragmented bureaucracy people are
forced to deal with when they try to learn about and access
existing care options. GAO's Means-Tested Programs: Information
on Program Access Can be an Important Management Tool (March
2005) documents the information and decision-making barriers
that fragmentation in existing public programs creates for
consumers. The AoA and CMS ADRC initiative is in direct
response to this documented need to streamline access to long
term care.
AGing Integrated Database (AGID)
AGID is an on-line query system using AoA's performance
measurement data and surveys, supplemented by information from
the Census Bureau. AGID users can produce customized tables by
selecting data elements and further results based on geographic
locations or demographic stratifiers.
Lead Agency: Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Agency Mission: The mission of the Administration on Aging
(AoA) is to help elderly individuals maintain their dignity and
independence in their homes and communities for as long as
possible. AoA does this by serving as the Federal agency
responsible for advancing the concerns and interests of older
people, and by working with and through a nationwide network of
29,000 community-based organizations, known as the Aging
Services Network, to promote the development of comprehensive
and coordinated systems of care at the community level that
respond to the needs and preferences of older people and their
family caregivers.
Principal investigator: Saadia Greenberg, Director, Office
of Evaluation, U.S. Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Partner agency: Social & Scientific Systems, Inc.
General Description: AGID is an on-line query system that
provides dynamic access to AoA-related program performance
results, AoA-supported surveys and Census population data. The
purpose of the system is to allow users to produce customized
tables in a step-by-step process and output the results in
print or spreadsheet form. AGID users have the ability to
select only those data elements applicable to their needs, and
to further refine their results based on geographic locations
(such as individual states or AoA regions) or demographic
stratifiers that are meaningful to their application. In
addition, the results from user queries can be downloaded in
spreadsheet form and, in turn, post-processed for graphical
displays or more in-depth analyses.
The system is based on aggregate statistics reports to
speed up data access and protect individual records. Since
there are many thousands of data elements available in the
original databases, only the analytically relevant variables
were carried over to AGID. If there is a query that the user
would like to see but AGID does not support, the user can
submit a request using the ``Submit Feedback'' link on the AGID
homepage and the user will receive a prompt response. Although
there are constructed variables and some restructuring of the
database files, most of the data elements appearing in the
system are in the form as reported by the states or survey
participants.
The databases that are currently available in the system
are listed below:
AoA Databases: State Program Reports (SPR) 2000-2006;
National Ombudsman Reporting System (NORS) 2006-2006; National
Surveys of Older Americans Act (OAA) Participants 2003-2005;
National Survey of Area Agencies on Aging (AAA) 2005/2006.
Census Databases: American Community Survey (ACS) Data
which includes State-Level ACS Data 2004-2006; Population
Estimates Data which includes State-Level Population Data 2000-
2006 and County-Level Population Data 2006.
A unique feature of the AGID system is the ability to build
your own customized database. The user has the option of
selecting a single database in generating database-specific
tables or combining data elements from multiple databases to
build a customized table. The user is able to build state-level
tables with data from multiple databases. AGID can be accessed
at www.data.aoa.gov.
Excellence: What makes this project exceptional?
AGID provides dynamic access to aging population
statistics, program performance reports, and surveys of OAA
program participants. The system allows users to produce
customized reports and statistics from multiple databases. It
is user-friendly in that it provides a step-by-step process and
outputs the results in print or spreadsheet form.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
AGID is significant because it improves the handling of
data and provides multiple data sources related to aging. This
enables the State and local decision makers to examine trends,
compare themselves to others, and develop the best senior
programs available to them. It can be used for the following
analyses: compare to Census, compare to national averages,
compare to other States, develop benchmarks, develop per capita
ratio, compare over time, examine cost per unit, and examine
usage per client.
Effectiveness: What is the impact and/or application of
this research to older persons?
AGID improves data reporting, comparison, analysis, and
timeliness.
Innovativeness: Why is this research exciting or
newsworthy?
AGID is available to everyone. This database provides
detailed information not previously available to the public and
data can be queried from various sources. The system constantly
adds new data and features.
National Aging Program Information System Comprehensive Aging Reporting
and Data System (CARDS)
The CARDS program is a web-based decision support system
for NAPIS and houses all NAPIS data. It includes a web-based
tool for SUAs to submit data and enable reporting for AoA.
Lead Agency: Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Agency Mission: The mission of the Administration on Aging
(AoA) is to help elderly individuals maintain their dignity and
independence in their homes and communities for as long as
possible. AoA does this by serving as the Federal agency
responsible for advancing the concerns and interests of older
people, and by working with and through a nationwide network of
29,000 community-based organizations, known as the Aging
Services Network, to promote the development of comprehensive
and coordinated systems of care at the community-level that
respond to the needs and preferences of older people and their
family caregivers.
Principal Investigator: Saadia Greenberg, Director, Office
of Evaluation, U.S. Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Partner agency: Harmony Information Systems, Inc., State
Agencies on Aging.
General Description: The CARDS system houses the data
warehouse and reporting tools for program information and
services provided under the Older Americans Act (OAA). The OAA,
administered by AoA, provides grant programs for an array of
supportive services, as well as state and local efforts to
develop comprehensive systems of car for older people and their
family caregivers. Data and information on these programs is
gathered through the National Aging Program Information System
(NAPIS) in collaboration with an Aging Network that includes 56
State Units on Aging (SUAs), 655 Area Agencies on Aging (AAAs),
244 Tribal organizations, and over 29,000 local community
service organizations.
The NAPIS database system has multiple components. Review,
analysis and infrastructure upgrades of each part of the system
are crucial for continued stability, security and validity of
the data and the elements contained within the database and web
elements. The NAPIS data allows AoA to develop and dissect
information about aging services to Congress, states and other
stakeholders. NAPIS components include State Program Report
(SPR), National Ombudsman Reporting system (NORS), title IV of
the OAA, Senior Medicare Patrols Project (SMP), and the Census
data.
The CARDS system houses AoA's NAPIS data and provides the
following benefits:
One-stop shopping because the system is a web-
based portal using single ``Hub'' application.
Easy-to-use single-click electronic report
submission, which does not require any email or file transfer
protocol.
Simple method to capture, validate and report
data.
Decision support system and projections.
Improve data timeliness, reliability, efficiency
and effectiveness.
24/365 availability.
Automatic backup.
Year-by-year, multi-year, state-by-state and
multi-state reporting, allowing local and nationwide reports.
Ad hoc analysis.
Standardized reports and procedures.
Cross-program reporting.
Historical analysis including variance reporting.
Single data repository.
Automated tracking, notification and logs.
Role-based use.
Third-party data import allowing flexibility.
Scalable.
Streamlined support.
Streamlined training.
Excellence: What makes this project exceptional?
The CARDS program is exceptional because it enables state
and other grantees to electronically submit data and
information to the NAPIS database. It captures, validates and
reports on data, and serves as a decision-support system for
AoA. It enhances the timeliness, reliability, efficiency and
effectiveness with which AoA manages data; and it establishes a
web-based, hosted database and decision-support system to be
operational, initially for SPR, NORS and information from the
U.S. Census Bureau.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The CARDS data is designed to assist States and grantees to
do reporting in a quick and efficient manner. The software is
user-friendly and the system is designed to detect anomalies in
data. As a result, the system can help reduce redundancy, lower
costs, and maximize the level of care provided to consumers.
Effectiveness: What is the impact and/or application of
this research to older persons?
The data makes it possible for AoA to develop and
disseminate information about services for the aging to
Congress, states and other stakeholders.
Innovativeness: Why is this research exciting or
newsworthy?
The CARDS program provides an integrated environment to
house AoA program and performance data. The data and
information is gathered through NAPIS in collaboration with an
Aging Network that includes 56 SUAs, 655 AAAs, 244 Tribal
organizations, and over 29,000 local community service
organizations.
Recognition of Excellence in Aging Research Submission Form: AoA
Performance Measurement
AoA, in concert with State and local partners, uses
performance measurement tools of GPRA to improve services. The
results.aoa.gov website is designed to provide program results
and evaluation information.
Lead government department/agency conducting, sponsoring or
administering the research: Administration on Aging.
Mission of department/agency: The mission of the
Administration on Aging (AoA) is to help elderly individuals
maintain their dignity and independence in their homes and
communities for as long as possible. AoA does this by serving
as the Federal agency responsible for advancing the concerns
and interests of older people, and by working with and through
a nationwide network of 29,000 community-based organizations,
known as the Aging Services Network, to promote the development
of comprehensive and coordinated systems of care at the
community-level that respond to the needs and preferences of
older people and their family caregivers.
Name, title, mailing address, email address, and phone
number of principal investigator(s)/lead researcher(s) for the
research project: Saadia Greenberg, Director, Office of
Evaluation, U.S. Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Partner agencies or organizations that participated in the
research project: Office of Management and Budget, U.S.
Department of Health and Human Services.
General Description: For over ten years, AoA has developed,
tested and implemented performance measurement indicators that
measure the effectiveness of the Older Americans Act (OAA)
program. AoA performance measurement indicators are required
under the Government Performance and Results Act (GPRA), which
requires federal agencies to establish standards measuring
their performance and effectiveness. The AoA indicators are
described in an Online Performance Appendix which can be found
on the website results.aoa.gov.
Since enacted in 1993, AoA has accepted GPRA as an
opportunity to document each year the results that are produced
through the programs we administer under the authority of the
OAA. It is the intent and commitment of AoA, in concert with
State and local program partners, to use the performance
measurement tools of GPRA to continuously improve OAA programs
and services for the elderly. The results are included in AoA's
annual budget request to Congress.
The Online Performance Appendix is part of AoA's annual
budget request which provides detailed performance information.
Fiscal year 2009 represents the fourth year that AoA aggregated
all budget line items into a single GPRA program, AoA's Aging
Services Program, for purposes of performance measurement. AoA
program activities have a fundamental common purpose reflecting
the primary legislative intent of the OAA: to make community-
based services available to elders who are at risk of losing
their independence, to prevent disease and disability through
community-based activities, and to support the efforts of
family caregivers. It is intended that States, Tribal
organizations and communities actively participate in funding
community-based services and develop the capacity to support
the home and community-based service needs of elderly
individuals with particular attention to low-income, frail and
isolated older individuals.
These fundamental objectives led AoA to focus on three
measurement areas to assess program activities through
performance measurement:
1. Improving efficiency;
2. Improving client outcomes; and
3. Effectively targeting to vulnerable elderly
populations.
Each of these measures represents several activities across
the Aging Services Program budget and progress toward
achievement of the outcome is tracked using number indicators.
The website results.aoa.gov was developed by AoA to measure
program performance results. It includes:
Annual reports on indicators of performance
measures of the OAA program;
Performance Outcome Measurement Projects
which develop and test new and established performance
outcome measures at the state and sub-state levels;
Reports of National Surveys of OAA
Participants;
OAA program performance information reported
by the states under the State Program Report and the
National Ombudsman Reporting System;
AoA compiled statistics on the older
population; and
A series of past, current, and planned
program evaluations and related studies.
These program evaluations and related reports ensure that
the most relevant data are available to policy makers,
demonstrate the value of programs to taxpayers, and track
results. AoA strives to evaluate programs in an integrated
manner combining process, outcome, impact and cost-benefit
analysis of evaluation activities. This site provides links to
reports and results from these evaluation efforts.
Excellence: What makes this project exceptional?
AoA's Aging Services Program received an ``Effective''
rating--the highest rating--from the Office of Management and
Budget in the 2007 Program Assessment Rating Tool (PART) rating
process for its clear purpose, good management, strong
performance measures, and positive evaluations. The review
found that AoA efficiently provides home and community-based
services while maintaining high service quality. AoA continues
to enhance program evaluation activities to improve program
management.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
In concert with State and local program partners, AoA uses
the performance measurement tools of GPRA to demonstrate the
effectiveness of OAA programs and services for the elderly.
AoA's three performance measurement categories of program
efficiency, client outcomes, and effectively targeting to
vulnerable elderly populations contribute to measuring of the
success of the national aging services network. The States have
mirrored these measures to gauge their impact and improve
performance.
Effectiveness: What is the impact and/or application of
this research to older persons?
The impact of AoA's Performance Measurement for older
persons is that it has achieved the primary legislative intent
of the OAA: to make community-based services available to
elders who are at risk of losing their independence, to prevent
disease and disability through community-based activities, and
to support the efforts of family caregivers.
Innovativeness: Why is this research exciting or
newsworthy?
The Performance Measurement enables the Executive branch,
Congress, and decision makers to appreciate the value of the
Aging Services programs. AoA's performance data shows that the
national aging services network is providing high quality
services to the most vulnerable older adults and doing so in a
very efficient and cost-effective manner. Consumers believe
these services contribute in an essential way to maintaining
their independence, and they report a high level of quality for
those services.
The Evaluation of Select Consumer, Program, and System Characteristics
Under the Supportive Services Program (Title III-B) of the Older
Americans Act (The Evaluation of the Title III-B Program)
The Evaluation of the Title III-B Program found that the
Title III-B program effectively served the targeted
population--vulnerable older adults at risk for
institutionalization. Program clients confirmed the benefits of
the program.
Lead Agency: Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Agency Mission: The mission of the Administration on Aging
(AoA) is to help elderly individuals maintain their dignity and
independence in their homes and communities for as long as
possible. AoA does this by serving as the Federal agency
responsible for advancing the concerns and interests of older
people, and by working with and through a nationwide network of
29,000 community-based organizations, known as the Aging
Services Network, to promote the development of comprehensive
and coordinated systems of care at the community-level that
respond to the needs and preferences of older people and their
family caregivers.
Principal Investigator: Saadia Greenberg, Director, Office
of Evaluation, U.S. Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Partner agency: Research Triangle Institute International.
General Description: This study evaluated the Older
Americans Act (OAA) Title III-B program including its role in
planning, coordinating, and providing community services for
older people. The OAA was established in 1965 to help provide
older Americans with the supportive services they need to live
independently in the community for as long as possible.
The Title III-B program is one of the largest components of
the OAA. Title III-B funds helped to develop the infrastructure
that constitutes the Aging Network, the system of state
agencies, called State Units on Aging (SUAs), Area Agencies of
Aging (AAAs), and local community service providers that plan,
coordinate and deliver services. The Title III-B program helped
the Aging Network to serve as the entry point into the long-
term care system, providing critical information, case
management services, and direct funding of long-term care
services for individuals who otherwise might go without needed
assistance.
The overarching research question for this study was,
``how, to what extent, and with what results has the Aging
Network implemented Title III-B of the Older Americans Act?''
This study question was addressed through the following three
sub-questions:
1. What is the role/importance of providing information and
assistance and care planning (case management) services for
older persons through the Aging Network and what is the role/
importance of providing assessment and care planning for
community-based long-term care services to the Aging Network?
2. What is the role/importance of providing transportation
and home care (personal care, chore, and homemaker) services
for older persons through the Aging Network and what is the
role/importance of providing transportation and home care
services to the Aging Network?
3. What is the role/importance of financing long-term care
services for older persons (via home care, transportation, and
other Title III-B in-home services) through the Aging Network
and what is the role of financing and delivering long-term care
services to the Aging Network?
The project used a combination of quantitative and
qualitative methods to evaluate the Aging Network's involvement
with key services supported by the Title III-B program: case
management, information and assistance, personal care, chore
services, homemaker services, transportation, and assisted
transportation services.
Research Triangle Institute International (RTI) used
several data sources to examine the characteristics of
participants and Title III-B services and to evaluate the role/
importance and administration of Title III-B services for older
persons and their families. The quantitative data sources used
for this study included the 2003 and 2004 National Surveys of
OAA Program Participants, the 2001 through 2004 National Aging
Program Information System State Program Performance Report
data, and the 2006 National Survey of AAAs. Information from
the AARP and the Urban Institute also was used to help
understand the financial role of Title III-B services within
the universe of home and community-based services. In addition,
RTI conducted six focus group sessions with AAA directors, SUA
directors, and community-based providers in order to more fully
examine the issues that could not be addressed by the
quantitative data.
The study found that the Title III-B program had
successfully extended services to the targeted population--
vulnerable older adults at risk for nursing home placement. The
percent of program participants that were at high risk of
institutionalization increased. The population that received
home care services was older (aged 75+), lived alone, and had
three or more Activities of Daily Living (ADL) impairments.
Users of transportation services relied heavily on these
services, with over half reporting that the service was used
for at least 75% of their trips. Most of these participants
lived alone and were at least 75 years old. In addition to
reaching the program's target population, participants were
highly satisfied. For example, over 80% of survey respondents
rated home care services as positive. Finally, Title III-B
program funds were highly leveraged. Depending on the service,
the study found that for every $1 of Title III-B funding, local
programs leverage $2 to $6 from other sources. Overall, the
Title III-B program was a key component of the OAA and it was
performing as intended; assisting vulnerable older adults to
remain independent and active in their communities.
Excellence: What makes this project exceptional?
This evaluation is the first time that the Title III-B
program has been analyzed to examine the programs results,
financing and characteristics of program implementation.
Multiple years of data from a new annual performance survey at
the participant level were now available and combined with
annual program data and Aging Network data to provide a robust
assessment of a program that is highly valued by participants
and has helped the Aging Network serve as the entry point into
the long-term care system. The Title III-B program helped the
Aging Network to serve as the entry point into the long-term
care system and provided critical information, case management
services, and direct funding of long-term care services for
individuals who otherwise might go without needed assistance.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Understanding the impact of the program and how it operates
affects a significant number of older persons and their
families. The Title III-B program services a substantial number
of older adults and indirectly their families. Specifically,
over 400,000 participants annually relied on Title III-B case
management services during the years 2001 to 2004. Similarly,
over 9 million hours of Title III-B personal care services were
delivered annually, over 10 million hours of Title III-B
homemaker services were provided, and over 1 million hours of
chore services were supplied to older persons and their
families during this 4-year period. In addition, over 34
million one-way trips were provided to general transportation
users, and approximately 2 million assisted transportation
trips were supplied annually to individuals with physical or
cognitive impairments needing help to get to their
appointments.
Title III-B transportation services facilitated access to
health, wellness, and social activities, which were key factors
to living a meaningful life in the community. Title III-B
participants relied on these transportation services a great
deal.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research evaluated how and with what results the Title
III-B program achieves its purpose of promoting the economic
independence and social well-being of individuals and families
across the lifespan.
The research found that Title III-B service participants
valued these services highly. Over 80% of survey respondents
rated aspects of homemaker service as good or better, while the
vast majority of respondents rated Title III-B transportation
services as good, very good, or excellent. Overall, Title III-B
provided older Americans with a range of needed services and
helped them navigate a complex and confusing long-term care
system.
Innovativeness: Why is this research exciting or
newsworthy?
The Evaluation of the Title III-B program is exciting and
newsworthy because the grants by the AoA and the Centers for
Medicare & Medicaid Services for Aging and Disability Resource
Centers consciously built on the expertise and infrastructure
developed by Title III-B on information and assistance and case
management. The Aging and Disability Resource Center Program
initiative supported state efforts to develop ``one-stop shop''
programs at the community level that would help people make
informed decisions about their service use and support options
and serve as the entry point to the long-term care system.
Performance Outcome Measurement Project (POMP)
AoA, in concert with State and local partners, uses
performance measurement tools of GPRA to improve services. The
results.aoa.gov website is designed to provide program results
and evaluation information.
Lead agency: Administration on Aging, One Massachusetts
Avenue, NW., Washington, DC 20001.
Agency Mission: The mission of the Administration on Aging
(AoA) is to help elderly individuals maintain their dignity and
independence in their homes and communities for as long as
possible. AoA does this by serving as the Federal agency
responsible for advancing the concerns and interests of older
people, and by working with and through a nationwide network of
29,000 community-based organizations, known as the Aging
Services Network, to promote the development of comprehensive
and coordinated systems of care at the community-level that
respond to the needs and preferences of older people and their
family caregivers.
Principal Investigator: Cynthia Bauer, Project Officer,
U.S. Administration on Aging, One Massachusetts Avenue, NW.,
Washington, DC 20001.
Partner agency: Current participants in the both Standard
and Advanced POMP include Arizona, Florida, Georgia, Iowa,
Massachusetts, New York, North Carolina, Ohio and Rhode Island.
Past participants include Alabama, California, Delaware,
Hawaii, Indiana, Illinois, Maryland, Oklahoma, South Carolina
and Virginia.
General Description: The Government Performance and Results
Act (GPRA) requires Federal agencies to use performance
measurement, particularly outcome measurement, to improve the
performance of Federal programs. Further, the Office of
Management and Budget (OMB) has introduced the Program
Assessment Rating Tool (PART), which they use to evaluate the
performance of Federal programs. The PART places additional
emphasis on assessing program performance through outcome
measurement. Results from POMP projects have been instrumental
in improving AoA's PART scores.
POMP is a multi-agency collaboration involving AoA, state
and local Agencies on Aging, a technical assistance contractor
and consultants. POMP helps State and Area Agencies on Aging
(AAAs) assess their own program performance, while assisting
AoA to meet the accountability provisions of GPRA and OMB
program assessment requirements. Over the past nine years, AoA
has sponsored the Standard POMP project for the Older Americans
Act (OAA), Title III programs. This project with State Units on
Aging (SUAs) and AAAs has produced a core set of performance
measurement instruments. The instruments have been developed to
obtain consumer-reported outcomes and quality assessment for
critical OAA services. The instruments also measure special
needs characteristics of the people who receive services such
as physical and social functioning. Other measurement tools
address the adequacy and benefit of services that support
family caregivers. Performance measurement tools developed
under POMP can be located at www.grpa.net. Work on Standard
POMP is nearing completion. Final validity/reliability testing
of the POMP surveys will be completed by December 2008.
In fiscal year 2004, AoA determined that while consumer
assessment will continue to be an important component of
program performance measurement, it was time for the POMP
project to begin the process of evolving into a more
sophisticated performance measurement system to assess program
impacts in relation to costs. AoA collaborated with the
grantees and technical assistance contractors to develop
performance impact measures called ``Advanced POMP.'' The first
Advanced POMP competition occurred in 2004. The first year of
Advanced POMP was a planning year. Grantees developed a
statement of the project's overarching goals as follows:
Goal 1: Demonstrate Cost Savings or Cost Avoidance
Attributed to OAA programs;
Goal 2: Demonstrate Efficiency of OAA programs; and
Goal 3: Demonstrate Effectiveness of OAA programs.
The grantees are working on statistical models predicting
nursing home delay or diversion, the analysis of emergency room
and hospital utilization data compared for OAA and non-OAA
clients, and the effectiveness of senior centers or congregate
meals programs in terms of improved nutrition, health, and
social and emotional well-being. These projects are scheduled
to be completed in September 2009. However, preliminary
findings are very promising. Nursing home predictor modeling
for four States has consistently shown that receipt of
additional types of service yields increased time living in the
community and a comparison of Medicaid home-delivered meal
clients and non-clients shows fewer hospital admissions and
emergency room visits for those older people receiving home-
delivered meals.
AoA is currently launching a new project, the Next
Generation: POMP, which will commence as a two-year planning
and development grant. This project will establish the
framework for Next Generation: POMP and will include as
follows:
The development and preparation of the toolkit
``POMP TO GO,'' along with the redesigned POMP website, will
provide user friendly performance measurement survey tools for
the network and ``POMP TO GO'' will provide a protocol to be
used for the future dissemination of more sophisticated POMP
methodologies.
The development of longitudinal survey
instruments. The Standard POMP surveys will serve as a starting
point but extensive developmental work is needed to identify
performance data likely to show meaningful change over time.
The review of the synthesis of nursing home
predictors identified in Advanced POMP and the development of a
specific strategy for cross-validating the ``generic'' model.
The identification of key variables across earlier
POMP surveys for consistency and development of an analytical
protocol for testing the predictive value of survey items.
Excellence: What makes this project exceptional?
The POMP projects are exceptional because they represent a
true collaborative effort between AoA, State Agencies on Aging
and AAAs. The projects have successfully evolved over the years
and the performance measurement capability throughout the Aging
Network has also evolved. The results of the project are useful
at all levels of the Aging Network. At the national level, the
projects have enabled AoA to demonstrate program performance
excellence.
Standard POMP: The following areas have been studied under
POMP:
1. Case Management
2. Congregate Nutrition Program
3. Homemaker Service
4. Home Delivered Nutrition Program
5. Information and Assistance Assessment
6. Senior Centers
7. Transportation Service
8. Family Caregiver Support
9. Providers
In addition, survey instruments were designed to document
client characteristics. These include physical functioning,
social functioning, emotional well-being, and demographic
information.
A website, www.gpra.net, was established to show the POMP
activities and surveys, which include consumer reported
outcomes and consumer-assessment of service quality.
Consumer assessment surveys developed under POMP have
enabled AoA and our State and AAA partners to demonstrate that
services provided by the National Aging Services Network:
Are highly rated by recipients.
Are effectively targeted to vulnerable individuals
and those who need services.
Provide assistance to individuals and caregivers
that is instrumental in allowing older persons to maintain
their independence and avoid premature nursing home placement.
Advanced POMP: The grantees are working on statistical
models predicting nursing home diversions, the analysis of
emergency room and hospital utilization data compared for the
OAA and non-OAA clients, and the effectiveness of senior
centers or congregate meals programs in terms of improved
nutrition, health, and social and emotional well-being.
Preliminary results are all positive. Nursing home predictor
modeling for four States has consistently shown that receipt of
additional types of service yields increased time living in the
community and a comparison of Medicaid home-delivered meal
clients and non-clients shows fewer hospital admissions and
emergency room visits for those older people receiving home-
delivered meals.
Next Generation: POMP: Building on the earlier results of
the POMP demonstrations, AoA is launching a new project
entitled ``Next Generation: POMP.'' The first phase of this
project is developmental and will encompass the development and
preparation of the ``POMP TO GO'' generic toolkit, the
development of longitudinal performance measurement survey
instruments, the development of a specific strategy to cross-
validate the ``generic'' nursing home predictor model under
development in Advanced POMP, and the identification of key
variables from Standard POMP surveys that are predictors of
nursing home placement.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Demonstrating the effectiveness of OAA services at the
Federal, State and AAA levels is of paramount importance during
this time of fiscal constraints. The POMP is relevant to older
persons, populations and/or an aging society because AoA works
with the States and AAAs to document the benefits of OAA
services. The results of POMP are then used to improve program
management and leverage additional funding thereby improving
services provided to older persons.
Effectiveness: What is the impact and/or application of
this research to older persons?
AoA's annual performance measurement surveys demonstrate
that services provided by the Aging Network are highly rated by
recipients, effectively targeted to vulnerable populations and
individuals, and provide assistance to individuals and
caregivers that help older persons maintain their independence
and remain in the community. Over the years, the Grantees have
used the POMP project to leverage funding and improve program
performance and management which benefits older persons.
POMP documents the high quality of services provided under
the OAA. For example, consumer ratings obtained from the AoA's
annual performance measurement surveys consistently show high
(over 90%) customer quality ratings of key OAA services, such
as home delivered meals, transportation, and family caregiver
support services.
In addition, the results of POMP are used to directly
benefit older persons as demonstrated by the following
examples:
Improve program performance and management. North
Carolina expanded information collected, enhanced advocacy, and
improved program management. New York used the transportation
survey to improve service and provide in-service training for
dispatchers, and used the nutrition survey to demonstrate that
home delivered meals represent a substantial portion of elderly
persons' daily food intake, resulting in a meal site, scheduled
to be shut down, remaining open.
Leverage funding. During the 2006 legislative
session, South Carolina used results of Advanced POMP with
partners to obtain a $2.9 million supplemental appropriation.
This is the first new money that the SUA has been able to
obtain in ten years. New York used POMP nutrition survey
results to illustrate the impact of the Home Delivered Meal
program on clients. As a result, additional funding from the
county legislature was added in order to provide another Home
Delivered Meal route in one AAA. Another New York AAA used POMP
nutrition survey results to justify the need for an increase in
county funds. With the increase in funding, the AAA did not
have to create a waiting list for meals.
Innovativeness: Why is this research exciting or
newsworthy?
The POMP is exciting and newsworthy because POMP is a true
Federal/State/AAA partnership where the results are used
effectively at all levels of the Aging Network. At the national
level, AoA uses POMP to conduct national surveys using the POMP
instruments. AoA uses the results of our national surveys to
establish and report on performance measures that are included
in the annual GPRA plan, the strategic plan and the PART
assessment. The improvement in AoA's performance measurement
capacity has resulted in improved PART assessments. In the 2007
PART assessment, AoA received a rating of ``Effective,'' the
highest possible rating, and AoA was cited in the OMB
Director's memo for exemplary performance.
At the State level, POMP results are used in various ways
(e.g. developing performance measures in State plans and
budgets, improving information systems, developing high risk
assessment tools, developing provider ``scorecards,'' and
justifying budget requests). At the AAA level, the results are
used to improve program management, justify budgets, leverage
funding from other sources, and justify the maintenance or
expansion of OAA programs/services.
U.S. Department of Health and Human Services: Assisted Living for
Americans
To develop tools and materials that help assisted living
consumers, and consumer intermediaries (e.g., local Aging
agencies) obtain uniform information on the characteristics,
services and costs of individual AL/RC facilities--to aid
consumers in determining which AL/RC community best meets their
priorities and needs. Now known collectively as the AL
Disclosure Collaborative (ALDC), the ALDC members--representing
25 national organizations--have agreed to develop the tools
(and eventually disseminate ALDC endorsed tools/materials)
using a voluntary consensus process in partnership with AHRQ,
the latter providing the research support to insure the
resulting tools are based on sound scientific methods.
Lead Agency: U.S. Department of Health and Human Services,
Agency for Healthcare Research and Quality (AHRQ)
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
Principal Investigators: D.E.B. Potter, M.S. (2005-
present), Senior Survey Statistician, Agency for Healthcare
Research and Quality, 540 Gaither Road, Suite 500, Rockville,
MD 20850; William Spector, PhD (2003-2005), Senior Social
Science Researcher, Agency for Healthcare Research and Quality,
540 Gaither Road, Suite 500, Rockville, MD 20850.
Partner Agencies: AARP; Benjamin Rose Institute; University
of Minnesota, Minneapolis (Division of Health Policy and
Management, School of Public Health); University of
Massachusetts (Gerontology Institute); Jessie F. Richardson
Foundation (Clackamas, OR), National Academy of State Health
Policy; Texas A&M Health Science Center at College Station
(School of Rural Public Health)*; University of North Carolina
at Chapel Hill; VA Puget Sound Health Care System (Health
Services Research and Development); Westat, Inc.; University of
Pittsburg (Center for Research on Health Care); National
Academy of State Health Policy; Harvard Medical School,
Massachusetts; RAND, California; American Institutes for
Research; and Texas A&M Health Science Center at College
Station (School of Rural Public Health).
General Description: Assisted living/residential care (AL/
RC) is an important care option for people with health needs
and functional impairments, especially for frail elders needing
protective oversight, but not continuous nursing care. The
typical assisted living resident is an 86-year-old woman who
needs help managing medications and is in need of assistance
with approximately two activities of daily living (i.e., help
with bathing, dressing, toiling, transferring, or eating; NCAL,
2008). With the capacity to serve over a million residents
(Mollica et al., 2007), AL/RC is gradually approaching the size
of the nursing home resident population (1.4 million residents;
AHCA 2008).
Currently, differences in State requirements and a wide
variety of services and amenities offered by AL/RC providers
make it difficult for consumers to obtain uniform information
to determine which AL/RC setting best meets their priorities
and needs. This is in contrast to information that is provided
to nursing home and home health consumers on the national
Medicare.gov web site (and maintained by U.S. Centers for
Medicare and Medicaid Services), in part, as a result of
federal regulations.
The goal of the Agency for Healthcare Research and
Quality's Assisted Living Initiative is to help AL/RC
consumers, and consumer intermediates (e.g., local Aging
agencies, hospital discharge planners), differentiate between
individual AL/RC facilities to determine what best meets the
consumer's priorities and needs.
Phase I of the Initiative began by funding a working
conference of AL researchers, consumers, providers and
Government officials. The 2004 meeting developed a national AL
research agenda (see references in Question II.5 for agenda); a
key conclusion from the conference was ``Consumers lack
information for making informed decisions concerning AL''
(Kane, Wilson and Spector, 2007).
Subsequently (Phase II of the Initiative), AHRQ funded a
research scan of available AL/RC consumer measures and state
consumer tools, and conducted consumer and provider focus group
research. Findings from these efforts were assessed and
presented at a second AL/RC stakeholder meeting. The 2006 group
recommended the development of uniform information that would
describe the services and characteristics of individual AL/RC
communities.
Phase III of the project began late in 2006 with the
establishment of a partnership between AHRQ and the Center for
Excellence in Assisted Living. Jointly they invited key AL/RC
stakeholders to work collaboratively through a voluntary,
consensus process to develop a uniform instrument (based on
evidence when available) that would be used to describe
individual AL/RC communities. Efforts are focusing on: services
available; pricing information for services; move-in and move-
out criteria; staffing information (RN staffing, 24/7 staffing,
staff training and turnover); dementia services; and resident
rights, house rules and life safety. Known as the Assisted
Living Disclosure Collaborative, this national voluntary
consensus body is now composed of 22 member organizations (with
expectations of more) and several ad hoc federal and national
organizations. Once the uniform instrument is developed
(planned for fall 2009), a formal testing period (small and
large scale) will ensue with consumers and providers, followed
by dissemination of the ALDC endorsed instrument, associated
materials and information.
Excellence: What makes this project exceptional?
The AL initiative from its outset has been a public/private
partnership that involved key assisted living stakeholders in
the AL research process. The research community, the AL
provider community, organizations that advocate for older
Americans and the disabled as well as consumers, have all
voiced their need for consumer information on AL/RC.
What is exceptional is that for very little federal
investment and no federal regulation--in contrast to the
spending and regulation required to obtain uniform public
information about individual nursing homes and home health
agencies--the resulting AL/RC tools (based upon science when
available) could (after development and dissemination) aid
consumers in their informed choice of an AL/RC communities by
providing information on the characteristics, services and
costs of individual AL/RC residences.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The average age of an assisted living consumer is 85 years
old (NCAL, 2008). The population age 85 and older is the
fastest growing segment of the U.S. population, expected to
grow from 8.5 million in 2006 to almost 21 million by 2050
(Federal Interagency Forum on Aging Related Statistics, 2008).
AL/RC is an important care option for people with health needs
and functional impairments, especially for frail elders and
those with dementia related problems not requiring continuous
nursing care. Informed consumer choice, especially a choice
that diverts older Americans from more costly care alternatives
(while simultaneously meeting their needs and priorities), has
the potential to reduce the pace of public long-term care
spending (62 percent of nursing home care in 2005 was financed
by either Medicare or Medicaid; Komisar and Thompson, 2007).
Effectiveness: What is the impact and/or application of
this research to older persons?
The goal of this project is to aid consumers and consumer
intermediaries (e.g., local Aging agencies, hospital discharge
planners) in their effective identification and choice of AL/RC
residence(s) that meets their priorities and needs. Uniform
information about the characteristics and costs of health care
providers is an essential element of informed consumer choice.
The tool in development is to be designed to obtain uniform
information on the characteristics, services and costs of
individual AL/RC facilities, using evidence-based information
when available.
Innovativeness: Why is this research exciting and
newsworthy?
Information (based on a national standard) about individual
nursing homes and home health agencies was made available to
the public, in part, due to federal regulation. The efforts of
AHRQ's Assisted Living Initiative have the potential of
providing consumers with uniform information as the result of a
voluntary consensus process of key AL/RC industry stakeholders
(see Question I.5 for a list of project partners) that work in
partnership with the Federal government, i.e. AHRQ--supporting
the development of AL/RC tools that are based on sound research
principals that inform consumer decisionmaking.
Agency for Healthcare Research and Quality (AHRQ): Efficiency of Health
Care
To understand how therapeutics' safety and effectiveness
may vary with aging and its associated healthcare needs.
Improve knowledge of ways to influence the effectiveness and
optimal use of therapeutics in older adults. Improve
healthcare's organization and delivery of therapeutics in
healthcare for older adults.
Lead Agency: Agency for Healthcare Research and Quality
(AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
Principal Investigator: Anne Trontell, MD, MPH, Program
Director, Centers for Education and Research in Therapeutics
(CERTs), Senior Advisor on Pharmaceutical Outcomes and Risk
Management Center for Outcomes and Evidence, Agency for
Healthcare Research and Quality, 540 Gaither Road, Suite 6222,
Rockville, MD 20850.
Partner Agencies: Brigham and Women's Hospital; Duke
University Medical Center; HMO Research Network; Rutgers, The
State University of New Jersey; University of Alabama at
Birmingham; University of Arizona CERT at The Critical Path
Institute (C-Path); University of Iowa; Cincinnati Hospital
Children's Medical Center; University of Pennsylvania School of
Medicine; University of Texas M.D. Anderson Cancer Center and
Baylor College of Medicine; Vanderbilt University Medical
Center; Weill Medical College of Cornell University; and
University of Chicago.
General Description: The Centers for Education and Research
on Therapeutics (CERTs) research program is an on-going
national research demonstration initiative to conduct research
and provide education that advances the optimal use of
therapeutics (i.e., drugs, medical devices, and biological
products). Begun in 1999, the program currently consists of 14
research centers and a Coordinating Center and is funded and
run as a cooperative agreement by the Agency for Healthcare
Research and Quality (AHRQ), in consultation with the U.S. Food
and Drug Administration (FDA). A National Steering Committee
includes at-large members from other Federal agencies such as
CMS, CDC, and NIH and membership from consumers, the health
care sector, and the therapeutics industry.
The CERTs leverage their core public funding from AHRQ and
FDA with other Federal and private resources. The research
conducted by the CERTs program has three major aims which have
significant impact, high relevance, and direct benefit to the
elderly, who disproportionately use multiple and complicated
therapeutic regimens:
1. To increase awareness of both the uses and risks of new
drugs and drug combinations, biological products, and devices,
as well as of mechanisms to improve their safe and effective
use.
2. To provide clinical information to patients and
consumers; health care providers; pharmacists, pharmacy benefit
managers, and purchasers; health maintenance organizations
(HMOs) and health care delivery systems; insurers; and
government agencies.
3. To improve quality while reducing cost of care by
increasing the appropriate use of drugs, biological products,
and devices and by preventing their adverse effects and
consequences of these effects (such as unnecessary
hospitalizations).
As an AHRQ priority population, the elderly and their
healthcare needs are a prominent research focus of the CERTs.
The publications cited at the end of this form showcase the
CERTs' examination of the special healthcare needs of older
adults and their families, encompassing physiological, mental
and social issues related to aging, elders' needs for
therapeutics and for psychological and mental care, family and
social supports, end of life care, financial challenges, and
overall quality of life.
Emblematic of the importance of therapeutics among the
elderly, AHRQ solicited a new CERT Center with a thematic
emphasis in aging, resulting in a 2006 award to the University
of Iowa CERT, since designated as the ``elderly care CERT'' and
focusing on research and education in therapeutics and optimal
healthcare for the elderly. A significant portion of older
adults consume many medications and also have symptoms due to
aging that may be confused with medication side effects,
placing them at high risk for harmful drug interations. Among
its many projects, the Iowa CERT is developing a medication
review tool that will assist pharmacists in identifying and
remedying clinically significant medication problems and
dangerous drug interactions among the elderly they serve.
Excellence: What makes this project exceptional?
The CERTs research program is exceptional in the breadth,
depth, quality, and impact of its research products in
improving the health and quality of life of the aging. Topics
that have been addressed include the aging process itself, the
special healthcare needs of the elderly surrounding
therapeutics, the effectiveness, safety, and comparative
effectiveness of different therapeutic choices, and the quality
and efficiency of elderly health care involving therapeutics.
Significance: How is this research relevant to older
persons, populations and/or aging society?
In addressing the optimal use of therapeutics, a
significant component of elderly care, the CERTs Program is
particularly relevant to an aging society and to older persons
where the most extensive and complicated use of therapeutics
occurs. Research by the CERTs has direct relevance to the
elderly covered by Medicare and Medicaid, including the dually
eligible who are especially vulnerable to adverse events from
therapeutics.
Effectiveness: What is the impact and/or application of
this research to older persons?
Information developed by the CERTs program informs the
elderly, their physicians, and policy and decisionmakers
throughout the healthcare system in making informed choices
among therapeutic options in order to promote the
effectiveness, safety, efficiency, and quality of care received
by the elderly. By developing research and translating it into
educational products that will be used throughout the health
care system, the CERTs enable the optimal use of therapeutics
health care for all, but especially the elderly who use more
drugs than any other age group of the population.
Innovativeness: Why is this research exciting or
newsworthy?
In terms of innovativeness, CERTs research is exciting and
newsworthy in addressing conditions among the elderly that are
preventable through the optimal use of therapeutics. These
include such important and timely topics as the prevention of
medication errors in the elderly, the avoidance of
hospitalization or death for treatable conditions among older
adults, and the risk of inappropriate prescribing to the
elderly outside of hospital settings.
Agency for Healthcare Research and Quality: Effective Health Care
Programs
The Effective Health Care Program conducts and supports
research with a focus on outcomes, comparative clinical
effectiveness, and appropriateness of pharmaceuticals, devices,
and health care services. The program focuses on issues of
special importance to Medicare, Medicaid and the State
Children's Health Insurance Program (SCHIP).
Lead Agency: Agency for Healthcare Research and Quality
(AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
Principal Investigator: Jean R. Slutsky, Director, Center
for Outcomes and Evidence, Agency for Healthcare Research and
Quality, John M. Eisenberg Building, 540 Gaither Road,
Rockville, MD 20850.
Partner Agencies: Centers for Medicare & Medicaid Services
(CMS), Food and Drug Administration (FDA), National Institutes
of Health (NIH).
General Description: AHRQ's Effective Health Care Program
provides current, unbiased evidence about the comparative
effectiveness of different health care interventions. The
object is to help consumers, health care providers, and others
make informed choices among treatment alternatives, including
drugs. The program was created under Section 1013 of the
Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 to conduct research regarding ``the outcomes,
comparative clinical effectiveness, and appropriateness of
health care items and services.'' The program was launched in
2005 and focused initially on issues of special importance to
Medicare but has been expanded to include Medicaid and the
State Children's Health Insurance Program (SCHIP).
The Effective Health Care Program employs three approaches
to its comparative effectiveness research:
Synthesize knowledge--AHRQ's 14 Evidence-based Practice
Centers perform systematic reviews of published and unpublished
scientific evidence. They produce reviews of comparative
effectiveness, synthesizing what is known and where further
research is needed.
Generate knowledge--A 13-member research network (the
Developing Evidence to Inform Decisions about Effectiveness
[DEcIDE] network) carries out accelerated practical studies as
well as research to improve analytic tools.
Translate knowledge--The John M. Eisenberg Clinical
Decisions and Communications Science Center distills research
and presents results in a variety of useful and understandable
formats. The Center also develops decision aid tools for
consumers.
In the Effective Health Care Program, AHRQ seeks an
emphasis on timely and usable findings, building on the
thoroughness and unbiased reliability that have been hallmarks
of efforts so far. Equally important is broad ongoing
consultation with stakeholders which helps ensure that the
program responds to issues most pressing for health care
decision makers. Collaboration is also a key principle of the
program and AHRQ works closely with many agencies of DHHS to
identify topics for research under the program and to
communicate findings, including identified research gaps.
All reports produced by the program are available on the
Effective Health Care Web site, http://
www.EffectiveHealthCare.ahrq.gov. The Web site also includes
features for the public to participate in the Effective Health
Care Program. Users can sign up to receive notification when
new reports are available. They can also be notified when draft
reports and other features are posted for comment, and comments
can be submitted through the Web site. The public is also
invited to use the Web site to nominate topics for research by
the Effective Health Care Program.
Innovativeness: Why is this research exciting and
newsworthy?
Which medical treatments are most effective? Which carry
the most risks? AHRQ's Effective Health Care Program is the
Federal Government's leading effort to make evidence-based
comparisons of health care interventions. The Effective Health
Care Program, with funding that doubled to $30 million in 2008,
is unique among comparative effectiveness initiatives. Research
topics reflect Federal priorities to improve the health of all
Americans and include critical issues facing today's elderly
population.
Pursuant to the legislate mandate and the impending
implementation of the Medicare prescription drugs benefit, the
Secretary in 2005 chose an initial set of 10 priority
conditions focusing primarily on the needs of Medicare program.
Through discussion with and extensive input from stakeholders,
the Secretary in 2008 expanded the list of priority conditions
to include conditions relevant not only to the Medicare
program, but also Medicaid and SCHIP programs. This updated
list of clinical conditions guides research, synthesis and
translation and dissemination priorities for the Effective
Health Care Program:
--Arthritis and nontraumatic joint disorders (Muscle,
bone, and joint conditions)
--Cancer (Cancer)
--Cardiovascular disease, including stroke and
hypertension (Heart and blood vessel conditions)
--Dementia, including Alzheimer's Disease (Brain and
nerve conditions)
--Depression and other mental health disorders
(Mental health)
--Developmental delays, attention-deficit
hyperactivity disorder and autism (Developmental
delays, ADHD, autism)
--Diabetes Mellitus (Diabetes)
--Functional limitations and disability (Functional
limitations and physical disabilities)
--Infectious diseases including HIV/AIDS (Infectious
diseases and HIV/AIDS)
--Obesity (Obesity)
--Peptic ulcer disease and dyspepsia (Digestive
system conditions)
--Pregnancy including pre-term birth (Pregnancy and
childbirth)
--Pulmonary disease/Asthma (Breathing conditions)
--Substance abuse (Alcohol and drug abuse)
One part of the Effective Health Care Program, The John M.
Eisenberg Clinical Decisions and Communications Science Center,
is devoted to developing tools to help people make decisions
about health care. The Eisenberg Center translates knowledge
about effective health care into summaries that use
understandable, actionable language. An important function of
the Eisenberg Center is to transform complex scientific
information into short, plain language materials that can be
used to assess treatments, medications, and technologies. The
Eisenberg Center develops information summaries for three
audience groups--consumers, clinicians, and policymakers. The
guides are designed to help people including older persons,
populations and an aging society use scientific information to
maximize the benefits of health care, minimize harm, and
optimize the use of health care resources.
The Effective Health Care Program has published a variety
of research reviews, new research reports, and summary guides
on a variety of topics relevant to the needs of people age 65
or older. Selected research is listed below and all products
are available online, some with audio links for the visually
impaired (www.effectivehealthcare.arhq.gov).
Comparative effectiveness research is changing practice.
Our mission will be fulfilled when health care decision
makers--including patients, clinicians, purchasers, and
policymakers--use up-to-date, evidence-based information about
their treatment options to make informed health care decisions.
Agency for Healthcare Research and Quality (AHRQ)
Three falls prevention projects are funded to study the
feasibility of long term care facilities incorporating these
evidence based programs into their day to day practice. The
goal is to foster improved quality of care and quality of life
and safety in residential settings by demonstrating feasibility
of evidence-based models to ultimately foster the dissemination
of these model programs on a broader scale.
Lead Agency: Agency for Healthcare Research and Quality
(AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of healthcare for all Americans.
Principal Investigators: William Spector, PhD (Agency
Lead), Senior Social Scientist, Agency for Healthcare Research
and Quality 540 Gaither Road, Rockville, MD 20850.
Falls Management Project for Nursing Homes (Contract PI),
Joseph Ouslander, MD, Professor, Department of Medicine,
Division of Geriatric Medicine and Gerontology, Wesley Woods
Health Center, Emory University School of Medicine, Atlanta, GA
30329.
Falls Prevention Program in Assisted Living (Contract PI),
Sheryl Zimmerman, PhD, Professor, School of Social Work,
University of North Carolina at Chapel Hill, 301 Pittsboro
Street, Campus Box 3550, Chapel Hill, NC 27599.
Preventing Disability Among Residents of Continuing Care
Residential Communities (Contract PI), Helaine E. Resnick, PhD,
Director of Research, Institute for the Future of Aging
Services, American Association of Homes and Services for the
Aging, 2519 Connecticut Avenue, NW., Washington, DC 20008-1520.
Development of Injurious Falls Measures for Nursing Homes
(Contract PI), Terry Moore, MPH, Principal Associate, Abt
Associates Inc., 55 Wheeler St., Cambridge, MA 02138.
Partner Agencies: National Institute for Aging (Preventing
disability among residents of CCRC).
General Description: The Falls Prevention in Long Term Care
Program at AHRQ focuses on the prevention of injurious falls
and related injuries and disabilities in nursing home and
residential care settings. Three contracts have been funded (1)
implementation of an evidence-based falls prevention program in
nursing homes; (2) implementation of a falls prevention program
in assisted living facilities; and (3) preventing disability
among residents of Continuing Care Residential Community
(CCRC). In addition, one contract develops a method for
comparing case-mix adjusted rates of injurious falls across
nursing homes. AHRQ staff research on fractures in nursing
homes has contributed to the evidence base.
The first project involved the implementation of the Falls
Management Program (FMP) in 19 nursing homes owned and operated
by a single nonprofit nursing home chain in Georgia. The FMP is
based on work at the Vanderbilt University School of Medicine
that has been developed, tested and refined over several years
involving >250 facilities. FMP is an interdisciplinary,
multifaceted approach to reducing fall risk that includes
systematic screening, assessment, individualized care planning,
resident monitoring, and the elimination of environmental
safety hazards. The FMP is initiated by a self-assessment
process that assists nursing homes in identifying areas that
need improvement so that staff can tailor implementation to
their own facility's needs. The FMP incorporates education on
best practices and uses several quality improvement (QI) tools
designed to assist nursing homes with program implementation.
Core components of the program include administrative and
clinical leadership, interdisciplinary teamwork using QI
methodology, support by advance practice nurses, and an 8-step
fall response system to facilitate the comprehensive
investigation and documentation of falls, primary care provider
involvement, and development of individualized fall risk
reduction strategies.
The second project is a multi-component falls intervention
program that assesses the feasibility of carrying out this
program in assisted living facilities. The falls intervention
includes medication review, assessment, environmental
modification, and exercise, to reduce risk factors for falls
and fall and fracture rates among residents of assisted living
facilities. The project involves the following activities:
adapting a multi-faceted, evidence-based falls prevention
program to a protocol tailored to the assisted living
environment; implementing the pilot protocol and collecting
clinical and process data pre-post intervention; and evaluating
the results of interventions. This project is currently on-
going and being implemented in two assisted living facilities
in North Carolina (with 2 control facilities).
The third project focuses on preventing disability among
residents of CCRCs. This project will test the feasibility of
screening, providing an evidence-based exercise program, and
counseling to encourage exercise program adherence. The
screening tool is the Short Physical Performance Battery
(SPPB), a tool developed by the National Institute of Aging, to
detect sub-clinical disability in older adults who the study
involves 300 residents in 6 CCRCs. The goals are to show that
CCRCs can feasibly incorporate this program into their daily
practice and reduce the disability risk of their residents.
Falls rates, mortality and hospitalizations will also be
monitored. Implementation challenges and lessons learned will
be summarized. This project is scheduled to commence July 2008.
The aim of developing an injurious falls measure in nursing
homes is to help nursing homes and older consumers to compare
nursing home on a measure of safety. With this measure,
consumers can make better choices and facilities can monitor
and improve the safety of the environment they provide to their
residents. This project is being accomplished in collaboration
with CMS and uses CMS data.
Innovativeness: Why is this research exciting and
newsworthy?
This research program is ultimately designed to make long-
term care facilities safer for an aging population and to
provide programs that reduce the risk of older persons falling.
Falls are significant problems for elderly persons who reside
in long-term care facilities because they are the primary cause
of fractures and other physical injuries which in turn, result
in reduced physical function and quality of life, increased
morbidity and mortality, and related health care utilization
and costs. In addition by preventing disability and serious
falls this research will contribute to the reduction of
avoidable health care costs. An injurious fall increases
nursing home cost by $5,325 per year. In the year 2000, the
direct medical costs for fatal and non-fatal fall injuries of
elderly in the U.S. totaled $19.2 billion.
The three implementation projects are exceptional in that
they test evidence-based models of care in long term care
settings to demonstrate that long term care facilities can
incorporate best practices into their daily work flow. By
testing models in the three main residential care settings that
elderly live, this program provides evidence to help improve
the safety of a wide range of housing options for older persons
who need long term care services.
These studies will facilitate the dissemination of these
models to other comparable long term care facilities, providing
them with information to help them decide if they want to adopt
a model that has been tried by their peers.
In nursing homes, where multiple interventions are often
occurring at the same time, we have shown that when a restraint
reduction program is being implemented, if the FMP was also
implemented, the falls rate remained stable. Without the FMP
the rate of falls increased.
Spector et al. (2007) demonstrates the importance of
monitoring prescription drug ordering practices in nursing home
when trying to prevent avoidable falls and fractures, although
the FMP implementation study indicated that it is difficult for
nursing homes to influence physician prescription drug orders.
FMP tools have been made available at the MedQIC web site that
supports Medicare Quality Improvement Organizations (QIOs) and
providers in finding, using, and sharing quality improvement
resources.
Successful translation of research into clinical practice
that improves care is complex. These projects are identifying
how to make evidence based practices available to aging
consumers who need long term care services in residential
settings. As the population ages there will be increased demand
for these types of services and it is important to assure that
these environments can be made as safe as possible and can
encourage persons to age as disability-free as possible.
Agency for Healthcare Research and Quality
The CAHPS Hospital Survey, sometimes known as H-CAHPS or
Hospital CAHPS, is a standardized survey of the experiences of
adult inpatients with hospital care and services. Hospitals
across the country are using this survey and voluntarily
reporting data to the Centers for Medicare & Medicaid Services
(CMS). CMS began public reporting of the results in March 2008.
Lead Agency: Agency for Healthcare Research and Quality
(AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
Principal Investigators: Paul Cleary, PhD, Dean, Yale
School of Public Health, 60 College Street, P.O. Box 208034,
New Haven, CT 06520; Ronald Hays, Professor of Medicine, UCLA
School of Medicine, Division of General Internal Medicine and
Health Services Research, 911 Broxton Plaza, Box 951736, Los
Angeles, CA 90095-1736, Steven Garfinkel, Managing Research
Scientist, American Institutes for Research, 101 Connor Drive,
Suite 301, Chapel Hill, NC 27514.
Partner Agencies: Centers for Medicare and Medicaid
Services, Hospital Quality Alliance (Member organizations
include American Hospital Association, Federation of American
Hospitals, American Nurses Association, AARP, AFL-CIO, The
Disclosure Group, and others).
General Description: In June 2002, the Centers for Medicare
and Medicaid Services asked AHRQ to develop a questionnaire
through which hospital patients could rate the care that they
receive. They asked AHRQ to perform this work through the
Consumer Assessment of Health Providers and Services project
(CAHPS), which at that time was a consortium of three research
organizations (RAND, Harvard and the American Institutes of
Research) and a contractor (Westat). Though many hospital
surveys exist, consumers can't compare hospital performance
unless (1) all hospitals use the same survey and (2) survey
results are routinely reported to a single organization and (3)
these results are easily available to consumers. Development of
the CAHPS Hospital Survey and aggregation/publication of the
results by CMS has made these three things possible.
Excellence: What makes this project exceptional?
The HCAHPS project developed a rigorously tested,
standardized questionnaire through which hospital patients can
assess the care they receive in hospitals. To make sure that
the survey included questions that people really want the
answers to before they select a hospital, we conducted 16 focus
groups with a variety of individuals across the country. This
led us to develop questions that focused on provider
communication skills, communication about medications, pain
control, information for care after discharge, and many other
areas. The great majority of American hospitals report HCAHPS
data to CMS, who then publish the results on their Hospital
Compare website. In the first week after publication of HCAHPS
data, page views of this website increased from 161,000 to 1.4
million, and people are continuing to consult this resource in
large numbers. HCAHPS data are especially relevant to older
persons since, as we age, the likelihood that we will need
hospital care increases. Development of HCAHPS was an
exceptional achievement since we faced extreme push-back from
the hospital data vendor industry. Because AHRQ and CMS joined
forces with the Hospital Quality Alliance, we were able to
respond successfully to extreme public scrutiny of the
instrument and our data collection methods.
Department of Health and Human Services: Agency for Healthcare Research
and Quality
The Healthcare Cost and Utilization Project (HCUP) is an
important part of the research infrastructure for studies on
the health care of older adults in the U.S. HCUP provides data
and research software and tools that support a wide range of
studies related to the health care of the elderly including
cost and quality of health services, medical practice patterns,
access to health care programs, and outcomes of treatments at
the national, State, and local levels. HCUP is the only source
of data on hospital care for the all elderly U.S. residents
that can provide statistics at both the national and local
levels.
Lead Agency: Department of Health and Human Services,
Agency for Healthcare Research and Quality.
Agency Mission: The Agency for Healthcare Research and
Quality (AHRQ) is the lead Federal agency charged with
improving the quality, safety, efficiency, and effectiveness of
health care for all Americans. As one of 12 agencies within the
Department of Health and Human Services, AHRQ supports health
services research that will improve the quality of health care
and promote evidence-based decisionmaking.
Principal Investigator: Jenny A. Schnaier, HCUP Project
Officer, Center for Delivery, Organization and Markets (CDOM),
Agency for Healthcare Research and Quality (AHRQ), 540 Gaither
Road, Rockville, MD 20850.
Partner Agencies: Arizona--Department of Health Services;
Arkansas--Department of Health & Human Services; California--
Office of Statewide Health Planning & Development; Colorado--
Hospital Association; Connecticut--Integrated Health
Information (Chime, Inc.); Florida--Agency for Health Care
Administration; Georgia--Hospital Association; Hawaii--Health
Information Corporation; Illinois--Health Care Cost Containment
Council and Department of Public Health; Indiana--Hospital &
Health Association; Iowa--Hospital Association; Kansas--
Hospital Association; Kentucky--Cabinet for Health and Family
Services; Maine--Health Data Organization; Maryland--Health
Services Cost Review Commission; Massachusetts--Division of
Health Care Finance and Policy; Michigan--Health & Hospital
Association; Minnesota--Hospital Association; Missouri--
Hospital Industry Data Institute; Nebraska--Hospital
Association; Nevada--Division of Health Care Financing and
Policy, Department of Health and Human Services; New
Hampshire--Department of Health & Human Services; New Jersey--
Department of Health & Senior Services; New York--State
Department of Health; North Carolina--Department of Health and
Human Services; Ohio--Hospital Association; Oklahoma--Health
Care Information Center for Health Statistics; Oregon--
Association of Hospitals and Health Systems; Rhode Island--
Department of Health; South Carolina--State Budget & Control
Board; South Dakota--Association of Healthcare Organizations;
Tennessee--Hospital Association; Texas--Department of State
Health Services; Utah--Department of Health; Vermont--
Association of Hospitals and Health Systems; Virginia--Health
Information; Washington--State Department of Health; West
Virginia--Health Care Authority; and Wisconsin--Department of
Health & Family Services.
General Description: The Healthcare Cost and Utilization
Project (HCUP) (http://www.hcup-us.ahrq.gov) is an important
part of the research infrastructure for studies on the health
care of older adults in the U.S. HCUP provides data and
research software and tools that support a wide range of
studies related to the health care of the elderly including
cost and quality of health services, medical practice patterns,
access to health care programs, and outcomes of treatments at
the national, State, and local levels.
The Healthcare Cost and Utilization Project (HCUP) is a
unique Federal-State-Industry partnership and sponsored by the
Agency for Healthcare Research and Quality (AHRQ) that brings
together the data collection efforts of State data
organizations, hospital associations, private data
organizations, and the Federal government to create a national
information resource of patient-level health care data. HCUP
includes the largest collection of longitudinal hospital care
data in the United States, with all-payer, encounter-level
information beginning in 1988.
In support of AHRQ's mission, the goals of HCUP are to:
Create and enhance a powerful source of national
and state all-payer health care data.
Produce a broad set of software tools and products
to facilitate the use of HCUP and other administrative data.
Enrich a collaborative partnership with statewide
data organizations aimed at increasing the quality and use of
health care data.
Conduct and translate research to inform decision
making and improve health care delivery.
The HCUP Databases contain encounter-level information for
all payers compiled in a uniform format with privacy
protections in place. HCUP databases contain a core set of
clinical and nonclinical information found in a typical
discharge abstract (or billing record) including all-listed
diagnoses and surgeries, patient status at discharge, patient
demographics, and billed charges. HCUP data also include
information about the hospital to support aggregate research.
HCUP include the following hospital inpatient and outpatient
databases that are used for analyses of health care for older
persons:
The Nationwide Inpatient Sample (NIS) with
inpatient data from a national sample of over 1,000 hospitals
designed for making national estimates.
The State Inpatient Databases (SID) contain the
universe of inpatient discharge abstracts from participating
states.
The State Ambulatory Surgery Databases (SASD)
contain data from ambulatory care encounters from hospital-
affiliated and sometimes freestanding ambulatory surgery sites.
The State Emergency Department Databases (SEDD)
contain data from hospital-affiliated emergency departments for
visits that do not result in hospitalizations.
The HCUP databases have been a powerful resource for the
development of software and tools that can be applied to other
similar databases by health services researchers and decision
makers. These tools include an online query system (HCUPnet)
for generating statistics in a table format using HCUP data
(http://hcupnet.ahrq.gov/), software to measure quality of
hospital care (AHRQ Quality Indicators) and software for
classifying diagnoses or surgeries into clinically meaningful
categories for ease of statistical reporting (Clinical
Classification Software).
HCUP also produces reports that summarize important
findings from the databases. The HCUP Statistical Briefs
present simple, descriptive statistics on a variety of
specific, focused topics. Most of these topics have relevance
to the elderly. And one focused specifically on the elderly--
(HCUP Statistical Brief #14 ``Trends in Elderly
Hospitalizations, 1997-2004'').
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
HCUP includes the largest collection of longitudinal
hospital care data in the United States, with all-payer,
encounter-level information beginning in 1988. Unlike the
hospital files maintained by the Centers for Medicare and
Medicaid, HCUP files include records for Medicare patients who
are enrolled in managed care and it includes records for
elderly who are not covered by Medicare (primarily foreign-born
who were not part of the Social Security system). Because of
the unique Federal, State, industry partnership in data, HCUP
can support both national and local analyses of health care
among the elderly. As a result, HCUP is the only source of data
on hospital care for elderly residents that can provide
statistics at both the national and local levels.
HCUP databases capture the hospital inpatient experience of
the 32.7 million people who are 65 years and older and who
reside in the 39 HCUP Partner states (88% of all persons age 65
and older in the U.S.). In 2006, this represents approximately
11.3 million hospital inpatient records.
HCUP not only provides access to data files for
researchers, but it also has an online query system (HCUPnet)
that is designed for both researchers and non-researchers.
Using this online query system, the average person has easy
access to statistics on the care of elderly almost
instantaneously. Options are available for statistics on older
patients for individual diagnoses or surgeries broken down by
hospital characteristics. Available statistics include the
average cost and length of hospital stays, the percentage
admitted through the emergency room, discharged to nursing
homes or those who died. The following is an example of
information that can be generated from HCUPnet within seconds:
Congestive heart failure was the single most
common condition primarily responsible for the hospitalization
of persons age 65 and older in 2006 (about 810,000
hospitalizations); pneumonia was the second most common reason
for hospitalization (about 700,000 hospitalizations).
HCUP data are used to support many of the measures used for
the Congressionally-mandated National Healthcare Quality Report
and National Healthcare Disparity Report. HCUP supplies all
quality and disparity statistics for these annual reports
separately for the elderly population. Thus, HCUP statistics
are being used to monitor quality of care for the older
population. Below is an example table for the National
Healthcare Quality Report that shows the decline in hospital
deaths for acute myocardial infarction (heart attack) since
2000.
DEATHS PER 1,000 ADMISSIONS WITH ACUTE MYOCARDIAL INFARCTION (AMI) AS
PRINCIPAL DIAGNOSIS
------------------------------------------------------------------------
2005 2004 2000
------------------------------------------------------------------------
Total............ ....................... 77.5 83.0 105.8
Age.............. 18-44.................. 16.8 20.9 21.1
45-64.................. 35.1 35.3 45.5
65 and over............ 107.9 115.5 144.9
Age.............. 65-69.................. 58.1 68.5 88.6
70-74.................. 81.1 83.6 113.2
75-79.................. 102.2 106.6 140.6
80-84.................. 124.5 132.7 161.2
85 and over............ 150.7 165.9 207.5
------------------------------------------------------------------------
Source: HCUP Nationwide Inpatient Sample.
HCUP can support a wide-range of research and health policy
topics that can improve the health of the elderly. In the last
decade, over 600 peer-reviewed articles have been written based
on HCUP data and related software tools, with 160 professional
journal articles published in 2007 alone. In addition, there
are many health care journalists who rely on HCUPnet for quick
statistics to support their news stories. In 2007 there were
nearly 400 non-journal publications (e-journals, magazines and
newspapers) that featured HCUP. Most of these articles were on
topics that focused on the elderly or on health care topics of
relevance to the elderly.
Agency for Healthcare Research and Quality: The Rural Oregon Adult
Memory Study
Researchers and clinicians in the Rural Oregon Adult Memory
Study (ROAM), a pilot study with seven rural primary care
practices, designed, implemented, and evaluated the feasibility
of a universal screening program for dementia in adults over 75
years.
Lead Agency: Agency for Healthcare Research and Quality
(AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
Principal Investigator: Linda Boise, PhD, Principal
Investigator, Oregon Health & Science University, 3181 SW Sam
Jackson Park Rd. (CR131), Portland, OR 97239.
Partner Agencies: Agency for Healthcare Research and
Quality; Oregon Health Sciences University; Oregon Rural
Practice-based Research Network.
General Description: The purpose of this small feasibility
study, the Rural Oregon Adult Memory Study (ROAM) was to
improve the recognition, diagnosis and care for persons with
dementia in rural communities through innovative support for
rural primary care offices. The study team, in close
collaboration with rural physicians, adapted a set of tools
that had not been studied in rural communities in order to
allow systematic dementia screening, evaluation, and patient
and family education for patients age 75 and over. The goals of
the study were to implement and test this newly developed
clinical practice model in a small set of rural practices and
to gather pilot data on whether the practices could
successfully implement the model and the outcomes of universal
screening and follow-up evaluation. The team studied the
satisfaction of patients and families as well as clinicians and
office staff to the program. The study is the first piece in a
long range program, the goal of which is to utilize effective
education and practice change strategies to improve healthcare
for older persons with dementia in rural Oregon communities.
The study was conducted in four phases over 12 months,
including intervention adaptation to rural practice, training,
conduction of screening, and analysis. The model for ROAM was
the Assessing Care of the Vulnerable Elders model (ACOVE),
developed by geriatric experts at University of California, Los
Angeles and Rand. This model, which utilizes efficient
collection of condition-specific clinical data, physician
education and decision supports, and patient and caregiver
education materials to encourage activation of the patient's
role in follow-up, was designed to be effectively and
efficiently implemented in primary care practice. Until now,
the model had only been evaluated in urban and suburban
practices, often in communities with access to specialized
evaluation and treatment centers and other community supports.
The ROAM study was intended to build on the ACOVE model,
introducing into practice a system to efficiently screen for
possible dementia, encouraging the performance of clinical
follow-up for patients who screen positive through guided
memory evaluation forms, and provision of patient education and
resource materials.
Seven clinics recruited from among Oregon Rural Practice-
based Research Network participated in ROAM involving 19
clinicians and over 20 staff members. 436 or 94% of eligible
patients over 75 years of age where screened during the
intervention with 49% having a positive screen. Of 66 patients
who received a full evaluation during the intervention period,
21 were diagnosed with mild cognitive impairment or dementia.
The intervention was very favorably reviewed by clinicians and
staff members and the ROAM tools were revised based on
feedback. Patients were very pleased to have been asked about
their memory, with over 90% reporting that they believed it was
good idea for primary care clinicians to assess older patients'
memory and thinking.
With the success of this feasibility study, the team is
moving forward with other step in their plan to improve
healthcare for older persons with dementia in rural
communities.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting and
newsworthy?
The ROAM study brought together academic researchers and
rural primary care practices to jointly refine an existing
evidence-based model for universal screening for dementia for
use in rural communities.
Dementia is one of the most challenging conditions to
diagnose and manage and is also one of the most common
conditions affecting older Americans. The prevalence of
dementia in persons 75 or older is estimated to be 15% and up
to 50% for those aged 85 or older. The most common form of
dementia in the elderly is Alzheimer's disease. For most older
adults, the primary healthcare provider is the first clinician
to be contacted by patients suffering from Alzheimer's disease
or related dementias and in many cases is the only clinician
involved in the person's care. The challenges of effectively
diagnosing and caring for Alzheimer's patients are even greater
in rural practices. Specialty clinical diagnostic and
management services are often remote or not available and
community resources are generally limited.
Numerous studies, however, have found that a considerable
number, as many as 50% of cognitively impaired patients, have
not been evaluated or diagnosed especially, though not
exclusively, at earlier stages of the disease.
Improved patient-centered outcomes for people with dementia
will require engagement of primary care practices for the
screening, evaluation, management, and patient and family
education and support. This is especially true in rural
communities where specialized resources are often not
available.
This project included the adaptation and implementation of
an evidence-based clinical model for screening and evaluation
for dementia in rural primary care practices. It is the first
known testing of the ACOVE model in a rural setting.
The results of this pilot study, which found that the model
can be successfully implemented in rural primary care practices
and that rural elders are eager to talk with their primary care
teams about their memory function, support the team's plans to
move forward with their larger effort to utilize effective
education and practice change strategies to improve healthcare
for older persons with dementia in rural Oregon communities.
Their accomplishments will have value to rural clinicians and
communities across the country and already have produced an
adapted and revised set of tools that rural primary care
practices may use to screen and evaluate adults over 75 years
old for dementia.
Agency for Healthcare Research and Quality: The Pressure Ulcer Program
The Pressure Ulcer program is an innovative program
designed to improve day-to-day practice in nursing homes,
improve and redesign workflow, improve productivity of direct-
care workers, and reduce pressure ulcers.
Lead Agency: Agency for Healthcare Research and Quality
(AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
Principal Investigators: William Spector, PhD, Senior
Social Scientist, Agency for Healthcare Research and Quality,
540 Gaither Road, Rockville, MD 20850; Susan Horn, PhD
(Contract PI), Vice President, Research, Institute for Clinical
Outcomes Research, International Severity Information Systems,
Inc., 699 E. South Temple, Suite 100, Salt Lake City, UT 84102-
1282.
Partner Agencies: New York State Department of Health;
California and District of Columbia QIO (Centers for Medicare
and Medicaid Services); California Health Care Foundation.
General Description: The Pressure Ulcer Prevention and
Healing Research Program is carried out under the leadership of
AHRQ staff working with contractors and partner organizations.
The major activity, ``On-Time Quality Improvement (QI) for
Long-Term Care'' has been the development of a pressure ulcer
and healing quality improvement program to help nursing home
staff identify high risk residents and to integrate evidence-
based tools and documentation tools into daily workflow and
care planning structures. This project applies and extends
knowledge that had been learn in ``Real Time Optimal Care Plans
for Nursing Home QI'', grant funded by AHRQ, to new nursing
homes using Health Information Technology (HIT).
The ``On-Time'' model integrates clinical guidelines and
clinical information into each nursing home's daily routine and
processes for assessment, care planning, care delivery,
communication and reassessment using HIT. The ``On-Time'' model
streamlines Certified Nursing Aide (CNA) documentation and
focuses their documentation on critical data. Using HIT, CNAs
spend less time documenting (redundancies are eliminated), but
they document more information in a standardized way and it is
more accurate, meaningful, and useful to them in their daily
assignments. New work is integrated into daily routines rather
than added on to them. The model facilitates timely information
flow that informs weekly monitoring of resident status and on-
going care planning. The communication mechanisms used in the
``On-Time'' model are effective and efficient and provide staff
with current and accurate information on the resident on a
weekly or more frequent basis. Ultimately, the project aimed to
redesign clinical workflow--instead of concentrating on
improving existing processes only--to reduce the incidence of
pressure ulcers among nursing homes residents.
``On-Time'' has been implemented, tested and refined in 30+
nursing homes across the nation. Twenty-One nursing facilities
across the country have completed the prevention program.
Fifteen of the participating facilities are in California.
Sixteen facilities have begun implementing in 2008 in New York
State. All facilities in the District of Columbia plan are
planning to participate beginning in 2008 and 2009. The ``On-
Time'' has also expanded it scope by including pressure ulcer
healing. Ten of the facilities in California are currently
implementing pressure ulcer healing tools that supplements on-
going work on pressure ulcer prevention.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting and
newsworthy?
The elderly are at greatest risk of developing pressure
ulcers because of age-related changes in soft tissues and
decreases in skin perfusion and subcutaneous fat. Pressure
ulcers in elderly can be extremely painful and can lead to
other complications if left untreated. It has been estimated
that over $355 million are spent annually on pressure ulcer
treatment in long-term care settings.
This project has developed a quality improvement model that
can be applied to all aspects of care, not just care for
pressure ulcers, through better documentation of all aspects of
resident care and through on-time feedback reports to inform
care planning. Of all nursing home staff, CNAs spend the most
time with residents. It integrates and uses CNA clinical
reports to enhance communication across disciplines, and
promote teamwork. The ``On-Time'' reports, designed with input
from multiple disciplines, identify residents at highest risk
for pressure ulcer development, show trends in multiple
outcomes for these residents over time, and help staff monitor
the effectiveness of care in a timely fashion. By documenting
key observations on every shift, and using these data
summarized in weekly reports focusing on high risk residents,
critical information is made available for decision making by
the entire care team.
The initial grant pilot facilities achieved an average 33%
annual reduction in pressure ulcer prevalence among 11
participating nursing homes. Some facilities reduced prevalence
by up to 73% and incidence by up to 65%. In this project (21
facilities completing the program), for facilities with a high
level of implementation there was a 30.7% decline (from 13.1%
to 9.1%) in the CMS pressure ulcer quality measure and a 42%
decline in in-house pressure ulcer rates (from 4% to 2.3%).
Seven HIT vendors have now programmed the ``On-Time''
specifications into their products making these tools available
to their customers.
U.S. Preventive Services Task Force: Clinical Preventive Strategies
This research project aims to develop innovative approaches
to reviewing the evidence on clinical preventive strategies in
older adults and making recommendations to physicians for
prevention in older adults. Evidence on clinical strategies to
prevent falls will be reviewed. Additional outcomes of interest
to older adults will be reviewed including the prevention of
fall-related injuries, quality of life, maintenance of
independence, and prevention of disability.
Lead Agency: U.S. Preventive Services Task Force Program at
the Agency for Healthcare Research and Quality (AHRQ).
Agency Mission: The mission of the Agency for Healthcare
Research and Quality is to improve the safety, quality,
effectiveness, and efficiency of health care for all Americans.
The mission of the U.S. Preventive Services Task Force (USPSTF)
is to evaluate the benefits of individual services based on
age, gender, and risk factors for disease; make recommendations
about which preventive services should be incorporated
routinely into primary medical care and for which populations;
and identify a research agenda for clinical preventive care.
Principal Investigators: Evelyn Whitlock, MD, MPH,
Principal Investigator, Oregon Evidence-Based Practice Center,
3800 North Interstate Avenue, Portland, OR 97227 and Yvonne
Michael, ScD, MS, Project Lead Investigator, Oregon Health and
Sciences University, Evidence-Based Practice Center, 3181 SW
Sam Jackson Park Rd, CB 669, Portland, OR 97239-3098.
Partner Agency: Oregon Evidence-Based Practice Center.
General Description: This research project aims to develop
innovative approaches to reviewing the evidence on clinical
preventive strategies in older adults and making
recommendations to physicians for prevention in older adults.
The U.S. Preventive Services Task Force (USPSTF), first
convened by the U.S. Public Health Service in 1984, and since
1998 sponsored by the Agency for Healthcare Research and
Quality (AHRQ), is the leading independent panel of private-
sector experts in prevention and primary care. The USPSTF
conducts rigorous, impartial assessments of the scientific
evidence for the effectiveness of a broad range of clinical
preventive services, including screening, counseling, and
preventive medications. Its recommendations are considered the
``gold standard'' for clinical preventive services. The USPSTF
recently began work to update its recommendation on fall
prevention in older adults. Preliminary work revealed that the
usual methods of reviewing evidence may not be the most
appropriate for addressing prevention in older adults. This is
because: (a) some interventions (for example, vision screening)
cut across several topics; (b) prevention may not be the only
purpose of screening (care management may be another reason);
and (c) falls are not the result of one ``disease'' but may
result from myriad causes. Another very important reason that
traditional review methods may not work for preventive
strategies in older adults is the different outcomes in older
adults compared to younger adults. While preventing or
forestalling death may be the goal, other important outcomes
are quality of life, maintenance of independence, and
prevention of disability. Future plans for this work include
the application of the newly-developed methods to the review of
other prevention strategies in older adults.
Excellence: What makes this project exceptional?
Falls are an important cause of morbidity and mortality in
older adults. This project has developed methods that have
forced researches and policy makers to ``think outside the
box.''
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The U.S. Census Bureau projects that the number of persons
65 years and older will more than double by 2030. Falls and
fall-related injuries increase with age. Between 30 and 40
percent of community-dwelling persons aged 65 years and older
fall at least once per year. Falls are the leading cause of
injury in people 65 years of age or older. In 2004, more than
1.8 million older adults were treated for fall-related injuries
in U.S. hospital emergency departments, and more than 433,000
were hospitalized. In 2003, the Centers for Disease Control and
Prevention (CDC) reported that falls were the leading cause of
injury deaths and the ninth leading cause of death from all
causes among those 65 years of age and older. Twenty to thirty
percent of those who fall incur moderate to severe injuries
that result in decreased mobility that subsequently impacts the
individual's independence. These limitations will likely
decrease the injured person's quality of life. In addition to
these limitations, this degree of injury increases an older
adult's risk of premature death, and mortality from falls is
significantly higher in older adults.
Effectiveness: What is the impact and/or application of
this research to older persons?
The results of this project will be used by the USPSTF to
make recommendations to primary care doctors about what is
effective to prevent falls and fall-related outcomes in older
adults. Many professional organizations and other guideline-
making organizations consider the USPSTF the gold-standard for
prevention recommendation and these organizations often use the
USPSTF reviews as a basis for their own recommendations.
Innovativeness: Why is this research exciting and
newsworthy?
Falls are an important cause of morbidity in older adults--
between 30 and 40 percent of community-dwelling older adults
fall at least once per year. Traditional methods of
synthesizing evidence may not be appropriate for older adults.
In contrast to the traditional USPSTF methods of reviewing
evidence for improvements in morbidity and mortality this
project will also review evidence on outcomes that may be of
most importance to older adults: quality of life, maintenance
of independence, and prevention of disability.
The Appalachian Commission: The Aging of Appalachia
This report uses data from Census 2000 to show how and why
the age structure of the Appalachian population differs from
the national average and varies within the Region. The report
examines implications for the region and argues that they are
not all negative. The changing age structure will be an
important fact of life for decision-makers in both the public
and private sectors in Appalachia in coming years.
Lead Agency: Appalachian Regional Commission.
Agency Mission: The Appalachian Regional Commission's
mission is to be an advocate for and partner with the people of
Appalachia to create opportunities for self-sustaining economic
development and improved quality of life.
Principal Investigator: John Haaga, Deputy Director of the
Behavioral and Social Research Program, National Institute on
Aging, Building 31, Room 5C27, 31 Center Drive, MSC 2292
Bethesda, MD 20892.
Partner Agency: Population Reference Bureau.
General Description: The Aging of Appalachia, by John
Haaga, Population Reference Bureau, July 2004. This report uses
data from Census 2000 to show how and why the age structure of
the Appalachian population differs from the national average
and varies within the Region. The report examines implications
for the region and argues that they are not all negative. The
changing age structure will be an important fact of life for
decisionmakers in both the public and private sectors in
Appalachia in coming years. In 2000, 14.3 percent of
Appalachian residents were ages 65 and over, compared with 12.4
percent of all U.S. residents. Northern Appalachia had the
oldest population among the subregions, with 16.0 percent ages
65 and over. Pennsylvania and West Virginia ranked second and
third among states in 2000 in the percentage of their
population ages 65 and over; only Florida ranked higher. The
major reason for the difference in age structure between the
Appalachian population and that of the United States as a whole
is the net out-migration of young adults from Appalachia to
other parts of the country, and Appalachia's relatively low
share of immigrants from other countries. Three of the four
Appalachian subregions analyzed here had disability rates--
overall, mobility, and self-care--generally somewhat higher
than those for elderly people in the nation as a whole. The
sub-regions of Appalachia vary widely in poverty rates among
older people. High poverty rates among elderly people living
alone are a particular problem for the Appalachian region,
where higher proportions of older people live alone than the
national average. Poverty rates for the over-65 population were
fairly close to the national average in southwestern
Pennsylvania, southern West Virginia, and western North
Carolina, but poverty rates were higher for the over-65
population as a whole and for all subgroups in eastern
Kentucky. The oldest-old, those ages 85 and over, were more
likely to be poor than the entire over-65 population.
Demographic projections prepared by Regional Economic Models,
Inc., show that, with current trends, the Appalachian region
will be home to over 5 million people ages 65 and over in 2025,
just under 20 percent of the total population. One of every 40
Appalachian residents will be among the oldest old, those ages
85 and over, in 2025. As is currently the case, Northern
Appalachia is expected in 2025 to have a significantly older
population than the rest of the region and the nation as a
whole, with 23.5 percent of its population ages 65 and over.
The report assesses both the service and fiscal demands of the
higher regional proportion of older people on state and local
governments, but also looks at the economic development
potential of the ``young old'' (those ages 60 to 75) who may
actually bring more retirement assets than demands to
localities, and who may bring skills and experience into
regional labor markets through ``bridge jobs'' in their
retirement.
Excellence: What makes this project exceptional?
The report examines the regional dynamics of population
change and aging in place and the economic development
implications for a high poverty region.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
It examines both the regional actuarial demands of an aging
population and the potential economic development opportunities
of the younger cohort of the senior population.
Effectiveness: What is the impact and/or application of
this research to older persons?
It has been used by the Local Development Districts for
policy and planning purposes in both retirement destination
communities, as well as fiscally strapped communities in the
northern sub-region of Appalachia.
Innovativeness: Why is this research exciting or
newsworthy?
It examines both the regional actuarial demands of an aging
population and the potential economic development opportunities
of the younger cohort of the senior population. This finding
is, by and large, lacking in most journalistic and policy
discussions of the implications of aging.
Office of the Assistant Secretary for Planning and Evaluation: Adult
Day Services
This study of adult day services (ADS) examined the role of
ADS in state long-term care systems and identified operational
and regulatory issues facing providers.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Janet O'Keeffe, Dr. P.H., R.N.,
Program on Aging, Disability, and Long-Term Care, Research
Triangle Institute, 3040 Cornwallis Road, Research Triangle
Park, NC 27709-2194.
General Description:
ADULT DAY SERVICES: A KEY COMMUNITY SERVICE FOR OLDER ADULTS AND A
REGULATORY REVIEW OF ADULT DAY SERVICES
Adult Day Services (ADS) are community long-term services
provided outside an individual's home that consist of
therapeutic activities and assistance with activities of daily
living. These services often also meet family caregivers' needs
for respite care or to enable them to work. States are
interested in the potential of adult day services to reduce
health care costs, and prevent or delay nursing home placement.
Although promoted as community-based service for older persons,
little was known about the provision, use, or outcomes of adult
day services prior to this study. This research identified
operational and regulatory issues facing adult day service
providers, and provided information to guide future research
and policy analysis.
The purpose of this study was threefold: to inform
policymakers about the current and potential role of ADS in the
health care and long-term care systems as determined by state
regulation; to identify operational and regulatory issues
facing ADS providers under different ADS models and in
different regulatory and financing environments; and to provide
information that can guide future research and policy analysis
on ADS for elderly persons.
The study used several qualitative research methods,
including: an in-depth review of state approaches to regulating
ADS; consultation with a Technical Advisory Group, subject
experts, state regulatory and Medicaid staff, and state
provider associations; and site visits to ADS providers in five
states: Georgia, Illinois, Maryland, North Carolina, and
Washington.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
While State and Federal long-term care spending on home and
community services has increased significantly in recent years,
most of the research and policy literature on home- and
community-based services for elderly persons has focused on
home care and residential care. Less attention has been paid to
adult day services (ADS)--a nonresidential community service
provided outside the home.
Little is known about the provision, use, or outcomes of
ADS, particularly the medical model, and the ADS industry's
capacity to provide health services. Research has been hampered
by the considerable variation in the characteristics of ADS
programs both within and across States, and by a lack of data.
ADS programs are of interest to States because of their
potential to delay or prevent nursing home placement, in large
part by supporting informal caregiving. Informal caregivers are
the backbone of the nation's long-term care system. Over seven
million Americans provide 120 million hours of care to about
4.2 million elderly persons with functional limitations each
week. The estimated economic value of this care ranges from
$45-$96 billion a year. Research has found that caregivers who
experience stress and burden are more likely to
institutionalize relatives suffering from dementia. Once the
physical resources of caregivers decline and other home and
community resources (paid or unpaid) are unavailable, nursing
home placement is more likely. Many caregivers who use ADS are
providing care to family members with dementia who need
constant supervision to assure their safety. The respite
provided by ADS is thought to lessen the caregiving burden,
making it possible to delay nursing home admission.
All States fund some form of ADS through a Medicaid State
plan or a waiver programs States are interested in the
potential of ADS to reduce health care costs by providing
health monitoring, preventive health care, and timely provision
of primary care, particularly for individuals at risk for
incurring high medical costs. These include elderly individuals
who are dually eligible for Medicare and Medicaid--called dual
eligibles--who comprised 18 percent of all Medicare
beneficiaries in 2000, but accounted for 24 percent of total
Medicare spending. Similarly, in 2002, they represented 16
percent of all Medicaid enrollees but 42 percent of program
spending.
Adult day services are relatively inexpensive compared to
home care or nursing home care. However, the study identified a
number of barriers to the use of these services. High cost or
the lack of transportation is a major impediment to the use of
adult day services. The study also found that adult day service
providers have difficulty covering their costs solely through
private payments and public program reimbursements. Nearly all
providers receive a significant portion of their operating
revenue through Medicaid or other public funding sources, but
these reimbursements generally do not cover providers' costs.
Many programs rely on volunteers, in-kind contributions and
charitable donations to subsidize their operations.
Office of the Assistant Secretary for Planning and Evaluation: Pilot
Study of Technology and Aging
This project developed an 8-10 minute modular survey to
measure the existence, addition, and use of assistive devices
and home modifications by older adults. The survey instrument
was determined to have good statistical properties (i.e., good
validity and reliability) and a version of the survey was
included as part of the 2006 Health and Retirement Study.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Vicki A. Freedman, Ph.D.,
Professor, Department of Health Systems and Policy, School of
Public Health, University of Medicine and Dentistry of New
Jersey, 683 Hoes Lane West, P.O. Box 9, Room 312, Piscataway,
NJ 08854.
Partner Agency: National Center for Health Statistics,
Centers for Disease Control and Prevention, National Institute
on Aging, University of Medicine and Dentistry of New Jersey,
Johns Hopkins University, and The Urban Institute.
General Description:
PILOT STUDY OF TECHNOLOGY AND AGING
Assistive technologies and home modifications can help
older Americans with disabilities and chronic illnesses live
independently in the community. Having good information on the
home environment and the prevalence and use of assistive
devices is therefore critical to policymakers seeking to
promote the independence of the elderly; however, national
surveys have rarely collected this type of information and we
have little knowledge about the extent to which technology
mitigates disability and enhances the lives of older persons.
In 2003, the Office of the Assistant Secretary for Planning
and Evaluation, in conjunction with the National Center for
Health Statistics and the National Institute on Aging, began a
project to develop, pilot, and disseminate a new survey on
assistive technology use and the home environment. The goal was
to develop a set of questions that could be easily added to
existing or new surveys that would better capture the
population at-risk for a disability because of an environmental
barrier or lack of modification to the home, and track the
adoption and use of assistive devices and technology. The new
instrument could better address key questions such as: what
role do assistive technologies and home modifications play in
the lives of older Americans?; how extensively are they used?;
and ultimately, how effective is assistive technology in
increasing older American's well-being, social engagement, and
participation in valued activities?
After extensive design, pilot testing, and evaluation, a
final 8-10 minute survey instrument was developed that included
five modules: home environment, mobility and other devices,
effectiveness, information and communication technology, and
residual activity of daily living/ instrumental activity of
daily living difficulty. A shorter version of the survey
instrument that could be administered in 2-3 minutes was also
developed. The full instrument was included as part of a module
on the 2006 Health and Retirement Study (HRS), a nationally
representative survey of the noninstitutionalized population
age 50 and older living in the U.S. Preliminary findings
indicate that a substantial portion of the HRS sample has
access to or uses assistive devices/home modifications. For
example, approximately two-thirds of the sample report having
at least one assistive home feature (e.g., a ramp at their
home's entrance, emergency call system, grab bars in shower/
tub, raised toilet seat, etc.); one-third reported adding at
least one of these features to their home; and assistive home
features were shown to enable independent performance of
activities. A final report more fully describing the findings
form the HRS will be available in late 2008.
Office of the Assistant Secretary for Planning and Evaluation: Report
to Congress on Advance Directives
The Report to Congress on Advance Directives will provide a
set of recommendations based on findings from the literature
review, in-depth commissioned papers and the roundtable
discussions on how best to improve advance directive use and
advance care planning as a means of expressing wishes for end-
of-life care.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Lisa R. Shugarman, Ph.D., Health
Policy Researcher, RAND Corporation, 1776 Main Street, PO Box
2138, Santa Monica, CA 90094.
Partner Agency: ABA Commission on Law and Aging, Center for
Practical Bioethics, Yeshiva University.
General Description:
REPORT TO CONGRESS ON ADVANCE DIRECTIVES
Over the past century, the experience of dying has changed
tremendously. At the beginning of the 1900s, the majority of
people died at home, usually from a sudden illness or injury.
Now, the majority of Americans die of chronic, progressive
illnesses often with prolonged periods of physical dependency
(Peres & Kaplan, 2002). Over a decade of research has
documented that dying in America is painful, isolating and
costly (SUPPORT, 1995; IOM, 1997; Hogan et al., 2001). A key
predictor of good end-of-life care is whether people have
articulated about their preferences ahead of a crisis. This is
known as advance care planning. Advance directives are the
cornerstone of advance planning and these directives consist of
a person's oral and written instructions about his or her
future medical care in the event that he or she becomes unable
to communicate or becomes incompetent to make health care
decisions. There are two types of advance directives: a living
will and a health care power of attorney/health care proxy.
Living wills (sometimes called medical directives) are written
instructions for care in the event that a person is not able to
make medical decisions for him or herself (Fagerlin, 2004). The
health care proxy or surrogate is a document by which the
patient appoints a trusted person to make decisions about his
or her medical care if he or she cannot make those decisions.
Congress enacted the Patient Self-Determination Act (PSDA)
in 1990 to encourage competent adults to complete advance
directives. The PSDA requires all health care facilities
receiving Medicare or Medicaid reimbursements to ask if
patients have advance directives, to provide information about
advance directives, and to incorporate advance directives into
the medical record (PSDA, 1990). Unfortunately, waiting until
the crisis of admission to a facility is not the ideal setting
for developing an advance care plan.
In recognition of the need for greater understanding of
advance care planning, the Health Education and Labor Committee
2006 Appropriations provided for the Secretary of Health and
Human Services (HHS) to develop a Report to Congress on advance
directives. As provided, Public Law 109-149 ``* * * directs the
Secretary to conduct a study to determine the best way to
promote the use of advance directives among competent adults as
a means of specifying their wishes about end-of-life care and
provide recommendations to Congress on changes to federal law
needed to ensure appropriate use of advance directives.'' The
Secretary is instructed to involve persons with disabilities
and identify options for people with cognitive disabilities as
well.
The Office of the Assistant Secretary for Planning and
Evaluation contracted with RAND to commission a literature
review, topic-specific papers on: (1) the historical and
current legal issues with advance directives; (2) advance care
planning among persons with intellectual and physical
disabilities; and (3) public engagement with advance
directives. In addition, we held Roundtable Discussion meetings
with advance care planning experts, and included an emphasis on
people with disabilities. This background work will form the
basis for the report from the Secretary of HHS to Congress
outlining the recommendations on how best to promote advance
directives.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The literature review examines the empirical evidence about
the degree to which advance directives and advance care
planning have met their intended goals. The report is one of
the most comprehensive reviews of what the medical literature
reports concerning the use of advance directives and advance
care planning, disparities among groups in their use, and
interventions to enhance the use and value of advance
directives and advance care planning.
Of the 2.5 million people who die in the U.S. each year,
about 85 percent are Medicare beneficiaries (Hogan et al.,
2001). A recent Centers for Medicare and Medicaid Services
(CMS) report on Medicare spending in the last year of life
indicated that expenditures have steadily increased from 26% of
total expenditures in 1994 to 29% in 1999 (CMS, 2005). Although
considerable sums are spent on prolonging life, relatively
little is spent for pain relief, quality of remaining life and
emotional support for older persons and their families.
In addition, the concerns, perspectives, and values of
people with disabilities have often been overlooked in the
research, programs, and policies regarding advance directives,
advance care planning, and end-of-life care more generally.
While the process for advance care planning for people with
physical and intellectual disabilities is the same as for non-
disabled people, there are unique community perspectives and
issues to be addressed in policies seeking to promote such
plans.
The Patient Self-Determination Act (PSDA) requires that all
health care facilities receiving Medicare or Medicaid
reimbursements must inform patients of their rights to make
choices about the treatment they receive and to prepare advance
directives. Advance directives are not only focused on what
treatments one does not want, they are equally applicable and
viable to indicate all of the treatments that one wants. Our
Report to Congress will recommend strategies to help strengthen
the advance care planning process for elders, people with
disabilities and their families.
Generally, the research suggests that even when advance
directives are executed, physicians are frequently unaware of
them, advance directives are not easily available to surrogates
when needed, advance directives are too general and/or are
inapplicable to clinical circumstances, and/or they are invoked
late in the dying process or are at times over-ridden by
providers and families. Only in the context of a comprehensive
community effort do advance directives and advance care
planning appear to substantially change care at the end of
life. Despite the weakness of advance directives as an
individual intervention, research points to promising
interventions.
Office of the Assistant Secretary for Planning and Evaluation, Ensuring
a Qualified Long-Term Care Workforce: From Pre-Employment Screens to
On-the-Job Monitoring
This study examined different state approaches to screening
and monitoring long-term care workers for criminal background
and history of elder abuse and the efficacy of these
approaches.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Karen W. Linkins, Ph.D., Vice
President, The Lewin Group, 3130 Fairview Park Drive, Suite
800, Falls Church, VA 22042.
Partner Agencies: HHS Office of the Inspector General,
Centers for Medicare and Medicaid Services (CMS), Federal
Bureau of Investigations (FBI), U.S. Department of Justice,
Nursing Home Initiative, U.S. Health Resources and Services
Administration (HRSA), Kansas Department of Health and
Environment, San Diego Prosecutors Office.
General Description:
ENSURING A QUALIFIED LONG-TERM CARE WORKFORCE: FROM PRE-EMPLOYMENT
SCREENS TO ON-THE-JOB MONITORING
There has been renewed focus on reducing the incidence of
elder abuse, especially in long-term care facilities. One
commonly suggested solution is more rigorous background
screenings and monitoring of long-term care workers. However,
the efficacy and cost effectiveness of such interventions is
not known.
This project examined the efficacy of various approaches to
pre-employment screening and on-the-job monitoring of nurse
assistants to prevent resident abuse in nursing homes. The goal
was to inform policymakers, providers, consumers and other
interested parties about the relative contributions and
perceived effectiveness of existing federal mandates and state
and provider-based strategies for preventing or reducing the
abuse of vulnerable adults.
Federal and state governments, education and training
centers, and employers have created a variety of formal
mechanisms aimed at preventing incidences of abuse, neglect and
exploitation in nursing homes and other long-term care
settings. These mechanisms can include certification and
licensure of paraprofessional long-term care workers, various
pre-employment screenings, (e.g., nurse aide registries,
criminal background checks and drug tests), and on-the-job
training and monitoring.
The two primary methods used for pre-employment screening
include checking nurse aide registries and conducting criminal
background checks. Federal guidelines require each state to
establish and maintain a registry of nurse aides that includes
certification information and substantiated findings of abuse,
neglect, or financial exploitation in nursing homes. Federal
guidelines require nursing facilities to check their State
nurse aide registry to ensure that hired nurse aides are
certified to work and meet all state requirements, and that
they do not have any substantiated findings of abuse, neglect
or misappropriation associated with their license. In addition,
long-term care facilities may check other relevant databases
they believe will include any information on the potential
employee (e.g., criminal background database).
Some states, either through law or by choice, collect data
beyond the scope mandated by federal requirements for
maintaining nurse aide registries. For example, states
registries may include data on certified and non-certified
health care workers in addition to nurse aides, along with
additional demographic information such as race/ethnicity,
education level, or current employer.
Previous studies have examined rates of abuse in nursing
facilities, direct service worker capacity issues, and
compliance of states to maintain nurse aide registries. This
study looked across all of these issues, by examining the
process states go through to collect and maintain information
in their registries, state and employer mandated background
check procedures, reporting and investigating policies/
practices when abuse allegations are made, and the impact of
such processes on the direct service workforce, employers and
state agencies.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
Examining the efficacy of long-term care worker employment
screening mechanisms (such as state nurse aide registries and
criminal background checks) comes at a particularly relevant
time. Recent federal studies highlight the urgency for the
study from both a long-term care staffing perspective and from
a quality care perspective. The Medicare Prescription Drug,
Improvement, and Modernization Act (MMA) authorized a
background check pilot program in seven states. Additionally,
there have been numerous legislative proposals in recent years
to address long-term care worker screenings to prevent elder
abuse in long-term care. However, the efficacy and cost
effectiveness of such interventions is not clear. Nor is there
information on the impact that more rigorous background
screenings might have on the supply of long-term care workers.
The goal of this study was to examine current practices at
the state and facility levels regarding pre-employment
screening and on-the-job monitoring, and how these influence
the quality of the long-term care workforce.
Extensive variation across states affected the ability of
the researchers to make a definitive statement about the
efficacy of these strategies to ensure a qualified workforce.
The study's in-depth examination of four states revealed that
some aspects of these systems work well, but limitations exist
in each state that affects the overall utility of these
practices. The technology, coordination capabilities and
infrastructure exist through on-line registries, fingerprint
databases and abuse registries to help employers make the best
hiring decisions possible to protect the elderly in their care.
States are building on their knowledge, experience, and
capabilities to streamline these processes, but there is still
room for improvement while balancing the resource intensiveness
of making these changes.
Key findings from the study:
Criminal background checks are a valuable tool for
employers during the hiring process and their use does not
limit the pool of potential job applicants. None of the nursing
facilities experienced any negative impact on their applicant
pool as a result of this requirement.
A correlation exists between criminal history and
incidences of abuse. Based on data from Arizona and Kansas, it
does appear that nurse aides who had a previous criminal
conviction (non-disqualifying offense) had higher rates of
substantiated abuse than nurse aides without a criminal
history.
Criminal background checks are only one component of
preventing abuse. Other effective strategies for preventing
abuse include: adequate supervision/monitoring, presence of
managers on the floor, decreasing staff burnout, adequate
staffing levels, rotating nurse aides on the floor to alleviate
pressure of difficult residents, increased education and
training, obtaining meaningful employment references (beyond
verification of employment dates), instituting a drug-free
workplace policy, minimizing temporary hires, and pointing out
negative behaviors in the moment and using them as a staff
development opportunity.
There are fewer policies in place that support or reinforce
post-employment strategies to ensure a qualified workforce.
Most states have no process in place to notify employers if an
active employee commits a crime that would have prohibited them
from working during their background check prior to employment.
One innovative state program monitors criminal behavior of
individuals working in positions of direct care and service of
potentially vulnerable populations (nursing facilities, home
health, child care agencies, etc.) While the program is an
exemplar, it also illustrates that such on-going monitoring
requires significant commitment of resources and participation
across agencies.
Previous studies on this issue have examined rates of abuse
in nursing facilities, direct service worker capacity issues,
and compliance of states to maintain nurse aide registries.
This study is unique because it looked across all of these
issues and provides valuable information to states considering
changes to their long-term care worker requirements to prevent
elder abuse.
Office of the Assistant Secretary for Planning and Evaluation:
Specification of the Long Term Care Nursing Home (LTC-NH) Electronic
Health Record System (EHR-S) Functional Profile
This project, sponsored by the Office of the Assistant
Secretary for Planning and Evaluation (ASPE), in conjunction
with significant private support, identified the LTC-NH EHR-S
Functional Profile. The Functional Profile has been shared with
HL7 and CCHIT.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Jennie Harvell, M. Ed., Senior
Policy Analyst, Department of Health and Human Services, Office
of the Assistant Secretary for Planning and Evaluation, 200
Independence Ave., SW., Room 424E, Washington, DC 20201;
Michelle Dougherty, MA, RHIA, CHP, Director, Practice
Leadership, American Health Information Management Association;
Nathan Lake, RN, BSN, MSHA, Director, Clinical Design, American
HEALTHTECH; Sue Mitchell, RHIA, Director of Clinical Systems,
Omnicare Information Solutions, 5148 Blacklick Eastern Rd. NW,
Baltimore, OH 43105; and Hugh McDonough, Senior Associate, Abt
Associates, 55 Wheeler Street, Cambridge, MA 02138.
Partner Agencies: American Association of Homes and
Services for the Aging/Center for Aging Services Technology
(AAHSA/CAST), American Health Care Association/National Centers
for Assisted Living (AHCA/NCAL), American Health Information
Management Association (AHIMA), and National Association for
the Support of Long Term Care (NASL).
General Description: Specification of the Long Term Care
Nursing Home (LTC-NH) Electronic Health Record System (EHR-S)
Functional Profile.
Consensus has emerged that interoperable health information
technology (HIT) and electronic health records (EHRs) are
needed to improve quality, safety, and effectiveness of health
care while simultaneously enhancing efficiency and reducing
costs.
The HHS 2004 report entitled, ``The Decade of Health
Information Technology--Framework for Strategic Action''
recommended establishing private sector certification of HIT
products to reduce the risk of product failure and increase the
uptake of EHR implementation. HHS subsequently authorized and
funded the Certification Commission for Healthcare Information
Technology (CCHIT) to specify certification criteria for
electronic health records (EHRs) and to implement a process
through which EHR products would be certified as meeting the
certification criteria. In late 2006, HHS authorized and funded
the CCHIT to expand its certification scope to begin addressing
EHR products for nursing homes. In March 2007, CCHIT announced
that nursing homes would be included in their ``Roadmap'' for
expansion of product certifications. In specifying
certification criteria for nursing home EHR products, CCHIT
will draw heavily on the requirements published in the 2007 HL7
EHR-System Functional Model (EHR-S FM) standard (also developed
with ASPE funding), and industry specific requirements that are
specified in a nursing home-specific Functional Profile.
With the funding provided by ASPE and significant staff
resources provided by the long-term care community, the public
and private sector sectors specified the Long Term Care Nursing
Home (LTC-NH) Electronic Health Record System (EHR-S)
Functional Profile. The LTC-NH EHR-S Functional Profile
identifies the subset of functions from the HL7 EHR-S FM that
reflects the unique aspects and needs for EHR systems in the
long term care-nursing home setting. The LTC-NH EHR-S
Functional Profile identifies needed EHR functions and criteria
in the domains of direct care, supportive services, and
information infrastructure.
The LTC-NH EHR-S Functional Profile has been registered by
HL7 and will be balloted as an industry standard.
The LTC-NH EHR-S Functional Profile has also been sent to
CCHIT to help inform their efforts related to certification of
nursing home EHR products. CCHIT will use the LTC EHR-S
Functional Profile as a reference as they develop the
functionality, interoperability, and security requirements for
certified nursing home EHR system products.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The LTC-NH EHR-S Functional Profile represents the best
efforts of a broad array of long term care professionals and
stakeholders from the public and private sectors to derive
functional requirements and timelines for these requirements
for EHR systems in nursing homes using the HL7 EHR-S Functional
Model. The LTC-NH EHR-S Functional Profile will be undergoing
balloting by HL7 Electronic Health Record Technical Committee
to become an industry standard. The LTC-NH EHR-S Functional
Profile has been sent to the Certification Commission for
Health Information Technology (CCHIT) to help inform their
efforts as they specify certification criteria for nursing home
EHR products and begin to certify nursing home EHRs as meeting
these criteria. CCHIT is expected to begin certifying NH EHRs
in 2009.
The development of the Functional Profile, the anticipated
recognition by HL7 of the LTC-NH EHR-S Functional Profile as an
industry standard, and the use of the LTC-NH EHR-S Functional
Profile by CCHIT in specifying the certification criteria for
NH EHRs is expected to inform nursing home providers of the EHR
functionality they could acquire, and will provide a roadmap
for nursing home HIT vendors as to the type of functionality
that certified products will be required to meet and when. Such
information is expected to encourage and accelerate
implementation of interoperable EHRs by nursing home providers.
Use of interoperable EHRs is expected to support needed quality
and continuity of care improvements, efficiency gains, and cost
reductions.
Office of the Assistant Secretary for Planning and Evaluation: National
Data on Elder Abuse
This research will inform a report to Congress from the
Secretary of Health and Human Services, which will address the
feasibility of collecting uniform national data on elder abuse.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Karen Linkins, Project Director,
Sharon Zeruld, Project Manager, Bernadette Wright, Associate,
Sarah Lash, Associate, The Lewin Group, 3130 Fairview Park Dr.,
Suite 800, Falls Church, VA 22042.
Partner Agencies: Department of Justice, Administration on
Aging, and Centers for Disease Control.
General Description: Congress directed the Secretary of the
Department of Health and Human Services (HHS) to conduct a
study, in consultation with the Attorney General, assessing
current elder abuse data collection systems and examining the
feasibility of establishing a uniform national elder abuse
database to improve the quality and accessibility of data (P.L.
109-432). To develop the basis for its report to Congress, the
HHS Office of the Assistant Secretary for Planning and
Evaluation (ASPE) contracted with The Lewin Group, and
subcontractor Dr. Catherine Hawes, to conduct research to
address these issues.
A focused literature review and inventory of existing elder
abuse data collection and reporting efforts represents one
component of that research. Findings are based on a review of
the published literature on elder abuse data collection and
reporting as well as information gleaned from telephone
discussions with over 30 experts in related fields. This review
addresses the following questions:
a. How is elder abuse currently defined in Federal and
state laws and by researchers and other organizations?
b. How have studies measured the prevalence and incidence
of elder abuse, and what are the strengths, challenges and
limitations of these studies?
c. What are the current practices in investigating,
substantiating, and reporting elder abuse at the Federal,
state, and local levels?
d. How do confidentiality laws and policies affect the
sharing of information about elder abuse among agencies?
e. What are the shortcomings and strengths of existing data
collection and reporting efforts?
f. How are data collected on child abuse and intimate
partner violence? How have these fields addressed challenges
such as underreporting, differing definitions, and difficulties
in detecting abuse?
g. What state practices have been developed to enhance
elder abuse reporting, investigation, and data collection?
Based on the findings, the report identifies areas that
will need to be addressed in determining the feasibility of a
national elder abuse database. The project's other major
activities include: developing a memorandum that outlines key
issues and approaches for establishing a uniform national
dataset on elder abuse; obtaining input from government,
research, advocacy, and industry experts; and preparing a
report that synthesizes all findings and discusses implications
for implementing a uniform national database on elder abuse.
This project will inform a report to Congress to be issued
by the Secretary of HHS.
Older adults can be vulnerable to abuse, neglect, and
financial exploitation perpetrated by caregivers, others in
positions of trust, and relative strangers, as well as self-
neglect. The true incidence of elder abuse in the United States
is unknown, although several studies have attempted to measure
the scope of the problem. Chronic underreporting and a lack of
a standard definition are commonly reported problems that make
it difficult to report precise figures. However, most experts
agree that elder mistreatment is a large and growing problem
that has only recently begun to attract the public attention it
deserves.
The scope and purpose of definitions of elder abuse vary
across states and local agencies, and data collection methods
are similarly diverse, complicated by the involvement of many
autonomous agencies operating under different mandates.
A national database or consistent national data collection
strategy on elder abuse data have been recommended as possible
solutions to the problems associated with varying and
uncoordinated state and local data collection and reporting
systems. As early as 1992, the Department of Health and Human
Services (HHS) Secretary's Task Force on Elder Abuse
recommended the development and funding of a national elder
abuse research and data collection strategy. More recently, a
number of studies have recommended increased standardization of
elder abuse definitions and data collection systems.
This study will inform a report to Congress from the
Secretary of Health and Human Services on the feasibility of
collecting uniform national data on elder abuse. It will inform
an important debate among policymakers and lawmakers currently
considering strategies for tackling the growing societal
problem of elder abuse and mistreatment in the United States.
Office of the Assistant Secretary for Planning and Evaluation:
Preventing Costly Falls Among Older Americans
This demonstration, sponsored by the Office of the
Assistant Secretary for Planning in conjunction with Bankers
Life and Casualty Company and the John Hancock Life Insurance
Company, will test whether a comprehensive falls prevention
program will reduce the incidence of falls among older
Americans and use of subsequent acute health and long-term care
services.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Jessica Miller, Director of
Analytic Services, LifePlans, Inc., 51 Sawyer Road, Suite 340,
Waltham, MA 02453.
Partner Agencies: Abt Associates, LifePlans, Inc., Bankers
Life and Casualty Company, and John Hancock Life Insurance
Company.
General Description:
PREVENTING COSTLY FALLS AMONG OLDER AMERICANS
Falls constitute one of the most significant and common
causes of injury and disability for the elderly. One in every
three people age 65 and older living in the community falls
during a year and fall-related injuries cost an estimated $17
billion annually. Falls are also associated with subsequent
admission to a nursing home and use of long-term care services.
While there are numerous studies identifying the major risk
factors associated with falling (e.g., poor muscle strength/
gait and balance, cognitive impairment, polypharmacy, and
unsafe physical environment), there is virtually no research
demonstrating the cost-effectiveness of comprehensive programs
designed to reduce the incidence and impact of falls. This
project will fill a significant research gap and answer a
critical question posed by policymakers: can an affordable
falls prevention program reduce the incidence of falls in the
elderly and lower spending for acute health and long-term care
services?
The Office of the Assistant Secretary for Planning and
Evaluation (OASPE) contracted with Abt Associates and
LifePlans, Inc. in 2003 to design a demonstration to determine
the cost-effectiveness of a fall prevention program for older
Americans. After further refinement of the intervention,
methodological approach and assessment instruments, OASPE began
the next phase of the demonstration with LifePlans in 2006--the
actual implementation and evaluation of the program. The
demonstration uses a classic experimental design where a random
sample of older persons receives a full falls-risk assessment
and intervention (treatment) and others do not (control).
Unlike other falls prevention programs, the demonstration will
provide a comprehensive falls risk assessment (both via the
telephone and in-person), clinical review of assessment
findings, individualized action plan with specific
recommendations, and periodic follow-up and case management.
One of the unique aspects of the project is the partnership
between the federal government and two well-known and
established providers of long-term care insurance: Bankers Life
and Casualty Company, and the John Hancock Life Insurance
Company. Persons age 75 and older who have a long-term care
insurance policy with one of the two companies will have the
opportunity to participate in the demonstration, with
approximately 5,600 persons divided into a treatment group and
various control groups. Medicare claims data will be used as
part of the demonstration, thereby allowing researchers to
determine whether or not the falls prevention program reduces
acute health care cost as well as long-term care expenses.
Office of the Assistant Secretary for Planning and Evaluation:
Standardizing Assessments and Supporting Health Information Exchange
This project, sponsored by the Office of the Assistant
Secretary for Planning and Evaluation (ASPE), in conjunction
with FORE/AHIMA and several collaborating experts will link
required and recognized HIT standards to the MDSv3 and OASIS-C.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Michelle Dougherty, MA, RHIA, CHP,
Director, Practice Leadership, American Health Information
Management Association.
Partner Agencies: Alschuler Associates, LLC, College of
American Pathologists--SNOMED Terminology Solutions, Indiana
University of Regenstrief Institute, Inc., Apelon, Inc.,
TerraStar Consulting, and Center for Aging Services Technology
(CAST).
General Description: Standardizing Assessments and
Supporting Health Information Exchange.
Consensus has emerged that interoperable health information
technology (HIT) and electronic health records (EHRs) are
needed to improve quality, safety, and effectiveness of health
care while simultaneously enhancing efficiency and reducing
costs. The use of HIT standards is needed to make
interoperability a reality.
Much of the national HIT policy focus has not considered
the standards and HIT applications needed in long-term care,
including nursing facilities (NFs) and home health agencies
(HHAs).
Each year in the U.S., thousands of NFs and HHAs provide
services to millions of patients--many of whom are medically
complex and frail requiring either short-term (post-acute) or
long-term care. Caring for these individuals involves inter-
disciplinary teams of health care professionals and
paraprofessionals in NFs and HHAs, millions of physician
encounters each year, and frequent transitions in care in and
out of NFs and HHAs and to other health care settings.
Timely access to complete and useable health information is
important in providing and improving quality and continuity of
care provided to persons receiving NF and HHA services, and for
increasing efficiencies in and the cost effectiveness of health
care delivery to these individuals.
CMS requires NFs and HHAs complete and electronically
transmit federally-developed patient assessments: the Minimum
Data Set (MDS) assessment and the Outcome and Assessment
Information Set (OASIS), respectively. CMS will be updating
these instruments to the MDSv3 and OASIS-C.
Federally-required assessments are the backbone of HIT
products available to NF/HHA providers. Presently, these
assessments are not linked with HIT standards and HIT products
used by most of these providers are not standardized. Linking
accepted HIT standards to federally-required assessments is
expected to enable NF/HHA providers to engage in interoperable
health information exchange with hospitals and doctors to
improve critical information sharing between the sectors,
support quality and continuity of care improvements, increase
efficiencies, and reduce costs.
The Office of the Assistant Secretary for Planning and
Evaluation has contracted with the Foundation of Research and
Education (FORE) of the American Health Information Management
Association (AHIMA) to apply recognized and required HIT
standards to the MDSv3 and OASIS-C. FORE/AHIMA has convened
several persons with expertise in HIT content and messaging
standards, and expertise in the MDS and OASIS instruments to
link required/recognized HIT standards to these patient
assessment instruments.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The project to link accepted HIT standards to the emerging
NF MDSv3 and HHA OASIS-C patient assessment instruments is
exceptional in its focus on applying HIT standards to a key
business function in NFs and HHAs. Much of the national HIT
policy focus has not taken into account long-term care.
This project will leverage standards that have been (i)
recognized by the public and private sectors for use in
exchanging health information, and (ii) required for use by the
Secretary of HHS for Federal health care programs. Certain
Federal health care programs (including Medicare) are required
to use HIT systems and products that meet ``recognized
interoperability standards'' as designated by the Secretary of
HHS. This project will re-use and link applicable ``recognized
interoperability standards'' to the MDSv3 and OASIS content and
for the exchange of these assessments.
In addition, the Secretary of HHS has required the use of
accepted CHI (Consolidated Health Informatics) Standards by
``all federal agencies in implementing new, and as feasible,
updating existing health information technology systems.'' The
accepted CHI standards include HIT standards for assessment
content and for the exchange of assessment instruments. The CHI
standards are consistent and compatible with the standards that
have emerged from HITSP and recognized by the Secretary of HHS.
This project will also link CHI-required standards to the MDSv3
and OASIS-C.
The LTC Community (NF and HHA providers, physicians, and
vendors) have requested that LTC be included in the emerging
Nationwide Health Information Network (NHIN) and have
specifically requested the linkage to and use of these HIT
standards of the MDSv3 and OASIS-C.
Linking and using accepted and recognized HIT standards to
federally-required assessments is a critical step that will
enable NF/HHA providers to engage in interoperable health
information exchange in the emerging NHIN, support quality and
continuity of care improvements, increase efficiencies, and
decrease costs.
Office of the Assistant Secretary for Planning and Evaluation: Modeling
the Decision To Purchase Private Long-term Care Insurance
This project estimated how the purchase of private long-
term care insurance is influenced by various economic and
demographic factors, including the effect of tax incentives. If
all taxpayers could fully deduct premium expenses from income
subject to federal income taxes, the number of older adults
with coverage would increase by about 36 percent.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Richard W. Johnson, The Urban
Institute, 2100 M Street, NW., Washington, DC 20037.
General Description:
MODELING THE DECISION TO PURCHASE PRIVATE LONG-TERM CARE INSURANCE
Long-term care spending is expected to soar in coming
decades as the population ages. Enhanced private insurance
coverage of long-term care needs might ease the looming crisis.
Raising private insurance coverage rates would increase the
pool of funds set aside to finance future services and would
reduce reliance on public resources. Enhanced private coverage
could also protect families from catastrophic long-term care
costs. Some policymakers have proposed expanding tax incentives
for private long-term care coverage to stimulate demand.
Like traditional medical insurance, private long-term care
insurance is a financial contract whereby the insurer agrees to
provide covered benefits in exchange for regular premium
payments by the policyholder. Policies are guaranteed
renewable, and premiums remain fixed over the life of the
contract. However, rates can rise for an entire class of
policyholders if insurers can demonstrate that their costs
exceed premium revenue, and rate increases have been common in
recent years.
The analysis estimated hazard models of time to purchase
private long-term care insurance as a function of the net
benefit that individuals expect to derive from the policy. The
net expected benefit is the difference between what
policyholders expect to receive in benefit payouts from the
plan over their lifetimes, in present value terms, and what
they expect to pay into the plan in the form of premiums. The
measure, which accounted for state-level fluctuations in
premiums and Medicaid eligibility rules, varied widely across
individuals.
Data came primarily from the Health and Retirement Study
(HRS), a nationally representative longitudinal survey of older
Americans. The sample consisted of person-year observations
between 1992 and 2004 on adults ages 51 to 61 in 1992 who did
not have coverage in the previous year. The sample was
restricted to respondents likely to satisfy long-term care
insurers' underwriting restrictions and thus able to purchase
private coverage.
The net expected benefit of coverage significantly
increased the likelihood of taking-up private long-term care
insurance coverage, although the impact was modest. Every
$1,000 increase in the net expected benefit of coverage would
raise purchase probabilities by about 2.3 percent. Take-up
rates also increased with age, education, health status, and
the self-assessed probability of using nursing home care in the
next year. They declined with the number of children, perhaps
because children help with their parents' home care or help
finance nursing home costs.
Creating additional federal tax incentives for the purchase
of private long-term care insurance would modestly boost take-
up rates. Take-up rates would rise to 19 percent if all
taxpayers could fully deduct premium expenses from income
subject to federal income taxes, representing about a 36
percent boost in the number of older adults with coverage. The
impact of tax incentives on private long-term care insurance
would be concentrated among high-income taxpayers. Tax breaks
would have very little impact on coverage rates for adults in
the bottom half of the income distribution.
Office of the Assistant Secretary for Planning and Evaluation: A
Profile of Medicaid Institutional and Community-Based Long-Term Care
Service
This project estimated how Medicaid long-term care is
balanced between institutional and community-based care.
Significant variation across states and age groups was found.
The proportion of Medicaid long-term care expenditures that are
for community-based services declines with age.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Audra T. Wenzlow, Ph.D.,
Mathematica Policy Research, Inc., 555 S. Forest Ave., Suite 3,
Ann Arbor, MI 48104.
General Description:
A PROFILE OF MEDICAID INSTITUTIONAL AND COMMUNITY-BASED LONG-TERM CARE
SERVICE USE AND EXPENDITURES AMONG THE AGED AND DISABLED USING MAX 2002
Since 1982, states have increasingly utilized Medicaid
Section 1915(c) waivers and optional state community-based
programs to shift long-term care for the aged and disabled from
institutions to the community. New rules introduced under the
Deficit Reduction Act (DRA) of 2005 provide states with even
more flexibility to provide home and community-based long-term
care services to their low-income populations. Two overarching
goals underlie these policies: (1) to provide long-term care
services more cost-effectively; and (2) to give aged and
disabled people more options in how they receive their care.
As baby boomers enter their senior years and increase the
need for long-term care services nationally, information about
how Medicaid community long-term care programs have functioned
in the past will be critical for assisting states in choosing
how to utilize the new options provided under the DRA. Until
recently, only limited aggregate data and some national surveys
have been available to examine Medicaid community-based long-
term care service use and compare it with use of institutional
care. The Medicaid Analytic eXtract (MAX) data system produced
by Centers for Medicare & Medicaid Services now enables much
more detailed analyses of long-term care utilization and
expenditures at the person level.
This study evaluates the potential of using MAX Person
Summary files to examine how successfully states have
rebalanced their long-term care systems and how Medicaid
enrollees who utilize community-based long-term care services
differ from people in institutions. Data for 2002 were analyzed
for 37 states that have reliable MAX long-term care data.
In 2002, only 34 percent of Medicaid long-term care
expenditures paid for persons served were for community-based
services in 2002, while almost 59 percent of long-term care
users used community-based services. National estimates mask
significant variation across states. Community-based services
accounted for over 60 percent of long-term care expenditures in
Alaska and New Mexico but less than 12 percent in the District
of Columbia and Mississippi. Use of community-based services
among long-term care users ranged from 87 percent in Alaska to
23 percent in Indiana.
Institutional and community long-term care expenditures
were much more balanced among young disabled Medicaid enrollees
than their aged counterparts in 2002. Over half of long-term
care expenditures were for community-based services among
disabled enrollees but less than 20 percent were for community-
based care among those over 65. Community-based service
expenditures as a share of total long-term care expenditures
ranged from 50 percent for people under age 65, 31 percent for
people between ages 65 and 74, 21 percent for people between
ages 75 and 84, and 13 percent for those age 85 and older.
Rates of community-based service utilization were higher but
followed a similar pattern by age.
People using both institutional and community-based
services (6 percent of long-term care users) had higher average
total Medicaid expenditures ($46,055) than users of
institutional care only ($38,844) or community care only
($24,966). Aged and disabled enrollees using Medicaid long-term
care services accounted for 7.7 percent of all full-benefit
Medicaid enrollees in our 37 sample states but represented over
50 percent of their total Medicaid expenditures.
Office of the Assistant Secretary for Planning and Evaluation: A
Profile of Medicaid Institutional and Community-Based Long-Term Care
Service Use and Expenditures Among the Aged and Disabled Using MAX 2002
This project estimated how Medicaid long-term care is
balanced between institutional and community-based care.
Significant variation across states and age groups was found.
The proportion of Medicaid long-term care expenditures that are
for community-based services declines with age.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Audra T. Wenzlow, Ph.D.,
Mathematica Policy Research, Inc., 555 S. Forest Ave., Suite 3,
Ann Arbor, MI 48104.
General Description:
A PROFILE OF MEDICAID INSTITUTIONAL AND COMMUNITY-BASED LONG-TERM CARE
SERVICE USE AND EXPENDITURES AMONG THE AGED AND DISABLED USING MAX 2002
Since 1982, states have increasingly utilized Medicaid
Section 1915(c) waivers and optional state community-based
programs to shift long-term care for the aged and disabled from
institutions to the community. New rules introduced under the
Deficit Reduction Act (DRA) of 2005 provide states with even
more flexibility to provide home and community-based long-term
care services to their low-income populations. Two overarching
goals underlie these policies: (1) to provide long-term care
services more cost-effectively; and (2) to give aged and
disabled people more options in how they receive their care.
As baby boomers enter their senior years and increase the
need for long-term care services nationally, information about
how Medicaid community long-term care programs have functioned
in the past will be critical for assisting states in choosing
how to utilize the new options provided under the DRA. Until
recently, only limited aggregate data and some national surveys
have been available to examine Medicaid community-based long-
term care service use and compare it with use of institutional
care. The Medicaid Analytic eXtract (MAX) data system produced
by Centers for Medicare & Medicaid Services now enables much
more detailed analyses of long-term care utilization and
expenditures at the person level.
This study evaluates the potential of using MAX Person
Summary files to examine how successfully states have
rebalanced their long-term care systems and how Medicaid
enrollees who utilize community-based long-term care services
differ from people in institutions. Data for 2002 were analyzed
for 37 states that have reliable MAX long-term care data.
In 2002, only 34 percent of Medicaid long-term care
expenditures paid for persons served were for community-based
services in 2002, while almost 59 percent of long-term care
users used community-based services. National estimates mask
significant variation across states. Community-based services
accounted for over 60 percent of long-term care expenditures in
Alaska and New Mexico but less than 12 percent in the District
of Columbia and Mississippi. Use of community-based services
among long-term care users ranged from 87 percent in Alaska to
23 percent in Indiana.
Institutional and community long-term care expenditures
were much more balanced among young disabled Medicaid enrollees
than their aged counterparts in 2002. Over half of long-term
care expenditures were for community-based services among
disabled enrollees but less than 20 percent were for community-
based care among those over 65. Community-based service
expenditures as a share of total long-term care expenditures
ranged from 50 percent for people under age 65, 31 percent for
people between ages 65 and 74, 21 percent for people between
ages 75 and 84, and 13 percent for those age 85 and older.
Rates of community-based service utilization were higher but
followed a similar pattern by age.
People using both institutional and community-based
services (6 percent of long-term care users) had higher average
total Medicaid expenditures ($46,055) than users of
institutional care only ($38,844) or community care only
($24,966). Aged and disabled enrollees using Medicaid long-term
care services accounted for 7.7 percent of all full-benefit
Medicaid enrollees in our 37 sample states but represented over
50 percent of their total Medicaid expenditures.
Office of the Assistant Secretary for Planning and Evaluation: National
Nursing Assistant Survey
Our nation is facing a major shortage of health care
workers who provide for the long term care needs of residents
in nursing homes and other places. The National Nursing
Assistant Survey is the first nationally representative study
of nursing assistants working in U.S. nursing homes. This new
survey provides information that can inform state and federal
initiatives to recruit, retain, and expand the workforce, and
could be used to examine the important role of workers in
providing care to a growing elderly and chronically ill
population.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Marie R. Squillace, Ph.D., Social
Science Analyst, Office of the Assistant Secretary for Planning
and Evaluation, Hubert H. Humphrey Building, Room 424E.20, 200
Independence Avenue, SW., Washington, DC 20201.
Partner Agency: National Center for Health Statistics,
Centers for Disease Control and Prevention, Mathematica Policy
Research, Inc., and Westat, Inc.
General Description:
NATIONAL NURSING ASSISTANT SURVEY
Our nation is facing a major shortage of health care
workers who provide for the long-term care needs of residents
in nursing homes and other places. Many direct care workers are
leaving the field and too few are entering. Projections of a
substantial health care workforce imbalance have motivated
policymakers, providers, private foundations, and others to
seek immediate and sustainable solutions to stabilize the
health care workforce. Current demographic, economic and policy
trends suggest that without serious intervention, the supply of
health care workers could significantly worsen in the coming
decades.
The National Nursing Assistant Survey is the first
nationally representative survey of nursing assistants working
in U.S. nursing homes. This new survey provides information
that will inform state and federal initiatives to recruit,
retain, and expand the long-term care workforce. It also
provides important information about the role of workers in
caring for a growing elderly and chronically ill population.
The survey collected information on whether workers plan to
continue working in their present positions and what factors
affect their decisions, including job satisfaction, nature of
the work environment, training, advancement opportunities,
benefits, working conditions, and personal or family demands.
By identifying the priorities of nursing assistants, the survey
can help identify ways to meet those priorities and how to
prevent staffing shortages in the future.
The survey design and implementation were made possible
through collaborations with two independent research
organizations, a national advisory group, and a sustained
partnership with the National Center for Health Statistics,
Centers for Disease Control and Prevention.
Excellence: What makes this project exceptional?
The National Nursing Assistant Survey represents a major
advance in the data available about health care workers in U.S.
nursing homes and provides a rich resource for evidence-based
policy, practice and applied research initiatives. This survey
can be linked to other existing data sets thereby expanding the
usefulness of the data by enabling researchers to examine more
comprehensive and complex relationships between worker,
facility, resident, and community characteristics.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The care of 1.5 million elderly and chronically ill persons
in the United States is largely in the hands of nursing
assistants--the individuals who provide eight out of every ten
hours of care residents receive in nursing homes. Turnover of
these direct care workers is high which profoundly decreases
the quality of life and care of the residents. This research
provides industry and policy leaders with information that is
useful for improving the attractiveness of caregiving jobs and
for reducing worker turnover.
Effectiveness: What is the impact and/or application of
this research to older persons?
As at least 36 states currently consider workforce
vacancies to be a serious issue, results from this research
will provide an invaluable resource in federal and state labor,
welfare and health policy discussions on expanding the pool of
workers, and on reimbursement, regulation and program design.
Ultimately, this will result in improvements in the quality of
life and care of older Americans in U.S. nursing homes.
Innovativeness: Why is this research exciting or
newsworthy?
The major advance of this survey over other studies is its
use of a nationally representative sample of certified nursing
assistants within a nationally representative sample of nursing
homes. Previous studies have been of local or regional samples
that were not representative of the country as a whole.
Office of the Assistant Secretary for Planning and Evaluation: Nursing
Home Divestiture and Corporate Restructuring
Analyses of large national nursing home chains indicated a
trend towards consolidation, with smaller chains operating in
fewer states and, in some states, emergent regional chains
replacing the national chains, particularly in Florida and
Texas where malpractice litigation has been particularly acute.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: David Stevenson, Ph.D., Department
of Health Care Policy, Harvard Medical School, 180 Longwood
Avenue, Boston, MA 02115.
General Description:
NURSING HOME DIVESTITURE AND CORPORATE RESTRUCTURING
Over the past two decades, the nursing home industry has
experienced changes in the financial, regulatory, and
competitive environments. Nursing homes have been greatly
impacted by federal and state policies, such as the regulatory
reforms of the Omnibus Budget Reconciliation Act of 1987 and
the payment reforms of the Balanced Budget Act of 1997.
Occupancy rates have fallen in the context of shortened lengths
of stay for residents and increased competition from assisted
living facilities and other home and community-based care.
Medicaid payment rates vary substantially across states and
have gone through periods of relative generosity and parsimony.
Nursing home malpractice litigation has increased, leading to
an increase in overall operating costs, especially in a handful
of states.
Responding to these and other policy and market factors,
the nation's largest nursing home chains have undergone periods
of considerable expansion, contraction, and retrenchment. The
role of chain providers, which represent more than half of all
facilities, is significant in the nursing home industry. To
investigate these issues further, the Assistant Secretary of
Planning and Evaluation (ASPE) contracted with Harvard Medical
School to study recent trends in nursing home divestiture and
corporate restructuring of the nation's largest nursing home
chains.
After a review of the literature and analyses of On-line
Survey, Certification, and Reporting (OSCAR) data, the final
report describes the trends in nursing home ownership by
national chains over the past decade and discusses policy
implications. The literature review identified the policy and
market incentives that led the nursing home industry and
especially national chains to expand substantially. The
generous cost-based reimbursement policies attracted investment
in the industry and encouraged substantial merger and
acquisition activities. The review highlighted several
challenges that followed when market conditions were less
favorable, leading highly leveraged chains to bankruptcy,
divestiture, and corporate restructuring.
The outcome of these challenges is a national chain sector
that is smaller and has a different focus than 10 years ago.
Government financing remains vital, with corporate structure
also heavily influenced by factors such as litigation, state
reimbursement climates, and geographic considerations. The
industry today maintains a moderately healthy capital
structure. The industry's reemergence and relatively better
financial condition are attributed to more rational portfolios
of nursing home ownership, improved access to capital, and
improved Medicare reimbursement.
Guided by the literature review, analysis of OSCAR data
from 1993-2004, and review of information on public companies,
the report describes the nursing home industry and documents
ownership trends over the last decade. The focus was on the
characteristics and activities of the nation's largest nursing
home chain providers. Analyses of these data nationally, within
states, and across specific chains, revealed several broad
themes. Nationally, nursing home chains have consistently owned
or operated half of all facilities. Chains sold nursing homes
in high litigation states to regional chains, sold assets to
real estates investment trusts (REITs), and restructured
corporation with private equity firms. Importantly, these
aggregate findings mask important state- and chain-specific
trends.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact or application of this
research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
This study is the only analysis of the corporate
divestiture and restructuring of the large national nursing
home chains that represent the majority of over 16,000 nursing
homes in the country. The analyses show that there is
substantial variation across national chain providers in the
strategies with which they navigate policy and market
conditions, and highlights the need to investigate more about
the specific characteristics and practices of the parent
company. As the population over 85 years of age continue to
grow, continuity of care from stable nursing home industry is
essential.
Some of the restructuring and financing trends that were
identified have unclear implications for the quality of care
received by nursing home residents. Although further research
into some topics is made difficult by the lack of comprehensive
data on facility ownership, further analytic work is ultimately
needed to investigate these trends more thoroughly and to
analyze whether they have had any impact on nursing home
residents' quality of care. Several congressional hearings have
been conducted in the past year on this subject.
Office of the Assistant Secretary for Planning and Evaluation: The
National Survey of Residential Care Facilities (NSCRF)
The National Survey of Residential Care Facilities (NSCRF)
will fill a gap in federal long-term care data collection and
provide nationally representative data on residential care
facilities and their residents.
Lead Agency: Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: John D. Loft, Ph.D., Principal
Scientist, Survey Research Division, RTI International, 230 W.
Monroe Street, Suite 2100, Chicago, IL 60606.
Partner Agencies: National Center for Health Statistics
(NCHS), Agency for Health Research and Quality (AHRQ), CDC
National Center for Chronic Care and Disease Prevention and
Health Promotion--Division of Heart Disease and Stroke
Prevention, and Veterans' Administration (VA).
General Description: Unlike nursing homes and home and
hospice care, the federal government does not currently collect
data on residential care. Without this data it is impossible to
understand the entire spectrum of long-term care options.
States are responsible for regulating residential care and
state policies, licensure requirements, and terminology vary
widely across states. This makes accurate national estimates of
facility services and the total number of residents
challenging.
To address this issue the Office of the Assistant Secretary
for Planning and Evaluation (ASPE) with the National Center for
Health Statistics (NCHS) is conducting a National Survey of
Residential Care Facilities (NSRCF). This will be the first
nationally representative sample survey of residential care in
the United States. The survey will determine the
characteristics of residential care facilities, such as their
structure and environment, types of services offered, the staff
they employ, and the requirements for admission, retention, and
discharge. Additionally the survey will determine the
characteristics of residents living in residential care
settings, such as demographics, levels of functional disability
and cognitive impairment, service needs, and the types of
services used.
A general shift in state Medicaid long-term care policy
toward community-based care over the past 25 years, and
independent growth in private-pay residential care (e.g.,
assisted living) since the late 1980s have led to a burgeoning,
yet still not clearly delineated, set of residential care
alternatives to home care and traditional skilled nursing
facilities. Residential care facilities, such as assisted
living facilities or board and care homes, are a critical
component of long-term care systems, serving individuals who
cannot live at home without assistance, but who do not require
the level of skilled nursing care found in nursing homes.
Collecting information on residential care is critical
because it is impossible to understand the changing dynamics of
publicly financed long-term care (i.e., Medicare home health,
Medicaid Home and Community Based Services (HCBS), and nursing
home care) without a complete picture of the entire spectrum of
residential care options available to persons with
disabilities. Without an accurate source of information on the
characteristics of all residential care facilities, the
services they provide, and their residents, policymakers and
providers will be unable to fully understand the current long-
term care system and the likely impact of policy changes.
This essential national study will help policymakers have a
more complete picture of the long term care spectrum and of the
residential care industry and residents. The pretest will be
administered in Fall 2008, and the national survey will be
fielded in early 2010.
Office of the Assistant Secretary of Planning and Evaluation: Long-Term
Care Reverse Mortgage
This project features the development of special reverse
mortgages for persons likely to need long-term care within a
year. The mortgages will be cheaper than those on the market
today and targeted at home values of $175,000 and less.
Lead Agency: Office of the Assistant Secretary of Planning
and Evaluation, U.S. Department of Health and Human Services.
Agency Mission: The Assistant Secretary for Planning and
Evaluation advises the Secretary of the Department of Health
and Human Services on policy development in health, disability
and aging, human services, and science and data policy, and
provides advice and analysis on economic policy. The Office of
the Assistant Secretary for Planning and Evaluation (OASPE)
leads special initiatives, coordinates the Department's
evaluation, research and demonstration activities, and manages
cross-Department planning activities such as strategic
planning, legislative planning and review of regulations.
Integral to this role, OASPE conducts research and evaluation
studies, develops policy analyses, and estimates the cost and
benefits of policy alternatives under consideration by the
Department or Congress.
Principal Investigator: Barb Stucki, National Council on
Aging, 1901 L Street, NW., 4th Floor, Washington, DC 20036.
Partner Agency: U.S. Administration on Aging and U.S.
Department of Housing and Urban Development.
General Description:
LONG-TERM CARE REVERSE MORTGAGE
As the population ages and more and more people need long-
term care, it is critical to understand the potential of
different financing options. Reverse equity mortgages have been
around for some time, but they have yet to play a significant
role in financing long-term care. Home equity is considered an
asset for Medicaid eligibility, and states have begun to
explore helping older adults tap into this equity in order
finance long-term care while remaining at home.
This project will investigate the potential for reverse
equity mortgages to assume a greater role in financing long-
term care in three states: Minnesota, New Jersey, and Georgia.
The Office of the Assistant Secretary for Planning and
Evaluation, in conjunction with the U.S. Department of Housing
and Urban Development, the U.S. Administration on Aging, and
state leaders is developing special reverse mortgages
structured specifically for use by persons likely to need long-
term care with in a year's time. These reverse mortgages will
be less expensive than current products and be targeted at home
values of $175,000.
Before expanding such reverse mortgages to a larger number
of states, it is critical to understand whether consumers are
interested in such arrangements, and how effective this
financial tool is at keeping elders in the community. Staff
from the aging networks will serve as reverse mortgages
counselors, and assist consumers in determining whether their
situation is appropriate for a reverse mortgage. The reverse
mortgages resources will then be used in combination with
public case management and public services to serve older
persons in their homes for as long as possible. The reverse
mortgage funds have the flexibility to provide those services
which are not otherwise available, and are expected to extend
the time an individual can receive less-costly care in a
setting they prefer--home.
Excellence: What makes this project exceptional?
This project is exception in its use of an existing asset
to finance long-term care. Many long-term care financing
proposals require a new funding source while this one taps an
existing source in a way that maximizes consumer direction. It
also expands this potential funding source to people with lower
home equity who are more likely to utilize costly Medicaid
services.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This project is significant because it features the
conversion of previously unavailable (for most homeowners)
assets for the purpose of financing long-term care. Many older
persons want to remain in their homes but have no way to pay
for the care they require. This project has the potential to
release billions of dollars for long-term care financing while
facilitating continued residence at home. Without this project
these resources are unlikely to be converted for this purpose,
particularly given the high cost of existing reverse mortgages
and a mortgage structure that does not favor frail older
persons.
Effectiveness: What is the impact and/or application of
this research to older persons?
This project has the potential for immediate effectiveness
upon completion because it includes a financing approach that
has been demonstrated in three states. Other states can readily
replicate the approach and thereby expand this option to a
large number of vulnerable elders in need of long-term care.
Innovativeness: Why is this research exciting or
newsworthy?
This project is innovative in its use of an existing asset
to financing consumer directed care in a new way. Budget
constraints will limit the ability of Medicaid to fund all of
the long-term care that the baby boomers will need. This
research supports another financing option that facilitates the
ability of older adults to purchase their own care, remain in
their own homes while making use of public services when
appropriate.
U.S. Census Bureau
LEHD's Older Worker Profile series is an innovative use of
a unique new data source, which covers the employment history
and characteristics of workers (including older workers) and
the firms that employ them in the United States while their
confidentiality is protected.
Lead Agency: The U.S. Census Bureau.
Agency Mission: The Census Bureau serves as the leading
source of quality data about the nation's people and economy.
We honor privacy, protect confidentiality, share our expertise
globally, and conduct our work openly. We are guided on this
mission by our strong and capable workforce, our readiness to
innovate, and our abiding commitment to our customers.
Principal Investigator: Matthew Graham, Longitudinal
Employer-Household Dynamics Program, Center for Economic
Studies, U.S. Census Bureau, Room 6H141, 4600 Silver Hill Road,
Suitland, Maryland 20746.
Partner Agencies: Employment and Training Administration,
U.S. Department of Labor and National Institute on Aging (NIA),
National Institutes of Health.
General Description: The Longitudinal Employer-Household
Dynamics (LEHD) Program is in the process of producing a series
of reports on Older Worker Profiles and associated tables by
state.
To date, reports for 15 states have been issued, covering
Arkansas, Colorado, Delaware, Hawaii, Indiana, Iowa, Kentucky,
Maine, Maryland, Montana, New Jersey, Oklahoma, South Carolina,
Vermont, and Wisconsin. Reports for about 15 more states under
the Local Employment Dynamics (LED) partnership will be
released in the coming months.
Drawing on the unique collection of databases developed by
LEHD, the Older Worker Profiles highlight the age composition
of the state's workforce, job gains and losses for older
workers by industry, industries in which older workers are
concentrated, and their job stability and earnings.
In addition, forty-two (42) different supplementary and
appendix tables are provided for additional details. These
reports and tables are made available from the LEHD website
located at http://lehd.did.census.gov.
The unique collection of databases developed by LEHD is
also known as a job frame, designed to cover the employment
history and characteristics of every worker in the United
States and the employment history and characteristics of every
job-linked employer in the nation.
The job frame is created by integrating historical and
current data from state agencies, the Census Bureau, and sister
federal agencies. It currently contains over 6 billion records
and is growing with new records of recent data every 90 days.
Additional products have been derived from this job frame
for older workers, including:
OnTheMap. An interactive mapping and reporting
application that shows where people live and work with
companion reports on age, earnings, industry, and cross-state
patterns of residence and workplace. OnTheMap also allows for
mapping and reporting for older workers only.
Quarterly Workforce Indicators. A set of 30
indicators that describe the dynamics of local employment,
earnings, turnover, and job changes by geography, gender,
industry and time in year and quarter for all workers and older
workers only.
Excellence: What makes this project exceptional?
The Older Worker Profiles produced by LEHD are exceptional
because they provide unique and valuable information on the
labor market outcomes for the aging population that are useful
for both research and policy evaluation. Each Older Worker
Profile, which consists of a report and a series of
supplementary and appendix tables for a single state,
identifies key features of the local (to the Metropolitan and
County areas) employment dynamics for older workers. Because
the underlying microdata is tagged with a number of
socioeconomic variables (including age and industry), detailed
answers about local labor market conditions can be reported.
Specifically, the Older Worker Profile exposes lay
audiences to a new set of statistics called Quarterly Workforce
Indicators (QWIs). These data describe--at quarterly intervals
with a historical sequence back to 1990 for some states--
various statistical aspects of local labor markets, including
but not limited to: Employment, New Hires, Job Separations,
Turnover, and Average Earnings. QWIs for older workers in the
report portion of the Profile are available at the 2-digit
NAICS industry sector level and in the downloadable tables at
the 3-digit NAICS industry subsector level. Using the QWI, the
Older Worker Profiles generate information on the types of jobs
that older workers are leaving and being hired.
Additionally, the Older Worker Profiles are exceptional
because they are only the tip of the iceberg with respect to
the data source from which they were extracted. The LEHD data
infrastructure provides opportunities for a comprehensive and
longitudinal analysis of older workers across the nation and
down to the county level. Extensions of this research are
expected to bring further detail to the database through the
addition of external data sources and the application of more
advanced confidentiality protection systems, which should allow
greater geographic/characteristic detail while maintaining
strict confidentiality protection and increasing analytical
validity.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The research on older workers goes right to the heart of
questions of the economic health of the United States in the
coming decades. As older workers--specifically of the aging
Baby Boom generation--move through the traditional retirement
age, outcomes of their employment opportunities and choices
will have significant impacts on policy choices and options at
every level of government and private industry. Whether or not
older workers choose to move directly to retirement, continue
to work full time, or move into semi-retirement; which jobs
older works choose or are forced into holding because of their
economic resources; and whether or not older workers continue
to be compensated for their experience are all questions whose
answers will have important consequences for the national and
local economies. These are all questions that can be
illuminated by the data and research that underlie LEHD's Older
Worker Profile series.
Effectiveness: What is the impact and/or application of
this research to older persons?
The primary impact of this research is to lead the way in
making use of a unique dataset for the purposes of evaluating
the consequences of an important change coming in the workforce
as the Baby Boom generation moves through the traditional
retirement age. This research and these data can guide programs
and policy to address the needs of and support older workers
who continue to participate in the workforce. In addition, the
dataset provides the ability to answer questions about
potential gaps in knowledge as a large cohort of experienced
workers faces retirement. What are the industries in which
there will most likely be knowledge/experience gaps? In which
industries will older workers continue on through retirement,
reaping the rewards of their long experience? In which
industries will we expect to find those older Americans who did
not plan adequately for retirement and how will their
compensation compare with their younger colleagues? The
research being done and the research to come on older workers
will have a significant impact on how these questions are
interpreted and how they are answered by economic and labor
force policy at all levels.
Innovativeness: Why is this research exciting or
newsworthy?
The Older Worker Profiles are exciting and newsworthy
because they report on a much-needed dataset at exactly the
right time. As communities see their labor forces age and
retire, local, regional, state, and national leaders are
looking for information to help them understand how to respond.
At the same time, business and industry want to know how many
jobs they will need to fill in the coming years. These reports
begin the process of uncovering the answers to these questions.
This research is also exciting and newsworthy because it
makes use of a relatively new dataset that has the opportunity
to open up whole new lines of research into the labor force
dynamics of older workers. The Older Worker Profiles (reports
and supplementary tables) report on public-use data that has
been cleared by the Census Bureau's Disclosure Review Board.
These data are available in a number of extended forms (the
Older Worker Profiles are merely one slice of it) that extend
the information on the QWIs as well as show more detailed
geographical distributions of the data. Additionally, a rich
series of confidential microdata is available through approved
research projects, and the possibilities for this research and
almost limitless.
National Center for Health Statistics
The goal of the Federal Interagency Forum on Aging-Related
Statistics (Forum) is to bring together Federal agencies that
share a common interest in improving aging-related data. The
Forum provides agencies with a venue to discuss data issues
that cut across agency boundaries
Lead Agency: National Center for Health Statistics.
Agency Mission: The mission of the National Center for
Health Statistics (NCHS) is to provide statistical information
that will guide actions and policies to improve the health of
the American people. As the Nation's principal health
statistics agency, NCHS leads the way with accurate, relevant,
and timely data.
Principal Investigator: Jennifer Madans, Co-Acting Deputy
Director/Associate Director for Science, National Center for
Health Statistics, 3311 Toledo Road, Room 7207, Hyattsville, MD
20782.
Partner Agencies: Administration on Aging, Agency for
Healthcare Research and Quality, Bureau of Labor Statistics,
Centers for Medicare and Medicaid Services, Department of
Housing and Urban Development, Department of Veterans Affairs,
Employee Benefits Security Administration, Environmental
Protection Agency, National Institute on Aging, Office of
Management and Budget, Office of the Assistant Secretary for
Planning and Evaluation, HHS, Social Security Administration,
Substance Abuse and Mental Health Services Administration, and
U.S. Census Bureau.
General Description: The Federal Interagency Forum on
Aging-Related Statistics, established in 1986 by the National
Center for Health Statistics, National Institute on Aging, and
the U.S. Census Bureau, fosters collaboration among Federal
agencies that produce or use statistical data on the older
population.
The Forum plays a key role in improving aging-related data
by critically evaluating existing data resources and
limitations, stimulating new database development, encouraging
cooperation and data sharing among Federal agencies, and
preparing collaborative statistical reports. In 1998, the Forum
was reorganized and expanded to include several new members. In
addition to the original three core agencies, the members of
the Forum now include the Administration on Aging, Agency for
Healthcare Research and Quality, Bureau of Labor Statistics,
Centers for Medicare and Medicaid Services, Department of
Housing and Urban Development, Department of Veterans Affairs,
Employee Benefits Security Administration, Environmental
Protection Agency, Office of Management and Budget, Office of
the Assistant Secretary for Planning and Evaluation in the
Department of Health and Human Services, Social Security
Administration, and Substance Abuse and Mental Health Services
Administration.
Excellence: What makes this project exceptional?
The Federal Interagency Forum on Aging-Related Statistics
(Forum) is an interagency committee dedicated to improving the
quality of Federal statistics on older Americans. It is a
collection of 15 Federal government agencies that collect,
analyze, and report data on issues related to people age 65 and
over. The Forum is exceptional because it brings together such
a wide variety of Federal agencies with the primary purpose of
improving both the quality and utility of data on the aging
population. The specific goals of the Forum are to:
widen access to information on the aging
population through periodic publications and other
means;
promote communication among data producers,
researchers, and public policymakers;
coordinate the development and use of
statistical databases among Federal agencies;
identify information gaps and data
inconsistencies;
investigate questions of data quality;
encourage cross-national research and data
collection on the aging population; and
address concerns regarding collection,
access, and dissemination of data.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Americans age 65 and over are an important and growing
segment of our population. Many Federal agencies provide data
on aspects of older Americans' lives, but it can be difficult
to fit the pieces together. Thus, it has become increasingly
important for policymakers and the general public to have an
accessible, easy to understand portrait that shows how older
Americans are faring. The Forum's periodic report Older
Americans: Key Indicators of Well-Being monitors the health and
well-being of older Americans through a broad range of
indicators in five important areas: population, economics,
health status, health risks and behaviors, and health care. It
provides data on 37 key indicators carefully selected by the
Forum to portray important aspects of the lives of older
Americans and their families.
Effectiveness: What is the impact and/or application of
this research to older persons?
The Forum's periodic report, Older Americans: Key
Indicators of Well-Being, provides the Nation with a summary of
national indicators of well-being and monitors changes in these
indicators over time. By following these data trends, more
accessible information becomes available to target efforts that
can improve the lives of older Americans and their families.
Older Americans reflects the Forum's commitment to advancing
our understanding of where older Americans stand today and what
they may face tomorrow.
Innovativeness: Why is this research exciting or
newsworthy?
The Forum's mission is to encourage cooperation and
collaboration among Federal agencies to improve the quality and
utility of data on the aging population. To accomplish this
mission, the Forum provides agencies with a venue to discuss
data issues and concerns that cut across agency boundaries,
facilitates the development of new databases, improves
mechanisms currently used to disseminate information on aging-
related data, invites researchers to report on cutting-edge
analyses of data, and encourages international collaboration.
The work of the Forum is newsworthy because in an era of
agencies competing for research funds, the Forum members work
together on projects that cross agency boundaries to share
resources and enhance the work of the Federal statistical
system.
The Prevention Research Center: 10 Keys to Healthy Aging
The University of Pittsburgh's Center for Healthy Aging
created the 10 Keys to Healthy Aging program to encourage
healthy living among older adults. Research combines learning
about the ``10 keys'' with education and physical activity to
find the best combination for reducing participants' risk for
stroke, heart failure, cancer, disability,
institutionalization, and suicide. Preliminary results showed
the 10 keys led to health improvements, and the information has
been shared across Pennsylvania and in Europe.
Lead Agencies: Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health
Promotion, Division of Adult and Community Health, Prevention
Research Centers Program.
Agency Mission: The Prevention Research Centers work as an
interdependent network of community, academic, and public
health partners to conduct prevention research and promote the
wide use of practices proven to promote good health.
Principal Investigator: Anne P. Newman, M.D., M.P.H.,
University of Pittsburgh Center for Healthy Aging, 130 N.
Bellefield Avenue, Room 550, Pittsburgh, PA 15213.
Partner Agency: PRC Healthy Aging Research Network.
General Description: The 10 Keys to Healthy Aging, based on
epidemiological, clinical, and laboratory studies, address 10
conditions essential for maintaining health in older adults:
(1) prevent bone loss and muscle weakness, (2) control blood
pressure, (3) increase physical activity, (4) regulate blood
sugar, (5) stop smoking, (6) maintain social contact, (7)
participate in cancer screening, (8) get regular immunizations,
(9) lower cholesterol, and (10) combat depression. Researchers
are collaborating with community partners to refine
interventions around several of these conditions.
Project staff are implementing and evaluating two
interventions for about 1,000 older adults: a healthy lifestyle
intervention and a brief education intervention. After
completing an initial 4-hour assessment related to the ten
keys, participants are randomly assigned to an intervention
group. Participants in both groups meet with a health counselor
who explains the results of their assessments and offers
recommendations. Participants identify one or two goals for
improving their results and are referred to their doctors as
needed. People in the brief education group are referred to
community resources and receive follow-up calls from a health
counselor every 3 months.
Adults in the healthy lifestyle intervention join in
walking groups and attend group sessions about healthy food
choices for controlling blood pressure and diabetes, and
exercises to improve strength, flexibility, and endurance. In
social activities, participants can get support from peers;
practice techniques to maintain and enhance memory and other
mental abilities; and learn about the risk factors conditions
associated with aging. All participants will complete the
assessments after the intervention and every year thereafter
for 3-4 years. Post-intervention results of the 2 groups will
be compared with each other and with individuals' initial
assessments. Evaluators will analyze the extent to which the
interventions decreased participants' risk for stroke, heart
failure, cancer, disability, institutionalization, and suicide.
Excellence: What makes this project exceptional?
The 10 Keys to Healthy Aging intervention is a portable and
simple method to address the leading causes of illness in older
adults. The research involves older adults in every step of its
development. Laypersons are recruited from the community, learn
about how to prevent disease and promote health, and become
Community Health Ambassadors. They work with researchers to
design and test interventions and spread health messages among
their peers.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Older adults are at risk for heart disease and stroke,
diabetes, influenza, pneumonia, disability, suicide, and other
preventable conditions. However, those who engage in physical
activity, healthy diets, socially and mentally stimulating
activities, cancer screening, and other positive health
behaviors can often maintain active and healthy lives.
Effectiveness: What is the impact and/or application of
this research to older persons?
Community Health Ambassadors have shared the research
across the state of Pennsylvania and through a partnership with
a multinational corporation, with corporation employees working
in Europe. One thousand older adults are participating in the
second-round trials of the research project.
Innovativeness: Why is this research exciting or
newsworthy?
Older adults are bombarded by health messages about every
aspect of life. The 10 keys intervention simplifies health
messages to a consistent, evidence-based set of priorities that
helps without overwhelming the audience. Older adults work
alongside researchers to develop and test the 10 keys, and can
attest to its effectiveness and ease of use.
The Prevention Research Center: PEARLS (Program to Encourage Active,
Rewarding Lives for Seniors)
PEARLS reduces minor depression among older adults by
teaching participants behavioral techniques during in-home
counseling sessions. The program has been proven to reduce
depression and hospital visits, and has been recognized in the
National Registry of Evidence-Based Programs and Practices.
Lead Agency: Prevention Research Centers Program.
Agency Mission: The Prevention Research Centers work as an
interdependent network of community, academic, and public
health partners to conduct prevention research and promote the
wide use of practices proven to promote good health.
Principal Investigator: Sheryl Schwartz, Principal
Investigator, University of Washington, Health Promotion
Research Center, 1107 NE 45th St., Suite 200, Seattle, WA
98105.
Partner Agencies: Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Division of Adult and Community Health, City
of Seattle Aging and Disability Services, Senior Services of
Seattle/King County, Washington State Unit on Aging, Washington
State Aging and Disability Services Administration, and
Substance Abuse and Mental Health Services Administration.
General Description: PEARLS aims to reduce minor depression
and resulting disability among older adults by teaching them
depression management techniques. It consists of eight in-home
counseling sessions followed by monthly telephone calls for 6
months. The counseling covers three behavioral approaches to
managing depression: (1) Participants are taught a set of steps
they can use to solve their problems--from clearly defining the
problem to implementing their chosen solution. These steps help
participants recognize symptoms of depression and understand
the link between unsolved problems and depression. (2)
Participants are encouraged to meet recommended levels of
social and physical activity by using community settings, such
as senior centers. (3) Participants are taught to identify and
participate in activities pleasurable to them. The intervention
was shown to significantly reduce depression and has been
listed in the National Registry of Evidence-Based Programs and
Practices, a service of the Substance Abuse and Mental Health
Services Administration. King County now offers the program to
seniors who receive social services and have minor depression,
and the program is available via an online toolkit for wide
dissemination.
Excellence: What makes this project exceptional?
Local participants report having benefited from the
program. It has the potential to substantially improve health
and quality of life for older adults who suffer from minor
depression or dysthymia, and are receiving social case
management services. Because dissemination can occur within
existing community social services programs, eligible older
adults could be readily identified and enrolled in the program.
Moreover, because most social services agencies have access to
mental health experts who could supervise training of staff and
the implementation of PEARLS, the program does not require
large increases in local funding. Thus PEARLS has the potential
to benefit many ill, disabled, and frail older adults.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Minor depression affects 15%-20% of older adults and is
known to profoundly compromise health and quality of life.
People who are socially isolated and in frail health are
especially at risk for depression. Doctors and their older
patients often incorrectly assume that depression is an
unavoidable consequence of aging, and many depressed elders do
not receive treatment.
Effectiveness: What is the impact and/or application of
this research to older persons?
After one year, 43% of seniors in the intervention group
reported at least a 50% decline in depressive symptoms. Only
15% of seniors in the control group reported the same decline.
Depression resolved completely for 36% of PEARLS participants,
compared with 12% of nonparticipants. PEARLS participants
experienced significant improvements in functional and
emotional well-being. Current efforts are focused on
replicating the PEARLS program, making it available to a broad
range of older adults and to all adults with chronic medical
conditions.
Innovativeness: Why is this research exciting or
newsworthy?
Researchers have made a PEARLS Toolkit available online, so
the program can be implemented in any community in the United
States.
The Prevention Research Centers: Enhance Fitness
EnhanceFitness is a physical activity program for adults,
aged 60 years or older, that emphasizes activities to increase
endurance, strength, balance, and flexibility. Participants
improve in physical and social functioning as well as levels of
pain and depression. Their health care costs are also
significantly reduced.
Lead Agency: The Prevention Research Center.
Agency Mission: The Prevention Research Centers work as an
interdependent network of community, academic, and public
health partners to conduct prevention research and promote the
wide use of practices proven to promote good health.
Principal Investigator: Sheryl Schwartz, Principal
Investigator, University of Washington, Health Promotion
Research Center, 1107 NE 45th St., Suite 200, Seattle, WA
98105.
Partner Agencies: Group Health Cooperative of Puget Sound
and Senior Services of Seattle/King County Administration on
Aging, National Council on Aging.
General Description: Researchers collaborated to develop a
physical activity program for adults aged 60 years or older.
The program emphasizes activities to increase endurance,
strength, balance, and flexibility. The pilot study showed that
participants improved significantly in almost every area
tested--from physical and social functioning to levels of pain
and depression. The health care costs for participants
attending at least once a week were significantly reduced. Now
the program is offered at 158 community sites in 17 states, and
the researchers continue to dissemination research. In 2003,
the National Council on Aging recognized the physical activity
program as one of the top ten physical activity programs for
U.S. seniors.
Excellence: What makes this project exceptional?
EnhanceFitness is feasible and well-attended when offered
in senior centers and other community-based settings. It is
sustainable and portable. The number of participants continues
to increase--by 76% in a recent calendar year.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
An analysis of Group Health Cooperative Medicare enrollees
showed that people who participated in EnhanceFitness at least
once per week had significantly fewer hospitalizations (by
7.9%), and lower health care costs (by $1,057) than
nonparticipants. The availability of such a successful program
becomes more and more pertinent as the U.S. population ages,
disability prevention among the elderly becomes a higher
national priority, and health care costs continue to climb.
Effectiveness: What is the impact and/or application of
this research to older persons?
The program was adapted for dissemination and portability
by developing standards; manuals for instructors,
administrators, and participants; and procedures for monitoring
outcomes. Now in development as a ``train-the-trainer'' program
and pilot programs in Hispanic and American Indian communities.
It also receives funding from local foundations to help defray
the cost of the program for low-income older adults of color.
Innovativeness: Why is this research exciting or
newsworthy?
The decline in strength, endurance, flexibility, and
balance that occurs with aging contributes to diminished
independence, diminished vitality, and increased likelihood of
disabling injury. EnhanceFitness has been proven to enhance
physical and psychosocial function. Such gains can help ensure
that older adults retain independence and a high quality of
life.
Center for Disease Control and Prevention: Special Projects Branch:
Linked Medicare
The Special Projects Branch, Data Linkage Team completed a
comprehensive data enhancement and research infrastructure
project by linking several important NCHS surveys with Medicare
enrollment and claims records collected from the Centers for
Medicare and Medicaid Services (CMS). Linkage of the NCHS
survey participants with the CMS Medicare data provides the
opportunity to study changes in health status, health care
utilization, and expenditures in the elderly and disabled U.S.
population.
Lead Agency: Center for Disease Control and Prevention/
National Center for Health Statistics/Office of Analysis and
Epidemiology.
Agency Mission: The mission of the National Center for
Health Statistics (NCHS) is to provide statistical information
that will guide actions and policies to improve the health of
the American people. As the Nation's principal health
statistics agency, NCHS leads the way with accurate, relevant,
and timely data.
Principal Investigator: Christine S. Cox, M.S., Chief,
Special Projects Branch, Centers for Disease Control and
Prevention, National Center for Health Statistics, 3311 Toledo
Road, Room 6317, Hyattsville, MD 20782.
Partner Agencies: Centers for Medicare and Medicaid
Services (CMS).
General Description: NCHS has linked its population based
survey data with Medicare enrollment and claims data collected
from the Centers for Medicare and Medicaid Services (CMS).
These linked survey files provide the data needed to formulate
and answer vital research questions by profiling Medicare
service use and assessing health care costs.
Medicare enrollment and claims data are available for those
NCHS survey participants who agreed to provide personal
identification data to NCHS and for whom NCHS was able to
validate and match with Medicare administrative records. CMS
provided NCHS with Medicare benefit claims data for 1991
through 2000 for all successfully matched NCHS survey
participants.
The following NCHS surveys were linked to Medicare
enrollment and claims files:
--1994-1998 National Health Interview Survey (NHIS)
--NHANES I Epidemiologic Follow-up Study (NHEFS)
--Second National Health and Nutrition Examination
Survey (NHANES II)
--Third National Health and Nutrition Examination
Survey (NHANES III)
--The Second Longitudinal Study of Aging (LSOA II)
For successfully matched NCHS survey participants, Medicare
enrollment and claims information are available from the
following CMS files:
--Denominator
--MedPAR Hospital Stay
--MedPAR Skilled Nursing Facility
--Carrier file (formerly the Physician/Supplier Part
B file)
--Outpatient
--Home Health Agency
--Hospice
--Durable Medical Equipment
Excellence: What makes this project exceptional?
The Special Projects Branch within OAE is responsible for
conducting record linkage projects, developing linked data
files for analytic use, evaluating the linked data and
promoting the data for public health and health policy
research. Demand for more comprehensive data from the research
and public health policy communities coupled with the need for
cost-effective data collection efforts, indicates the
importance of the development of linked data sets. This project
demonstrates the successful collaboration and cooperation
between federal agencies to enhance the research infrastructure
for aging research.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Medicare administrative records provide one of the most
valuable sources of information on health events, health care
utilization and costs for the U.S. population aged 65 years or
older. However, Medicare data alone does not provide a complete
picture of beneficiary's health status. NCHS population based
surveys linked to Medicare data can provide a more
comprehensive view of health status, not only for specific
chronic conditions or functioning, but also can provide a
longitudinal component to the beneficiary's health status.
Effectiveness: What is the impact and/or application of
this research to older persons?
By linking Medicare administrative data with NCHS survey
data, researchers and policy makers can improve understanding
of the health status, utilization, and expenditure patterns of
the Medicare population.
Innovativeness: Why is this research exciting or
newsworthy?
The linkage of NCHS survey participants to their individual
administrative records on Medicare enrollment and claims
provide a cost-effective means to enrich and expand the
available information on health status, functional limitations,
medical care utilization and costs. The linked NCHS-Medicare
files provide a single source of data on various domains of
interest to researchers that, in general, are difficult to
find. For each of the NCHS surveys linked to Medicare
administrative records, there are approximately 80 different
files available for researchers.
National Center for Health Statistics: Nursing Home Care
The 2004 National Nursing Home Survey (NNHS) is the latest
in a continuing series of surveys of United States nursing
homes, their services, their staff, and their residents. The
NNHS is the only periodic nationally representative survey of
nursing home facilities. As the U.S. population ages and people
are living longer with chronic diseases, the 2004 NNHS permits
researchers, policy makers, and the nursing home industry to
assess the adequacy of current nursing home care and future
long-term care needs.
Lead Agency: National Center for Health Statistics (NCHS),
Centers for Disease Control and Prevention (CDC).
Agency Mission: The mission of the National Center for
Health Statistics (NCHS) is to provide statistical information
that will guide actions and policies to improve the health of
the American people. As the Nation's principal health
statistics agency, NCHS leads the way with accurate, relevant,
and timely data.
Principal Investigator: Robin E. Remsburg, PhD, RN, GCNS-
BC, FNGNA, FAAN, Deputy Director, Division of Health Care
Statistics, National Center for Health Statistics, 3311 Toledo
Road, Hyattsville, MD 20782.
Partner Agencies: United States Department of Veterans
Affairs, Office of the Assistant Secretary for Planning and
Evaluation (ASPE), United States Department of Health and Human
Services.
General Description: The 2004 National Nursing Home Survey
(NNHS) is the latest in a continuing series of nationally
representative sample surveys of United States nursing homes,
their services, their staff, and their residents. The 2004 NNHS
was redesigned and expanded to collect many new data items. The
2004 NNHS will permit researchers, policy makers, and the
nursing home industry to assess the adequacy of current nursing
home care and future long-term care needs.
Data collected about the facilities include characteristics
such as bed size, number of residents, ownership, top
management training and tenure, staffing levels, turnover,
Medicare/Medicaid certification, geographic region, services
provided and specialty programs offered, and charges. Data
collected about the residents include information such as
demographic characteristics, functional and cognitive status,
continence, diagnoses, length of time since admission, services
received, pain management, pressure ulcers, vaccinations,
physical restraints, advance directives, falls, fractures,
weight management, emergency department visits,
hospitalizations, medications taken, and sources of payment.
Data for the 2004 NNHS were obtained through in-person
interviews with facility administrators and designated staff
that used administrative records to answer questions about the
facilities, staff, services and programs, along with interviews
with staff familiar with the medical records to answer
questions about the sampled residents.
All nursing homes that participated in the 2004 NNHS had at
least three beds and were either certified by Medicare or
Medicaid or had a State license to operate as a nursing home. A
representative sample of nursing homes was selected from
nursing home facilities in the United States. The 2004 survey
sample consisted of about 1,500 facilities throughout the
United States and up to 12 current residents from each
facility.
The 2004 NNHS was administered using a computer-assisted
personal interviewing (CAPI) system and included a supplemental
survey of nursing assistants employed by nursing homes, the
National Nursing Assistant Survey (NNAS). The NNAS, sponsored
by the Office of the Assistant Secretary for Planning and
Evaluation (APSE), is the first-ever nationwide survey of
nursing assistants, the group of health care workers who
provide the majority of direct care (such as assistance with
bathing or showering, dressing, getting in or out of bed or a
chair, using the toilet, and eating) to the country's almost
1.5 million nursing home residents. A sample of up to eight
nursing assistants was selected from about half of the nursing
home sample at the time of the facility interview. The NNAS was
administered after the nursing home visit, using a computer-
assisted telephone interview (CATI) system.
For the 2004 NNHS: 1,174 nursing facilities participated,
representing 16,100 nursing homes and 1,492,200 residents
nationally. For the NNAS, 3,017 nursing assistants
participated, representing 702,500 nursing assistants working
in U.S. nursing homes in 2004. The next NNHS is currently
scheduled to be fielded in 2011.
Excellence: What makes this project exceptional?
The 2004 NNHS was significantly re-designed from previous
years, including a four-fold increase in survey content, sample
design modifications, and migrating from paper-and-pencil to
CAPI data collection to facilitate data collection and improve
data quality. The content enhancements include measures of
quality of care, safety, staffing characteristics, outcomes of
care, and palliative and end-of-life care. The sample design
enhancements include increasing the sample size, enabling new
subgroup analyses by selected diagnosis and race groups. The
re-designed survey also enables linkage to other Federal data
sets to enable access to and analysis of more clinical
information.
The data from the 2004 NNHS are available on the Internet
as public-use files. For the first time in 2004, the public-use
files include the sample design variables that improve the
accuracy of the results produced through the public-use files.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The NNHS is the only periodic nationally representative
survey of nursing home facilities. The public health impact of
this project is to improve the public's health by monitoring
care and outcomes of care provided to elderly residents in
nursing home settings and to provide data for research that can
assist health services researchers, federal stakeholders,
policy analysts, and the long-term care industry. As the U.S.
population ages, these data are especially important to explore
the relationship between the services provided in these
settings with patient safety, quality of care, and desired
clinical outcomes.
Effectiveness: What is the impact and/or application of
this research to older persons?
Today, nursing facilities continue to provide much needed
long-term care services to a large segment of the country's
disabled and elderly population. As the nation's total
population of older adults grows and the average lifespan
continues to increase, we need to continue to assess the
availability and adequacy of these services. Data from the NNHS
will have a direct impact on the health and well being of
individuals residing in long-term care settings. The NNAS will
provide extremely valuable information, which will guide future
policy initiatives to increase the supply of nursing assistants
in long-term care.
Innovativeness: Why is this research exciting or
newsworthy?
Conducting the NNAS as part of the 2004 NNHS reduced
duplication of data collected on nursing homes, reduced
respondent burden, reduced costs, increased efficiency of data
collection and dissemination, and increased the analytical
potential for both the NNHS and the NNAS. The successful
fielding of a health care worker survey, as a component of a
health care provider survey, will serve as a model for future
surveys of these types of workers including home health aides
and aides working in other non-nursing home residential care.
The NNAS will provide extremely valuable information, which
will guide future policy initiatives to increase the supply of
nursing assistants in long-term care. Data from the NNHS will
have a direct impact on the health and well being of
individuals residing in long-term care settings.
Center for Disease Control's National Center for Health Statistics
Healthy People 2010
Assess the progress of The Healthy People 2010 goal to
increase the quality and years of healthy life in the U.S. by
measuring expected years in good or better health, expected
years free of activity limitation, and expected years free of
selected chronic diseases.
Lead Agency: Center for Disease Control's National Center
for Health Statistics--Office of Analysis and Epidemiology.
Agency Mission: The mission of the National Center for
Health Statistics (NCHS) is to provide statistical information
that will guide actions and policies to improve the health of
the American people. As the Nation's principal health
statistics agency, NCHS leads the way with accurate, relevant,
and timely data.
Principal Investigator: Richard J. Klein, MPH, Chief,
Health Promotion Statistics Branch, Centers for Disease Control
and Prevention, National Center for Health Statistics, 3311
Toledo Road, Room 6317, Hyattsville, MD 20782.
General Description: The concept of healthy life expectancy
reflects the fact that not all years of a person's life are
lived in perfect health. As the prevalence of chronic disease
and disability tend to increase with age, a population with a
higher life expectancy may not actually be the healthiest.
One of the goals of Healthy People 2010 is to increase the
quality and years of healthy life in the U.S. Progress towards
this goal is assessed by 3 healthy life expectancy measures:
expected years in good or better health; expected years free of
activity limitation; and expected years free of selected
chronic diseases. These measures can provide an indication of
expected years of healthy life remaining at birth or other ages
such as 55 years, 65 years, or 85 years.
Analysis completed for the Healthy People 2010 Midcourse
Review revealed a slight overall increase in both expected
years remaining in good or better health and years free of
activity limitation at birth and at age 65, and an overall
decrease in expected years remaining free of selected chronic
conditions at birth and at age 65; gender and racial
differences were present in all three of these measures. Future
plans include the development of additional measures, focus on
additional domains including mental health and health
behaviors, and improving the understanding and interpretation
of healthy life expectancy.
The use of healthy life expectancy in Healthy People 2010
was recently presented to the European Commission's Task Force
on Health Expectancies. Plans for continued discussions on
international comparability between the U.S. and European
measures are in progress.
Excellence: What makes this project exceptional?
There is currently no consensus on how to measure the
quality and years of healthy life.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The concept of healthy life expectancy reflects the fact
that not all years of a person's life are lived in perfect
health. As the prevalence of chronic disease and disability
tend to increase with age, a population with a higher life
expectancy may not actually be the healthiest.
Effectiveness: What is the impact and/or application of
this research to older persons?
If healthy life expectancy is increasing more quickly than
general life expectancy within the population, then the aging
population is living a greater portion of life free of chronic
diseases and disabilities. If not, then education of policy
makers could result in re-allocation of resources to promote a
healthier life at later stages.
Innovativeness: Why is this research exciting or
newsworthy?
This research provides the opportunity for international
comparability between the healthy life expectancy measures
being used in the U.S. and by the European Commission.
The National Center for Health Statistics
This project investigates the trends in functional
limitations for Americans age 65 and over from 1992 to 2003 and
found decreases in years spent with functional limitations.
Lead Agencies: Centers for Disease Control and Prevention,
National Center for Health Statistics (NCHS).
Agency Mission: The mission of NCHS is to provide
statistical information that will guide actions and policies to
improve the health of the American people. As the Nation's
principal health statistics agency, NCHS leads the way with
accurate, relevant, and timely data.
Principal Investigator: Liming Cai, Ph.D., Senior Service
Fellow, National Center for Health Statistics, 3311 Toledo
Road, Rm. 6330, Hyattsville, MD 20782.
General Description: Background. Life expectancy for older
Americans has risen substantially over the past five decades
due to reductions in mortality from chronic diseases,
especially cardiovascular disease. Whether these added years
are mostly free of disability has been the focus of debate.
Different hypotheses of trends in population aging have been
proposed: compression of morbidity, expansion of morbidity and
dynamic equilibrium (an increase in moderate disability and a
decrease in severe disability, as medical advances increase
survival from chronic diseases and lessen their effects).
This study uses functional status (activities of daily
living and instrumental activities of daily living (ADLs and
IADLs), e.g., ability to perform tasks of everyday life like
bathing, dressing, housework) to measure morbidity among
Americans age 65 and over. We investigate whether the years
spent with functional limitations have decreased (compression
of morbidity), increased (expansion of morbidity) or if the
picture is mixed (dynamic equilibrium) in the period 1992 to
2003.
Data. We used data from the Medicare Current Beneficiary
Survey (MCBS), a nationally representative, multistage,
longitudinal survey of the Medicare population, sponsored by
the Centers for Medicare and Medicaid Services. Based on a
person's difficulty or inability to perform ADLs and IADLs due
to health problems, we constructed four mutually exclusive
states:
1. Active health (no difficulty with IADLs or ADLs)
2. Moderate disability (difficulty with at least one
or more IADLs and/or two or less ADLs)
3. Severe disability (difficulty with at least three
ADLs)
4. Death (the fourth and absorbing state)
The analysis sample consists of 40,320 beneficiaries of age
65 and over, including 23,958 women, with 131,141 person-year
observations and 90,821 pairs of observations.
Method. This project applied a multi-state life table model
to longitudinal person-level data to develop probability
estimates for incidence of and recovery from disability, as
well as death. After age-specific transition probabilities are
estimated, the authors simulate a large cohort of 65-year-olds,
by year and sex, and record their complete trajectories of
changes in disability status until death. Simulation is a
powerful computation technique that facilitates estimation of
those statistics that are difficult to obtain otherwise.
Results. This project found that all of the increase in
life expectancy during 1992-2003 period was accounted for by an
increase in life spent without functional limitations. The time
spent with severe limitations decreased due to a combination of
factors, including delayed onset, reduced incidence, shorter
episodes and increased probability of recovery.
During the study period, elderly men spent more years
without limitations than elderly women; this may reflect the
greater gains in total life expectancy for men in the last
decade. In addition, all persons 85 years of age experienced
gains in time spent without limitations and reductions in time
spent with severe limitations.
Conclusion. These trends are consistent with elements of
both the theory of compression of morbidity and the theory of
dynamic equilibrium. We will continue monitoring these trends
using the latest MCBS data to see if time spent with functional
limitations continues to decrease.
Excellence: What makes this project exceptional?
This project is the first U.S. study to comprehensively
evaluate the latest trends in functional health to test whether
they support the two most popular theories predicting the
future health of the elderly population--expansion versus
compression of morbidity. It used innovative statistical
methods, including multi-state life table approaches and micro-
simulation to gain insights that are otherwise hidden. For
example, it finds that the recent decrease in life spent with
severe functional limitations is due to a combination of
factors, including delayed onset of limitations, reduced
incidence, shorter episodes and increased probability of
recovery. It has advanced our knowledge of the nature of trends
in the health of older persons and has developed methods that
will be used to track future trends.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This project focuses exclusively on the American elderly of
age 65 and over. Its analysis revealed the complex pattern of
trends in functional health among the elderly, and identified a
number of factors associated with the recent improvement. This
provides critical background information for policy makers to
assess the direction of future trends in elderly health as the
first wave of baby boomers enter Medicare. It may also assist
the development of a range of health and public policies to
reduce health disparities among the elderly and improve the
overall well-being of the nation's older population.
Effectiveness: What is the impact and/or application of
this research to older persons?
The finding may lead to policies affecting the lives of
older persons. The findings demonstrate that a combination of
improved risk factor profiles and medical advances has likely
increased health life expectancy for older persons. The
findings support increased emphasis on health promotion
activities among the middle aged and older populations. The
findings also support policies to encourage work force
participation by the 65 and over population as a way to ease
pressure on Social Security and Medicare, since the proportion
of the older population with limitations that might hinder
employment is decreasing.
Innovativeness: Why is this research exciting or
newsworthy?
It demonstrates that the older Americans have experienced
an increase in years without functional limitations and
highlights the importance and the feasibility of following
future trends to see if the good news continues.
Centers for Disease Control and Prevention: Trends in Health and Aging
This project provides reliable up-to-date information on
trends in the health and health care utilization of the elderly
population, using data primarily from the National Center for
Health Statistics and the Centers for Medicare and Medicaid
Services.
Lead Agency: Centers for Disease Control and Prevention,
National Center for Health Statistics (NCHS).
Agency Mission: The mission of NCHS is to provide
statistical information that will guide actions and policies to
improve the health of the American people. As the Nation's
principal health statistics agency, NCHS leads the way with
accurate, relevant, and timely data.
Principal Investigators: Yelena Gorina, M.S., Aging and
Chronic Disease Statistics Branch, Centers for Disease Control
and Prevention, National Center for Health Statistics, 3311
Toledo Road, Room 6331, Hyattsville, MD 20782 and Ellen
Kramarow, Ph.D., Aging and Chronic Disease Statistics Branch,
Centers for Disease Control and Prevention, National Center for
Health Statistics, 3311 Toledo Road, Room 6332, Hyattsville, MD
20782.
General Description: The Trends in Health and Aging (THA)
project uses the statistical resources of NCHS and other
federal agencies to provide current, policy-relevant
information on the health and well-being of the older
population in the United States. The core of the project has
been the THA web-site (www.cdc.gov/nchs/agingact.htm), which
allows access to a wealth of data presented in a consistent
manner. The compilation, analysis and dissemination of these
data are coordinated by staff of the Aging and Chronic Disease
Statistics Branch of the Office of Analysis and Epidemiology
(OAE) of NCHS. This branch brings together researchers with
expertise in epidemiology, demography, and economics, assuring
that the data are of high quality and presented in a manner
useful to policy-makers and researchers. These researchers have
used the data to produce a series of simple, policy relevant,
topical reports on a range of topics relating to health and
aging. (See: www.cdc.gov/nchs/about/otheract/aging/research-
publications.htm)
In the near future, NCHS plans to merge the THA website
with another web-based interactive data system--Health Data for
All Ages--to produce a system that has consistent data across
the lifespan. This new system will allow for the tracking of
trends in the health and health care utilization of the future
elderly.
Excellence: What makes this project exceptional?
Trends in Health and Aging is a powerful web-based resource
that employs user-friendly software to provide access to up-to-
date trend data on the health of the elderly population. By
distilling data from complex surveys and data systems into
user-friendly tools and reports, it provides a model of data
and research dissemination for other federal agencies.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The entire focus of the project is to provide information
on trends in the health of the elderly population.
Effectiveness: What is the impact and/or application of
this research to older persons?
THA provides reliable, readily accessible information on
the health of the elderly to policymakers, educators,
researchers, and the public resulting in more informed decision
making and better training tools.
Innovativeness: Why is this research exciting or
newsworthy?
The project represents a powerful use of web-based tools to
disseminate complex data in a user-friendly way.
National Center for Health Statistics: Disability Statistics and Care
With a focus on the equalization of opportunities and
social participation, this project provides a universal
approach to the measurement of disability and functioning that
is of particular relevance to an aging population that is often
restricted by chronic and disabling conditions.
Lead Agency: Centers for Disease Control and Prevention,
National Center for Health Statistics (NCHS).
Agency Mission: The mission of NCHS is to provide
statistical information that will guide actions and policies to
improve the health of the American people. As the Nation's
principal health statistics agency, NCHS leads the way with
accurate, relevant, and timely data.
Principal Investigators:
Jennifer H. Madans, Ph.D., Co-Acting Deputy Director,
Associate Director for Science, Office of the Center Director,
Centers for Disease Control and Prevention, National Center for
Health Statistics, 3311 Toledo Road, Room 7207, Hyattsville, MD
20782.
Julie Dawson Weeks, Ph.D., Health Statistician, Office of
Analysis and Epidemiology, Aging and Chronic Disease Statistics
Branch, Centers for Disease Control and Prevention, National
Center for Health Statistics, 3311 Toledo Road, Room 6327,
Hyattsville, MD 20782.
Mitchell Loeb, M.Sc., Research Fellow, Office of Analysis
and Epidemiology, Aging and Chronic Disease Statistics Branch,
Centers for Disease Control and Prevention, National Center for
Health Statistics, 3311 Toledo Road, Room 6325, Hyattsville, MD
20782.
Cordell Golden, Health Statistician, Office of Analysis and
Epidemiology, Special Projects Branch, Centers for Disease
Control and Prevention, National Center for Health Statistics,
3311 Toledo Road, Room 6426, Hyattsville, MD 20782.
Partner Agencies: The United Nations Statistical Commission
and representatives from National Statistical Offices from over
50 countries have been involved in this project.
General Description: Internationally comparable disability
measures are being developed by the Washington Group on
Disability Statistics (WG), a ``city group'' established by and
operating under the aegis of the United Nations Statistical
Commission. The WG was established in response to the United
Nations International Seminar on the Measurement of Disability
held in June 2001 to develop questions and instruments that
could be used in national surveys and censuses to measure
disability among a variety of populations. It is a cooperative
effort among national statistical offices of developed and
developing countries, international statistical organizations,
and international organizations representing persons with
disabilities.
The primary objective of the WG is to promote and
coordinate international cooperation in the area of disability
statistics, focusing on measures that will provide basic, more
comparable information on disability throughout the world.
Activities include the development of a small set of general
disability measures suitable for use in censuses, sample
surveys, or other statistical formats; the design of one or
more extended sets of survey items intended to be used as
components of population surveys or as supplements to specialty
surveys; and the conduct of methodological studies.
In keeping with its purpose, the WG has developed a small
set of questions on disability that address the issue of
assessing equalization of opportunity. In developing these
questions, special attention was directed to international
comparability of the resulting data. Cognitive and field tests
have been conducted in 17 countries to determine how well the
questions perform across different cultures. The results of the
tests demonstrated that the questions were being interpreted as
intended in countries in Africa, South America, North America,
and Asia. The approach to data collection developed by the WG
has also been incorporated into the UN Principles and
Recommendations for the 2010 Census. At its eighth annual
meeting, scheduled for October 2008, the WG will produce
batteries of extended sets of questions on disability for use
on surveys. These question sets will undergo cognitive and
field testing over the next 12 months. All papers and products
of the WG are available at www.cdc.gov/nchs/citygroup.htm.
In January, 2008, a disability module that is consistent
with the approach and conceptualization outlined in the United
Nations' recommendations was incorporated into the American
Community Survey (ACS). The ACS questions will also be added to
the Current Population and the National Crime Victimization
Survey in 2008. In addition, a joint research project is under
way that will add the ACS disability questions to the National
Health Interview Survey (NHIS). This project is part of a
broader interagency effort to improve the collection and
interpretation of information on disability. The NCHS will also
be undertaking a review of the disability and functioning
measures currently on the NHIS to identify design changes that
would enhance its comparability with other national and
international data collections and provide the more detailed
information necessary to fully understand the complexities of
disability.
Excellence: What makes this project exceptional?
The approach of the Washington Group on Disability
Statistics to the operationalization and measurement of
disability is unique and represents a milestone in recognizing
the shift in attitudes and approaches to persons with
disabilities that have been evolving over the past few decades.
The WG recognizes the changing nature of disability and that it
is manifested as a result of the interaction between persons
with impairments and the barriers (both attitudinal and
environmental) that hinder their full and effective
participation in society on an equal basis with others.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
While the focus of the research is on producing global,
comparable measures of disability and functioning, an aging
society bears the burden of many chronic and disabling
conditions. By focusing on the needs of this particular sub-
population and their level of participation in society we can
improve both their quality of life and their continued
contribution to society.
Effectiveness: What is the impact and/or application of
this research to older persons?
It has been demonstrated that life expectancy among the
elderly has been improving for many decades, and there is also
evidence to indicate that health among the elderly is also
improving; however, while life expectancy at older ages has
increased, so has the prevalence of chronic diseases and the
associated effects of deceased functioning.
By providing a universal measure of disability and
functioning that focuses on the equalization of opportunities
it would be possible to focus efforts on improving the quality
of life of the older population that is overburdened by the
effects of chronic, disabling conditions.
Innovativeness: Why is this research exciting or
newsworthy?
The project represents a novel approach to the
conceptualization and measurement of disability--that builds
the model of disability proposed by the World Health
Organization's International Classification of Functioning,
Disability and Health.
The Prevention Research Centers: Healthy Aging Research Network
The Healthy Aging Network is made up of 9 universities with
expertise in the health of older adults. Member universities
collaborate on research to identify best practices for physical
activity programs for older adults and to set a research for
studying healthy aging.
Lead Agency: The Prevention Research Centers.
Agency Mission: The Prevention Research Centers work as an
interdependent network of community, academic, and public
health partners to conduct prevention research and promote the
wide use of practices proven to promote good health.
Principal Investigator: Basia Belza, Ph.D., R.N.,
Professor, Aljoya Endowed Professor in Aging, School of
Nursing, Box 357266, Health Science Building, T618D, University
of Washington, Seattle, WA 98195-7266.
Partner Agencies: Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Division of Adult and Community Health,
Robert Wood Johnson Foundation, National Council on Aging,
National Association of Chronic Disease Directors, Alzheimer's
Association, American Society on Aging, Administration on
Aging, CDC's Division of Nutrition and Physical Activity, and
CDC's Prevention Research Centers.
General Description: The Healthy Aging Research Network is
developing a research agenda around the public health aspects
of healthy aging. The nine universities participating in the
network are a subset of 33 Prevention Research Centers the CDC
funds.
The prevention research agenda is intended to increase
understanding of the determinants of healthy aging, identify
interventions that promote healthy aging, and translate
research into sustainable community-based programs that can be
used throughout the nation. The researchers are identifying the
key health-promoting skills and behaviors as well as the organ
systems and syndromes that can affect healthy aging. The
network members are also consulting with federal and state
organizations on establishing local programs for healthy aging
and working with national organizations to identify the most
effective physical activity programs. The network members and
other stakeholders are also conducting a literature review
about the effectiveness and cost-effectiveness of cross-cutting
interventions for older adults that can affect multiple health
outcomes. The results are intended as recommendations to be
used by researchers in the network and the U.S. Task Force on
Community Preventive Services to create a chapter for the
Community Guide to Preventive Services on evidence-based
interventions for promoting health in older adults.
Excellence: What makes this project exceptional?
The project is a collaboration of leading researchers in
aging from across the country, spanning academia, government,
and private foundations, who have come together to review and
set a research agenda for healthy aging.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The U.S. aging population is growing, and this research is
vital to maintaining health and quality of life for this large
subset of the U.S. population.
Effectiveness: What is the impact and/or application of
this research to older persons?
Three national demonstration projects have been completed.
(1) An in-depth, evidence-based review and statement of
public health's role in addressing physical activity for older
adults.
(2) A network-wide survey and report of community-based
physical activity opportunities for older adults at seven
national sites.
(3) An environmental audit to assess the built environment
as it relates to physical activity for older adults.
Innovativeness: Why is this research exciting or
newsworthy?
The network is unique in fostering collaboration among
researchers on the issue of aging.
National Center for Health Statistics: Long Term Residential Care
The goal of this project was to develop a national
typology, or classification system, of long-term residential
care places. Making state-to-state comparisons regarding long-
term care availability, use, and related research and policy
questions is extremely difficult because states differ in their
licensing and labeling practices for these residences. A
national typology that classifies similar places in different
states by a common set of characteristics, such as size,
services provided, or population served will allow researchers
and policymakers to compare the supply, distribution, and
characteristics of the full continuum of long-term care
residential places and facilities.
Lead Agency: National Center for Health Statistics (NCHS),
Centers for Disease Control and Prevention (CDC).
Agency Mission: The mission of the National Center for
Health Statistics (NCHS) is to provide statistical information
that will guide actions and policies to improve the health of
the American people. As the Nation's principal health
statistics agency, NCHS leads the way with accurate, relevant,
and timely data.
Principal Investigators: Robin E. Remsburg, PhD, RN, GCNS-
BC, FNGNA, FAAN, Deputy Director, Division of Health Care
Statistics, National Center for Health Statistics, 3311 Toledo
Road, Hyattsville, MD 20782, and Amy Bernstein, Sc.D., National
Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD
20782.
Partner Agency: National Institute on Aging.
General Description: The well-documented aging of the
population, particularly those aged 85 and older, will lead to
an increase in the number of people who need long-term care
services. While most people who need long-term care services
receive them in their own home, personal care received outside
both the home and traditional nursing facilities is an
important and growing service option. This is especially the
case for people who can no longer live alone but do not require
the skilled level of care provided by a nursing home. This type
of care--broadly referred to here as residential care--includes
congregate settings that provide both housing and supportive
services.
In 2002, states reported a total of 36,399 licensed long-
term care residential facilities with 910,486 units or beds, a
14.5% increase over 2000. However, there is no existing agreed-
upon classification system that allows one to distinguish the
different types of long-term care residential places across the
country. In 2003, the Assisted Living Workgroup (ALW), formed
by the U.S. Senate Special Committee on Aging in 2001,
recommended that places designated as assisted living
facilities provide 24-hour supervision, provision and oversight
of personal and supportive services (assistance with activities
of daily living (ADLs)) and instrumental activities of daily
living (IADLs), health-related services (e.g., medication
management services), social services, recreational activities,
meals, housekeeping and laundry, and transportation services.
The precursor to the Typology project--the 2001 Inventory
of Long-Term Care Residential Places (ILTCRP) project--was
sponsored by the National Center for Health Statistics (NCHS),
the Agency for Healthcare Research and Quality (AHRQ), and the
Office of the Assistant Secretary for Planning and Evaluation
(ASPE) of the U.S. Department of Health and Human Services
(HHS). Based on state licensing criteria and state regulations
obtained in the ILTCRP, relevant literature review, and expert
opinions, a typology of long-term care residential places in
the U.S. was developed.
The typology proposed includes any place licensed,
registered, or officially listed by a state that houses older
adults and provides residential care, such as 24-hour
supervision/responsibility, provision and oversight of personal
and supportive services (ADLs and IADLs), medication
management, meals, housekeeping, and laundry. The typology
excludes: (1) nursing homes, (2) hospitals, (3) facilities for
only mentally ill, mentally retarded, or developmentally
disabled; (4) places that house military population; (5) HUD
section 202 subsidized housing; (6) senior citizen
cooperatives; (7) naturally-occurring retirement communities
(NORC); (8) commercial retirement communities (that do not
include licensed or certified places described above); and (9)
other places for independent living.
On January 12-13, 2004, the National Center for Health
Statistics (NCHS) conducted an expert meeting of about 50 long-
term care researchers, residential care providers, industry
representatives, and colleagues from various federal agencies.
The objectives of the meeting were to: review, critique, and
refine a proposed typology of long-term care residential
places; discuss issues related to surveying these places;
confirm the need for a survey of long-term care residential
places; discuss the challenges of developing a sampling frame
and classifying long-term care residential places; identify the
places that should be included in a survey of long-term care
residential places; and offer recommendations for refining the
proposed typology of residential care places. Subsequent
initiatives associated with this project have included the
design of a national survey of residential care facilities, the
development of an unduplicated sampling frame from which the
sample for the national survey will be drawn, and preparations
for conducting a nationally representative survey of
residential care facilities and their residents.
Excellence: What makes this project exceptional?
Creating a uniform classification system or typology for
long-term care residential places would enable the federal
government to monitor long-term care policy and payment
initiatives more effectively. A sampling frame that covers the
full continuum of existing long-term care residences in the
U.S. could be established. A typology would enable researchers
to tailor their sampling methodologies and data collection
strategies for the different types of long-term care
residential places, direct care workers, and residents. The
typology development has served as one of the precursor
activities to the design of a national survey of residential
care facilities and preparations for conducting a nationally
representative survey of residential care facilities and their
residents. This project has been part of a larger effort
characterized by collaboration among multiple Federal agencies
within the U.S. Department of Health and Human Services (HHS)
to enable a better understanding of long-term care residential
places.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
There are various types of ``long-term care'' residential
places in the U.S. States differ in their licensing and
labeling practices for long-term care residential places and
services, making cross state comparisons extremely difficult.
The term ``assisted living'' is used in the regulations or
statutes in 32 states and the District of Columbia in 2002,
however the characteristics of facilities labeled as assisted
living vary dramatically across states. Even within states, the
labeling among various hybrid facilities or residential
communities that provide long-term care services but are not
certified nursing homes is inconsistent. Facility licensing,
regulation, and payment policy also vary considerably across
states. Places licensed as board and care facilities in one
state may be licensed as assisted living facilities in another
state.
Effectiveness: What is the impact and/or application of
this research to older persons?
Creating a uniform classification system or typology for
long-term care residential places would enable the federal
government to monitor long-term care policy and payment
initiatives more effectively. A sampling frame that covers the
full continuum of existing long-term care residences in the
U.S. could be established. A typology would enable researchers
to tailor their sampling methodologies and data collection
strategies for the different types of long-term care
residential places, direct care workers, and residents.
Innovativeness: Why is this research exciting or
newsworthy?
The experts convened for this two-day meeting concluded
that a nationally representative survey of long-term care
residential places is needed. Many consumers are confused about
the different types of residential care places and the services
they provide. Researchers and policy makers need to understand
how services and populations change among residential care
settings and be able to track the evolution of residential care
over time. Given survey costs and budgetary constraints, most
participants recognized that the scope of a survey may need to
be limited to residential care places licensed/registered and
listed by the state.
Most participants recommended conducting a provider-based
survey, which will provide more information on characteristics
of the selected types of residential care places than a
population-based survey. This project was a precursor to the
National Survey of Residential Care Facilities being conducted
by the National Center for Health Statistics in partnership
with the Office of the Assistant Secretary for Planning and
Evaluation (ASPE), United States Department of Health and Human
Services, the Agency for Healthcare Quality and Research
(AHRQ), United States Department of Health and Human Services,
and the United States Department of Veterans Affairs.
Centers for Medicare & Medicaid Services (CMS) & the National Cancer
Institute (NCI): Cancer Epidemiology Research
The NCI sponsors the SEER program, which contracts with 15
tumor registries to provide selected information on all newly
diagnosed cancers in their reporting areas; CMS provides
Medicare claims and enrollment records for the elderly and
disabled populations. The linked database has been used to
study a wide variety of issues related to cancer epidemiology
and health services research.
Lead Agency: The research data project is a joint effort
between the Centers for Medicare & Medicaid Services (CMS) and
the National Cancer Institute (NCI).
Agency Mission: The mission of CMS is to administer the
Medicare, Medicaid, and State Children's Health Insurance
Programs and to promote quality care for beneficiaries.
Principal Investigators: Gerald F. Riley, M.S.P.H., Senior
Researcher, Centers for Medicare & Medicaid Services, 7500
Security Blvd., Mail stop C3-21-27, Baltimore, MD 21244 and
Joan L. Warren, Ph.D., National Cancer Institute, EPN Room
4005, 6130 Executive Blvd., MSC 7344, Bethesda, MD 20892-7344.
General Description: The Surveillance, Epidemiology, and
End Results (SEER)-Medicare database is the linkage of two
large population-based data sources that provide detailed
information about elderly persons with cancer. The CMS
collaborates with the NCI to link SEER data to Medicare claims
and enrollment records for elderly and disabled populations.
NCI sponsors the SEER program, which contracts with 15 tumor
registries to provide selected information on all newly
diagnosed cancers in their reporting areas. These areas
currently include about 25 percent of the U.S. population. The
SEER data collected about each new cancer case includes site of
cancer, month and year of diagnosis, data about the cancer
(e.g., histology, stage, and grade), type of surgical
treatment, radiation therapy, patient demographics, follow-up
of vital status, and cause of death. National statistics on
cancer incidence, survival, and mortality are generated from
the SEER database.
The CMS provides Medicare claims and enrollment data for
the SEER-Medicare linked database, including information on
specific procedures like cancer screening services,
chemotherapy, and post-treatment surveillance. Diagnoses
reported on the claims can be used to identify comorbid
conditions, and costs of care can be estimated from payment
data. Enrollment records indicate enrollment and disenrollment
from managed care. Medicare records for a 5 percent sample of
cancer-free beneficiaries residing in SEER reporting areas are
also included in the database for comparison purposes.
The SEER-Medicare linked database includes cancer cases
diagnosed from 1973 to 2002, and cases diagnosed from 2003-2005
are currently being added. Medicare data are available from
1991 to 2006. The database has been used to study a wide
variety of issues related to cancer epidemiology and health
services research. Several studies have addressed patterns of
care by cancer site, as well as outcomes of care. Costs of
cancer care have been estimated by phase of care, as well as on
a lifetime basis from diagnosis to death. Effects of
comorbidities on treatment and outcomes have been studied, and
comparisons made of treatment under managed care and fee-for-
service. Additional topics include volume-outcome studies and
disparities in cancer treatment and outcomes.
The linked database has been used by CMS and NCI
researchers to study numerous policy issues related to cancer
epidemiology and health services. The data have also been made
available on a de-identified basis to epidemiologists and
health services researchers outside these two agencies for
research purposes, subject to strict confidentiality rules, and
appropriate reviews and approvals. To date, over 250 articles
have appeared in the peer-reviewed literature based on SEER-
Medicare data. The agencies intend to continue updating the
linkage on a biannual basis for the foreseeable future.
Excellence: What makes this project exceptional?
The SEER and Medicare data have complemented each other to
produce a unique powerful tool for examining issues related to
cancer care for the elderly. The linked database has made
possible a broad range of studies that have resulted in more
than 250 published articles in peer-reviewed journals. The
project has required close collaboration between CMS and NCI,
as well as with the participating SEER registries.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Cancer greatly affects the elderly, as 60 percent of new
cancers and 70 percent of cancer deaths now occur in the
population of those over the age of 65. The SEER-Medicare
linked data provide a powerful tool for studying patterns of
care, outcomes, and costs of cancer care among the elderly
population.
Effectiveness: What is the impact and/or application of
this research to older persons?
Research based on SEER-Medicare data has provided important
information to policymakers, providers, and beneficiary
organizations concerned with cancer care for the elderly.
Innovativeness: Why is this research exciting or
newsworthy?
The linked database provides a unique wealth of
information, not available in other databases, on a very large
number of cancer cases among the elderly population. SEER data
on cancer incidence, survival, and mortality are linked to
Medicare data on cancer screening services, chemotherapy, and
post-treatment surveillance.
Medicare Psychiatric Admissions
In 2005, Medicare implemented a new prospective payment
system for inpatient psychiatric facilities (IPF PPS). This
project analyzed Medicare psychiatric admissions between 1987
and 2004. Special attention was given to differences in use of
inpatient psychiatric care by aged and non-aged disabled
Medicare beneficiaries. Analysis of Medicare psychiatric
inpatient claims for 1987-2004 provides insights into future
experience post-IPF PPS.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer the
Medicare, Medicaid, and State Children's Health Insurance
Programs and to promote quality care for beneficiaries.
Principal Investigator: Philip G. Cotterill, Ph.D..
Economist, Centers for Medicare & Medicaid Services, 7500
Security Blvd., Mail stop C3-21-28, Baltimore, MD 21244.
General Description: In 2005, Medicare implemented a new
prospective payment system for inpatient psychiatric facilities
(IPF PPS). This analysis of Medicare psychiatric hospital stays
begins in 1987, soon after the 1983 implementation of the DRG-
based inpatient hospital prospective payment system (IPPS). It
continues through 2004--the last year in which freestanding
psychiatric hospitals and psychiatric units within short-stay
general hospitals were paid under the cost-based TEFRA system.
The factors that influenced utilization of psychiatric
inpatient care in the pre-IPF PPS past provide the basis for
hypotheses about the impact of the IPF PPS and future trends in
this Medicare benefit.
Medicare pays for psychiatric inpatient care in three
provider settings--freestanding psychiatric hospitals, short
stay general hospital certified psychiatric units, and short
stay general hospital beds (either as ``scatterbeds'' or
uncertified psychiatric units). As noted earlier, the first two
types of providers were exempted from the IPPS and paid under
the cost-based TEFRA system until 2005. Uncertified units and
scatterbeds have been paid under the DRG-based IPPS from its
inception. Hospitals and units specializing in alcohol and drug
treatment were exempt from the IPPS until 1988 when, following
some refinement of the alcohol and drug DRGs, they were brought
under the IPPS.
Medicare payment policy has the potential to affect the
utilization of psychiatric inpatient care in several ways. The
use of different Medicare inpatient payment systems for
different provider settings is very likely to affect how
providers organize care. Differences in payment units, such as
per case payments under the IPPS and per diem payments under
the IPF PPS, provide different incentives. Differences in
relative payment levels for these settings may also influence
their relative utilization. Broader impacts are also possible.
Relative Medicare payments for inpatient versus outpatient care
may influence care choices between inpatient and community-
based services. Finally, Medicare coverage and payment for
psychiatric inpatient care may encourage its utilization versus
comparable utilization in long-term care residential settings
not covered by Medicare.
Medicare payment policy was only one of many factors that
influenced psychiatric admissions between 1987 and 2004. In
order to identify other factors, the study first decomposes
admission trends into components representing changes in the
number of beneficiaries, the rate of service use by
beneficiaries, and the number of admissions per user. This part
of the analysis also determines how various groups of Medicare
beneficiaries were differentially affected by these factors.
Second, the study examines the changes in care delivery
patterns that resulted from the interaction of Medicare payment
incentives and the factors identified in the first part of the
study. The paper concludes with a discussion of the potential
implications of these results for the delivery of Medicare
psychiatric inpatient care in the future.
Excellence: What makes this project exceptional?
The study uses analysis of trends over 17-year period to
pose questions about future developments in inpatient
psychiatric care for Medicare beneficiaries.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Psychiatric care for the elderly has received less
attention than psychiatric care for the chronically mentally
ill population. This study highlights differences between the
elderly and the chronically mentally ill in terms of their
mental health conditions and care delivery patterns.
Effectiveness: What is the impact and/or application of
this research to older persons?
The study shows that the growth of psychiatric units within
general hospitals was a significant source of inpatient care
for elderly dementia patients. The study asks whether
Medicare's inpatient psychiatric facility payment system
implemented in 2005 will alter the care delivery pattern that
developed under the earlier payment system.
Innovativeness: Why is this research exciting or
newsworthy?
This study is the first publication to summarize trends in
inpatient psychiatric care during recent decades in a way that
provides a context for future research.
Medicare Current Beneficiary Survey
The MCBS is a longitudinal study, continually collected
since 1991, that takes a comprehensive look at the Medicare
population. Linked to Medicare claims data, this database is
used to manage the Medicare program and help formulate future
changes.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer the
Medicare, Medicaid, and State Children's Health Insurance
Programs and to promote quality care for beneficiaries.
Principal Investigator: Franklin Eppig, J.D., Director,
Medicare Current Beneficiary Survey, Centers for Medicare &
Medicaid Services, 7500 Security Blvd., Mail stop C3-16-27,
Baltimore, MD 21244.
General Description: The MCBS is a continuous, multipurpose
survey of a representative sample of the Medicare population
designed to aid the Centers for Medicare & Medicaid Service's
(CMS) administration, monitoring and evaluation of the Medicare
program. The survey is focused on health care use, cost and
sources of payment. Data from the MCBS enables CMS to determine
sources of payment for all medical services used by Medicare
beneficiaries, including co-payments, deductibles, and non-
covered services; develop reliable and current information on
the use and cost of services not covered by Medicare (such as
prescription drugs and long-term care); ascertain all types of
health insurance coverage and relate coverage to sources of
payment; and monitor the financial effects of changes in the
Medicare program. Additionally, the MCBS is the only source of
multi-dimensional person based information about the
characteristics of the Medicare population and their access to
and satisfaction with Medicare services and information about
the Medicare program.
Sample Characteristics:
Universe: Medicare enrollees, both aged and disabled,
whether in the community or in an institution.
Periodicity: Three rounds per year, each 4 months in
length.
Unit of Analysis: Persons / Medicare beneficiaries.
Sample Design: Multi-stage stratified random list sample.
Survey Design: Rotating Panel / Each panel followed for 12
interviews.
Survey Methodology: In-person interviews using computer
assisted personal interviewing (CAPI).
Sample Strata: The MCBS sample is stratified by age group
within the Medicare aged and disabled sub-populations. Both the
disabled and the very old are over sampled to achieve a desired
number of sample persons in each age strata. The over sample
insures sufficient cases for analysis by age strata and
increases the number of institutionalized persons in the
sample. Approximately 16,000 sample persons are interviewed in
each round. However, because of the rotating panel design, only
12,000 sample persons receive all three interviews in a given
calendar year.
------------------------------------------------------------------------
Sample size
Age group per -------------------------
Round Annual
------------------------------------------------------------------------
0-44.......................................... 1,334 1,000
45-64......................................... 1,334 1,000
65-69......................................... 2,667 2,000
70-74......................................... 2,667 2,000
75-79......................................... 2,667 2,000
80-84......................................... 2,667 2,000
85+........................................... 2,667 2,000
------------------------------------------------------------------------
Questionnaire Content: The MCBS collects information on:
health care use, cost and sources of payment; health insurance
coverage; household composition; socio-demographic
characteristics; health status and physical functioning; income
and assets; access to care; satisfaction with care; usual
source of care; and how beneficiaries get information about
Medicare.
Availability of Data: Information collected in the survey
is combined with information from CMS' administrative data
files and made available through data files. The Access to Care
data file combines survey responses from the fall round of the
MCBS with complete calendar year Medicare claims data. ``Access
to Care'' data files are available within a year of the close
of the subject calendar year. The complete medical use, cost
and source of payment data file takes twice as long to produce
because it requires complex editing and imputation activities
which are built upon an event level match of survey collected
information with Medicare claims and administrative data.
For More Information Visit The MCBS Web Site:
www.cms.hhs.gov/mcbs.
Excellence: What makes this project exceptional?
The MCBS is in a unique position to monitor effects of the
Medicare program on its beneficiaries and provide the basic
information needed to estimate the benefits and costs of
program changes and expansions. The MCBS is used as a program
management tool to assess legislative proposals (e.g., proposed
expansion of home health care). Once decisions on health care
reforms are made, the MCBS is in position to monitor their
effects upon the Medicare population (e.g., enacted
prescription drug benefit).
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The MCBS is identified to assist policy makers and
researchers in monitoring and evaluating the Medicare program
and produce statistics and linked data files. This function is
generalized, but not limited to the following tasks:
1. responses to MCBS questions on access to care are
used to measure our beneficiaries' ability to get the
health care services in a timely manner in both fee-
for-service and managed care settings;
2. responses to questions on satisfaction from the
MCBS are used to measure the degree to which a
beneficiary's perception of care received meets or
exceeds his or her expectation for care, in both fee-
for-service and managed care settings;
3. responses to questions on utilization from the
MCBS and the associated Medicare claims are used to
track the percent of Medicare beneficiaries who receive
preventative health services to include but not be
limited to:
--an annual vaccination for influenza and a
lifetime vaccination for pneumococcal;
--a screening or diagnostic mammogram within
a 2-year period; and
--diabetic eye exam for beneficiaries
diagnosed with diabetes.
4. responses to questions on beneficiary needs
measure the effectiveness of CMS' dissemination of
Medicare information to it's beneficiary population;
and
5. responses to questions on beneficiary knowledge
measures the effectiveness of CMS' initiative to
increase beneficiary understanding of basic features of
the Medicare program.
Effectiveness: What is the impact and/or application of
this research to older persons?
Research based on MCBS data has provided important
information to program managers and policymakers concerned with
the Medicare program. Most recently data from the MCBS helped
shape and inform the crafting of the 2003 Medicare Prescription
Drug, Improvement and Modernization Act--MCBS was the only
source of self-reported prescription drug utilization by the
Medicare population. The MCBS continues to serves as a
collection tool for non-covered prescription drugs as well as
to measure the impact of the legislation on the Medicare
program.
Innovativeness: Why is this research exciting or
newsworthy?
In 2006, nearly 37 million people age 65 and over lived in
the United States, accounting for just over 12% of the total
population. To give historical perspective, over the 20th
century the 65 and over population grew from 3 million to 35
million. The Baby Boom Generation will start turning 65 in 2011
causing a dramatic increase in this population over the
following two decades. In 2030, this 65 and over population is
projected to be twice as large as their counterparts in 2000,
growing from 35 million to 72 million and representing 20% of
the total U.S. population. From 2030 onward the proportion of
aged 65 and over will remain relatively stable, at around 20%.
While this demographic shift is interesting what truly makes
this change exciting and newsworthy is that the 2008 Annual
Trustees Report states that costs will exceed income, excluding
interest, for the Medicare Hospital Insurance Trust Fund
beginning in 2008. Beginning in 2010, costs are projected to
exceed income including interest. It is projected that by 2019
the trust fund will be exhausted.
Over the next few years the Medicare program will most
likely undergo increasing scrutiny. The MCBS will continue to
play an active role in shaping and informing public debate. If
and when changes to the program are enacted, the MCBS will
again serve to measure the affects of those changes on the
program and on the Medicare population.
End-Stage Renal Disease Clinical Performance Measures Project
This submission pertains to studies of quality of care for
End-Stage Renal Disease (ESRD) patients, the majority of which
are over the age of 65 years. Several of these studies use the
Centers for Medicare & Medicaid Services' (CMS's) ESRD Clinical
Performance Measures (CPM) Project data, either stand alone or
linked with other CMS administrative data. These data have been
used to study a wide variety of issues related to the quality
of care for ESRD patients.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer
Medicare, Medicaid, and the State Children's Health Insurance
Program and to promote quality of care for beneficiaries.
Principal Investigator: Diane L. Frankenfield, DrPH, MPH,
BSPharm., Senior Researcher, Centers for Medicare and Medicaid
Services, 7500 Security Blvd., Mail stop C3-21-28, Baltimore,
Md. 21244.
Partner Agencies: National Institutes of Health, National
Institute of Diabetes & Digestive & Kidney Diseases, The United
States Renal Data System, Kidney Epidemiology and Cost Center,
Wake Forest University, Section on Nephrology, University of
Wisconsin, Department of Pharmacy, Henry Ford Hospital,
Department of Nephrology, Emory University, School of Public
Health, and Duke Clinical Research Institute, Duke University
Medical Center.
General Description: End-Stage Renal Disease (ESRD)
represents a significant disease and economic burden on the
elderly. The CMS research program has emphasized studies of
patterns of quality of care for ESRD patients.
Several studies have explored patterns of care by sex,
race, Hispanic ethnicity, and geographic location to determine
if disparity in care exists for different patient groups. In
addition, studies have been conducted to examine patterns of
care by facility characteristics, such as profit-status, chain
affiliation, and size. Different clinical outcomes examined
have included intermediate outcomes such as dialysis adequacy,
anemia management, type of vascular access in use, and
nutritional factors, as well as outcomes such as
hospitalization and mortality.
On-going studies include (1) examining the association of
erythropoietin stimulating agents (ESAs) dose and route of
administration (intravenous vs. subcutaneous) with subsequent
hospitalization and death; and (2) trending of anemia
management among dialysis patients over time in response to
changing FDA recommendations and clinical practice guidelines.
Excellence: What makes this project exceptional?
CMS, NIH, and other research organizations have
collaborated to produce a series of policy-relevant studies of
ESRD care in the elderly Medicare population. The studies have
used several data sources, most notably CMS's ESRD CPM Project
database and CMS administrative data. Analyses have addressed
many facets of ESRD care, including treatment, outcomes, and
costs.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
ESRD is largely a disease of the elderly. Research on
patterns and costs of care inform Medicare policies in these
areas. Analyses of patterns of care may result in improvements
to beneficiary health as well as reducing/eliminating
disparities in care for different patient groups.
Effectiveness: What is the impact and/or application of
this research to older persons?
Research on patterns of ESRD care has provided important
information to policymakers, providers, and beneficiary
organizations.
Innovativeness: Why is this research exciting or
newsworthy?
The use of special databases has enabled researchers to
conduct unusually detailed analyses of ESRD care that elderly
Medicare beneficiaries are receiving.
Medicare Beneficiaries With Multiple Chronic Conditions
This project found that although diabetes care services
decreased and the odds of dying increased among those with
multiple chronic conditions as compared to diabetes only, the
receipt of these diabetes care services was associated with
half the odds of dying and lower costs to Medicare.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer
Medicare, Medicaid, and the State Children's Health Insurance
Program and to promote quality of care for beneficiaries.
Principal Investigators: A. Marshall McBean, M.D., M.Sc.,
Professor, University of Minnesota School of Public Health, 420
Delaware St., SE Mayo A369, Minneapolis, MN 55455.
General Description: The purpose of Activity #1 of this
study was to examine the extent to which elderly Medicare
beneficiaries with multiple chronic conditions received
recommended care and preventative services and to determine
whether each additional condition had an impact on whether the
beneficiaries received those services. The following chronic
diseases and disease combinations were considered: diabetes;
diabetes and depression; diabetes and chronic obstructive
pulmonary disease (COPD); and diabetes and depression and COPD.
The study outcomes included three diabetes care measures (serum
hemoglobin A1c (HbA1c) and lipid (LDL-C) testing, and eye
examination) as well as three preventive care measures that are
recommended for all elderly beneficiaries (or one gender):
influenza immunization, mammography and screening prostate
specific antigen (PSA) testing. Rates of screenings and
preventative care services were determined and multivariate
logistic regression analyses were carried out to examine the
effect of additional disease burden on the rate of receipt
diabetes care and preventive care services. Baseline age-
adjusted rates among Medicare beneficiaries with diabetes were
as follows: HbA1c test (72.9%), lipid testing (66.5%), eye
examination (50.7%), influenza vaccination (54.7%), mammogram
among women (45.4%), and prostate specific antigen (PSA) test
among men (42%). Across all measures, rates generally became
lower among beneficiaries with diabetes and COPD, and even
lower among those with diabetes, COPD and depression, a set of
findings that was also supported by the regression analyses.
Results were more variable among those with diabetes and
depression, but not COPD.
The purpose of Activity #2 of this study was to examine
costs of care and likelihood of mortality among elderly
Medicare beneficiaries with multiple chronic conditions. The
following chronic diseases and disease combinations were
considered: diabetes; diabetes and depression; diabetes and
chronic obstructive pulmonary disease (COPD); and diabetes and
depression and COPD. Multivariate regression analyses were
carried out for each disease cohort, as well as all cohorts
combined, in order to examine the effect of adding additional
disease burden on mortality and costs. The mean per beneficiary
cost to Medicare in 2003 varied almost three fold between the
cohort with diabetes only ($9,052) and diabetes, COPD and
depression ($26,707) with intermediate cost burdens of $14,647
for those with diabetes and depression and $18,756 for those
with diabetes and COPD. A key cost-related finding is that the
receipt of diabetes care services was strongly and linearly
related to lower costs to Medicare for all four cohorts of
beneficiaries. Compared with those diagnosed with diabetes
only, there was a 75% greater likelihood of dying within two
years among those with diabetes and COPD, and the risk was more
than double for those with diabetes, COPD and depression. As
the number of diabetes care services increased, a beneficiary's
odds of dying decreased. Those who had received all three
diabetes care measures (serum hemoglobin A1c (HbA1c) and lipid
(LDL-C) testing, and eye examination) slashed their odds of
dying in half, compared with those who had received none of
these services.
Excellence: What makes this project exceptional?
This project is the first to look at the additional burden
of multiple chronic diseases in conjunction with likelihood of
receipt and health and cost impact of preventive healthcare
services that are recommended for persons with diabetes and
other chronic diseases.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This project is relevant to aging populations because it
not only focuses on Medicare beneficiaries who are sixty five
years of age and older, but also it hones in on issues of
particular importance to this group of older Americans.
Specifically, it addresses the experience of those suffering
multiple chronic conditions as opposed to those with zero to
one chronic disease. Sixty five percent of Medicare
beneficiaries in this age group suffer two or more chronic
conditions, 43 percent have three or more chronic conditions,
and 24 percent have four or more chronic conditions.
Effectiveness: What is the impact and/or application of
this research to older persons?
This highlights the need for older Americans with one or
more chronic disease to receive all the recommended screening
and preventive care services. Not only do these reduce the odds
of dying by one half, but also they are significantly
associated with reduced cost to Medicare.
Innovativeness: Why is this research exciting or
newsworthy?
This research is exciting because the screenings have been
associated with both reduced mortality and decreased cost to
Medicare. This is a win-win for patient care and Medicare cost
containment.
Effects of Disease Management Demonstrations on Elderly Medicare
Populations
CMS has conducted seven disease management (DM)
demonstrations, social experiments on whether and how DM
approaches by various health care providers affects the cost,
access to, and the quality of care provided to groups of frail
elderly with Medicare coverage. Evaluations have been
conducted, results together constituting a significant body of
knowledge on effects on DM programs on frail elderly Medicare
populations.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer
Medicare, Medicaid, and the State Children's Health Insurance
Program and to promote quality of care for beneficiaries.
Principal Investigators: David Bott, Mary Kapp, Lorraine
Johnson, Carol Magee, CMS, Baltimore, 7500 Security Boulevard,
Baltimore, MD 21244,
Partner Agencies: Contractors included Mathematica Policy
Research, RTI International.
General Description: During the last decade, CMS has
conducted seven disease management (DM) demonstrations,
involving approximately 300,000 fee-for-service Medicare
beneficiaries served by 35 programs. Programs include provider-
based, third party, and hybrid models, located in different
geographic regions across the country. CMS staff, assisted by
funded contractors, have conducted evaluations of these
demonstrations. These analyses constitute a significant
contribution to knowledge on effects on DM programs on frail
elderly Medicare populations.
Excellence: What makes this project exceptional?
The volume of high-quality work underlying the evaluations
of DM on the Medicare fee-for-service population.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Results improve understanding of effects of DM for frail
Medicare populations and point to future research opportunities
that will have direct relevance to the Medicare program.
Effectiveness: What is the impact and/or application of
this research to older persons?
Research contributes to understanding of policy makers in
shaping the Medicare program, which impacts cost, quality, and
access to care of the elderly.
Innovativeness: Why is this research exciting or
newsworthy?
Research focuses on the application of DM activities to
sicker Medicare populations, whereas these DM activities were
previously applied to under-age-65-populations. Thus, findings
potentially improve the understanding of policy makers in
shaping the Medicare program.
Medicare Fee-for-Service Beneficiaries' Transitions Through Home Health
Care
The authors selected a 5% random sample of Medicare fee-
for-service (FFS) beneficiaries and analyzed their
administrative data (enrollment, claims, and OASIS assessments)
from 2004 to document the substantial health needs and medical
complexity of home health patients.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer the
Medicare, Medicaid, and State Children's Health Insurance
Programs and to promote quality care for beneficiaries.
Principal Investigators: Jennifer L. Wolff, Ph.D.,
Department of Health Policy and Management, Johns Hopkins
University, 624 N. Broadway, Room 692, Baltimore, MD 21205.
Partner Agencies: Johns Hopkins University, Johns Hopkins
School of Medicine, Johns Hopkins Bayview Center for Innovative
Medicine.
General Description: The purpose of this research was to
describe Medicare fee-for-service (FFS) beneficiaries'
transitions through home health care within the context of
other acute and post-acute services, to examine health
indicators among home health services patients, and to examine
agreement within administrative claims and Outcome and
Assessment Information Set (OASIS) measures of health services
use. To conduct this study, the authors exploited a new CMS
data resource, the Chronic Condition Data Warehouse (CCW). The
CCW was created pursuant to Section 723 of the Medicare
Modernization Act of 2003, whose intent was to improve the
quality of care and reduce the cost of care for chronically ill
Medicare beneficiaries.
Excellence: What makes this project exceptional?
This project contributes knowledge to an important but less
well understood area of the health care continuum. Existing
home health quality initiatives are setting-specific and
limited to information generated by providers that submit OASIS
assessments to the government. The authors found that
approximately two-thirds of home health patients incurred acute
or post-acute services in the 2 weeks preceding entry into home
health, and that one-third incurred further acute and/or post-
acute services during the month after discharge. This result
suggests there would be merit in articulating patient-specific
rather than setting-specific measures of home health care
quality.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Approximately 7.4% of beneficiaries in 2004 used home
health care. According to this study, home health users'
average age is five years higher than the age of beneficiaries
generally (77.0 vs. 71.9 years), and more than one-quarter are
at least 85 years old. More than one-quarter used Medicaid as
well as Medicare. Upon initial assessment, nearly 1 in 3
participants were dependent on others for help with activities
of daily living; virtually all were disabled in instrumental
activities of daily living. Claims-based indicators of chronic
illness from the CCW suggested that one-quarter of home health
users in 2004 had Alzheimer's disease or senile dementia, and
one quarter had an indication of major depression within the
last year. High rates of neurological and emotional disorder in
this population of Medicare beneficiaries suggest substantial
challenges are inherent in caring for ill elders at home, often
shortly following a stay at an acute hospital.
Effectiveness: What is the impact and/or application of
this research to older persons?
The study documents the substantial health needs and
medical complexity of Medicare home health patients, as well as
the high frequency of their transitions through the health care
system. Findings substantiate the practical importance of CMS
current efforts to develop a new, psychometrically sound,
uniform post-acute assessment tool to improve information
transfer between care settings, coordination of care, and
patients' transitions across health care delivery settings.
Innovativeness: Why is this research exciting or
newsworthy?
This study documents an important but less well understood
area of the home health care continuum as it affects elderly
Americans. The research also demonstrates the utility of
enhancing traditional administrative data with a relatively new
routine data resource, provider-submitted assessments, and with
longitudinal summary data that facilitate efficient analysis.
Characteristics of Enrollees and Enrollment in Medicare Part D Plans
Projects provide insights related to Part D and drugs
including beneficiary enrollment, enhanced benefits offered
among Part D plans, medication therapy management, and
transitioning dual eligibles and other low-income subsidy
beneficiaries into Part D.
Lead Agency: Centers for Medicare & Medicaid Services
(CMS).
Agency Mission: The mission of CMS is to administer
Medicare, Medicaid, and the State Children's Health Insurance
Program and to promote quality care for beneficiaries.
Principal Investigators:
Aman Bhandari, Economist, Centers for Medicare & Medicaid
Services, Office of Research, Development and Information, 7500
Security Blvd, MS C3-19-26, Baltimore, MD 21244
Steve Blackwell, Social Science Research Analyst, Centers
for Medicare & Medicaid Services, Office of Research,
Development and Information 7500 Security Blvd, MS C3-19-26,
Baltimore, MD 21244.
Gerald Riley, Senior Social Science Research Analyst,
Centers for Medicare & Medicaid Services, Office of Research,
Development and Information 7500 Security Blvd, MS C3-19-26,
Baltimore, MD 21244.
Iris Wei, Social Science Research Analyst, Centers for
Medicare & Medicaid Services, Office of Research, Development
and Information 7500 Security Blvd, MS C3-19-26, Baltimore, MD
21244.
Partner Agencies: Research Triangle Institute, Mathematica
Policy Research, and Abt Associates.
General Description: The Medicare Part D benefit,
established in the Medicare Prescription Drug, Improvement and
Modernization Act (MMA) of 2003 represents the largest
expansion of Medicare benefits since the program's inception in
1965. CMS has undertaken several Part D and drug related
research in the areas of enrollment, payment, and medication
therapy management. All of these research projects together
provide a picture of some aspects of the early implementation
years of Part D that is valuable for any future decisions
relating to the program.
CMS has several research projects relating to
characteristics of enrollees and enrollment in Part D plans.
One study provides information on characteristics of
beneficiaries who obtained coverage in 2006 through Part D, the
retiree drug subsidy, other creditable coverage arrangements,
or who had no known source of coverage. Preliminary analyses
suggest that Part D enrollees do not have unusually high
prescription drug costs, but had high out-of pocket drug costs
prior to Part D enrollment. Prescription drug plans, especially
those offering gap coverage appeared to have enrolled
beneficiaries with higher baseline drug costs. Another study
examined enrollment in plans with enhanced benefits. CMS
launched the Part D payment demonstration allowing plans to
choose alternative payment methods for re-insurance and to
increase beneficiaries' choices of and access to supplemental
drug coverage. CMS evaluated enrollment in the demonstration
versus, selection bias for the demonstration plans, and impact
of the demonstration on overall Part D enrollment. In general,
the study found that the majority of enrollees in enhanced Part
D plans were in non-demonstration plans and there was little
evidence of selection bias among the plan types. Both of these
studies have possible implication on the long-term financial
impact of Part D on Medicare financing.
CMS also evaluated the demonstration to transition
unassigned full dual eligibles and other low-income subsidy
(LIS) beneficiaries to a Medicare Part D plan at the point-of-
sale (POS). CMS put in place a contract with a prescription
drug plan to provide temporary drug coverage at the pharmacy
counter for beneficiaries who were eligible but who were not
yet enrolled in a Part D plan. States also took temporary
action to provide emergency coverage for dual eligibles and
other low-income beneficiaries during the transition of having
drug coverage from Medicaid to Medicare. This study documented
gains in administrative efficiency within the point-of sale
facilitated enrollment process and highlighted pitfalls to
avoid and options to pursue for future efforts that States and
CMS may undertake to facilitate access to Part D benefits for
dual eligibles.
The MMA also required prescription drug plans (PDPs) and
Medicare Advantage plans that offer prescription drug coverage
(MA-PDs) to have a Medication Therapy Management Program
(MTMP), to improve medication use and reduce adverse events for
high-risk beneficiaries. CMS conducted a study to explore the
evolving field of MTM in order to identify and understand the
attributes of MTM that may be most effective for the Medicare
prescription drug program.
Excellence: What makes this project exceptional?
The collection of research studies provides a wide range of
topics related to Part D and drugs. The findings from these
studies provide some of the earliest information about
enrollment, benefits, payment and some aspects of service
delivery relating to Part D.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
As of January 2008, over 25.4 million Medicare
beneficiaries are receiving drug coverage through private
plans, either through stand-alone prescription drug plans or
Medicare Advantage plans with prescription drug coverage. The
research findings and possible implications from these findings
affect these 25.4 million beneficiaries enrolled in Part D and
millions more who may enroll in the program.
Effectiveness: What is the impact and/or application of
this research to older persons?
Since the Medicare program serves the population of those
who are 65 and older, the research has implications for the
enrollment and plan experience, and service delivery to older
persons who are in the Medicare program.
Innovativeness: Why is this research exciting or
newsworthy?
These studies present the earliest findings and insights to
several aspects of the Part D program. The studies relating to
enrollment in Part D provide information on the plans and
benefits offered and utilized by beneficiaries. Information
about improving the transition of dual eligibles and other low-
income beneficiaries to Part D is valuable for decision makers
and for those serving this vulnerable segment of the
population. Finally, while the information on medication
therapy management still has many gaps, the CMS research on MTM
provides the information for how it is being utilized for the
Medicare population and provides some relevant information for
future research.
Corporation for National and Community Service: Keeping Baby Boomers
Volunteering
Lead Agency: Corporation for National and Community
Service.
Agency Mission: The mission of the Corporation for National
and Community Service is to improve lives, strengthen
communities, and foster civic engagement through service and
volunteering.
Principal Investigator: John Foster-Bey, Senior Advisor,
Office of Research and Policy Development, Corporation for
National and Community Service, 1201 New York Avenue NW, Room
10909, Washington, DC 20525.
General Description: The Baby Boomer generation is more
educated, experienced, and larger than any previous U.S.
generation. As they begin to retire, they will leave the
workforce with unprecedented knowledge and skills. Engaging
Boomers through volunteerism represents a tremendous
opportunity for nonprofits. To ensure their participation, it
is imperative to understand how best to capture their
experience and energy in initial recruiting efforts. Secondly,
organizations must understand what factors will impact their
decision to continue volunteering from year-to-year.
``Keeping Baby Boomers Volunteering'' used data obtained
from the Current Population Survey (CPS) from 1974, 1989, and
each year from 2002-2006. The CPS is a monthly national
household survey administered by the U.S. Census Bureau and is
the primary source of employment information on our nation's
labor force. The CPS volunteer supplement provides reliable
data on volunteering behavior among American households. The
data trace the volunteer habits of the same sample of Baby
Boomers over two consecutive years, as well as a similar sample
of pre-Boomers (the 1974 and 1989 surveys).
``Keeping Baby Boomers Volunteering'' highlights several
trends that ultimately will help nonprofits design volunteer
management programs to generate more volunteer opportunities
for Boomers and improve retention. These findings include:
The number of volunteers age 65 and older in the
U.S. will increase 50% by 2020, from just under 9 million in
2007 to over 13 million. The number of senior volunteers will
double by 2036.
Boomers volunteer today at higher rates than past
generations did at a similar age. Boomers between the ages 46
to 57 volunteer at a rate of 30.9%, compared to 25.3% recorded
by that age cohort in 1974 (the Greatest Generation, born 1910-
1930) and 23.2% recorded in 1989 (the Silent Generation, born
1931-1945).
Education and having children are two key
predictors of volunteer levels. Boomers' high education rate
and propensity to have children later in life explain their
high volunteer rate. This accounts in part for the fact that
the volunteer rate for Baby Boomers is peaking later in life
than past generations.
Baby Boomers have different volunteer interests
than past generations. Volunteers ages 41 to 59 were most
likely to volunteer with religious organizations in both 1989
and 2005. However, in 1989, the second most popular type of
volunteer organizations were civic, political, business, and
international. By 2005, the second most popular type of
volunteer organization for Baby Boomers were educational and
youth services.
The type of volunteer activities done by Boomers
affects retention. Baby Boomers who engage in professional or
management activities are the most likely to keep volunteering
(74.8% retention). Baby Boomers who engage in general labor or
supply transportation are the least likely to volunteer the
following year (55.6% retention).
Excellence: What makes this project exceptional?
As more and more Baby Boomers reach retirement age over the
next several decades, they will have a dramatic and costly
impact on Social Security, Medicare, and other social services.
``Keeping Baby Boomers Volunteering'' emphasizes their
importance to society, viewing Baby Boomers as valuable assets
to public service in America. The report describes the
volunteering characteristics of this highly educated and
skilled generation and uses this information to develop a plan
for nonprofits to efficiently utilize their abilities for the
next three to four decades.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
``Keeping Baby Boomers Volunteering'' describes the
volunteering characteristics of Baby Boomers, who are poised to
become the most highly educated and skilled generation of older
Americans in history, and the reasons why so many of them
volunteer one year but drop out in the next. The report uses
this information to help nonprofit organizations develop a plan
to harness the abilities and skills of Baby Boomer volunteers
for the next three to four decades.
For organizations to effectively utilize Baby Boomers as
volunteers, they must be aware of certain trends. Baby Boomers
are more active in volunteering activities then their
predecessors, but like other age groups, a large proportion
(over 30%) of volunteers drop out the following year. The
report outlines possible volunteer management practices that
will reduce this attrition. Organizations must recognize that
Baby Boomers have different volunteering preferences than
previous generations. Additionally, they serve for different
motivations and prefer specific activities for service
(professional management work as opposed to physical labor). To
harness Baby Boomers' experience and energy, the study proposes
several recommendations to develop a meaningful volunteering
experience for volunteers and organizations.
1. Rethink how to attract and utilize Baby Boomers as
volunteers.
2. To improve retention, put Boomers' skills to use through
challenging projects.
3. Treat volunteers in the same fashion as employees and
donors. The more positive experience a volunteer has, the more
likely (s)he will return, just like an employee or donor.
4. Adopt progressive management practices, such as matching
volunteers with appropriate assignments and providing
professional development opportunities for volunteers. This can
build organizational capacity and sustain volunteer
participation.
5. Because volunteering and giving are related, find ways
to encourage substantial volunteering. This could produce
considerable monetary contributions.
Effectiveness: What is the impact and/or application of
this research to older persons?
The bulk of the Baby Boomer population is rapidly
approaching retirement age. Boomers have accumulated
exceptional wealth, education, and experience, and many of them
will look to continue to have a positive impact on society.
Other studies, including one by CNCS, have demonstrated the
health benefits of volunteering. By engaging more Boomers in
volunteering, they are improving their health, maintaining
connections with the community, and contributing their
knowledge to the rest of society.
Innovativeness: Why is this research exciting or
newsworthy?
The research suggests the relationship between Baby Boomers
and nonprofit organizations is symbiotic: by engaging Baby
Boomers in volunteering, both the organization and the
volunteers can benefit. Boomers are leaving the workforce with
unprecedented skills and knowledge, and millions of them are
able and willing to make positive contributions to their
communities. By understanding how Boomers like to volunteer,
nonprofits can both improve the experience of Boomer
volunteers, while at the same time maximizing the benefits of
the service provided by the volunteers. This in turn provides
society with more help in addressing critical areas of need--
for example, health care for the aging population. The ability
to live independently is one of the primary concerns of
retiring Boomers; older volunteers can help their neighbors
live at home longer, while preserving their own health by
staying active within their communities.
Corporation for National and Community Service: The Health Benefits of
Volunteering
Numerous studies have found that when older adults
volunteer, they not only help their community but also
experience better physical and mental health in later years.
These findings suggest Baby Boomers and older Americans who
volunteer may be more likely to maintain their health and
independence as they age.
Lead Agency: Corporation for National and Community
Service.
Agency Mission: The mission of the Corporation for National
and Community Service is to improve lives, strengthen
communities, and foster civic engagement through service and
volunteering.
Principal Investigator: Robert Grimm, Jr., Director of
Research and Policy Development, Corporation for National and
Community Service, 1201 New York Avenue, NW., Room 10909,
Washington, DC 20525.
General Description: A growing body of research finds that
volunteering provides individual health benefits to those
donating their time. This research has found that those who
volunteer have lower mortality rates, greater functional
ability, and lower rates of depression later in life than those
who do not volunteer. ``The Health Benefits of Volunteering: A
Review of Recent Research,'' describes some key findings from
this research, along with a state-level analysis of the
relationship between volunteering and incidence of mortality
and heart disease.
To produce the report the CNCS Office of Research and
Policy Development conducted a literature review of peer-
reviewed studies that have researched the relationship between
volunteering and health. These studies were analyzed and
summarized for the report. Additionally, the office obtained
state-by-state data from the U.S. Census Bureau's Current
Population Survey (CPS) and the Center for Disease Control to
conduct an analysis of volunteer rate in comparison to
mortality rates and incidences of heart disease for each state.
The CPS is a monthly national household survey that is the
primary source of employment information on our nation's labor
force. The CPS volunteer supplement provided up-to-date data on
volunteering behavior among American households for each state.
Some of the key findings of ``The Health Benefits of
Volunteering,'' include:
States with a high volunteer rate have lower rates
of mortality and incidences of heart disease. Health problems
are generally more prevalent in states where volunteer rates
are lowest.
Individuals who volunteer have greater functional
ability and better health outcomes and lower mortality rates,
even after controlling for physical health, age, socioeconomic
status, and gender. Additionally, when chronically or seriously
ill patients volunteer, they appear to receive some benefits
beyond what can be achieved through medical care.
The health benefits of volunteering, including
improved physical and mental health and greater life
satisfaction, are more pronounced among older volunteers than
among younger volunteers.
Volunteering often enhances the social networks of
citizens of all ages, reducing stress and the risk of disease.
Volunteering and health are positively
reinforcing. One study found that those who volunteered in 1986
reported higher levels of happiness and physical health in
1989, while those in 1986 who reported higher levels of
happiness and physical health were more likely to volunteer in
1989.
These findings are particularly relevant today as Baby
Boomers reach retirement age. Baby Boomers are volunteering at
a higher rate than earlier generations did at the same age.
With their demonstrated commitment to volunteerism combining
with medical advances that keep them serving later into life,
Baby Boomers may develop exceptional life expectancy over the
next three or four decades. Efforts should be made to keep Baby
Boomers serving in the future to enhance the health of the
growing number of older adults.
Excellence: What makes this project exceptional?
A number of studies have evaluated the correlation between
health and volunteering, but this report is a comprehensive
review of research that illustrates the robustness of the
findings. This report determines that many previous studies
have found a positively reinforcing relationship between health
and volunteering. Clearly, those in better health are more
likely to volunteer, but these studies demonstrate that
volunteering also leads to improved physical and mental health:
volunteering keeps healthy people healthy. Several studies show
that volunteering also can improve health of those battling
chronic or serious illness.
This study also is the first to compare mortality rates and
incidences of heart disease to volunteer data for every state.
Using the volunteer supplement to the monthly Current
Population Survey data produces reliable volunteering
information that can display the relationship between
volunteering and health. Breaking the data down by state allows
the researchers to graph these variables and use a line of
best-fit to display this relationship. This study demonstrates
yet another method to determine that volunteering has a
positive correlation to better health for older Americans.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
These studies find that older volunteers are more likely to
receive significant health benefits from volunteering than
younger volunteers. As Baby Boomers become eligible to retire,
the U.S. will have to find ways to care for the health of the
aging. This report suggests that volunteering may constitute a
low-cost solution to maintaining health among seniors. For
older adults, volunteering each week may be just as effective
as other recognized preventive measures to ensure a healthy
retirement. Additionally, seniors can volunteer to aid other
seniors, creating a double positive effect. This ethos provides
numerous positive effects for society as a whole.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research demonstrates the importance of engaging Baby
Boomers in volunteering activities as they reach retirement
age. With the costs of healthcare rising, these studies show
that volunteering is one of the most cost-effective ways to
stay physically and mentally healthy while also participating
in public service. Seniors looking for a healthy activity
should consider volunteerism. Organizations in need of
volunteers, particularly nonprofits, can utilize this
information to target volunteer management programs towards
senior citizens that will engage them in service while also
meeting organizational needs. Independent living, identified by
CNCS in other studies as a salient concern among seniors, can
benefit from seniors serving with each other to ensure those
dependent on others are not without aid.
Innovativeness: Why is this research exciting or
newsworthy?
Evidence suggests the possibility that the best way for
Baby Boomers and older Americans to remain physically and
mentally healthy as they age is to volunteer. While there have
been studies about the health benefits of volunteering, this
document assembles recent significant studies in an easily
comparable format and finds that they are constant in their
conclusions: there is a strong relationship between
volunteering and health benefits, particularly lower mortality
rates, greater functional ability, and lower rates of
depression later in life among those who volunteer as opposed
to those who do not. For those interested in adopting
volunteering as a method to stay healthy, this report
summarizes the theorized ``thresholds'' that a person must
cross to receive health benefits. There is also information
that finds state volunteer rates are strongly connected with
the physical health of the state's population, and this fact
may spark interest from localities around the nation.
The Corporation for National and Community Service: The Senior
Companion Program
``The Final Report of the Senior Companion Quality of Care
Evaluation'' finds that by pairing senior volunteers with
homebound seniors in frail health, the Senior Companion Program
improves the quality of life and care for both the clients and
primary caregivers being served. It also builds the capacity of
the organization sponsoring the program.''
Lead Agency: Corporation for National and Community
Service.
Agency Mission: The mission of the Corporation for National
and Community Service is to improve lives, strengthen
communities, and foster civic engagement through service and
volunteering.
Principal Investigator: Donna Rabiner, Ph.D., RTI
International, 3040 Cornwallis Road, P.O. Box 12194, Research
Triangle Park, NC 27709-2194.
Partner Agencies: Senior Corps and AmeriCorps.
General Description: The Senior Companion Program provides
grants to organizations that partner low-income senior
volunteers with homebound elderly people in frail physical and/
or mental health, most of whom live alone.
The ``Final Report of the Senior Companion Quality of Care
Evaluation'' examines the impact of the Senior Companion
Program on quality of life and quality of care outcomes for
clients and families/caregivers served. The study also examines
the value of individual Senior Companions to organizations
serving older Americans. To obtain a well-rounded understanding
of the program's impacts, the study surveyed clients, clients'
families/caregivers, and volunteer supervisors.
To examine the impact of the Senior Companion Program on
quality of life and quality of care outcomes for clients and
the clients' families/caregivers, interviews were conducted
over three time periods (at program entry, after three months,
and after nine months). Interviews were also conducted with two
comparison groups, one composed of potential clients on the
Senior Companion Program waiting list, the other of adults who
received care with other agencies, but not from Senior
Companions.
Overall, nine-month results reported by clients and/or
family members over time included:
The relative increase in Senior Companion
Program client self-reported health improvements;
The reduction in the number of depressive
symptoms reported by clients;
The reduction in client unmet needs for
assistance with various activities of daily living;
The increased ability of family members/
caregivers to remain employed as a result of having
Senior Companions care for their frail relatives at
home;
Fewer unmet needs for transportation
services, according to families/caregivers;
The relative increase in the likelihood of
families/caregivers being very satisfied with the
reliability of their Senior Companion.
Surveys of volunteer supervisors found that Senior
Companions played an important function in enabling
organizations to expand services to clients. Supervisors valued
the assistance that the Senior Companions provided to their
staff, and they were ``very satisfied'' with the roles that
Senior Companions performed at their various locations.
Supervisors also felt that other senior service providers, as
well as the broader community-at-large, valued the Senior
Companion Program.
Finally, the ``Final Report of the Senior Companion Quality
of Care Evaluation'' submits recommendations to address
qualitative feedback from those surveyed. Recommendations
include improving the overall quality of service by refining
existing training and screening programs. Additionally, clients
and family members perceive there to be a shortage of Senior
Companions who are available to serve. The report recommends
recruiting additional Senior Companions to serve the increasing
number of frail older adults who are eligible for program
services.
Excellence: What makes this project exceptional?
The impending retirement of the Baby Boomer generation has
created an impetus for policies that meet health, social,
transportation, and other needs of the aging population. The
``Final Report of the Senior Companion Quality of Care
Evaluation'' finds that Senior Companions improve the quality
of life for the clients they serve, as well as the quality of
care that their host organizations are able to provide.
The study, conducted by RTI (Research Triangle Institute),
is one of the most rigorous studies ever conducted on the
impacts volunteering has on the health and independent living
ability of older Americans. To measure the benefits received by
clients, it compares outcome data for a sample of Senior
Companion clients with data collected from random samples from
two comparison groups individuals on the SCP wait list and
individuals who received care from other providers--and
followed up with these groups over time. To measure client
impacts, the study examined ``adjusted'' differences in several
outcome measures, controlling for prior health status and many
other factors. To measure program impacts on other
beneficiaries, the study also surveyed Senior Companion
participants, family caregivers, and SCP host agencies.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The Senior Companion Program enables low-income persons
aged 60 and over to remain active through continued
participation in needed community service. It also provides
support primarily to homebound seniors with physical,
emotional, or mental health limitations, most of whom live
alone, in an effort to achieve and maintain their highest level
of living. With the large Baby Boomer population reaching
retirement age, the Senior Companion Program provides an
opportunity for well intentioned, low-income seniors to provide
necessary support for seniors who are homebound, typically live
alone, and often have mental and physical health problems.
Effectiveness: What is the impact and/or application of
this research to older persons?
Overall, the evidence suggests the Senior Companion Program
is responsible for a number of positive benefits, controlling
for other factors. The program has helped many senior citizens
retain their dignity and independence in spite of failing
health or disabilities. This program gives seniors the
opportunity to continue to live in their home with only
periodic assistance. Additionally, homebound seniors can build
social connections with other seniors, a very important aspect
of strong mental and physical health.
The ``Final Report of the Senior Companion Quality of Care
Evaluation'' also demonstrates the need for more volunteers in
the program, and recommends extending the Senior Companion
Program so more seniors can benefit from it. As the population
ages, the number of available volunteers aged 45 to 64 is
expected to increase by 34 percent over the next two decades.
By offering individuals new and expanded opportunities to serve
their communities, larger numbers of Baby Boomers would begin
to participate in this service program.
Innovativeness: Why is this research exciting or
newsworthy?
With the number of Americans over age 65 projected to
increase from 4.2 million in 2000 to 8.9 million in 2030, there
is a pressing need for policy makers to meet the needs of frail
seniors in the community. The Senior Companion Program is part
of the solution; it is composed of over 200 volunteer stations
around the country that support 15,000 Senior Companions and
61,000 elderly clients. This rigorous study examines the impact
of this program and finds that its relatively low-cost and
``low-tech'' approach has had a positive impact on the
agencies, clients, and family members/caregivers served by the
program.
USDA Agricultural Research Service: Improving Nutrition and Health for
Seniors
The Center has made pioneering discoveries about the role
of nutrition in improving the health and quality of life for
elderly Americans, including ways to reduce risk of heart
disease, bone fractures, eye disease, and dementia.
Lead Agency: USDA Agricultural Research Service (ARS).
Agency Mission: ARS conducts research to develop and
transfer solutions to agricultural problems of high national
priority and to provide information access and dissemination in
order to:
Ensure high-quality, safe food and other
agricultural products,
Assess the nutritional needs of Americans,
Sustain a competitive agricultural economy,
Enhance the natural resource base and the
environment, and
Provide economic opportunities for rural
citizens, communities, and society as a whole.
Principal Investigator: Robert Russell, MD, Center
Director, Jean Mayer USDA Human Nutrition Research Center on
Aging at Tufts University, 711 Washington Street, Boston, MA
02111.
Partner Agencies: Tufts University, National Institutes of
Health.
General Description: The Jean Mayer USDA Human Nutrition
Research Center on Aging at Tufts University (the Center) was
established by an Act of Congress 30 years ago. It quickly
became the premier institution in the world conducting research
on nutrition in the prevention of age-related chronic diseases.
The Center's accomplishments have greatly contributed to the
health of the American people. Select examples of recent
pioneering research that has impacted public health and served
to establish Federal nutrition policy include the discoveries
that:
High vitamin D levels in the elderly are
associated with fewer falls.
Dietary omega-3 fats are a means of preventing
dementia.
Lutein, a pigment found in corn, spinach, and egg
yolks, protects the eye against age-related macular
degeneration, the leading cause of blindness in the elderly.
Saturated and trans fats increase serum
cholesterol and the risk of heart disease.
Higher protein intake and exercise can decrease
the loss of muscle normally seen in aging.
Adequate intake of zinc can reduce the incidence
of pneumonia in elderly residents of nursing homes.
Vitamin K--not just calcium and vitamin D--is
critical for bone health.
The requirement for vitamin A is partially met by
plant sources of beta-carotene.
Folic acid can reduce the level of homocysteine in
the blood, which is a risk factor for heart and brain disease.
Excellence: What makes this project exceptional?
The Center is widely acknowledged as the premier research
institution studying the relationship between nutrition and
aging. What makes this project exceptional are the breadth and
strength of the scientists who staff it along with their
discoveries. The staff are routinely recognized with
prestigious awards from national and international nutrition
and health organizations.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Because nutrition is one of the few factors for health
under our complete control, this field offers people the
ability to manage their own health. Many of the discoveries
from the Center have stimulated other nutrition scientists to
investigate the same questions, and other scientists often
replicate the work of the Center. This is an acknowledgement by
peers that the studies carried out here are of high impact in
the field.
Effectiveness: What is the impact and/or application of
this research to older persons?
Nutrition research is relatively easily translated into
practical applications for older persons. From work done at the
Center, we know that vitamin D is more important than calcium
for bone health in the elderly. In addition, we know that
adequate intake of yellow and dark green vegetables can help
prevent both cataracts and age-related macular degeneration.
Small changes in the diet can improve health and reduce costs
associated with avoidable causes of morbidity and mortality and
have led the scientists to recently produce a food guide
pyramid specifically for older Americans.
Innovativeness: Why is this research exciting and
newsworthy?
This research is both exciting and newsworthy because a
series of dietary recommendations can be made for older people
to improve their health simply by substituting healthier
choices for the foods they commonly consume. Specific
recommendations can be made that have the potential for
improving bone health, the immune system, the cardiovascular
system, brain function (cognition), and the musculoskeletal
system. In other words, virtually every system in the body can
benefit from the work done at the Center.
United States Department of Commerce: Computer Assisted Orthopaedic
Surgery
This research promotes the establishment of standard
calibration and performance testing procedures for automated
surgical systems within the operating room to ensure more
predictable and successful hip replacement operations.
Lead Agency: National Institute of Standards and Technology
(Department of Commerce).
Agency Mission: To promote U.S. innovation and industrial
competitiveness by advancing measurement science, standards,
and technology in ways that enhance economic security and
improve our quality of life.
Principal Investigator: Dr. Nicholas Dagalakis, Mechanical
Engineer, 100 Bureau Drive MS 8230, Gaithersburg, MD 20899.
General Description: The nominee and his team are
developing state-of-the-art measuring techniques, similar to
those used in making aerospace components fit together
precisely, that soon could improve success rates for hip
replacement surgery. At the request of a group of prominent
orthopaedic surgeons and the American Academy of Orthopaedic
Surgeons (AAOS), the NIST researchers are working to improve
calibrations and operating room testing of the Computer
Assisted Orthopaedic Surgery (CAOS) tracking instruments
surgeons use to plan the delicate, highly complex joint
replacement surgery. As the U.S. population ages, the number of
hip replacement surgeries is increasing rapidly. According to
HCUPnet-2004, 225,900 hip replacements and 37,115 revision hip
surgeries were performed in the U.S. in 2004.
To be completely successful, CAOS hip replacement surgery
must take into account minute human skeletal differences.
Imprecise measurements, which could result from conditions
seemingly unrelated to the surgery, such as operation room
noise or temperature, can lead to poor positioning of implants,
leaving some patients with discomfort during walking and, in
rarer cases, a need to redo the operation.
The researchers have built a lightweight device called a
``phantom'' that resembles the artificial socket, ball and
femur substitutes that surgeons use to replace the joint and
bone in hip operations. They drilled tiny holes at precisely
measured intervals into the phantom and made cuts at precisely
measured angles, favored by surgeons for CAOS operations.
Because the precise coordinates of the mechanical (magnetic)
ball and socket joint center of rotation have been measured,
manufacturers of CAOS tracking sensors can use the phantom to
test the accuracy of their measuring instruments. Surgeons also
will be able to test the accuracy of their CAOS devices, just
before making their first incision, to measure ball and socket
joint center of rotation coordinates, angles for cuts into the
bone and places for the insertion of screws, all critical to a
successful outcome.
Currently, no standardized approach to the evaluation of
CAOS technology exists, but an ASTM International committee is
working on the establishment of such standards. In the coming
months NIST has submitted its hip CAOS phantom to orthopaedic
surgeons for review and has begun receiving very positive
feedback. Clinical trials could follow. If the device wins
Federal Drug Administration (FDA) approval, it can be expected
to find its way into operating rooms across the country and
world. The researchers look forward to extending the
application of the technology to surgical procedures on the
knee and shoulder, which are also becoming more prevalent for
older patients.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
This work is an excellent example of innovative use of NIST
precision engineering and dimensional metrology experience to
address a difficult biomedical engineering problem, which
affects the quality of life of hundreds of thousands of people
worldwide. Approximately one million joint reconstruction
operations are performed every year throughout the world. One
of the fastest-growing procedures is hip replacement, which has
grown 80% since 2000. With an aging population, the number of
hip replacements is expected to continue increasing for the
foreseeable future. According to HCUPnet-2004, 225,900 hip
replacements and 37,115 revision hip surgeries were performed
in the U.S. in 2004. A revision surgery is significantly more
risky and painful than the original operation. A significant
cause for revision hip surgery is malpositioning of the
implant. The effectiveness and reliability of joint-replacement
surgeries has been shown to improve through the use of
Computer-Assisted Orthopedic Surgery (CAOS). However, CAOS
requires precise measurements of position and angles in order
to fully realize these advantages. NIST contributed an artifact
that enables calibration and performance tests of CAOS tools
prior to an operation to ensure the accuracy of their position
measurements. Attaining greater measurement precision will
remove a critical barrier to wider use of computer-aided
surgery, which would increase the success rate of the initial
operations.
Critical measurements of patient dimensions must be taken
prior to and during the hip-replacement operation to ensure
that the prosthesis is properly sized and aligned. Otherwise,
the patient's leg length may not be correct or the prosthesis
could fail due to dislocation and premature wear. The
measurements are defined with respect to the patient pelvis
frontal and transverse coordinate planes, which are difficult
to locate while the patient is lying on the operating table. To
address these measurement problems during operations, surgeons
adopted robot calibration and performance measurement tracking
sensors, giving birth to Computer-Aided Orthopedic Surgery. The
tracking sensors use cameras to determine coordinates of active
or passive targets, which are usually attached to surgical
tools, helping surgeons precisely measure positions and
distances. The tracking sensors have accuracy problems,
however, that result in positioning errors. Sources of errors
include camera optics, camera position and orientation
determination, operating conditions (e.g., temperature, non-
uniform radiation field, distance from camera sensors), and
different sampling rate frequency for multiple targets.
Recognizing these challenging metrology errors, the American
Academy of Orthopaedic Surgeons asked NIST for help with the
calibration and performance testing of CAOS systems. NIST
responded by establishing a research project to mitigate the
measurement errors through calibration of the sensor tracking
system, which led to invention of the CAOS calibration artifact
hereafter referred to as the ``phantom.'' NIST researchers had
to work closely with surgeons to determine requirements and
constraints.
The NIST team defined requirements that: any metrology
solution had to be ``clinically relevant,'' meaning suitable
within an operating room, lightweight, have low coefficient of
thermal expansion, imitate the operation of human skeleton
parts, and allow the simulation of critical phases of
orthopaedic operations. NIST addressed these challenges by
designing an artifact that resembles the artificial prosthesis,
yet supports dimensional metrology calibration. The phantom is
made of a femur-like bar, a magnetic ball and socket, and an L-
shaped XY coordinate frame. Inherent in the design of the
phantom are easily-measured target features. The materials used
are suitable for both operating room environments and for
precision engineering dimensional metrology operations.
Surgeons use the phantom to calibrate their CAOS systems prior
to every operation to ensure that their measurements and
positioning of the implant are correct.
A prototype of the phantom was built and calibrated by
NIST. This prototype was tested by leading CAOS surgery
researchers in the operating room. They responded
enthusiastically to the phantom in terms of its design,
applicability, potential to improve their surgical procedures,
and reduce the need for revision surgeries. Dr. James B.
Stiehl, Columbia St. Mary's Hospital, a world-renowned CAOS
researcher, was the first to test the NIST CAOS phantom. His
reaction was ``The hip phantom that we worked on is an
important project for me. I have a new idea that I am trying to
work on and the phantom will be a critical tool to evaluate
that new approach.'' Industry is very interested in
commercializing the phantom: CAOS tracking experts from
Medtronic Navigation, the leading provider of integrated
navigation and intra-operative imaging solutions, are testing a
prototype.
United States Department of Commerce: Home Lift, Position and
Rehabilitation Chair
The HLPR chair is a testbed for developing assistive
mobility technology concepts for wheelchair-dependent people. A
prototype design has been developed that offers much greater
independence in safely transferring from the chair to other
locations.
Lead agency: National Institute of Standards and Technology
(Department of Commerce).
Agency Mission: To promote U.S. innovation and industrial
competitiveness by advancing measurement science, standards,
and technology in ways that enhance economic security and
improve our quality of life.
Principal Investigators: Roger Bostelman, Electronics
Engineer, Intelligent Systems Division, 100 Bureau Drive MS
8230, Gaithersburg, MD 20899; Dr. James Albus (retired),
Intelligent Systems Division, 100 Bureau Drive MS 8230,
Gaithersburg, MD 20899.
Partner agency: University of Delaware (through a National
Science Foundation Grant).
General Description: Engineers at the National Institute of
Standards and Technology (NIST) have developed a robotic system
that may offer wheelchair-dependent people independent, powered
mobility and the ability, depending on patient status, to move
to and from beds, chairs and toilets without assistance.
The lifting ability of the system, which is called the
``HLPR Chair'' (for Home Lift, Position and Rehabilitation),
also should significantly reduce caregiver and patient
injuries.
The HLPR chair draws on mobile robotic technology developed
at NIST for manufacturing and defense applications. It is built
on an off-the-shelf forklift with a U-frame base on wheel-like
casters and a rectangular vertical frame. The frame is small
enough to pass through the typical residential bathroom. The
user drives the chair using a joystick and other simple
controls.
The HLPR chair's drive, steering motors, batteries and
control electronics are positioned to keep its center of
gravity--even when carrying a patient--within the wheelbase.
This allows a person weighing up to 300 pounds, to rotate out,
from the inner chair frame, over a toilet, chair or bed while
supported by torso lifts. The torso lifts lower the patient
safely into the new position. The chair frame can even remain
in position to continue supporting the patient from potential
side, back or front falls.
In addition, the proof-of-concept prototype HLPR Chair
would allow stroke victims and others to keep their legs active
without supporting their entire body weight. Retractable seat
and foot rests, padded torso lifts for under arms (that, when
raised, act like crutches) and an open frame at the bottom of
the chair facilitate leg exercises. The patient, once lifted
and supported by the torso lifts, can walk as the HLPR Chair
moves forward at a slow pace. The current maximum speed is 27
inches per second (0.7m/s).
Future research possibilities include defining the sensing
and control requirements that would enable the HLPR to
autonomously dock with toilets, provide voice-activation
capability so patients can call the HLPR from another location,
and provide dial-in leg loading to limit leg forces during
rehabilitation.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
There has been an increasing need for wheelchairs over
time. Independent mobility is fundamental to health, social
integration and individual well-being of humans. Hence,
mobility must be viewed as being essential to the outcome of
the rehabilitation process of wheelchair-dependent persons and
to their successful (re-) integration into society and to a
productive and active life. The quality of the wheelchair, the
individual work capacity, the functionality of the wheelchair/
user combination, and the effectiveness of the rehabilitation
program do indeed determine the freedom of mobility.
Just as important as wheelchairs are the lift devices and
people who lift patients into wheelchairs and other seats,
beds, automobiles, etc. The need for patient lift devices will
also increase as generations get older. Beyond providing the
patient greater independence, lift devices can prevent numerous
injuries to both the patient and their care-givers. Example
statistics are: one in three nurses becomes injured while
moving non-ambulatory patients and one in two non-ambulatory
patients are injured from falls while being transferred between
a bed and a wheelchair.
Based on a survey of patient lift and mobility devices,
NIST researchers discovered a need for technology that includes
mobility devices that can lift and maneuver patients to other
seats and technology that can provide for rehabilitation to
help the patient become independent of the wheelchair. Their
study also determined there are no standards nor performance
metrics for such devices should they become available in the
commercial sector. Nursing home caregivers will develop back
injuries totaling 200,000 incidents this year alone from
transferring patients and cost the U.S. $2 Billion. Based on
these compelling needs, NIST designed a HLPR Chair testbed to
investigate patient transfer including specific areas of
mobility, lift and rehabilitation toward safety standards,
performance measurements of such devices, and advanced
autonomous controls.
The HLPR Chair testbeds are based on a manual, inexpensive,
off-the-shelf, sturdy forklift. The forklift includes a U-frame
base with casters in the front and rear and a rectangular
vertical frame. The lift and chair frame's dimensions allow it
to pass through even the smallest, typically 61 cm (24 in) wide
x 203 cm (80 in) high, residential bathroom doors.
The HLPR chair design is innovative in several ways. It is
designed to explore key challenges in wheelchair-bound
mobility, transfer to other surfaces, ability to reach high
objects, rehabilitation, and autonomous assistive navigation
for wheelchairs. The HLPR chair provides a seat/stand mechanism
that provides lift and rotation to the patient allowing
transfer to other chairs, beds, or toilets while maintaining
safety by having the center of gravity remain within the
wheelbase even if the patient is outside of it. See Figure 1
for a graphic illustrating a transfer. To place a HLPR Chair
user on another seat, they can drive to for example, a toilet,
seat, or bed. Once there, the HLPR Chair rotates the footrest
up and beneath the seat and the patients feet are placed on the
floor personally or by a caregiver. The HLPR Chair inner L-
frame can then be rotated manually with respect to the chair
frame allowing the patient to be above the toilet. Padded torso
lifts then lift the patient from beneath his/her arm joints
similar to crutches. The seat, with the footrest beneath, then
rotates from horizontal to vertical behind the patients back
clearing the area beneath the patient to be placed on the
toilet, seat, bed, etc. Patient lift is designed into the HLPR
Chair to allow user access to high shelves or other tall
objects while seated. The HLPR Chairs' patient lift is
approximately 1 m (36 in), equivalent to the reach of a
standing 2 m (6 ft) tall person. This is a distinct advantage
over marketed chairs and other concepts. The additional height
comes at no additional cost of frame and only minimally for
actuator cost.
The HLPR Chair enhances patient rehabilitation through a
load sensor and control on the lift actuator. The researchers
designed rehabilitation into the HLPR Chair, as shown in Figure
2, to allow, for example, stroke patients to keep their legs
active without supporting the entire load of the patients body
weight. The patient, once lifted, could walk while supported by
the HLPR Chair driving at a slow walking pace towards regaining
leg control and eliminating the need for a wheelchair.
Autonomous mobility control using a sophisticated control
architecture and advanced 3D imagers is nearly complete through
a teaming arrangement with the University of Delaware.
Commercialization is now being considered by the healthcare
industry.
United States Department of Commerce: NIST Biomedical Imaging
Today the information content of biomedical imaging, such
as in the reading of lung computed tomography (CT), is not
fully exploited. By using computer-assistive algorithms in
measuring the extent of disease and the response to therapy,
physicians could more rapidly identify effective treatments.
The Biomedical Imaging Project is researching measures and
standards for benchmarking medical imaging algorithms for use
in the measurement of disease.
Lead agency: National Institute of Standards and Technology
(NIST).
Agency Mission: To promote U.S. innovation and industrial
competitiveness by advancing measurement science, standards,
and technology in ways that enhance economic security and
improve our quality of life.
Principal Investigator: Charles Fenimore, Mathematician,
Information Technology Laboratory, National Institute of
Standards and Technology, 100 Bureau Drive, MS 8940,
Gaithersburg, MD 20899-8940.
Partner Agency: NIST ITL is collaborating with other
organizations, both inside and outside NIST.
NIST: The following organizations have
contributed assistance with measurements related to the
Biomedical Imaging Project: Polymers Division (Contact:
Marcus Cicerone); Precision Engineering Division
(Contact: Steve Phillips)
FDA : Center for Devices and Radiological
Health (CDRH, Contact: Nicholas Petrick)
National Cancer Institute including
sponsorees: Cancer Imaging Program (CIP, Contact:
Laurence Clarke); University of Michigan (Contact:
Charles Meyer); Cornell University (Contact: Anthony
Reeves)
Kitware Inc. (Contact: Rick Avila)
General Description:
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The Biomedical Imaging Project engages with the medical
imaging community and with other government scientists at NIST,
the FDA, and NCI in a broad-based investigation of the
performance of algorithms and computer-assisted diagnostic
(CAD) tools for reading biomedical imaging. Medical imaging
systems are widely used in the detection and staging of
disease, the assessment of response to therapy, and other
health-critical applications. Today, expert radiologists
provide subjective interpretation, often using computer-
assisted diagnostic (CAD) tools. Such measurements depend on
the expert, the software tools used, and the conditions of
imagery acquisition. The variation, even with computer
assistance, can be comparable in magnitude to clinically
significant change criteria. The lack of reliable ``ground
truth'' is a fundamental challenge in measuring CAD and
algorithm performance. Determining performance metrics is an
important area of investigation in the Project.
The Biomedical Imaging Project develops methods for
assessing the performance of algorithms and computer-assisted
diagnostic (CAD) tools. Currently, we are conducting a
multifaceted investigation of the performance of change
analysis algorithms applied to computed tomography (CT) imagery
of lung lesions. The principal elements of the project are the
design and the conduct of benchmarking trials of algorithm
performance, with the direct aim of developing reliable
algorithm assessment methods and the study, implementation, and
application of various change analysis algorithms, in order to
better understand and compare their performance. In addition,
the availability of a large number of CT scans with known
lesion characteristics is essential in conducting benchmarking
trials. We are investigating the production of synthetic
imagery, intended to eventually provide a robust set of imagery
for use in benchmarking evaluations.
This research is significant for aging populations because
it applies to the detection, staging, and measurement of
clinical response to therapy in cancers. As recently observed,
``Cancer in the older person is an increasingly common problem,
due to the progressive prolongation of life expectancy * * *''
(Carreca, I; Balducci, L; Extermann, M; Cancer in the older
person, Cancer treatment reviews [2005]). At the same time,
mortality from some cancers, particularly those of the lung,
have proven to be stubbornly resistant to modern medical
diagnostic and treatment methods.
The research focuses on the use of medical imaging
algorithms as part of the development of reliable systems for
measuring patient response to therapy. Today, there is rather
high uncertainty associated with the assessment of response.
A high reliability measurement of a patient's response to
therapy is expected to have impact on improving the
determination of malignancy and improving treatment options.
The result would improve the clinical practice of cancer
therapy. In addition, it promises to shorten clinical trials
used in the development of new pharmaceuticals, by giving the
pharmaceutical researcher more rapid indication of
effectiveness or lack of response.
Today, the standard method for measuring the extent of
disease using imagery, known as RECIST, does not use the full
potential of the CT data. We are in the early stages of
building a consensus on how to improve the measurement of
response to therapy. Measuring the performance of algorithms
and CAD tools through benchmarking has proven to be an
effective method for improving performance of algorithms in
biometrics for detection and identification. Because of our
long involvement in such measurements, the medical imaging
community is very welcoming of NIST's leadership.
United States Department of Commerce: NIST Health Informatics
Infrastructure
NIST research is contributing to the President's goals of
having electronic health records for most Americans, as well as
a nationwide health information network, by 2014, which will
improve quality and accessibility and reduce costs of
healthcare for older Americans.
Lead Agency: National Institute of Standards and Technology
(NIST).
Agency Mission: To promote U.S. innovation and industrial
competitiveness by advancing measurement science, standards,
and technology in ways that enhance economic security and
improve our quality of life.
Principal Investigator: Bettijoyce Lide, Scientific
Advisor, Health IT, Information Technology Laboratory, National
Institute of Standards and Technology, 100 Bureau Drive, Mail
Stop 8900, Gaithersburg, MD 20899-8900.
Partner Agency: Department of Health and Human Services,
American Telemedicine Association, Center for Aging Services
Technologies, Healthcare Information Technology Standards
Panel, Certification Commission for Healthcare Information
Technology, Integrating the Healthcare Enterprise, Continua,
among others.
General Description: The National Institute of Standards
and Technology (NIST) has a long and effective history for
contributing to the technical direction of health IT, which has
potential to improve the quality and accessibility of
healthcare for older Americans, while reducing costs.
Activities include supporting the efforts of the Department of
Health and Human Services Office of the National Coordinator
for Health IT and collaborations with a host of other public
and private organizations including the American Telemedicine
Association (ATA) and the Center for Aging Services
Technologies (CAST). NIST's laboratories are contributing to
this research and to the healthcare industry by providing
standards, measurement science, security technology, and
testing expertise. NIST collaborates with major standards
development organizations, professional societies, and the
public sector in fostering secure, interoperable, standards-
based solutions for the exchange of health information. NIST
focuses on advancing healthcare information standards that are
complete and testable, and by providing the necessary
conformance tests, interoperability tools, and techniques where
appropriate. These activities, when integrated into standards,
software, and certification processes, raise the quality of the
clinical outcomes, lower cost of health IT implementation, and
foster adoption of healthcare systems.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
This project is exceptional in that it brings together key
government departments and agencies such as those listed in
section I, response 5, to fulfill the President's Executive
Order, Number 13335, which calls for most Americans having
electronic health records and for our country to have a
nationwide health information network by 2014. Each public and
private entity brings its expertise to contribute to the goal.
This research is relevant to all Americans, but of
particular importance to our aging society. People are living
longer, and the demographic tidal wave will swell the ranks of
the elderly in America from approximately 12.5 today to 18.8
percent in 2025, a 50 percent increase. By 2030, the proportion
of the U.S. population 65 years old or greater will double to
71 million. By 2030, healthcare spending will increase 25
percent, largely due to an aging population. Unfortunately,
also, chronic conditions disproportionally affect older adults,
thus consuming a greater proportion of healthcare resources.
About 80 percent of older adults have at least one chronic
condition; at least 50 percent of older adults have at least
two chronic conditions.
The impact and/or application of this research is that it
will include applications of connected technologies that are
possible, practical, and affordable. It has potential to
improve the quality of healthcare that our aging populations
needs and deserves, for example, having test results available
when and where they are needed. It will also improve
accessibility, for example, through telemedicine, allowing
seniors to communicate with their healthcare providers remotely
without costly and time-consuming (and potentially difficult)
trips to the clinicians' offices. In addition, it can reduce
costs through, for example, minimizing duplicative tests, or
providing collaborative systems including personalized sensors
and software converging through wireless Internet capability to
permit seniors to stay in their own homes longer. Not only can
results of this research improve healthcare, but it can improve
the quality of life and preserve independence for our aging
population.
The research is exciting and newsworthy, because NIST has
already been able to use its core competencies as articulated
in our mission. Some of NIST's recent achievements in this area
include:
Developed software to advance the national goal of
providing doctors secure and appropriate access to all
patients' electronic health records, thereby enabling accurate
diagnosis and treatment of disease. This software is used by
U.S. regional healthcare systems (MA, NY, NC, Philadelphia)
with over 40 vendors (IBM, GE Healthcare, Siemens, etc.) and is
part of several national healthcare infrastructures (France,
Demark, Italy, Austria, Spain, China, and Japan). It is the
basis of the Healthcare Information Technology Standards
Panel's Manage Sharing of Document specification that was
recognized by the Secretary of HHS (Dec. 2007).
Developed test tools to validate healthcare
messages sent between healthcare systems. These tools have been
incorporated into testing for DICOM (radiology images), used by
the Certification Commission for Health Information Technology
(CCHIT) in testing interoperability of Electronic Health Record
systems, and used by the Veterans Administration, Kaiser
Permanente, Siemens, and IBM Healthcare & Life Science, among
others.
Authored the conformance strategy and model to
specify electronic health record (EHR) functions critical to
care settings and for certification of EHR systems.
Collaborated with the American Telemedicine
Association on practice guidelines. For example, the Practice
Guidelines for Ocular Telehealth have been adopted by several
major ocular health centers, including the Joslin Diabetes
Center, Inoveon, and the Walter Reed Medical Center.
With the Center for Aging Services Technologies,
hosted a major national summit that brought together a diverse
group of stakeholders to address the challenges and enabling
technologies needed to reach the vision of a connected home
environment for the aging population in which healthcare
devices are interoperable with home and consumer appliances,
providing the infrastructure for patient-centric healthcare and
wellness.
Leading the development of an integrated virtual
system to test interoperability of standards-based health
systems. This is expected to be used by the Healthcare
Information Technology Standards Panel (HITSP), the
Certification Commission for Healthcare Information Technology,
and implementers of the HITSP specifications. This test bed
offers developers of health information technology (health IT)
systems the interactions necessary to develop conformant
standards-based implementations, leading to optimal health IT
systems.
Working with the private sector to harmonize
healthcare standards and to develop specifications to enable
transmission of health information securely using standard
cryptographic technologies.
Working on tools and tests to assure medical
device interoperability.
Cross Document sharing (XDS) Reference Implementation and
Test Suite: http://ihewiki.wustl.edu/wiki/index.php/XDS Main
Page IEEE Medical Device Test Tools: http://xw2k.nist.gov/
medicaldevices/index.html.
Information on the NIST/CAST National Summit on Moving
Towards Interoperability: Affordable, Accessible Healthcare:
http://www.nist.gov/public_affairs/techbeat/tb2006_0831.htm;
http://www.itl.nist.gov/Healthcare%20Summit/index.htm.
NIST's role in this research area is recognized in reports
such as the following: The ONC-Coordinated Federal Health IT
Strategic Plan 2008-2012, released June 2008. Achieving
Electronic Connectivity in Healthcare, Connecting for Health
Collaborative, July 2004. Revolutionizing Health Care through
Information Technology, President's Information Technology
Advisory Committee, June 2004.
United States Department of Commerce: NIST Computational Biology
The Computational Biology Project aims to analyze and
characterize image-processing techniques used by cellular
biology researchers; provide guidance to researchers in
selecting the appropriate techniques for their research; and
bring computational and measurement science expertise to the
cellular biology community to help them to effectively deal
with the large amounts of images generated by their research.
Lead agency: National Institute of Standards and Technology
(NIST).
Agency Mission: To promote U.S. innovation and industrial
competitiveness by advancing measurement science, standards,
and technology in ways that enhance economic security and
improve our quality of life.
Principal Investigator: Alden Dima, Computer Scientist,
Information Technology Laboratory, National Institute of
Standards and Technology, 100 Bureau Drive, Stop 8970,
Gaithersburg, MD 20899-8970.
Partner Agency: Karen Kafadar, University of Colorado.
General Description: Research on aging, like all biological
research today, is being facilitated by automation that
provides instrumentation control and data acquisition. At the
same time, there have been advances in imaging and other
sensor-based technologies. Researchers are now able to quickly
collect large amounts of multimodal image-based data that
serves as the primary output of their experiments and as the
source of their measurements. These measurements ultimately
provide the information required to decipher complex cellular
processes including those related to aging.
Unfortunately, biological researchers are left with huge
amounts of image data to process and analyze using techniques
that are usually outside of their field of expertise. In
addition, the large amounts of images require large amounts of
secondary information (metadata) for their correct
interpretation, handling and storage; gone are the days when a
few sentence fragments in a lab notebook could jog memory and
guarantee understandable and repeatable results.
Scientific literature has many references to and
descriptions of image processing techniques, but experience
shows that many techniques have limited applicability; a method
that works well for optical character recognition may well fail
miserably in cell biology. Indeed, even within a well-defined
field, certain techniques work well only on certain types of
images; two images from different data channels of a microscope
may require fundamentally different techniques. As image-based
measurement becomes increasingly vital to biological research,
the measurement uncertainty associated with image processing is
increasingly becoming an issue.
Today, the biological researcher is expected to be an
expert in his/her field of research as well as a savvy user of
image processing software and techniques. There is a deluge of
available options, and typically the researcher chooses tools
and techniques that they have been exposed to and feel
comfortable with. There is little guidance available, and much
of the biological literature seems to give little information
about the methods used for analyzing experimental data and
their associated parameters. This situation essentially
distracts biological researchers from fulfilling the central
goals of their research, such as understanding the biology of
aging and developing new treatments for aging-related diseases.
Given that the U.S. population is aging and that scientific
resources are not unlimited, research that aims to improve the
ability of biological researchers to handle their critical
image-based data will ultimately facilitate the development of
new treatments for aging-related diseases.
A basic tenet of the Computational Biology project is that
image processing and analysis techniques, despite their
implementation in software, are fundamentally measurements and
not simply calculations. As such, they can be characterized and
understood in a manner similar to other measurement techniques.
This suggests that the measurement uncertainty associated with
the use of software-based image processing and analysis methods
can and should be determined. It also suggests that clear
guidance can be given to researchers to aid them in choosing
the correct image processing techniques and will facilitate the
interpretation of their research data.
The Computational Biology Project aims to analyze and
characterize image-processing techniques used by cellular
biology researchers; provide guidance to researchers in
selecting the appropriate techniques for their research; and
bring computational and measurement science expertise to the
cellular biology community to help them to effectively deal
with the large amounts of images generated by their research.
Excellence: What makes this project exceptional?
Though this project is very new, it is exceptional in its
approach to addressing some of the key issues hindering cell
biology research that depends on large quantities of multimodal
image data, including research on the biology of aging.
Typically, a cell biology research project will focus on an
area of interest, perhaps one or more particular cell processes
related to aging. The research staff will consist mostly of
biological researchers who will run experiments and collect
data including images from microscopes.
Given the complexity of cellular processes, at some point,
the researchers will run into bottlenecks that slow down the
pace of the research; perhaps they've collected huge amounts of
complex images that need to be analyzed using techniques with
which they are uncomfortable. They may bring in expertise from
outside of the project's central area of interest to provide
additional support. Over time, the project's success will
become increasingly dependent on measurement and analysis
techniques that are outside the scope of the biological
researchers' specialized domain. The project will tend to start
spending more time focusing on these ancillary issues instead
of making progress on its primary research goal. Given the
amount of biomedical research occurring, many projects will be
in effect competing for the same outside support to solve a
similar set of issues.
If outside expertise is not available, the biological
researchers may find themselves in the difficult position of
becoming competent in technical fields outside of their primary
area of expertise. They may make technical decisions that
ultimately hinder their ability to progress with their primary
research goals such as understanding the biology of aging and
developing new treatments for aging-related diseases.
The Computational Biology Project strategy is to
effectively invert the problem to directly tackle the
standards, measurements, and informatics issues that can slow
down biological research. For example, one key issue with
biological image data is the selection of the technique used to
extract key features from the rest of the image (segmentation
algorithms). Using cellular microscopy images generated by NIST
biological researchers, our computational scientists,
mathematicians, and statisticians intend to analyze and
characterize common segmentation algorithms so that we can
publish guidance for the biological research community as a
whole. This will effectively mitigate the need for each project
to address this issue and brings NIST measurement expertise to
bear on the problem.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
As the population ages, an increasing emphasis will be
placed on research related to the treatment of aging-related
diseases--much of which will share infrastructure, resources,
and expertise with other cell biology research.
Effectiveness: What is the impact and/or application of
this research to older persons?
A key component in the treatment of aging-related diseases
is the understanding of the complex cellular processes related
to aging. This understanding, in turn, depends on sophisticated
laboratory and data analysis techniques. By addressing some of
the key issues related to the analysis of image data generated
by cell biology research, the Computational Biology Project
will improve the efficacy of cell biology research in general
and as a result, research into the biology of aging will also
benefit. This should, in turn, aid in the development of new
treatments for aging-related diseases.
Innovativeness: Why is this research exciting or
newsworthy?
From our perspective, this research is exciting because it
brings NIST's traditional measurement expertise to bear in a
new domain (cellular biology) and has the potential to make
significant impact in terms of scientific and medical
advancements. As our work progresses, we hope that it will
become newsworthy in terms of the other advancements that were
enabled by it.
65+ in the United States: 2005
The report 65+ in the United States: 2005 provides a
comprehensive description of the older population in the United
States to foster a better understanding of their experiences
and challenges.
Lead Agency: Staff of the Population Division within the
U.S. Census Bureau, Department of Commerce, conducted the
research for the 65+ in the United States: 2005.
Agency Mission: The mission of the Census Bureau is to
serve as the leading source of quality data about the Nation's
people and economy. We honor privacy, protect confidentiality,
share our expertise globally, and conduct our work openly. We
are guided on this mission by our strong and capable workforce,
our readiness to innovate, and our abiding commitment to our
customers.
In addition, the specific mission of the Population
Division is to provide regularly updated information on the
population of the United States and countries around the world,
and their demographic, geographic, and other characteristics.
We share our expertise globally.
Principal Investigator: Victoria A. Velkoff, Assistant
Division Chief, Population Estimates and Projections, U.S.
Census Bureau, POP HQ-5H185, 4600 Silver Hill Road, Washington,
DC 20233, Victoria.A.Velkoff@census.gov, 301-763-7070.
Partner Agency: The National Institute on Aging.
General description: The report 65+ in the United States:
2005 provides a comprehensive description of the older
population in the United States to foster a better
understanding of their experiences and challenges.
The dynamics of aging are affected by many interrelated
factors, including demographic, social, economic, and medical
influences. The growth of the older population has been
dramatic. In the 20th century, this group increased from 3.1
million to over 35 million, and its size is projected to double
between 2000 and 2030. This substantial growth will challenge
society on a range of issues, many of which are highlighted in
this report.
Diversity is a distinguishing feature of the older
population in the United States and is highly likely to
increase in the future on at least some dimensions. This report
discusses diversity of age, sex, race, Hispanic origin, health,
economic status, geographic distribution, marital status,
living arrangements, and educational attainment among those
aged 65 and older.
The older population of tomorrow will differ from the older
population of today in many ways. They will most likely be
better educated and more racially and ethnically diverse than
today's older population. While the older population will grow
over the first half of the 21st century, the size of this
growth is not certain. For example, if mortality decreases
faster than projected, the older population of the future could
be much larger than currently projected.
How people experience aging depends on a variety of
factors, including social and economic characteristics and
health status, which are discussed in the chapters in this
report. The second chapter of this report looks at the growth
of the older population over the 20th century and into the 21st
century, and includes data on race and Hispanic origin. The
last section of this chapter provides a global context on
population aging. The third chapter focuses on the health
status of the older population. Trends in mortality are
examined, and chronic diseases and disability are discussed.
The fourth chapter covers economic characteristics of the older
population, including trends in labor force participation and
retirement. Data on wealth, income, and poverty are also
presented. In the fifth chapter, geographic distribution and
mobility of the older population are discussed. The sixth
chapter examines social characteristics of the older
population, such as marital status, living arrangements, and
educational attainment.
This report used data from a variety of sources. Data used
in this report are primarily from Census 2000 and previous
censuses; nationally-representative surveys such as the Current
Population Survey , the Survey of Income and Program
Participation, the National Health Interview Survey, the
Longitudinal Study on Aging, and the American Housing Survey;
recent population projections; and data compiled by other
federal agencies, including the National Center for Health
Statistics. This report also draws on information on the older
population in numerous reports prepared by the Census Bureau,
other federal agencies, and private researchers.
The report 65+ in the United States: 2005 is exceptional
because it provides a comprehensive portrait of the older
population in the United States using multiple data sources. It
presents demographic, social, and economic data on the older
population in a manner that is accessible to a wide range of
audiences.
Population aging is one of the most important demographic
dynamics affecting families and societies throughout the world.
People are living longer and healthier lives. According to
Census Bureau projections, a massive increase in the number of
older people will occur when the Baby-Boom generation (people
born between 1946 and 1964) begin to turn 65 in 2011. The older
population is projected to double from 36 million in 2003 to 72
million in 2030, and to increase from 12 percent to 20 percent
of the population.
The growth of the population aged 65 and over is
challenging policymakers, families, businesses, and health care
providers, among others, to meet the needs of aging
individuals. Policymakers need to understand the
characteristics of older populations, their strengths, and
their requirements. Understanding the dynamics of aging
requires accurate descriptions of older populations from
interrelated perspectives, including demographic, social, and
economic. This report is an effort to contribute to an accurate
description of the older population in the United States.
How people experience aging depends on a variety of
factors, including social and economic characteristics and
health status, which are discussed in this report. The growth
of the older population over the 20th century and into the 21st
century is presented, and data on race and Hispanic origin are
included. The report also provides a global context on
population aging. The health status of the older population is
examined in the report, and trends in mortality, chronic
diseases and disability are discussed. Information on the
economic characteristics of the older population, including
trends in labor force participation and retirement are
presented, as well as data on wealth, income, and poverty. The
geographic distribution and mobility of the older population
are discussed. Finally, social characteristics of the older
population, such as marital status, living arrangements, and
educational attainment that impact how people experience aging
are presented and discussed.
Department of Labor: Retirement Adequacy With an Emphasis on the Baby
Boom Generation
RAND has taken an integrated approach to studying
retirement adequacy with an emphasis on the Baby Boom
generation. They have incorporated trends in health care costs,
health, pension offerings and retirement behavior to provide a
multi-dimensional look at retirement decisions.
Lead Agency: Employee Benefits Security Administration
(Department of Labor).
Agency Mission: The Employee Benefits Security
Administration (EBSA) of the Department of Labor (DOL)
administers and enforces Title I and certain other provisions
of the Employee Retirement Income and Security Act of 1974
(ERISA). ERISA section 513(a) authorizes the Secretary to
``undertake research * * * and in connection therewith to
collect, compile, analyze, and publish data, information, and
statistics relating to employee benefit plans, including
retirement, deferred compensation, and welfare plans, and
[other] * * * plans not subject to this Act.''
Principal Investigator: Dr. Jeff Dominitz (Senior
Economist, RAND), 1200 South Hayes Street, Arlington, VA 22202.
Partner Agencies or Organizations: None.
General Description: The rise in health care costs, shift
from traditional defined benefit pension plans and erosion of
retiree health plans has made it increasingly important for
individuals to incorporate expected medical costs into their
retirement planning. However, detailed health information,
including expected health outcomes given medical expenditures
as well as disease and mortality prevalence, has been absent
from household financial data, hindering the ability of
researchers to forecast the economic well being of future
retirees. Absent this information, measures of retirement
adequacy are incomplete and may lead to a false sense of
security.
RAND, with support from the Employee Benefits Security
Administration (EBSA), has attempted to rectify this by taking
a more integrated approach in their research, including
projected health care costs into retirement planning, and by
considering the many factors which go into the decision to
retire. As a result, RAND has produced research for EBSA on
such diverse topics as: alternative measures of replacement
rates; offers of retiree health insurance; international
comparisons of individual's responses to government policies;
timing of retirement; and labor force transitions of older
workers.
In addition to their current research, RAND is expanding
the Future Elderly Model (FEM), a dynamic health model, to
include economic measures such as financial wealth, pension
claiming and labor force participation. RAND intends to use the
expanded model to perform various policy experiments, including
projecting the solvency of the Social Security Trust Fund and
the economic well-being of future cohorts, while controlling
for expected health costs.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The RAND research project sponsored by EBSA employs several
researchers with diverse backgrounds to examine issues facing
an aging society. Typically, researchers focus on a single
research topic and hold all other factors constant. RAND,
however, takes a more unified approach, acknowledging that
there are many issues which influence the choices made by aging
individuals. For example, in modeling retirement decisions,
RAND incorporates how health care coverage of a younger spouse
may affect timing of retirement. In developing both income and
consumption based replacement rates for retirement income, RAND
includes potential health care costs in their calculations and
presents the replacement rates in terms of the likelihood of
having sufficient retirement income. To investigate
institutional determinants of labor-force participation (with a
focus on older workers), RAND looks at data from 12 other
countries and develops standardized measures in order to
compare how individuals respond to changes in retirement and
health insurance policies. In its research, RAND take a
complete look at the issues facing an aging workforce and it is
this holistic approach that makes its research exceptional.
The EBSA-sponsored research by RAND has focused on the
effects of health insurance and pensions on labor-force
transitions for older workers. Health and financial security
are two of the most important issues facing older persons and
RAND's research sheds light on how older persons make decisions
that impact these issues.
By looking at what influences how and when older workers
retire as well as responses to various government policies,
RAND's research provides policy-makers with insights into these
difficult decisions. These new insights may in turn shape
future legislation and regulations which target older persons.
RAND's research is exciting because it combines different
data sources as well as researchers of different disciplines to
achieve a fuller picture of the issues facing older workers.
RAND's research considers the many components of retirement and
sheds light on how they interact with each other.
Department of Labor: Pension Simulations (PENSIM) From Government
Policies
PENSIM is a dynamic micro-simulation model used to estimate
the retirement income implications of government policies which
affect employer-sponsored pensions, employer offerings of
pensions, and employee behavior with respect to pensions.
PENSIM is a dynamic simulation model that produces life
histories for a sample of individuals born in a particular
year.
Lead Agency: Employee Benefits Security Administration
(Department of Labor).
Agency Mission: The Employee Benefits Security
Administration (EBSA) of the Department of Labor (DOL)
administers and enforces Title I and certain other provisions
of the Employee Retirement Income and Security Act of 1974
(ERISA). ERISA section 513(a) authorizes the Secretary to
``undertake research * * * and in connection therewith to
collect, compile, analyze, and publish data, information, and
statistics relating to employee benefit plans, including
retirement, deferred compensation, and welfare plans, and
[other] * * * plans not subject to this Act.''
Principal Investigator: Dr. Martin Holmer, President of the
Policy Simulation Group, 1314 Kearney Street, NE., Rm N5718,
Washington, DC 20210.
Partner Agencies or Organizations: The Office of Retirement
and Disability Policy (Social Security Administration) has
sponsored substantial development of SSASIM and GEMINI since
2001 in order to expand the range of Social Security reforms
that can be simulated and enable simulated life histories from
PENSIM to be used in producing aggregate Social Security
solvency estimates.
General Description: The U.S. Department of Labor's
Employee Benefits Security Administration (EBSA) began
supporting the development of PENSIM a dynamic micro-simulation
model produced by the Policy Simulation Group (PSG), in
September 1997. The model analyzes lifetime coverage and
adequacy issues related to employer-sponsored pension plans in
the United States using stimulated life histories of sample
cohorts and detailed pension characteristics imputed based on
National Compensation Survey establishment data.
The life history for a sample individual includes a variety
of life events and their timing: birth, schooling, marriage,
divorce, childbirth, immigration, emigration, disability onset
and recovery and death. In addition, a simulated life history
contains a complete record of jobs held by the individual,
including each job's starting and ending date, job
characteristics, pension coverage and plan characteristics. The
richness of the life history allows the estimation of, for each
year of an individual's life, their Social Security taxes and
benefits as well as employer-sponsored pension benefits.
The design of PENSIM has been strongly influenced by the
policy analysis needs of the EBSA. It has been used to study a
number of employer-sponsored issues, particularly the
sensitivity of future benefits to government policy, employer
offerings, and employee behavior and plan design. Findings from
PENSIM have been published in several GAO reports as well as
regulations published by the Department of Labor.
PSG began distributing PENSIM free to the public via its
website in spring 2007, enabling individual users to conduct
analysis of the simulated pension environment and produce
research papers. The model is currently being compared to
another pension model (Poterba, Rauh, Venti and Wise) to test
its validity. Beginning in fall 2008, PSG intends to add
defined contribution participant loans and hardship-
withdrawals, as well as federal income taxation of pension
income to the model, to better reflect current pension issues.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
Employer-sponsored pensions make up the third leg of the
``three-legged stool'' used to describe the major sources of
retirement income, along with Social Security and personal
savings. However, because not all employees are covered by
pensions throughout their working years, EBSA has become
increasingly concerned as to the adequacy of retirement income
provided by employer-sponsored pensions for some segments of
the population. In order to study this issue and how it is
impacted by government policy, EBSA commissioned work on the
PENSIM beginning in September 1997.
PENSIM is a smaller-scale model which represents the
interaction between employees and employers that determines
lifetime pension coverage and adequacy. PENSIM simulates life
histories which are rich enough to allow estimation for each
year in an individual's life of pension benefits as well as
Social Security taxes and benefits. It is uniquely able to
model pension accumulations of American workers across
populations and over time, and as a result, had been used by
EBSA as well as the Social Security Administration (SSA) and
the Government Accountability Office (GAO) on such policy
questions as Social Security and pension reform. PENSIM is
exceptional precisely because it was designed as a leading
rather than a lagging policy research activity that has been
able to contribute significantly to high priority, behavioral
analysis projects.
PENSIM regularly revises its assumptions with regard to
demographics and life events so that the simulated cohorts'
life histories closely mimic the actual populations. As such
PENSIM captures the ``graying'' of the workforce, the decline
of defined benefit (DB) pensions in favor of defined
contribution (DC) plans, changes in the Social Security rules,
the delaying of childbearing, increases in divorce as well as
other societal and generational shifts. This makes the model
and the research it generates relevant not only to current
retirees, but also to future retirees.
Because PENSIM is focused on retirement savings over a
lifetime, it is able to project the endowment an individual
will have at the time of death. Moreover, it is able to measure
the impact various policy proposals will have on this
endowment. This provides insights into the well-being of older
Americans under different economic and political assumptions
which can in turn influence which policies are ultimately
adopted and enforced by the government.
PENSIM is exciting and newsworthy because it is currently
being used to help shape pension legislation which will have
far-reaching effects on the retirement adequacy of this and
future generations. PENSIM is able to adjust to changes in the
pension landscape quickly so that it can project impacts of
proposals rather than analyze their effects after the fact.
This is essential to insure that those policies ultimately
adopted will best serve current and future retirees.
Department of Labor, U.S. Consumer Expenditure Survey
Research using the U.S. Consumer Expenditure Survey data
documents the rising share in out-of-pocket expenditures over
the past two decades of households at the retirement age. The
findings also show the higher costs for retired households.
Lead Agency: U.S. Bureau of Labor Statistics (BLS),
Division of Consumer Expenditure Surveys.
Agency Mission: Providing impartial, timely, and accurate
data relevant to the social and economic conditions of our
Nation, its workers, and their families.
Principal Investigator: Meaghan Duetsch, Phase 2 Section
Chief, Division of Consumer Expenditure Surveys, U.S. Bureau of
Labor Statistics, 2 Massachusetts Ave., NE., Room 3985 Postal
Square Building, Washington, DC 20212.
Partner Agencies: The U.S. Bureau of the Census collects
the Consumer Expenditure Survey data under contract with BLS.
All research was done within BLS.
General Description: This research project, Out-of-Pocket
Care Spending Patterns of Older Americans, as Measured by the
Consumer Expenditure Survey, used data from Consumer
Expenditure Surveys, 1985, 1995, and 2005 and examined the out-
of-pocket healthcare expenditures of older families in the age-
ranges just before and just after the Medicare eligibility age
of 65, and analyzed how health care expenditures for these two
groups have changed.
Components included in the study were health insurance
premiums paid for by the household members, as well as spending
for medical services, drugs, and medical supplies.
The research showed that over this 20-year period, there
was a greater percent increase in expenditures on health care
than in total expenditures. As a share of average total annual
expenditures, health care expenditures rose for both age groups
over the two decades. The share of expenditures allocated to
health care by the 65-74 year-old group is slightly more than
1.5 times the share allocated by 55-64 year-old group in all
three time periods.
Future Plans: As this research covered up to 2005, the
recent change to the new Medicare prescription drug benefit
will warrant further analysis.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The United States has experienced many changes over the
past two decades in the way health care is managed and the way
households allocate their spending. Families approaching
retirement need to understand these trends to prepare for the
future, and retired persons need to be aware of how their
spending patterns change. This research measures and documents
these changes using the only Federal source of expenditure data
linked to detailed household characteristics and demographics.
Expenditures on health care have risen faster than overall
spending, and retired households spend 50 percent more than do
households approaching retirement age.
Department of Labor: Gradual Retirement Through ``Bridge'' Jobs
This research project examines why so many retirees are
exiting the workforce gradually, in stages, and the economic
consequences of these decisions. It focuses on the types of
jobs that people take, the reasons behind their choices, and
their socioeconomic outcomes.
Lead Agency: U.S. Bureau of Labor Statistics.
Agency Mission: Providing impartial, timely, and accurate
data relevant to the social and economic conditions of our
Nation, its workers, and their families.
Principal Investigators: Michael D. Giandrea, PhD., U.S.
Bureau of Labor Statistics, Office of Productivity and
Technology, Postal Square Building, Room 2180, 2 Massachusetts
Ave., NE., Washington, DC 20212; Kevin E. Cahill, PhD.,
Analysis Group, Inc., 111 Huntington Avenue, 10th Floor,
Boston, MA 02199; Joseph F. Quinn, PhD., Department of
Economics, Boston College, Chestnut Hill, MA 02467.
Partner Agencies or Organizations: Dr. Cahill and Dr. Quinn
received funding from the Sloan Center on Aging and Work/
Workplace Flexibility at Boston College and also from the
Centre for Retirement Research at Boston College.
General Description: More often than not, older Americans
with full-time, long-tenure jobs move to a ``bridge'' job
before finally leaving the labor force. These bridge jobs are
voluntary for some, a way to try something new, remain socially
active, or benefit in some other nonpecuniary way. For others,
work later in life is a financial necessity to avoid hardship
in retirement. Measuring the extent of these experiences and
their consequences are of interest to policymakers. Policies
that encourage work later in life have been proposed as a way
to alleviate the expected economic strain on aging society.
This research project examines bridge jobs and retirement
transitions, including the extent to which bridge jobs are
utilized by older and younger workers, the role of self
employment in retirement transitions, and the relationship
between bridge jobs and retiree well-being.
One study in this project asked if today's younger retirees
are following in the footsteps of their older peers with
respect to gradual retirement. An earlier study by these
researchers, based on the Health and Retirement Study (HRS), an
ongoing nationally-representative survey of older Americans
that began in 1992, found that the majority of older Americans
with full-time career jobs later in life moved to another job
prior to complete labor force withdrawal. In this follow-up
study, the authors compared a cohort of older workers born
between 1942 and 1947 with those born between 1931 and 1941,
and found that younger retirees followed patterns of gradual-
retirement similar to those of their predecessors. This
conforms the view that traditional one-time, permanent
retirements remain the exception rather than the rule.
In another paper, the authors examined transitions into and
out of self employment among older workers who had career jobs.
They utilized the HRS to investigate the prevalence of self
employment transitions later in life and explored the factors
that determine the choice of wage-and-salary employment or self
employment. They found that post-career transitions into and
out of self employment were common, that self employment
increases in importance as workers age, and the health status,
career occupation, and financial variables were important
determinants of these transitions. As older Americans and the
country confront financial strains in retirement income in the
years ahead, self employment may be a vital part of the pro-
work solution.
Finally, another aspect of this research examined the
outcomes of older Americans who transitioned to bridge jobs
following career employment. The authors examined the extent to
which transitions onto bridge jobs were involuntary and how
workers' bridge jobs compared to the career jobs they had left
behind. They found that about 20 percent of those with full-
time career jobs later in life left these jobs involuntarily,
and that these individuals were less likely than others to move
to a bridge job. The large majority of older workers with full-
time career jobs, however, left these jobs voluntarily and
moved to bridge jobs before complete retirement, suggesting
that for most of these individuals work beyond career
employment may be an effective way to maintain an adequate
level of financial security and/or quality of life.
Excellence: What makes this project exceptional?
This research is timely and based on a nationally-
representative sample of older Americans born between 1931 and
1941. Today's retirees are changing the way older workers exit
the labor force. Traditional one-time, permanent retirements
are now the exception rather than the rule, as older workers
increasingly change jobs later in life or reenter the labor
force after ``retiring.'' The conclusions are based on analyses
of data from the Health and Retirement Study, a nationally-
representative sample of more than 12,000 older Americans
surveyed every other year from 1992 to 2006.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This research on work later in life is relevant because
today's retirees are experiencing more financial risk than
prior cohorts, and therefore may have to work later in life in
order to supplement income from Social Security, private
pensions, and savings.
The pro-work mindset of many of today's older Americans is
likely a reflection of many factors. People are healthier, are
living longer and have higher levels of education compared to
earlier generations. Jobs are also less physically demanding
now than in the past. Over the past two decades, a generally
strong labor market has provided older workers with job
opportunities. These changes have enabled older workers to
remain productive well beyond traditional retirement ages.
Many of the financial incentives surrounding retirement
have changed as well. Defined-benefit pension plans that offer
a guaranteed annuity payment upon retirement are less common in
today's private sector and many existing defined-benefit plans
are being converted to cash balance plans or replaced with
defined-contribution plans managed by the worker. Social
Security, the bedrock of financial security late in life, is
facing financial strain and will likely provide lower
replacement rates than in the past. Finally, private saving,
the third pillar of retirement income, is currently near record
low rates.
As a result, today's retirees are now in charge of their
retirement finances and face more financial risk than at any
time in the post-war era.
Effectiveness: What is the impact and/or application of
this research to older persons?
The shift towards ``do-it-yourself'' retirement has both
positive and negative consequences for older people. On the one
hand, workers have more control of their retirement assets and
they respond to many of the financial incentives associated
with retirement by working longer and by taking on bridge jobs
after career employment. The implication is that if retirement
assets are less than expected upon retirement many older
workers may remain active members of the labor force well into
their late 60's and 70's. Conversely, if work later in life is
not an option, because of factors such as health or inflexible
work options, some retirees' well-being will be vulnerable to
fluctuations in market conditions.
What is clear is that retirement incentives have changed
and these changes will likely influence the retirement
decisions of older workers for years to come.
Innovativeness: Why is this research exciting or
newsworthy?
This research is exciting because the topic of work later
in life is important to a large number of Americans who are on
the cusp of retirement. The leading edge of the Baby Boomers,
in particular, reached traditional retirement age in 2008.
Today's older workers are searching for increased levels of
financial security for the remainder of their increasingly long
lives. This research on bridge jobs illustrates how current
retirees have utilized transitional employment to smooth
financial shocks that may have occurred following full-time
career employment. These bridge jobs also help older workers
maintain social networks that are often available only among
fellow workers.
While other authors have investigated partial retirement
and employment among older workers, they have developed a
series of papers that relate and build upon each other. They
first described the prevalence of bridge jobs in a 2006
Gerontologist paper and then compared bridge job activity
between an older and a younger cohort of workers above the age
of 50 (forthcoming in Research on Aging). Building on this
framework, they investigated the economic outcomes of older
workers comparing those who retired directly from career jobs
to those who transitioned to bridge jobs. They found that most
transitions, particularly bridge jobs, were voluntary and that
most workers were happy with their jobs. They then examined one
of the most interesting transitions, from wage-and-salary
career employment to self-employment (Center on Aging & Work
Issue Brief).
The work decisions of older Americans are diverse and rich.
Policymakers should be interested in our findings, in light of
the fact that Americans may be asked to work later in life in
order to supplement traditional sources of retirement income.
Department of Labor: Details of Plan Generosity Among 401(k) Plans
Having Employer Matches 2002-2003
This project provides new measures of the generosity of the
401(k) plans provided by private employers in the United States
in the calendar years 2002 and 2003, using the microdata
collected as part of the Bureau of Labor Statistics' National
Compensation Survey (NCS).
Lead Agency: United States Bureau of Labor Statistics.
Agency Mission: Providing impartial, timely, and accurate
data relevant to the social and economic conditions of our
Nation, its workers, and their families.
Principal Investigator: Keenan Dworak-Fisher, Office of
Compensation and Working Conditions, U.S. Bureau of Labor
Statistics, Room 4130, 2 Massachusetts Ave., NE., Washington,
DC 20212.
General Description: This project provides new measures of
the generosity of the 401(k) plans provided by private
employers in the United States in the calendar years 2002 and
2003, using the microdata collected as part of the Bureau of
Labor Statistics' National Compensation Survey (NCS). With the
ongoing transformation of employer-provided retirement benefits
from a predominance of traditional Defined Benefit pensions to
a concentration on optional, Defined Contribution plans now
almost three decades old, understanding the generosity of these
types of employer benefits is more and more important. Yet,
much of what is known about these plans originates from small,
non-representative surveys and household surveys whose
potential for inaccuracy is oft cited. Regular BLS publications
use NCS to provide useful descriptive information about Defined
Contribution plans, but the complexity and variability of the
plans prevents such publications from going into comprehensive
detail on the generosity of 401(k) plans. This project provides
many of these needed details.
The generosity of the predominant type of 401(k) plans is
reflected in the form and extent of matching contributions that
the employer pledges to make when the employee contributes.
While the value of the benefits ultimately received by the
workers from their employers depends on the employees' own
actions (participation and contribution rates), the structures
of the employer matches themselves demonstrate the potential
for employer contributions to add to employees' retirement
savings. The paper draws on the coded microdata underlying NCS
publications, as well as additional data gleaned from
employers' plan brochure to describe the distribution of plan
generosity observed in the NCS sample, which is representative
of the nation as a whole.
The project portrays many dimensions of the wide variation
between the 401(k) plans offered by employers. Match rates are
seen throughout the 0-100 percent range, and even higher. These
matches are provided on 1 to 6 percent of employees' salaries,
and even higher. Some matching schemes provide ``flat''
matches, while other employers vary the match rate over the
distribution of employee contribution amounts, or between
employees with different amounts of tenure. The project shows
that some of these features of plan generosity are offsetting--
e.g., a low match rate is often compensated for by a high
amount of employee salary eligible to be matched. Nonetheless,
plans with variable match rates tend to be somewhat more
generous than those providing flat rates. The project also
documents how the generosities of plans differ by job and
employer characteristics--for example, workers in the Western
region tend have access to significantly more generous plans
than workers in the South.
This project has been published in the BLS's Monthly Labor
Review and circulated to interested retirement researchers at
other private and public organizations. It has also affected
plans for future BLS publications using NCS data. And it forms
a needed background and basis for the author's own continuing
work using the underlying data to examine how the
characteristics of 401(k) plans affect the participation rates
of employees having access to them.
Excellence: What makes this project exceptional?
The project uses accurate data representative of all
private employers in the United States to document 401(k) plan
characteristics. This provides a more comprehensive view of the
plans in existence than other studies, which have used samples
of large employers or other subsets of the population.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The amount of retirement saving is a key component of the
resources available to older populations. 401(k) plans provided
by employers are an increasingly large fraction of these
savings, reflecting the evolution of employers' retirement
benefits over the last three decades.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research will help establish a backdrop to further
studies of 401(k) benefits, including simulations of retirement
savings accumulations as well as studies of how plan details
affect savings behavior. It may also be used in policy
simulations that ask how changes to tax, Social Security, and
savings policy might be accommodated by the population.
Innovativeness: Why is this research exciting or
newsworthy?
The research demonstrates a wide variability between the
401(k) plans provided by different employers and uncovers some
of the correlates of plan generosity. Given the passive
behavior of employees with regard to plan participation that
has been documented in the literature, it seems likely that
much of this variation (and subsequent sufficiency of
retirement saving) is distributed arbitrarily across the
population. If so, it poses some interesting questions about
the operation of the labor market and may prompt interest in
public policies aimed at leveling out the variation in
generosity received.
Department of Labor: Survey of Occupational Injuries and Illnesses and
the Census of Fatal Occupational Injuries
Americans are living longer than ever before, and many are
staying in the workforce past age 55; although older workers
experience similar events leading to injury, they sustain more
severe injuries than their younger counterparts and require
more days away from work to recover.
Lead Agency: Bureau of Labor Statistics.
Providing impartial, timely, and accurate data relevant to
the social and economic conditions of our Nation, its workers,
and their families.
Principal Investigators: William J. Wiatrowski, Associate
Commissioner, Office of Compensation and Working Conditions,
Occupational Safety and Health Statistics, Postal Square
Building, Room 3180, 2 Massachusetts Ave., NE., Washington, DC
20212-0001; Elizabeth L. Rogers, Economist, Office of
Compensation and Working Conditions, Occupational Safety and
Health Statistics, Postal Square Building, Room 3180, 2
Massachusetts Ave., NE., Washington, DC 20212-0001.
General Description: Older workers face many of the same
workplace hazards as do other workers; the most prevalent
events leading to job-related injuries or fatalities are falls,
assault, harmful exposures, or transportation incidents. But in
many cases, the nature of the injury suffered by an older
worker is more severe than that suffered by younger workers.
Older workers who suffer a workplace injury may experience
longer recovery periods than their younger counterparts. And
older workers die from workplace injuries at a higher rate than
do younger workers. This analysis focuses on occupational
injuries, illnesses, and fatalities among older workers, and
identifies differences in the severity of the events as a
result of age.
Americans are living longer than ever before, and
increasing numbers of older Americans are working. These facts
have led to expanded interest in the activities of older
Americans and their work life. Americans born at the beginning
of the 21st century can expect to live an average of 77 years,
an increase of 9 years, compared with persons born a half
century ago. Those aged 65 in 2000 can expect to live 18 years.
Considering age 65 to be a typical retirement age, individuals
can expect to live nearly 2 additional decades. Both the need
to feel productive and the need for income may lead these older
Americans to work during what are typically considered
retirement years.
But the need to work does not come without potential
hazards. This article explores recent data on workplace
injuries, illnesses, and fatalities among older workers. Data
from the Bureau of Labor Statistics Survey of Occupational
Injuries and Illnesses and Census of Fatal Occupational
Injuries provide a wide range of information about the events
that led to an injury, illness, or fatality, the demographics
of the workers involved, and the types of occupations and
industries where these incidents occur.
Excellence: What makes this project exceptional?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Effectiveness: What is the impact and/or application of
this research to older persons?
Innovativeness: Why is this research exciting or
newsworthy?
The percentage of older Americans in the labor force has
been increasing. As it has, the need to understand the
particular experience of older workers has expanded with it.
Presenting the demographic data available from the Survey of
Occupational Injuries and Illnesses and the Census of Fatal
Occupational Injuries, this article demonstrates that older
workers need more time to recover from non-fatal work-related
injuries and illnesses, experience more traumatic injuries like
fractures and multiple injuries, and sustain a higher fatality
rate than do younger workers. Two case studies are included
that demonstrate that older workers are likely to have more
severe injuries even when the event leading to the injury was
not particularly serious.
These findings are important to policy makers, regulators,
employers, and safety and health researchers. They are used in
the development of safer workplaces for older workers, which is
important as the American workforce ages.
This article is innovative in that it presents demographic
data available from the Survey of Occupational Injuries and
Illnesses and the Census of Fatal Occupational Injuries, the
premier source of information on the safety and health of
American workers. Using these data, consistent comparisons
between older and younger workers across many different case
characteristics can be drawn. The data presented in this
article highlight the experiences of older workers, experiences
both anticipated and surprising.
U.S. Department of Transportation: Dementia and Driving Ability
This project explores the driving behaviors of people with
early-stage memory impairments by collecting objective driving
data from these people through custom in-vehicle technology.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigators: David W. Eby, Ph.D., Research
Associate Professor, Principal Investigator, Social and
Behavioral Analysis Division, University of Michigan
Transportation Research Institute, Director, Michigan Center
for Advancing Safe Transportation throughout the Lifespan, 2901
Baxter Rd., Ann Arbor, MI 48109-2150.
David J. LeBlanc, Ph.D., Associate Research Scientist,
Engineering Research Division, University of Michigan
Transportation Research Institute, 2901 Baxter Rd., Ann Arbor,
MI 48109-2150.
Lisa J. Molnar, M.H.S.A., Lead Research Associate, Social
and Behavioral Analysis Division, University of Michigan
Transportation Research Institute, Assistant Director, M-CASTL,
2901 Baxter Rd., Ann Arbor, MI 48109-2150.
Nina M. Silverstein, Ph.D. Professor and Program Director,
Gerontology, College of Public and Community Service,
University of Massachusetts Boston, 100 Morrissey Boulevard,
Boston, MA 02125-3383.
Geri Adler, Ph.D., Assistant Professor, Graduate College of
Social Work, University of Houston, 4800 Calhoun Rd., Houston,
TX 77004.
Partner Agencies: University of Michigan Transportation
Research Institute, University of Massachusetts, Boston,
University of Houston.
General Description: It is not unusual for a person who has
been diagnosed with early-stage Alzheimer's or other dementia
to continue to drive. While some studies indicate that those in
the earliest stages of dementia may retain their driving
skills, others document older drivers with dementia who
continue to drive even after being involved in crashes and
near-crashes. Thus, while many persons with early stage
dementia drive, their ability to drive safely, particularly as
the disease progresses, remains unclear.
Those who want to know whether a family member who has been
diagnosed with a form of dementia should continue to drive
often turn to professionals including physicians, eye care
specialists and retirement community personnel for guidance.
These professionals may base their opinions on the driver's
self assessment, the opinion of family members, or on the basis
of a formal assessment. However, professionals, family members,
and the drivers themselves may be unaware of the extent of
declines in driving skills.
Recent advances in technology make it possible to
automatically collect detailed information about driving
performance. This technology can be used to monitor the driving
behavior of individuals diagnosed with early stage dementia to
provide practitioners with a better sense of how to monitor
these drivers' changing skills. Moreover, the validity of
drivers' self-assessments and those of family members could be
investigated using in-vehicle data.
The primary objective of this project is to evaluate the
feasibility of using existing in-vehicle technology to monitor
a set of potentially hazardous driving behaviors common in
persons with early stage dementia.
Excellence: What makes this project exceptional?
Research has plainly shown that individuals with dementia
drive more poorly than drivers without dementia. Studies have
identified several driving problems associated with dementia,
including getting lost while driving, even in familiar areas,
vehicle speed control difficulties, particularly driving
consistently below posted speed limits, failure to signal lane
changes, failure to check blind spots before lane changes,
failure to maintain lateral lane position, running stop signs,
and failure to recognize and obey traffic signs and signals.
None of this research, however, examined driving behaviors
objectively under natural driving conditions. Some studies rely
on the self-report of family members, while others rely on the
observations of an evaluator who rides with the person in their
vehicle. Family member reports can be unreliable, the family
member is not always with the driver with dementia, and people
with dementia can improve their driving somewhat, if they know
they are being evaluated. This study will be the first to
collect objective driving measures in this population during a
everyday driving.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
According to the Alzheimer's Association, there is a new
case of Alzheimer's Disease diagnosed every 72 seconds.
Alzheimer's and related dementias are quite common in the older
adult population. With the first baby boomer reaching age 65 in
2011 and all baby boomers being age 65 or older by 2029, there
will be many older adults with dementia who will have mobility
needs that need to be met. This project is a critical first
step in studying the driving behaviors of this group of people,
so that more effective driving evaluators, family members,
health professionals, and others will have objective
information on the driving skills that are declining for people
with early-stage dementia.
Effectiveness: What is the impact and/or application of
this research to older persons?
This project is designed to help all people who work with
older adults become more aware of the how driving skills
decline in people with dementia. By understanding how skills
decline, more effective countermeasures can be developed to
help maintain safe mobility for people with dementia.
Ultimately, this research should help to identify those drivers
who are no longer safe to drive while also allowing those who
are safe drivers to continue driving even though they are
experiencing memory impairments.
Innovativeness: Why is this research exciting or
newsworthy?
This is the first project to use in-vehicle technology to
objectively record the driving behaviors of people diagnosed
with early-stage memory impairment (dementia). The project has
other innovative features. First, the project developed a
sensor-suite and computer system (collectively called a data-
acquisition system, DAS) that can be installed in the person's
own vehicle. This meant that the DAS needed to be versatile
enough to handle the huge variation in vehicle designs. Second,
the project needed to develop algorithms to convert the raw
sensor data into measures of nearly 20 driving behaviors. While
some of these algorithms had been developed in previous
studies, this project required that new ones be developed. For
example, one behavior that the researchers expected to find
with the memory-impairment subjects was that subjects will get
lost. Because this behavior is rare in non-memory-impaired
people, the project had to develop a way to analyze global
positioning system (GPS) data to yield trips where people got
lost. Finally, the project had to develop a sophisticated
subject recruitment system. The project needed to find people
with a diagnosis of early-stage memory impairment, who have
recently had their driving professionally evaluated and been
cleared to drive; and who were willing to have the technology
installed in their vehicle.
U.S. Department of Transportation: Aging Licensing Policies
This study will examine how the various types of special
screening and testing that State driver licensing agencies
apply to older drivers affect older driver crash rate,
licensing administration and older person quality of life.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Richard D. Blomberg, President,
Dunlap and Associates, Inc., 110 Lenox Avenue, Stamford, CT
06906-2300.
General Description: Some States attempt to screen out high
risk older drivers (65+) using various administrative
procedures and specific testing. This ongoing study focuses on
assessing the effects of these licensing procedures on the
crash rates of older drivers. The specific objectives of the
study are to:
Identify safety benefits and unintended
consequences of licensing policies that are specific to older
drivers.
Conduct a process evaluation of driver license
renewal policies and procedures that apply to the general
public and those that apply specifically to older drivers
across the United States.
Collect information about licensing processes and
procedures from each of the States as well as the District of
Columbia.
Select Special Emphasis States for a more
comprehensive examination of general and older driver licensing
procedures.
Gather information from DMV officials, older
drivers who have recently renewed their licenses and older
adults who no longer drive in each of the Special Emphasis
States.
Excellence: What makes this project exceptional?
This project is exceptional because it combines a
scientific examination of the effect on crashes of various
licensing policies for older drivers with a rigorous process
examination of the way these policies are applied. A
coordinated examination of outcome and process measures can
facilitate identifying the mechanisms through which various
State approaches work or whether ineffective implementation may
be the reason for the absence of a safety benefit. The
combination of a practical examination of the implementation of
interventions with a fully coordinated crash-based assessment
of safety benefit is unusual and should provide decision-makers
with the best possible information.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The literature on prior research well establishes that the
aging process can affect safe driving. Older drivers who are
still safe, however, do not want to be denied the driving
privilege simply because they reach a chronological milestone.
The challenge is to develop and successfully apply performance-
based criteria determining older driver fitness. This study
will identify whether the current specialized licensing
practices for the older driver as presently applied are
effective as safety interventions, are accepted by older
drivers and licensing officials and can reasonably be
implemented. As such, the results of this study will influence
licensing policies with respect to older drivers for the
foreseeable future.
Effectiveness: What is the impact and/or application of
this research to older persons?
Older drivers want fair treatment. The literature indicates
that they want to continue driving as long as they are safe and
that they are willing to forego driving when their abilities
are no longer capable of coping with the modern traffic
environment. This research will quantify the effectiveness and
consistency of application of some of the most widely used
licensing interventions. The quantitative results this study
will produce should allow all concerned to make data-driven and
unemotional decisions with respect to licensing approaches for
the older driver.
Innovativeness: Why is this research exciting or
newsworthy?
The older population is growing and covets its mobility and
independence. Crash studies show an increased rate of
involvement as a function of age, but the effects are far from
uniform. Licensing authorities and the older driver each need
well-founded information upon which to base decisions
concerning who should be prohibited from driving and how those
prohibitions will be implemented.
Current licensing policies for older drivers have evolved
based on general studies of the capabilities of older persons
and the professional judgments of State officials. This study
will not only examine multiple implementations of popular
approaches, but will also assess the extent to which approaches
are actually implemented and the reactions of older drivers and
license administration personnel to them. This appears to be
the first time that a crash-based assessment has been coupled
with an in-depth process examination of older driver licensing
policies. As such, the study will provide government decision-
makers, advocates for the older person and older drivers
themselves with better information to make informed decisions
on older driver fitness.
U.S. Department of Transportation: Medical Conditions and Driving
Abilities
This literature review summarizes forty years of research
related to older driver safety. It focuses on how medical
conditions affect driving skills and abilities. The report is a
valuable compendium that can help driver licensing authorities,
physicians, and policy-makers make appropriate decisions
related to older driver safety. This is the first report to
thoroughly address these issues.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Bonnie Dobbs, Associate Professor,
University of Alberta.
Partner Agencies: Association for the Advancement of
Automotive Medicine.
General Description: This report reviews the contribution
of medical conditions and functional limitations (e.g.,
sensory, motor, or cognitive functioning) to motor vehicle
crashes. It provides a comprehensive and up-to-date review of
the international research literature on the effects of medical
and functional conditions on driving performance. The report is
divided into 15 sections (Introduction, Vision, Hearing,
Cardiovascular Diseases, Cerebrovascular Diseases, Peripheral
Vascular Diseases, Diseases of the Nervous System, Respiratory
Diseases, Metabolic Diseases, Renal Diseases, Musculoskeletal
Disabilities, Psychiatric Diseases, Drugs, The Aging Driver,
and the Effects of Anesthesia and Surgery). Each section
contains a brief overview of the condition/illness; prevalence
information; a review of the medical, gerontological, and
epidemiological literature relevant to the condition/illness,
followed by current fitness to drive guidelines for the
condition/illness from Canada and Australia. The Appendix
presents preliminary guidelines for physicians to assess
medical fitness-to-drive. The report is a scholarly but
practical compendium that can serve as a valuable resource for
physicians, rehabilitation practitioners, other allied health
care professionals and educators, Department of Motor Vehicle
personnel, road and traffic safety personnel, transportation
planners, highway safety researchers, and public policymakers.
Its value is particularly relevant as the driving population
increases in size and age.
Excellence: What makes this project exceptional?
Because there will be an increase in the numbers of older
drivers in the coming decades, it is important to understand
the types of safety challenges facing this population and those
with whom they share the road. A special concern is age-related
illness and its potential to influence driving safety.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This report represents the first time that a compendium of
medical conditions and driving has been compiled. The report
presents findings that delineate the correlations between age-
related illnesses and safe driving ability that can be useful
for physicians dealing with older patients.
Effectiveness: What is the impact and/or application of
this research to older persons?
This project promotes safety and older citizen mobility by
providing crucial support for functional ability screening. It
has been used as a starting point for an evidence-based review
that was sponsored by the American Occupational Therapy
Association, and for research in Canada and the U.S.
Innovativeness: Why is this research exciting or
newsworthy?
The compendium fills significant knowledge gaps in our
understanding of the relationships between medical conditions,
functional abilities, and crash risks.
Federal Highway Administration: Safety and Mobility
The NHTS is a national survey of the American public that
provides detailed travel volume and behavior information on
older people that supports a wide range of safety, mobility,
and travel demand applications.
Lead Agency: Federal Highway Administration, Office of
Policy, Highway Policy Information.
Agency Mission: Enhancing mobility on our Nation's highways
through national leadership, innovation, and program delivery.
Principal Investigator: Heather Contrino, Travel Surveys
Team Leader, 1200 New Jersey Avenue, SE., Room E83-426,
Washington, DC 20590.
Partner Agency: FHWA Office of Policy, FHWA Office of
Safety, FHWA Research and Development, Federal Transit Agency,
American Association of Retired Persons (AARP).
General Description: The National Household Travel Survey
(NHTS) collects National, regional, and State level data on the
characteristics of travel by the American public. The gathering
and subsequent data analyses for older drivers are key
components of the NHTS program. The NHTS provides detailed
information aid in understanding and assessing mobility,
accessibility, and safety for older Americans. The NHTS is used
in research, policy, planning and engineering extensively
throughout the transportation community including Federal,
State and Local agencies, Non-profit organizations, and
University researchers.
Specifically, the NHTS surveys the public on travel
behavior, choices, and preferences, providing 40 years of trend
data on the past, current, and forecasted travel demand and
travel characteristics of older people. The study provides
estimates of vehicle miles of travel (VMT) person miles of
travel (PMT) on all modes of transportation, detailed trip
characteristics including time of day, speed, distance, trip
purpose, and vehicle occupancy, and vehicle information
including mileage, make, model, year, and primary driver.
As the only source of data on travel behavior by people,
NHTS data has been used extensively to support several older
people safety and mobility programs and policies within and
outside the Department of Transportation. In the 2001 NHTS our
oldest driver was 102 years old. Most recently, the NHTS data
was the core source of information for the 50-year forecast of
travel demand by the aging population for the Policy and
Revenue Commission.
Excellence: What makes this project exceptional?
The NHTS is an exceptional project because it provides a
comprehensive measure of travel by older people on all modes of
transportation and in all regions of the United States.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The NHTS Program is highly relevant to older persons now
and in the context of an aging population due to the direct
support of several planning and policy applications that are
core to the Department's mission in providing safety and
mobility for all Americans. These include:
Exposure rates, both VMT and PMT, for safety
measures,
40 Years of trend data on the travel volume
and behavior of older people,
Detailed vehicle/fleet data in the context
of travel volumes and demographics for safety and
mobility performance measurement and program
development,
Trip characteristics by age and gender which
support short and long range forecasts of demand by
older people as our society ages,
Information on the non-traveling public
provides measure of mobility for older people,
Disability data and impacts on travel
behavior provide information on barriers to travel,
difficulties in driving, special transportation needs,
and accessibility.
Effectiveness: What is the impact and/or application of
this research to older person?
The NHTS program connects older people with travel behavior
in the context of mode choice and vehicle characteristics so
that effective programs and policies can be put into place to
ensure mobility and safety of this large and important
population group. In addition, the NHTS supports performance
measurement of the system and for specific policies and
programs. With the NHTS, DOT understands the travel needs of
older people, can identify safety risk groups, and evaluate and
institute effective programs that improve safety and enhance
mobility.
Innovativeness: Why is this research exciting or
newsworthy?
Baby boomer population is aging and the sheer size of the
older person population over the next 10-20 years allows for a
potentially great impact on travel demand and travel behavior,
as they are a more mobile group that previous generations of
older people. This research gives DOT the information and tools
to be proactive in planning for the transportation needs and
safety of older people as this population grows.
Federal Aviation Administration: Air Traffic Control Performance
Researchers analyzed operational error data among Air
Traffic Control Specialists by age, found no difference in
error rates, suggested that the current age limitations may not
be necessary, and called for further research.
Lead Agency: Department of Transportation (DOT)--Federal
Aviation Administration (FAA), Office of Aerospace Safety
(AVS)-- Office of Aerospace Medicine (AAM)--Civil Aerospace
Medical Institute (CAMI)--Aerospace Human Factors Research
Division (AAM-500).
Agency Mission: FAA: Federal Aviation Administrations
mission is to provide the safest, most efficient aerospace
system in the world.
Aviation Safety and the Office of Aerospace Medicine's
mission is to enhance aerospace safety through surveillance,
research, education, medical standards, and the prevention of
illness and injury.
Principal Investigator: Dana Broach, Ph.D., Personnel
Research Psychologist, FAA Civil Aerospace Medical Institute,
P.O. Box 25082, Oklahoma City, OK 73125.
Partner Agency: FAA Human Factors Research and Engineering
Group (AJP-61).
General Description: This study analyzed operational error
data among Air Traffic Control Specialists above and below the
age of 55. The results in indicated no difference in error
rates, suggesting that the current age limitation may not be
necessary. U.S. federal law requires that air traffic control
specialists (ATCSs) hired after May 16, 1972 retire at age 56
on the premise that the risk of adverse events such as
operational errors (OEs) increases with age (U.S. House of
Representatives, 1971). OE count was modeled as a function of
en route ATCS age and exposure to test that premise using
Poisson regression. The odds of OE involvement for older (age
56 and older) and younger (age 55 or less) ATCSs were equal.
These results suggest that the rationale for mandatory
retirement of controllers might need to be reexamined through
continued research. While recognizing that the results called
into question the safety benefits of the law, they acknowledge
that policy change would require replication of their findings
and extension of analyses to other sources of data. They also
discussed the competition of changes in cognitive function with
age to accrual of experience with change. As such, the research
represents a good start towards balancing our desire to avoid
unwarranted discrimination with our desire to prevent errors
and safety concerns that may be associated with cognitive
changes.
Excellence: What makes this project exceptional?
This project was exceptional in its authors' recognition of
Operation Error data potential to address aging effects and the
careful conceptual approach taken to interpreting the data. The
opportunity to examine the impact of aging on error frequency
was presented by the age limitation decision by Congress in
1971. The authors made use of operational error data collected
by the Air Traffic Organization to examine possible age
effects. Their interpretation of findings was appropriately
limited to the dataset, but asked some fundamental questions
about aging and suggested possible policy reassessment.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The work is relevant to an aging society because it
questions the impact of known trends in cognitive performance
with age upon job performance. It suggests that while
tactically-oriented cognitive speed and flexibility decreases
with age may be accompanied by some degree of strategic
compensation--experience may lead controllers to prevent
situations that would require novel or speedy tactical
interventions. Were this finding further validated, it would
cause us to reassess most policies providing for firm age
limits for a job category in favor of more individual-
assessments of cognitive function, leading to a potentially
more fair set of decisions.
Effectiveness: What is the impact and/or application of
this research to older persons?
The impact of the research has been limited, however, in
that follow up activities were not sponsored or funded within
the agency.
Innovativeness: Why is this research exciting or
newsworthy?
The research is worthy of recognition because it challenges
how we think about age limitations in air traffic control. The
error data, at least, does not support our current policy. This
calls for further reassessment. The authors' thoughtful
interpretations call for more fundamental research about how
controllers perform their jobs as they age.
U.S. Department of Transportation: Clearview Highway Improvement
The Clearview font allows agencies to meet the needs of
older drivers, with regard to the legibility of guide signs,
without an increase in the size and cost of the signs. In
August 2004, the FHWA issued interim approval for the use of
the Clearview font for positive contrast legends on guide
signs.
Lead Agency: U.S. Department of Transportation/Federal
Highway Administration (FHWA).
Agency Mission: Improve mobility on our Nation's highways
through national leadership, innovation, and program delivery.
Principal Investigator: Carl K. Andersen, Roadway Team
Leader, Office of Safety Research & Development, Federal
Highway Administration, HRDS-05, 6300 Georgetown Pike, McLean,
VA 22101.
Partner Agency: Texas Department of Transportation,
Pennsylvania Department of Transportation.
General Description: The Clearview highway sign font was
developed through a decade of research starting in the early
1990s. Clearview font letters were developed to address four
issues with the legibility of standard highway sign alphabets:
(1) upgrade highway signing word messages to
accommodate the needs of older drivers without
increasing the overall size of the signs;
(2) improve word pattern recognition;
(3) improve the speed and accuracy of destination
recognition and the distance at which a sign can be
read; and
(4) control halation (glow that makes letters become
unrecognizable blobs) that may occur on high brightness
retroreflective materials for drivers with reduced
contrast sensitivity.
The concept for an improved highway sign font was developed
by Meeker & Associates, Inc., in response to the determination
by the FHWA that guide signs using the standard highway sign
alphabets would have to be increased in size to meet the needs
of older drivers. The initial research on Clearview was
conducted at the Pennsylvania Transportation Institute (PTI).
In two PTI studies, the use of an early version of Clearview
Bold improved nighttime sign reading distances by up to 16
percent when compared to the E-modified road sign typeface. An
initial study at the Texas Transportation Institute (TTI) found
that there were significant differences in the legibility of
full-size signs as compared to the smaller signs tested at PTI.
Meeker & Associates, Inc. made refinements to the Clearview
font that were used in additional joint FHWA/TxDOT studies
conducted by TTI.
A TTI study on nighttime sign legibility as a function of
retroreflective material and sign font found that the refined
Clearview font provided an 11 to 12 percent increase in
legibility distances for guide signs using Clearview. Both the
Pennsylvania and Texas Departments of Transportation reviewed
the research on the use of Clearview font for guide signs and
requested that Clearview font be allowed for use on positive
contrast guide signs.
Excellence: What makes this project exceptional?
This project is exceptional because the results allow
agencies to meet the nighttime guide sign legibility needs of
older drivers without a need to increase the physical size of
the signs. Increasing the sign size would potentially have
resulted in a need to redesign and replace sign support
structures. In many cases, larger signs are not feasible, as
the existing signs are already 12 feet in width.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Development and evaluation of Clearview font demonstrated
that the nighttime legibility requirements of older drivers
could be met without the need to increase the size and cost of
overhead guide signs. Without these results, it would have been
difficult, if not impossible, for agencies to meet this need.
The results are a significant improvement in the ability of the
national highway signage system to meet the needs of older
drivers, thereby improving their mobility and potentially
improving safety by permitting all drivers to acquire
information in a timely manner.
Effectiveness: What is the impact and/or application of
this research to older persons?
The FHWA has issued interim approval for the use of
Clearview font on positive contrast guide signs, which permits
agencies to install signs that meet the nighttime visual
requirements of older drivers.
Innovativeness: Why is this research exciting or
newsworthy?
The development and evaluation of the Clearview font was a
cooperative venture by a private company, two transportation
institutes, two State Departments of Transportation, and the
FHWA. Meeker & Associates, Inc. saw a national need that the
company felt uniquely capable of fulfilling, and initiated work
with the Pennsylvania DOT and PTI. The results of the initial
evaluations prompted the FHWA and Texas DOT to fund research at
TTI to complete the evaluation of the first alternative highway
sign font developed in the U.S. in the last 50 years.
U.S. Department of Transportation: Pedestrian Safety
Lead Agency: U.S. Department of Transportation, Federal
Highway Administration.
Agency Mission: FHWA is charged with the broad
responsibility of ensuring that America's roads and highways
continue to be the safest and most technologically up-to-date.
One of our Six Life Saving Strategies is to Reduce Roadway-
Related Pedestrian Deaths, which account for 12% of all roadway
fatalities and a disproportionate number of the deaths of
youthful and elderly crash victims: We encourage a systematic
approach to community safety, including comprehensive programs
to increase awareness of pedestrian safety issues; to provide
pedestrian safety training; to improve roadway designs to more
safely accommodate pedestrian needs; and to emphasize the need
for pedestrian safety planning by MPOs and other planning
organizations.
Principal Investigators: David Harkey, Director, University
of North Carolina, Highway Research Center, 730 Martin Luther
King, Jr. Blvd., CB# 3430, Chapel Hill, NC 27599-3430.
Tom Granda, PhD., Research Psychologist, Turner-Fairbank
Highway, Research Center, 6300 Georgetown Pike, McLean, VA
22101.
Beth Alicandri, Director, FHWA Office of Safety Programs,
1200 New Jersey Ave., SE., Washington, DC 20590.
Gabe Rousseau, PhD., FHWA Office of Environment, 1200 New
Jersey Ave., SE., Washington, DC 20590.
F. E. (Gene) Amparano, P.E., Safety Engineer, FHWA Resource
Center, Safety & Design Technical Services Team, 901 Locust
Street, Suite 466, Kansas City, MO 64106.
Gail Holley, Safe Mobility for Life Program and Research
Mgr., Florida Department of Transportation, State Traffic
Engineering and Operations Office, 605 Suwannee Street, M.S.
36.
Tom Welch, PE, State Transportation Safety Engineer, Iowa
Dept. of Transportation, 800 Lincoln Way.
Partner Agency: National Highway Traffic Safety
Administration.
General Description: In 1998 the Federal Highway
Administration published the first edition of the Older Driver
Highway Design Handbook. The original guide provided practical
information to transportation professionals about designing
roadways and traffic signals to improve safety for older
drivers. In 2001, FHWA released a revised edition and broadened
the scope to include other road users, namely pedestrians. It
is now called the Highway Design Handbook for Older Drivers and
Pedestrians. The 2001 Handbook provided detailed design
recommendations and provided literature reviews to show the
research basis for these recommendations. For example, the
Handbook provides recommendations for roadway signs to ensure
that older drivers can see them from an appropriate distance.
Although the Handbook itself is not a set of standards, many of
the recommendations in it have subsequently been incorporated
in roadway and traffic signal design standards. A third version
of the Handbook is currently being developed. The Handbook has
been and continues to be a popular and important resource for
transportation professionals who are trying to ensure that our
growing population of older adults will have safe
transportation options. The Handbook helps us address important
societal issues including roadway safety and independent
living.
The FHWA also offers a 1-day training workshop to
thoroughly review the recommendations and guidelines contained
in the Highway Design Handbook for Older Drivers and
Pedestrians. Interactive methods are used to help participants
fully understand the changes that occur with aging. It provides
information and demonstrations of the effects of aging on
vision, range of motion and cognition; goes over the
information in the handbook; and provides hands-on exercises
with real world case studies to allow participants to apply
what they have learned.
Modifications to the roadway system are identified that can
make it easier for older drivers and all drivers. Case studies
are used during the workshop. The workshop is designed
primarily for practicing highway and traffic engineers
responsible for highway design and operations, and over 3,000
transportation professionals have attended the workshop since
it began.
Demographic trends indicate that Americans are living
longer. This is certainly good news, but the trends require
that we examine how to ensure that Americans can maintain
independence and quality of life in their senior years. Perhaps
the key aspect of independence in our country pertains to
transportation. In many communities independence is synonymous
with being able to drive. As we grow older we experience age-
related changes in our vision, hearing, and cognition and these
changes can make it harder to safely walk or drive on our
roadways. In 2006, older adults comprised about 14 percent of
all traffic fatalities even though they represent only 12
percent of the population. Transportation researchers and
practitioners are trying to ensure that older Americans can
travel safely by using their knowledge of age-related ability
changes to revise standards for roadways and traffic signs and
signals. In 1998, the Federal Highway Administration published
the first version of what is now called the Highway Design
Handbook for Older Drivers and Pedestrians. The original
Handbook and the more recent 2001 version have been a key
resource for roadway designers and other transportation
professionals. Because of the popularity of the previous
Handbooks, it is currently being revised once again to
incorporate new research findings. The Handbook has been the
premier source of information for recommending design practices
to accommodate older drivers and pedestrians. In addition, many
of these recommendations have been incorporated into Federal
transportation standards such as the Manual on Uniform Traffic
Control Devices.
The Handbook is a synthesis of research pertaining to older
road users. What is unique about it is how it takes a wide
range of research findings and incorporates them into a single
document in order to develop recommendations for roadway
situations that pose increased risk for older adults. Some of
these situations include intersections, work zones, and roadway
curvature and passing zones. Based on the analysis of the
research, the Handbook presents recommendations on roadway
design features (e.g., the recommended font size on roadway
signs). One of the unique aspects of the Handbook is that for
each recommendation, the authors examined how these
recommendations compare or contrast for different standards
that transportation professionals rely on for designing roads
and traffic control devices (such as roadway signs). The intent
is to unify these sometimes disparate standards.
The aim of the guide is to improve safety for older adults
but it is likely that road users of all ages and abilities will
benefit from recommendations in the Handbook. Because the
Handbook will continue to be revised in the future, it can be
updated as new research emerges. New recommendations can be
developed and we will be able to examine roadway safety
statistics to determine what challenges older adults still
experience.
U.S. Department of Transportation: Visual Field Loss
This project compared drivers with visual field loss to
those with normal vision on driving scenarios at the National
Advanced Driving Simulator. Participants with visual field loss
showed more variance in maintaining the driving lane on curves,
when leaving the simulated freeway, and when responding to
peripheral information.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigators: Linda Boyle, Ph.D., Principal
Investigator, Department of Mechanical and Industrial
Engineering, University of Iowa, Iowa City, Iowa 52242-1320;
Matthew Rizzo, Department of Neurology, College of Medicine,
University of Iowa, Iowa City, Iowa 52242-1320; Mark Wilkinson,
Department of Ophthalmology and Visual Sciences, College of
Medicine, University of Iowa, Iowa City, Iowa 52242-1320.
General Description: Vision is clearly essential for safe
driving. Deterioration in vision through normal aging, as well
as from eye diseases such as cataracts and macular degeneration
has been shown to be a major contributing factor in changes in
driving strategies and performance. Drivers, however, may not
always compensate for their deterioration appropriately,
resulting in higher crash risks.
The goal of this study was to use the National Advanced
Driving Simulator (NADS) to compare driving performance in
participants with peripheral visual field loss (VFL) and those
with normal vision. NADS is a high fidelity simulator that
simulates the visual, auditory and haptic feedback one would
experience during real world driving. The driving task was
designed to capture compensatory behaviors in drivers with VFL
such as increased head movements, eye scanning patterns, and
mirror use in addition to driving performance measures in the
simulator.
The results from this study indicate that, while VFL and
Control participants' performance was similar in most tasks,
there were a few significant differences in driving performance
measures between the groups. Participants with VFL exhibited
some difficulties with lane maintenance on curves and when
departing the freeway as well as a delay in responding to the
vehicle incursion, an unanticipated hazard that originated in
the periphery during the simulator driving task.
Excellence: What makes this project exceptional?
This project suggests a safety risk for driving for people
with a reduced field of vision. The study identifies several
driving conditions (curves, exit ramps) where drivers with VFL
may be at increased risk.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Deterioration in vision through normal aging is a major
contributing factor in changes in driving strategies and
performance. Drivers may not always compensate for their
deterioration appropriately resulting in higher crash risks.
Understanding the degree to which visual field loss impairs
driving will be helpful to older drivers.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research provides preliminary information about how
visual field loss may impact the safe driving of older people.
Innovativeness: Why is this research exciting or
newsworthy?
This research uses advanced simulator technology to examine
how older drivers who have certain visual impairments that
reduce the useable visual field perform on simulated driving
tasks. Findings from this study will be used to build a
taxonomy of driving scenarios that may increase crash risk, and
suggest countermeasures to compensate for visual loss.
U.S. Department of Transportation: Functional Ability and Crash Risk
This project identified screening tools that can be used in
an office-based setting to determine whether a driver might be
at risk for crashing. Results revealed that a focus on
functional ability rather than age was an effective way to
examine crash risk. Recommendations for driver licensing policy
reflect the importance of functional ability in assessing
fitness to drive.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Loren Staplin, Principal,
TransAnalytics, 1722 Sumneytown Pike, Kulpsville, PA 19443,
215-855-5830, lstaplin@transanalytics.com.
Partner Agencies: Maryland Motor Vehicle Administration.
General Description: This research project studied the
feasibility as well as the scientific validity and utility of
performing functional capacity screening with older drivers. A
Model Program was described encompassing procedures to detect
functionally impaired drivers who pose an elevated risk to
themselves and others; to support remediation of functional
limitations if possible; to provide mobility counseling to
inform and connect individuals with local alternative
transportation options; and to educate the public and
professionals about the link between functional decline and
driving safety-all within a larger context of helping to
preserve and extend the mobility of older persons.
Early in this project, a questionnaire was developed and
distributed to Driver License Administrators in the U.S. and
Canada to broadly determine cost and time parameters, while
identifying legal, ethical, or policy implications that could
influence implementation of Model Program activities.
Subsequently, a battery of functional tests was developed and
pilot tested in Motor Vehicle Administration sites, and in the
community. A database of scores on functional ability measures,
driving habits information, and crash and violation history was
created for over 2,500 drivers in three samples drawn from
license renewal, medical referral, and residential community
populations. Cost estimates for functional capacity screening
and related Model Program activities were developed for
research and production settings. A set of guidelines for motor
vehicle administrators was also produced to update the 1992
publication by NHTSA and AAMVA of the same title.
Excellence: What makes this project exceptional?
This research project is exceptional because it changed the
dialogue within the Department from age-based testing to
functional-ability based testing. The pivotal nature of this
shift is reflected in all subsequent NHTSA research projects
and in research conducted by outside organizations.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The change in perspective to functional abilities
influences the 29 million currently licensed drivers not only
in their dealings with their state's driver licensing
authorities, but with their medical providers, social services
providers, and law enforcement officers.
Effectiveness: What is the impact and/or application of
this research to older persons?
The findings from this investigation have been incorporated
into educational materials for all of the people who help
determine if an older driver is safe.
Innovativeness: Why is this research exciting or
newsworthy?
By shifting the thinking about safety from age to ability,
we have the opportunity to help older drivers stay behind the
wheel as long as they are safe to do so.
U.S. Department of Transportation: Infrastructure Safety
In March 2008, a team of nine transportation safety,
traffic engineering, and human factors experts from the U.S.
visited Australia and Japan to evaluate infrastructure
improvements designed to aid older road users. The scan tour
members sought policy options and initiatives regarding
transportation system planning, operations, and design as they
relate to older road users. The information obtained during the
trip identified several planning, design, and operational
changes which could be implemented in the U.S. to improve the
mobility and safety of older road users.
Lead Agency: U.S. (U.S.) Department of Transportation
(DOT), Federal Highway Administration (FHWA).
Agency Mission: FHWA is charged with the broad
responsibility of ensuring that America's roads and highways
continue to be the safest and most technologically up-to-date.
Principal Investigators: Elizabeth Alicandri (Co-Chair),
Director, Office of Safety Programs, FHWA, HSSP, E-71, Room
310, 1200 New Jersey Avenue, SE., Washington, DC 20590-9898;
Pamela Hutton (Co-Chair), Chief Engineer, Colorado Department
of Transportation, 4201 East Arkansas Avenue, Room 262, Denver,
CO 80222.
Partner Agencies: Federal Highway Administration, Florida
Metropolitan Planning Organization Advisory Council, Missouri
Department of Transportation, Texas Transportation Institute,
University of North Carolina Highway Safety Research Center,
and West Virginia Department of Transportation.
General Description: In March 2008, a team of nine
transportation safety, traffic engineering, and human factors
experts from the U.S. visited Australia and Japan to evaluate
infrastructure improvements designed to aid older road users.
The scan tour members sought policy options and initiatives
regarding transportation system planning, operations, and
design as they relate to older road users. The group met with
state and federal government transportation officials,
University research centers, and staff from motorists' clubs
and other non-governmental organizations interested in the
mobility of older people. Although the primary focus of the
scan was on infrastructure improvements, the team also learned
about policies for older road user training, assessment, and
licensing. In addition, general road safety programs were
discussed with all agencies visited. The majority of these
programs provided a benefit to older road users although they
may not have been designed specifically with this user-group in
mind. The converse of this is true as well; programs and
policies developed for older road user safety and mobility will
improve transportation for all users. The information obtained
during the trip identified several planning, design, and
operational changes which could be implemented in the U.S. to
improve the mobility and safety of older road users.
Major issues of interest included the following:
Infrastructure-based international best practices
that improve safety and mobility for older road users that
could be applied in the near term on U.S. roadways.
Policy approaches to improving infrastructure to
better meet the needs and capabilities of older road users.
Transportation planning policy initiatives to
address mobility of older citizens in terms of land-use,
transit, and other alternatives to driving. Policy approaches
to improving older driver assessment, licensing, and training.
Safety research collaboration opportunities
between international and U.S. transportation research centers.
Ways to improve U.S. and international practices
for long-term transportation planning for older road users.
Excellence: What makes this project exceptional?
This effort is part of a national program that allows
transportation experts in the U.S. the opportunity to meet with
and discuss the major roadway infrastructure design and
operational issues that are particularly related to the older
road user. It further provides a sound basis for evaluating the
potential effectiveness of the foreign best practices and
lessons learned in regard to the application of those findings
to older road users in the U.S.
Significance: How is this research relevant to older
persons, populations, and/or aging society?
FHWA has a multitude of programs that are devoted to the
integration of older road user needs involving the full
spectrum of transportation systems. However, the focus of this
project was primarily on the implementation of infrastructure
improvements for older road users. Many countries, including
the U.S. and Australia, have published documents detailing how
the physical, perceptual, and cognitive changes associated with
aging affect a person's ability to use the existing
transportation system. These documents include recommendations
for improvements to infrastructure and operations to address
the needs of older road users, but few have reported on the
successful implementation of these recommendations. This
project also investigated policy initiatives regarding
transportation system planning, operations, and design as they
relate to older road users. The role of older road users in
road safety programming, funding, prioritization and evaluation
were also discussed with all of the governmental agencies.
As a recent GAO report notes, knowledge sharing between the
U.S. and other countries can help the U.S. prepare for the
coming increase in the proportion of older road users as the
baby boom population moves toward retirement in the coming
years.
Effectiveness: What is the impact and/or application of
this research to older persons?
The success of this international scan can be measured by
the number of ideas brought back to the U.S. and translated
into strategies that will improve safety and mobility for older
road users. The following is a tentative list of items that
will be further studied for implementation in the U.S.
Enhancement of U.S. Roadway Design and Operations Practice:
Integrate the knowledge of infrastructure improvements from
Australia and Japan into relevant U.S. documents and training
programs.
Outreach to Non-Government Organizations:
Further the development of partnerships between government
agencies, such as departments of transportation and health, and
between government and non-government organizations to address
the needs of older road users.
Targeted Research Program:
Develop a research program on policies and interventions
targeted at older road users. The scope of program should cover
evaluation of specific interventions aimed at improving safety
and mobility for older road users, development of new
procedures and tools to aid practitioners in making decisions,
and sharing of information on best practices through synthesis
documents and professional conferences.
Establish Development Guidelines:
Develop planning and land development guidelines for
congregate housing and related transportation facilities and
services that are intended to meet the growing needs older
populations and older road users. The guidelines would be
developed to assist local governments and the development
community in the planning and retrofitting of existing
facilities, as well as to assist local governments in their
evaluation of land development proposals as it relates to older
populations and older road users. The proposal could become a
joint venture research project to be cooperatively developed by
national transportation and land development organizations.
Innovativeness: Why is this research exciting or
newsworthy?
Application of innovative and successful ideas used in
Australia and Japan.
Establish a dialogue between older road user experts in the
U.S. and Australia and Japan.
Sharing of findings with transportation experts and
practitioners in state DOTs, academia, industry, and
transportation associations.
U.S. Department of Transportation: Medications and Crash Risk
This study examined medical insurance databases to show the
relative frequency of various combinations of medications used
by drivers who had a motor vehicle crash, analyzing the
impairing effects of multiple medications, drug interactions,
and drug-disease interactions on motor vehicle crashes for
persons 50 years and older.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Aida A. LeRoy, Iatrogen, LLC, World
Gate IV, Suite 500, 12801 World Gate Drive, Herndon, VA 20170.
General Description: The main objectives of this study were
to determine the relative frequency of various combinations of
medications used by those who have experienced a motor vehicle
crash and those who have not by analyzing proprietary and non-
proprietary databases; and to conduct a case-control study of
possible associations between the use of medications (and
combinations thereof) and motor vehicle crashes among older
drivers.
The results of the study revealed an association between
the kinds and number of medications used by older adults and
the risk of involvement in a motor vehicle crash. Drugs known
to have an impairing effect on the driving ability of older
drivers were the most commonly used by older adults who had
been involved in crash. The case control analysis suggested an
association between crashes and many potentially driver
impairing (PDI) medications, diseases, and various combinations
of drugs and diseases.
Study subjects taking any medication were found to be 1.43
times more likely to be involved in a crash than older adults
taking no medications. Compared to patients taking no PDI
medications, those taking one or two PDI medications were 1.29
times more likely to be involved in a crash and that risk
increased to 1.87 more likely in patients taking three or more
PDI medications. The risk for patients with one or two PDI
diseases was 1.49 times greater than that for older adults
without any PDI diseases. Three or more PDI diseases further
increased the risk for crash involvement to 2.20 times that of
older adults with no PDI diseases. Drug interactions were also
associated with a statistically significant increased risk of
crash involvement (odds ratio of 1.47 for 1-2 drug interactions
and 1.92 for patients with 3 or more drug interactions).
The results of this analysis suggest that both the kinds
and number of medication exposures, and the characteristics of
diseases/disorders present among study subjects may predict an
increase in risk for crashes among older adults. By
demonstrating a potential link between multiple drug therapies
and crash involvement, this study highlights the need for a
more thorough examination of the relationships between drugs,
diseases, and the older driver, and the factors affecting aging
adults and driving ability.
Excellence: What makes this project exceptional?
This is the only available report that provides current
data on prescription medication use and its relationship to
vehicle crashes.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This report provides valuable information to drivers about
the potentially impairing effects that combinations of certain
medications and illnesses have on the ability to drive safely.
Older adults are more likely to take multiple prescription
medications past the age of 50.
Effectiveness: What is the impact and/or application of
this research to older persons?
The results of this research point to the need to develop
educational programs to increase awareness among health care
providers and older drivers about the potential driver
impairing effects of pharmaceutical use.
Innovativeness: Why is this research exciting or
newsworthy?
This research names drug classes and illnesses that are
common to older drivers that are potentially dangerous when
combined with the driving task. Data come from large medical
databases.
U.S. Department of Transportation: Airline Passenger Health
To address the concerns of age and health-compromised
airline passenger population, the FAA, Harvard university, and
the Boeing Company collaborated to evaluate the physiological
effects of normal cabin pressure on a passenger population that
included both healthy and less than healthy older subjects.
Lead Agency: Department of Transportation (DOT)--Federal
Aviation Administration (FAA), Office of Aerospace Safety
(AVS)--office of Aerospace Medicine (AAM).
Agency Mission: Federal Aviation Administration's mission
is to provide the safest, most efficient aerospace system in
the world.
Aviation Safety and the Office of Aerospace Medicine's
mission is to enhance aerospace safety through surveillance,
research, education, medical standards, and the prevention of
illness and injury.
Principal Investigators: John D. Spengler, Ph.D, Harvard
University, School of Public Health, 677 Huntington Avenue,
Boston, MA 02115; Dennis Burian, Ph.D, AAM-600, FAA Civil
Aeromedical Institute, P.O. Box 25082, Oklahoma City, OK 73125.
Partner Agencies: Air Transportation Airliner Cabin
Environment Research (ACER) Center of Excellence program, The
Boeing Company, Harvard University School of Public Health, FAA
Civil Aeromedical Research Institute, AAM-600.
General Description: The demographics of the US flying
population show that airline passengers are rapidly getting
older and increasingly have significant health problems. To
address the concerns of age and health in the passenger
population, the FAA (CAMI), Harvard University and the Boeing
Company collaborated under the FAA Center of Excellence (COE)
for Airliner Cabin Environment Research (ACER) program to
evaluate the physiological effect of normal cabin pressure
(7,000 ft altitude) on a passenger population that included
both healthy and less than healthy older subjects. This project
evaluated subjects older than 55 years of age and included
three test groups: a normal group, a group that had implantable
cardiac defibrillators (ICD group) and a group of heavy
smokers. The medical condition of the subjects and the
extensive physiological evaluation of the subjects made this
program one of the most complex ever conducted at the Civil
Aerospace Medical Institute.
Excellence: What makes this project exceptional?
The study group represents a flying population for which
little data regarding the risk of flight in commercial aircraft
has been gathered. It is the first altitude study that
addressed the health effects of cabin pressure on older
passengers with cardiac and respiratory disease.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The demographics of the US flying population show that
airline passengers are rapidly getting older and increasingly
have significant health problems. Flight in commercial aircraft
typically exposes passengers to oxygen levels commensurate with
6,000 to 8,000 ft altitudes. Previous studies of altitude
exposure have been performed at higher altitudes and/or used
subjects of a relatively young age. This study is investigating
the effects of cabin altitude exposure on 55- to 80-year-old
groups of subjects, healthy subjects with little overall health
impairment, cardiac patients with implanted defibrillators, and
smokers without other overt clinical symptoms.
Effectiveness: What is the impact and/or application of
this research to older persons?
Data gathered during the study includes changes in physical
measurements from prolonged periods of being seated,
physiological changes reflected in oxygen saturation, pulse and
respiration rates, plasma and serum markers for organ function,
cytokine markers of inflammation, and intracellular changes
measured by gene expression analysis. Cognitive test data and
mood/sleepiness surveys are also being collected to assess
neuropsychological effects of mild altitude exposure. The
results of the research will provide guidance to passengers
relative to commercial air travel.
Innovativeness: Why is this research exciting or
newsworthy?
The research complexity has not been accomplished in past-
related research and has never addressed the physiological
aspects of older and health-compromised passengers.
The functional genomics scientific field defines the future
of aerospace medicine.
U.S. Department of Transportation: The Physician's Guide
The Physician's Guide is a tool for medical professionals
to use to help their patients understand whether they are safe
drivers. It provides office-based screening tools, information
on the linkages between medical conditions, functional ability,
and crash risk, and information on referring drivers to each
state's driver licensing authority. The goal is to help drivers
maintain their ability to drive safely, and to transition
appropriately when they can no longer drive.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Joanne Schwartzberg, American
Medical Association, 515 N State Street, Chicago, IL 60610.
Partner Agency: American Medical Association.
General Description: The Physician's Guide to Assessing and
Counseling Older Drivers was created by the American Medical
Association (AMA) with support from the National Highway
Traffic Safety Administration (NHTSA) to help physicians
address preventable injuries--in particular, those injuries
incurred in motor vehicle crashes. Currently, motor vehicle
crashes are the number one cause of injury-related deaths in
the 65-74 age group. While traffic safety programs have been
successful in reducing the fatality rate for drivers under the
age of 65, the fatality rate for older drivers has consistently
remained high. Physicians are in a position to address and
correct this problem. By providing effective health care,
physicians can help their patients maintain a high level of
fitness, enabling them to preserve safe driving skills later in
life and protecting them against serious injuries in the event
of a crash. By adopting preventive practices--including the
assessment and counseling strategies outlined in this guide--
physicians can better identify drivers at increased risk for
crashes, help them enhance their driving safety, and ease the
transition to driving retirement if and when it becomes
necessary. Through the practice of medicine, physicians have
the opportunity to promote the safety of their patients and of
the public. The goal of the Physician's Guide to Assessing and
Counseling Older Drivers is to forge a link between public
health and medicine, and to provide doctors with the tools and
information they need to advise their patients about safe
driving.
Older drivers and their families consistently identify
physicians as the most credible source for information related
to a person's ability to drive. Unfortunately, physicians have
not historically had the tools to comfortably assist older
patients in making a determination about driving. This Guide
provides physicians with advice on how to screen a driver, how
to counsel a driver on maintaining their driving abilities and
to document conversations about driving. Developed with the
American Medical Association, the Guide brings their medical
expertise and methods regarding functional abilities and
screening to an educational tool that promotes to physicians
having conversations with their patients about safe driving.
Thousands of physicians from around the world have been trained
on the use of the guide. Teams from multiple states have
brought driver licensing and state medical societies together
to promote the use of the guide. In FY 2008, AMA and NHTSA have
renewed their support for the Guide and are issuing a revision.
The partners are also developing a computer-based course
designed to train medical residents on the use of the Guide. By
using the Guide, physicians can help countless older drivers
stay safer, longer.
U.S. Department of Transportation: Pilot Health Study
The FAA Aeromedical Research Program has included the study
of diseases such as atrial fibrillation and diabetes that
increase with age and their significance in aviation safety.
The research provides the basis for ensuring the opportunity
for aging pilots to continue to fly safely.
Lead Agency: Department of Transportation (DOT)--Federal
Aviation Administration (FAA)--Office of Aviation Safety
(AVS)--Office of Aerospace Medicine (AAM)--Civil Aerospace
Medical Institute (CAMI)--Aerospace Medical Research Division
(AAM-600).
Agency Mission: FAA: Federal Aviation Administrations
mission is to provide the safest, most efficient aerospace
system in the world.
Aviation Safety and the Office of Aerospace Medicine's
mission is to enhance aerospace safety through surveillance,
research, education, medical standards, and the prevention of
illness and injury.
Principal Investigator: Estrella M. Forster, Ph.D.,
Aerospace Research Scientist, FAA CAMI, P.O. Box 25082,
Oklahoma City, OK 73125.
Partner Agency: FAA CAMI Aerospace Medical Education
Division (AAM-400), National University of Colombia School of
Medicine.
General Description: Insulin is required to move glucose
into cells where it can be metabolized. Diabetes is a disease
in which the body is dysfunctional in the production or use of
insulin. While still under investigation, both genetics and
environmental factors appear to contribute to the development
of the disease. The International Diabetes Federation projects
the worldwide incidence of diabetes to climb from 5.1% in 2003
to 6.3% in 2025. It also estimates that the world adult
population (age 20-79 yr.) will be 5.3 billion by 2025. By
then, 333 million people will have diabetes. This figure
signifies an increase from 2003 of 1.2% in the prevalence of
world diabetes. The highest prevalence of diabetes is in the
North American Region, expected to reach 9.7% by 2025. In 2005,
more than 9,000 diabetic pilots were certificated by the
Federal Aviation Administration (FAA) medical certification
process.
Atrial fibrillation (AFIB) is an abnormal heart rhythm
characterized as irregular, disorganized, electrical activity
of the upper chambers (atria) of the heart. The atria quiver
instead of regularly beating which causes them to move around
300-600 times a minute (instead of 60-80 times a minute).
Because the upper chambers are quivering so rapidly, the blood
is not allowed to completely empty and causes pooling in the
atria. Atrial fibrillation affects approximately 2.2 million
adults in the United States and is the most common sustained
heart rhythm disturbance observed in clinical practice. The
rate of atrial fibrillation increases with age, from <1% among
persons aged <60 years to approximately 10% among persons aged
*80 years. Civil aviators with AFIB may, after the appropriate
examination and follow-up, receive a special FAA medical
issuance to enable flying status. By 2003, 2,446 diabetic
pilots were certificated by the FAA medical certification
process.
Worldwide aeromedical specialists have made significant
changes in the criteria for allowing individuals with diabetes
and atrial fibrillation to pilot aircraft. The progress that
continues in the treatment of these diseases (medications,
insulin pumps, tissue/organ transplantation), the monitoring of
diabetes (glycosylated hemoglobin, glucometers), and improved
diagnostic classification of the same (types 1 and 2), promise
to push the frontiers of safety concerns in the future. With
the rapid worldwide increase in the prevalence of diabetes,
especially type 2 diabetes, along with an increase in the
population age, more individuals with diabetes will be entering
the aviation system as pilots, flight crew, air traffic
controllers, and passengers. Likewise, the incidence of atrial
fibrillation will increase as the pilot population ages with
time. Each group of individuals with these conditions can
affect safety in aviation. Factors that are of interest to
assess the potential risk to aviation implied by these diseases
have included the progression of the condition, associated
pathologies, medications, flight experience, and accident/
incident events if any experienced throughout the pilot's
career. Thus, the aerospace medicine specialist will be relied
upon to make wise, scientifically based decisions that ensure
aerospace safety while simultaneously allowing individuals with
diabetes or atrial fibrillation to have the maximum latitude to
participate in aerospace activities.
Excellence: What makes this project exceptional?
The civilian pilot population is aging. Specific diseases
such as atrial fibrillation and diabetes increase dramatically
with age. Civilian pilots with these medical problems have been
considered a risk for flying because of the potential for
sudden in-flight incapacitation associated with the disease,
associated co-morbidity, and treatment. This research project
has allowed the FAA to develop an understanding of aging pilots
with the diseases and verify the medical certification
decisions that can allow them to fly longer and simultaneously
ensure safely.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
More than half of the 16 million Americans estimated to
have diabetes are over age 60. Of those over age 65, almost 1
in 5 has diabetes, mostly type 2. According to the American
Diabetes Association, approximately 18.3% (8.6 million) of
Americans age 60 and older have diabetes. The prevalence of the
disease increases with age; an estimated 50% of all diabetes
happens in those aged 55 and older. The risk of developing type
2 diabetes also increases with age. Atrial fibrillation affects
approximately 2.2 million adults in the United States and is
the most common sustained heart rhythm disturbance observed in
clinical practice. The rate of atrial fibrillation increases
with age, from <1% among persons aged <60 years to
approximately 10% among persons aged *80 years. Over the last
23 years there has been a continuous decline in the size of the
population of civil aviation pilots as well as an increase in
age of both male and female pilots. To maintain this pilot
population and ensure their medical certification as well as
their optimum flight performance, this research was conducted
to increase our understanding of aging and its relationship to
medical conditions that may render a pilot unable to safely
continue his or her flying activities. As a pilot grows older
medical problems that include atrial fibrillation and the
current epidemic of type 2 diabetes become extremely important
to understand so as to assess the potential risk to aviation
implied by these diseases. The information gained from this
line of research effort will expand the FAA's understanding
these diseases and will assist in medical certification
decision-making processes involving the U.S. aging pilot
population.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research increases the opportunities for pilots in
both private and commercial aviation to continue the safe
participation in flying as they age, even when medical problems
associated with aging are present. Diseases that have a greatly
increased frequency with increasing age and were once totally
disqualifying can now be carefully managed through proper fact-
based medical certification that ensures individual and public
safety. The cardiac problem of atrial fibrillation is a growing
public health problem especially in our aging population. The
incidence of atrial fibrillation in the United States currently
is estimated at 2.3 million with a projection to increase to
5.6 million by 2050. Atrial fibrillation is associated with
increased risk of stroke, heart failure, cognitive dysfunction,
and premature death and has enormous socioeconomic
implications. Glucose tolerance progressively declines with
age, and there is a high prevalence of type 2 diabetes and the
potential for sudden incapacitation associated with diabetes,
its co-morbidity, and its treatment. Such problems are of
specific concern for flight safety, especially with a pilot
population that is increasing in age. Medical certification
decision making in aging pilots with problems that increase
with age is challenging but armed with fact-based research
knowledge continued optimum flight performance of aging pilots
can be accomplished while meeting the aviation safety goals of
the agency.
Innovativeness: Why is this research exciting or
newsworthy?
The FAA is making it possible for the pilots in our aging
population to enjoy and earn a living flying for more years,
even with disease processes (such as cardiac disease and
diabetes that increase as humans age) and to do it safely. The
development and utilization of the unique FAA Scientific
Information System strengthens the National Aerospace System's
medical research infrastructure and advances collaborative data
collection efforts. The research represents the first aerospace
medical research that integrates several fields of study
relative to toxicology, biochemistry, medicine, accident
investigation, functional genomics, and sophisticated
bioinformatics' data analysis methods. The SIS unique database
and analysis system enables the comprehensive review of almost
20 million electronic medical records from 2.5 million pilots
who were issued medical certificates between 1983 and 2005 and
demonstrates a successful application of Safety Management
Systems concepts. The research results provide the required
fact-based knowledge to make aging pilot medical certification
decisions that ensure safety while expanding the aging and
disease related envelope.
U.S. Department of Transportation: Medications and Driver Safety
This project examined the driving safety of older adults
who take multiple medications, comparing Occupational
Therapists' driving assessments with in-vehicle video
recordings of daily driving by older adults to assess safety
risk.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Loren Staplin, TransAnalytics, LLC,
1722 Sumneytown Pike, Box 328, Kulpsville, PA 19443.
Partner Agency: University of North Carolina Highway Safety
Research Center.
General Description: The use of medications and multiple
medications becomes more prevalent with increasing age. This
pilot study explored the relationship between polypharmacy and
driving functioning through separate but related research
activities. A patient-level administrative claims database
containing prescription information as well as E-codes
identifying the incidence of motor vehicle injuries was mined,
yielding combinations of drugs that became inclusion criteria
in a field study of driver performance among 44 older adults
(range: 57 to 89; mean: 79). Measures included driving
performance evaluations by an Occupational Therapist/Certified
Driving Rehabilitation Specialist, a brake response time
measure, and functional screening measures for the study
sample, whose drug profiles were documented through a ``brown
bag'' review by a licensed pharmacist. Descriptive data
summaries and regression analyses examined the relationship
between medication usage and each of these outcome measures.
Additional project activities included a current (to
October 2007) review of the literature on the prevalence of
prescription medications and effects on driving of specific
drugs and drug classes. The feasibility of conducting future
studies using large, administrative claims databases was
critically examined, with an overview of candidates and
evaluation of their suitability for NHTSA research.
Excellence: What makes this project exceptional?
This project developed a methodology to examine the effects
that talking multiple medications has on the ability of older
adults to drive safely. Combinations of medications were
selected using a patient-level administrative claims database
linked to crash codes.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This study provides a potential alternative methodology for
assessing driver functionality by using in-vehicle video
cameras that collects objective driving behavior information to
examine how these drivers perform under daily driving
conditions.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research provides important information to older
drivers on the risks associated with taking certain medications
and driving and for older driver specialists such as
Occupational Therapists or Certified Driver Rehabilitation
Specialists who may be conducting remedial driver training.
Innovativeness: Why is this research exciting or
newsworthy?
This research uses in-vehicle technology to examine how
older drivers taking multiple medications drive under their
normal daily conditions and compares it to how they drive
during a driving assessment administered by an occupational
therapist. There are differences in how they drive under these
circumstances.
U.S. Department of Transportation: Driver Self Screening
This project developed and tested a self-screening
instrument for older drivers focused on health concerns that
affect driving. It found the instrument useful as a first-tier
screening tool for drivers 75 and older.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA).
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: David W. Eby, Research Associate
Professor and Head, Social and Behavioral Analysis Division,
University of Michigan Transportation Research Institute, 2901
Baxter Road, Ann Arbor, MI 48109-2150.
Partner Agency: University of Michigan.
General Description: The purpose of this project was to
improve upon existing self-screening instruments for older
drivers by focusing entirely on ``health concerns'' that affect
driving--that is, the symptoms that people experience due to
medical conditions, the medications used to treat them, and the
general aging process. The objective was to create an easy-to-
use self-screening instrument. The instrument identifies health
symptoms experienced by the driver that relate to declines in
driving abilities, and provides individualized feedback to the
driver about those health conditions and what can be done to
continue driving safely. The study included a literature
review, deliberations by an expert panel, instrument
development, and an evaluation/validation study.
The literature review generated a list of health concerns
that might influence driving and a list of critical driving
skills. The expert panel finalized the lists of health concerns
and critical driving skills to include in the instrument;
discussed how severity levels of the health concerns influence
critical driving skills; and considered the content of the
self-screening instrument's feedback. Based on earlier project
activities, 27 health concerns and 15 critical driving skills
were included in the instrument.
Results of the validation study showed that drivers who had
a greater number of health concerns as identified by the self-
screening instrument also tended to have poorer observed
driving performance. In addition, drivers who had a greater
number of health concerns as identified by the instrument also
tended to have greater deficits in driving-related abilities as
identified by an occupational therapist. These relationships
were true only for subjects 75 and older, not for those 65-74.
Excellence: What makes this project exceptional?
It is well-established that aging can lead to declines in
perceptual, cognitive, and psychomotor functions. Accurately
assessing declines in driving abilities and relating them to
increased crash risk has been a goal of traffic safety
professionals for many years. This project provides promising
self-screening driving ability tools.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
There are several benefits of self screening: reluctant
drivers may be more willing to assess their own driving
abilities than to be professionally assessed; people may
discover declines at an earlier stage; and self screening
instruments can reach a wide variety of people because such
instruments are easily distributed.
Effectiveness: What is the impact and/or application of
this research to older persons?
This project provides five types of individualized feedback
for drivers: general awareness of how certain health concerns
can affect driving; self awareness about individual health
concerns and driving skills that may be declining;
individualized recommendations for behavioral changes to
maintain safe driving; individualized recommendations for
further evaluation; and individualized recommendations for
vehicle modifications to maintain safe driving.
Innovativeness: Why is this research exciting or
newsworthy?
The results of this project suggest that the instrument may
be a useful and valid self-screening instrument for older adult
drivers 75 and older.
U.S. Department of Transportation: Improving Our Nation's
Transportation System
The FHWA has revised the national standards for traffic
signs, signals, and markings to require these devices to be
bigger, brighter, more conspicuously located, and more
appropriately operated, in order to better meet the unique
needs of older people.
Lead Agency: U.S. Department of Transportation/Federal
Highway Administration (FHWA).
Agency Mission: Improve mobility on our Nation's highways
through national leadership, innovation, and program delivery.
Principal Investigator: Hari Kalla, MUTCD Team Leader,
Federal Highway Administration, HOTO-1, 1200 New Jersey Avenue,
SE., Washington, DC 20590.
General Description: FHWA is helping to improve the
nation's transportation system so that our increasingly older
population can safely travel and maintain productive and
independent lifestyles well into their senior years. With
increasing age, older persons often find driving more hazardous
and difficult as a result of vision problems, cognitive
limitations, side effects of medications, slower reaction
times, muscular difficulties, and other causes. Older citizens
also tend to walk at a slower pace and will continue to face
challenges in crossing busy streets and highways on foot.
The FHWA is responsible for developing and regularly
updating the Manual on Uniform Traffic Control Devices (MUTCD).
Traffic control devices are the signs, signals, pavement
markings, and other features that regulate, warn, and guide the
traveling public as they traverse our Nation's most vital
asset--its transportation system. Serving such a critical role
requires a uniform set of cues to travelers so that those
devices appear the same no matter where people travel
throughout the United States. The MUTCD is, by law, the
national standard governing all traffic control devices
installed by State and local jurisdictions on all streets and
highways open to public travel. With efforts that started in
2001 and are continuing through the present, the FHWA has
revised the MUTCD standards to better serve the needs of older
drivers and pedestrians by increasing the visibility of traffic
control devices, improving advance notification of traffic
situations and roadway patterns, and simplifying decision
making at intersection and interchange approaches.
In 2003, the FHWA issued a new edition of the MUTCD to
include a variety of new requirements designed to aid older
drivers and pedestrians. These included larger lettering on
street name signs to enhance readability, required use of
advance street name signs that inform drivers of upcoming
intersections, timing of pedestrian signals to provide longer
times for pedestrians to cross, introduction of optional
pedestrian countdown signal displays to inform pedestrians of
the number of seconds left to complete crossing the roadway,
and many other traffic control device enhancements.
In 2008, the FHWA initiated rulemaking to make further
changes to the MUTCD aimed at enhanced safety and mobility for
older citizens. One such change is a proposed increase in the
sizes of many signs to meet the legibility needs of drivers
with 20/40 corrected vision, the minimum in most states to
obtain or keep a driver's license. Based on research showing
better understanding by older drivers, a new, clearer
diagrammatic guide sign design featuring an upward arrow above
each lane has been proposed for standard use in some complex
highway situations. Also, a slower walking speed is proposed
for timing pedestrian crossing signals, to better accommodate
the increasing numbers of slower-walking individuals, including
wheelchair users. The FHWA has also proposed to change the
existing option of using pedestrian countdown displays to a
requirement for use with all pedestrian signals.
Excellence: What makes this project exceptional?
This project is exceptional because of its far-reaching
effects in upgrading the safety and convenience of older people
as drivers and as pedestrians. No other single project can
claim to have such direct, everyday positive impacts on the
mobility of older persons.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This project is relevant to all of the many millions of
older persons who drive or walk as a part of their daily lives.
The signs, signals, and markings older drivers and pedestrians
rely on for their safe and convenient mobility have been and
continue to be enhanced to better meet the needs of older
persons and the physical effects of increasing age, such as
declining vision, reaction times, and walking speeds.
Effectiveness: What is the impact and/or application of
this research to older persons?
The FHWA has revised the standards to increase the
visibility of traffic control devices, improve advance
notification of traffic situations and roadway patterns,
simplify decision making at intersection and interchange
approaches, and provide more time and better information to
pedestrians to aid their ability to cross streets. By upgrading
the nation's standards for traffic control devices, our
increasingly older population can safely travel and maintain
productive and independent lifestyles well into their senior
years.
Innovativeness: Why is this research exciting or
newsworthy?
This project is newsworthy and exciting because of the far-
reaching, direct impacts on the vast majority of the increasing
population of older people who wish to maintain their mobility
as drivers and pedestrians.
U.S. Department of Transportation: Taxonomy Project for Excellence
A Taxonomy Table will be developed that cross-references
driver performance errors to age-related functional deficits,
providing new insights into risk factors for older drivers.
This will be augmented with evaluations of behavioral
countermeasures to reduce crash risk for this group.
Lead Agency: U.S. Department of Transportation, National
Highway Traffic Safety Administration (NHTSA)
Agency Mission: Save lives, prevent injuries and reduce
economic costs due to road traffic crashes through education,
research, safety standards and enforcement activity.
Principal Investigator: Loren Staplin, Ph.D.,
TransAnalytics, LLC, 1722 Sumneytown Pike, Box 328, Kulpsville,
PA 19443.
Partner Agency: University of North Carolina Highway Safety
Research Center.
General Description: The project's objectives are to
identify risky behaviors, driving habits, and exposure patterns
that have been shown to increase the likelihood of crash
involvement among seniors, and to classify these crash
contributing factors according to a set of underlying
functional deficits specific to or more prevalent among older
people. Deficits may result from normal aging, age-related
medical conditions, or medication use. A further goal is to
identify and critically examine behavioral countermeasures with
the potential to mitigate functional loss and/or diminish the
occurrence of risky behavior(s)--and thus ameliorate crash
problems among older drivers.
The centerpiece of this project will be the development of
a Taxonomy Table that captures critical relationships between
topics and subtopics highlighted in the project literature
review and crash database analysis (FARS and GES). This table
is expected to contain entries describing:
Risky driving behaviors/driving errors
associated with older driver crash involvement;
Operational factors and conditions under
which driving errors are most likely to occur;
General and specific functional deficits
that have been identified as underlying causes of
driving errors and crash risk;
Behavioral countermeasures that have been
developed to address specific functional deficits and/
or associated risky behaviors;
Countermeasure evaluations, where they
exist.
Age-related functional losses in specific vision,
cognition, and physical abilities that have a demonstrated
relationship to increased crash risk for older drivers will be
listed. These will be followed by the driving behaviors
identified in the database analysis and literature review that
are associated with increased crash risk in this population.
Excellence: What makes this project exceptional?
The continuing growth of the older driver population
dictates a need to revisit and expand upon the base of
knowledge documenting older drivers' functional declines in the
abilities needed to drive safely. Contemporary investigations
into factors contributing to older driver crashes, together
with an update of research describing how age-related
functional changes translate into specific driving errors, will
provide valuable input to evaluations of the effectiveness of
existing behavioral countermeasures and to the development of
improved strategies to enhance older driver safety and mobility
in the future.
Significance: How is this research relevant to older
persons, populations and/or an aging society
This project is exceptional because its main product, the
Taxonomy Table, will be a resource that provides at-a-glance,
state-of-the-knowledge practical and research-based information
to assist researchers, health care practitioners, and others
concerned about older drivers to identify particular risk
factors, and what can be done to reduce the risk.
Effectiveness: What is the impact and/or application of
this research to older persons?
Equipping individuals with strategies and tactics to help
them safely negotiate problem situations should enhance older
driver safety and mobility.
U.S. Department of Veterans Affairs: The Oregon Brain Aging Study
The Oregon Brain Aging Study focuses on healthy brain aging
to determine factors that may confer resistance to cognitive
decline in aging. ``Average healthy'' oldest old were found
more resistant to dementia at advanced age than those
``exceptionally healthy.
Lead Agency: U.S. Department of Veterans Affairs (VA),
Veterans Health Administration (VHA).
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: William Goldberg, PhD, 810 Vermont
Ave NW., Washington DC 20420.
Partner Agency: National Institutes of Health/National
Institute of Aging (NIH/NIA)
General Description:
OREGON BRAIN AGING STUDY
The Oregon Brain Aging Study is a longitudinal study
focused on factors associated with healthy brain aging. Current
research questions are directed toward establishing biomarkers
of brain aging protection associated with a recently
identified, resistant to cognitive decline phenotype among the
oldest old, and determining how these biomarkers map to rates
or trajectories of functional decline prior to the emergence of
dementia. Finally, the study ultimately focuses on establishing
whether the resistive phenotype of cognitive decline and brain
aging is associated with distinct neuropathology.
Subjects enrolled in the longitudinal aging study are
followed semiannually with standardized clinical, cognitive and
volumetric Magnetic Resonance Imaging (MRI) to mark the
trajectories of the healthy aging cohorts who are more or less
resistant to developing mild cognitive decline. The accelerated
atrophy associated with incipient cognitive impairment will be
tracked with annually obtained biomarkers that have been shown
to be associated with relevant age-related neuropathology in
elderly subjects. Subjects will be followed to autopsy. Post
mortem examination will be used to correlate common age-
associated pathologies (e.g., neuritic plaques, neurofibrillary
tangles, micro infarcts) with rates of volume loss established
with Magnetic Resonance Imaging, as well as the change in
peripheral biomarkers.
Standardized clinical examinations and psychometric tests
are used to identify trajectories of cognitive and functional
change over time. Volumetric Magnetic Resonance Imaging is used
to measure the rates of atrophy characterizing subjects
destined to develop cognitive impairment compared to those
relatively resistant to decline. Biomarkers of plasma amyloid,
antioxidant stress (F2- isoprostanes), vascular disease and
brain damage (24S- hydroxycholesterol, plasma lipids,
homocysteine) are measured annually and examined for their
change relative to MRI established brain atrophy and cognitive
decline. Post mortem brain examination will follow a
standardized histopathological protocol and the coding system
of the National Alzheimer's Consortium.
Findings/Progress to Date: A cohort of average healthy
oldest old have been discovered to paradoxically be more
resistant to developing dementia at advanced age relative to an
exceptionally healthy age-matched group. This suggests a human
aging phenotype associated with the phenomenon of hormesis
where chronic, non-lethal stressors may precondition the brain
to be more capable of resisting insults than naively aging
brains. Those relatively resistant to cognitive decline have a
two phase acceleration of age-associated brain loss (on MRI)
prior to developing cognitive decline such that there is a long
premonitory period of accelerating loss followed by a more
rapid phase of volume loss occurring approximately 2-3 years
prior to apparent cognitive decline. This newly identified
trajectory provides the opportunity to map plasma biomarkers as
they emerge over time to detect signals of possible mechanisms
associated with the earliest stages of neurodegeneration
leading to cognitive decline. To date, plasma biomarkers have
been collected on 96 individual subjects and are undergoing
assay analysis.
Excellence: What makes this project exceptional?
Following a group of initially healthy aging subjects over
time with semiannual standardized clinical examinations and
psychometric tests that are used to identify trajectories of
cognitive and functional change.
Significance: How is this research relevant to older
person, populations and/or an aging society?
This study will establish the different characteristics of
neuropathology in two groups of healthy oldest old patients,
those that do and do not develop dementia.
Effectiveness: What is the impact and/or application of
this research to older persons?
This study will establish biomarkers in blood that may
predict early stages of neurodegeneration leading to cognitive
decline. The identification of these biomarkers, in aged
individuals with and without the development of dementia, may
also provide insights to the mechanism(s) that contributes to
the normal and abnormal brain aging.
Innovativeness: Why is this research exciting or
newsworthy?
To date, there are no reliable blood biomarkers that can
predict the development of dementia. With the identification of
these biomarkers, it will be possible to identify individuals
in the very early stages of the development of dementia. Early
diagnosis is important for physicians to identify treatable
causes of dementia, to effectively manage dementia and related
illnesses, and to offer support services to the patient and
family.
U.S. Department of Veterans Affairs: Risk Factors for Cardiovascular
Diseases
A sedentary lifestyle, high calorie-fat diets and genetic
susceptibility increase obesity, diabetes and cardiovascular
disease risk with aging. These can be modified by disease-
specific exercise and dietary interventions to improve health
and function in the elderly.
Lead Agency: Department of Veterans Affairs.
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: Andrew P. Goldberg, M.D., Director,
Baltimore GRECC, Baltimore VA Medical Center, Geriatrics
Service/GRECC (BT/18/GR), 10 N. Greene Street, Baltimore, MD
21201-1524.
Partner Agency: University of Maryland, Veterans Health
Administration, Baltimore Geriatric Research, Education and
Clinical Center.
General Description: Aging research at the Baltimore VA
GRECC examines the hypothesis that physiological declines in
cardiovascular and metabolic function that accelerate
cardiovascular disease (CVD) risk are predominately related to
the influence of genetic susceptibility, a sedentary lifestyle
and obesity-and that these can be effectively modified by
exercise and dietary interventions. Research designed to modify
CVD risk investigates (1) the effects of exercise and weight
loss on CVD risk, (2) genetic predictors of disease, and (3)
functional and health outcomes of structured exercise in
chronic stroke. A multidisciplinary team leverages resources
from six National Institutes of Health (NIH) and VA centers of
excellence to conduct patient-oriented translational research
and clinical trials in genetics, exercise and low-calorie
feeding that translates basic science research into clinical
practice to improve the health, function and quality of life in
older Americans.
Our research demonstrates that structured exercise and diet
interventions modify fundamental biological processes that
underlie diabetes and obesity in advancing age. GRECC
researchers examine the molecular, cellular and genetic
mechanisms by which fat produces inflammatory proteins and
muscle accumulates fat in type 2 diabetes and obesity, and how
these disease processes are reduced by exercise and weight
loss. The clinical translation exercise and weight loss program
in the VA--Managing Obesity for Veterans Everywhere (MOVE!)
improves exercise capacity, functional performance and body
composition to reduce diabetes and CVD risk. Research studies
examining the molecular, genetic and physiologic basis of these
improvements allow translation of basic mechanisms and novel
rehabilitation techniques into effective treatment, prevention
and rehabilitation modalities.
Researchers examine the genetic and environmental causes of
adult onset diabetes in the genetically homogeneous ``Founder
Old Order'' Amish population, ideal for studies of CVD-related
diseases. The Amish are as obese as the U.S. population, but
have half the prevalence of type 2 diabetes due to high levels
of physical activity. Amish subjects who are genetically
susceptible to weight gain reduce risk of obesity through
physical activity, suggesting genetic risk of obesity is
modifiable through healthy lifestyle choices. We have been able
to identify several common gene variations that are associated
with diabetes and metabolic syndrome. Extensions of these
genetic studies have identified new genes for hypertension,
hyperlipidemia, uric acid, and glucose levels that are under
exploration in other US populations at high risk for CVD.
Stroke results in chronic impairments in walking and
balance that limit functional independence and physical
activity, even years after conventional rehabilitation care.
This increases risk for diabetes and recurrent stroke. We
developed a model of ``task-oriented'' treadmill training that
facilitates recovery of walking by activating subcortical brain
networks, while providing aerobic exercise to improve
cardiovascular health and fitness in chronic stroke. This
program improves glucose metabolism to reduce diabetes risk and
reverse its prevalence in over half of exercising subjects.
Hence, treadmill training offers a new approach for
rehabilitation of older stroke victims that improves their
health and function, and decreases the risk for diabetes and
recurrent stroke.
Excellence: What makes this project exceptional?
This program is exceptional because it provides a unique
interface between basic science and clinical medicine to
advance knowledge into new approaches for the diagnosis and
treatment of CVD risk factors and disability conditions
prevalent in older people. There is an enriched environment of
interdisciplinary collaboration in ``bench to bedside''
research among GRECC investigators that examines the cellular,
molecular and genetic mechanisms by which lifestyle
interventions reduce CVD risk and improve functionality. This
in turn prevents obesity and diabetes-associated CVD and
stroke-associated disability. The conceptual model posits that
multiple physiological systems and genes interact to determine
the long-term cardiovascular health and functional independence
of older individuals. This multidisciplinary approach leverages
resources across multiple NIH and VA centers of excellence to
bring a basic science outlook to the design of novel structured
physical activity and exercise rehabilitation interventions.
Our goal is to prevent and treat diabetes, cardiovascular
disease and disability conditions to promote recovery in older
Americans living with chronic diseases and disability.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Aging and a sedentary lifestyle are associated with an
increasing prevalence of overweight and obesity. These place
older adults at greater risk for the development of diabetes,
CVD, functional impairments and disability. Innovative research
that translates interventions to the community will increase
physical activity and promote weight loss. This has the
potential to decrease morbidity and mortality and improve
quality of life in older adults with chronic CVD. GRECC genetic
research demonstrates the value of genetic screening to
identify susceptibility to disease. It also identifies who are
most likely to experience health benefits from exercise and
diet interventions. This will advance the science of
rehabilitation research in aging, leading to new discoveries to
identify, prevent and treat disease to reduce risk for frailty
and prolonged disability requiring long-term care. Our programs
provide hope and empower older Americans living with diabetes,
CVD and stroke to combat their chronic disability and improve
their health and well-being through exercise and dietary
lifestyle modification.
Effectiveness: What is the impact and/or application of
this research to older persons?
Our exercise training models are highly effective in
improving cardiovascular fitness, strength and muscle mass, and
glucose regulation to reduce CVD risk in older Americans living
with diabetes, obesity and stroke. We thereby are enhancing the
maintenance of functional independence even years after
diagnosis. Routine clinical management of older adults with
obesity, diabetes, CVD risk factors and disability associated
with stroke do not provide resources for sustained or disease-
specific exercise or nutritional interventions that are needed
to improve long-term health outcomes in the elderly. Our
research shows a synergy between exercise and dietary
interventions to optimize CVD risk modification for diabetes,
obesity and aging-related disability conditions. This research
provides data for evidence-based translation into the clinical
setting to develop national guidelines for disease, disability
and age-specific exercise and dietary recommendations for older
Americans.
Innovativeness: Why is this research exciting or
newsworthy?
GRECC researchers have presented novel findings at the
Institute of Medicine that task-oriented treadmill training
which combines ``motor learning'' with aerobic exercise
mediates brain plasticity to enhance mobility function, while
improving fitness and reversing diabetes in older chronic
stroke patients, even decades after the stroke. In 2008, these
findings will be incorporated in National Academies of Science,
Evidence-Based Guidelines for Physical Activity for All
Americans. These guidelines requested by the Secretary for
Health and Human Services, include the evidence for
effectiveness of physical activity in aging, chronic diseases
including diabetes and obesity, and disability including
stroke, will form the basis for new models of care.
Genetic screening may allow us to target disease-specific
interventions to subjects most likely to respond with
improvements in functional performance and cardio metabolic
health, even older people with multiple chronic medical
comorbidities and stroke. GRECC scientists investigate basic
science mechanisms at the cellular and molecular level for
these physiologic adaptations. This will generate new knowledge
and technologies to provide the scientific foundation and
rationale for the incorporation of disease-specific exercise
and dietary approaches for the prevention and treatment of CVD
and related disabilities into clinical practice.
U.S. Department of Veterans Affairs: Brain Monitoring Research
This research is defining how to monitor and classify the
brain dysfunction that occurs in 70 percent of critically ill
patients, determining its epidemiology in the aging population
at risk for ICU admission, and the role that sedatives and
analgesics play in causing these debilitating deficits.
Lead Agency: U.S. Department of Veterans Affairs.
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: Kenneth Shay, DDS, MS, Director of
Geriatric Programs, Office of Geriatrics and Extended Care
(114), Department of Veterans Affairs, 810 Vermont St., NW.,
Washington, DC 20420.
Partner Agency: Alliance for Aging Research (AFAR), John A.
Hartford Foundation, National Institutes of Health; National
Institute on Aging (NIH/NIA), Veterans Health Administration,
Tennessee Valley VA Health Care System.
General Description: This research is the outgrowth of an
unmet need in critical care medicine regarding the exceedingly
common occurrence of (a) delirium (acute brain dysfunction)
among patients, predominantly of advanced age, treated in
intensive care units (ICU) and (b) the associated long-term
cognitive impairment that occurs in over half of ICU survivors.
Every day, over 40,000 ICU patients in the United States alone
are suffering from delirium. This problem is getting larger
every year due to the aging of the population and the immense
growth of critical care beds. Traditionally, ICU delirium was
called ``ICU Psychosis,'' and professionals had erroneously not
thought it to be clinically significant.
Using clinical tools designed and validated through the VA
Geriatric Clinical Research Education Clinical Center (GRECC)
and at Vanderbilt University, the ICU Delirium and Cognitive
Impairment Study Group (www.icudelirium.org) has now shown that
delirium is associated with a tripling of the risk of death
within 6 months of ICU admission. They have further shown that
delirium occurs in about 50 to 80 percent of ICU patients. Even
considering other factors such as age, severity of illness,
duration of coma, and the use of psychoactive medications,
every day spent in delirium by ICU patients was associated with
a 10 percent higher risk of death and a 35 percent increased
risk of long-term cognitive impairment among survivors. The
occurrence of ICU delirium is also associated with dramatically
higher hospital costs of over $25,000 U.S. dollars per patient
when comparing those with mild vs. severe courses of delirium,
and this doesn't include the added costs and family burden of
having patients unable to return home due to the ongoing
neuropsychological deficits that we are finding in the majority
of younger and especially older survivors. We are only now
learning about the relationships between the ICU delirium and
the longer-term neuropsychological problems that plague ICU
delirium survivors.
Awareness of these issues is reaching a tipping point among
the medical and lay community. Thousands of ICUs around the
world are now implementing routine bedside monitoring of all
ICU patients for arousal levels and delirium based on the above
mentioned facts. In addition, there is growing interest in
post-ICU specialty clinics to help patients and families deal
with the unique constellation of acquired problems involved in
returning to a functional and whole human being. The tools
available from this research (e.g., a sedation scale called the
Richmond Agitation-Sedation Scale (RASS) and a well-validated
and easy to conduct delirium instrument called the Confusion
Assessment Method-ICU (CAM-ICU), as well as a new ``wake up and
breathe ABC sedation protocol'' that is proven to save 1 life
for every 7 patients so treated) have been translated into over
14 languages and international guidelines have recommended
delirium monitoring as standard of care. Ongoing clinical
trials are now exploring the safest and most effective ways to
prevent and treat ICU delirium in hopes that treatment will not
only reduce delirium but also the high morbidity and mortality
associated with it.
Excellence: What makes this project exceptional?
Every day, 30,000 to 40,000 people in ICUs are suffering
from delirium with potential devastating, long-lasting effects
on how their brain will work and a higher chance of death. Once
doctors and nurses in the ICU are aware of this problem, they
can look out for it, perform simple bedside tests and take
steps to reduce or maybe prevent it. The longer a person is
delirious, the more likely they are to die.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Critical Care Medicine is a young field of Medicine, with
early ICUs in this country appearing in the 1960s and not
routinely being available in most hospitals until the 1970s.
Survival rates for many critically ill conditions have shown
striking increases, even without evidence of clinical trials of
specific therapies showing objective benefits. Many more
critically ill patients are now surviving and, in the last
decade, it has become clear that these survivors of critical
illness have a burden of illness that was previously
unrecognized. This was first demonstrated by studies of the
self-assessed quality of life in ICU survivors. Initially this
finding was puzzling as the function of the failing organ
resulting in critical illness often (usually) returned to
normal or near-normal. This has been best studied in patients
with acute lung injury (often only the most prominent and most
severe clinical manifestation of multiple organ failure) where
lung function returns to normal or near normal within 6 months
whereas significant decrements in health-related quality of
life persisted for years.
Subsequent work has demonstrated that the most severe
abnormalities in these critical illness survivors are in three
related areas: neurocognitive deficits; psychological disorders
(depression, post-traumatic stress disorder and other anxiety
conditions); and neuromuscular abnormalities. We call this the
post-ICU syndrome. Again, in the case of acute lung injury
patients, a careful study showed that the majority of patients
at one year following ICU discharge had neuropsychological
abnormalities and 100 percent had significant neuromuscular
complaints accompanied by objective findings. It would be
difficult to over-exaggerate the magnitude of this problem; it
is clearly one of public health importance. One of the major
issues is that no medical discipline has owned this problem and
taken responsible action on it. Although it came to light
largely through the efforts of critical care investigators,
critical care physicians rarely follow these patients once they
leave the ICU. Primary care physicians, who will be following
the great majority of these victims, are almost completely
unaware of these abnormalities and they usually go
unrecognized. Finally, rehabilitation specialists and
psychiatrists have not been aware of these morbidities nor
involved in their evaluation or management in any meaningful
and organized way.
Effectiveness: What is the impact and/or application of
this research to older persons?
This work will define the approach over the next 30 to 40
years to preserving the minds of the millions of older patients
who plan to live productive and functional lives well into
their 80s and 90s but who, along the way, will have to sustain
care in an ICU for some length of time as they overcome an
unexpected critical illness.
Innovativeness: Why is this research exciting or
newsworthy?
In summary, the problem of post-ICU syndrome is one of
public health proportions, has enormous clinical, economic and
societal consequences, and yet the problem is largely
unrecognized or is being ignored by the medical community. This
is a problem which is ripe for attention and intervention, and
yet interventions are not going to be funded through the NIH
RO1 mechanism. The science of each of the components of the
morbidity is not mature, an intervention would by necessity be
complex, and preliminary data regarding interventions are
lacking; combined, these result in a kiss of death for
conventional NIH funding mechanisms, ensuring that the problem
will continue over decades. A fresh, innovative, necessarily
``high-risk'' approach is required to jump start therapeutic
solutions to this immense health problem.
U.S. Department of Veterans Affairs: Reducing the Risk of Dementia
This work explores the relationship between insulin
resistance and the development of cognitive impairment and
dementia in older adults. The team now is examining therapeutic
strategies for reducing the risk of dementia and reducing
cognitive impairment.
Lead Agency: U.S. Department of Veterans Affairs (VA),
Veterans Health Administration (VHA), Veterans Affairs Puget
Sound Health Care System.
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: Suzanne Craft, Ph.D., Associate
Director, Geriatric Research, Education and Clinical Center,
Veterans Affairs Puget Sound Health Care System, Professor of
Psychiatry and Behavioral Sciences, University of Washington
School of Medicine, GRECC S-182, VAPSHCS, 1660 South Columbian
Way, Seattle, Washington 98108.
Partner Agency: National Institute on Aging.
General Description: Dr. Craft's research program examines
the relationship between Alzheimer's disease and insulin
resistance, a condition in which insulin does not work
efficiently, leading to diabetes, obesity, and cardiovascular
disease. In one set of projects her lab investigated the
specific mechanisms through which insulin resistance affected
pathology related to Alzheimer's disease. Older adults received
infusions of insulin designed to mimic insulin resistance, and
then underwent spinal taps to measure levels of proteins
thought to cause Alzheimer's disease. High insulin levels
caused temporary increases in levels of these toxic proteins
and markers of inflammation that have been linked to
Alzheimer's disease, illustrating an important relationship
between insulin resistance and Alzheimer's disease. In an
ongoing study, we are examining the effect of low fat and high
fat diets on Alzheimer's disease markers in older adults and
patients with Alzheimer's disease. This study will provide
important data about environmental factors that can modulate
the risk of developing Alzheimer's disease. In other studies,
we have examined how treatments for insulin resistance have
therapeutic benefit for patients with Alzheimer's disease. In a
pilot study, medications used to treat patients with
Alzheimer's disease were shown to benefit patients with
Alzheimer's disease. In a second study, overcoming insulin
resistance by providing insulin directly to the brain with a
special nasal administration device resulted in improved memory
and attention in patients with Alzheimer's disease. A larger
clinical trial is now underway to determine whether long-term
intranasal administration of insulin can benefit patients with
Alzheimer's disease. Thus, her research projects have focused
on important disease mechanisms that have yielded novel
therapeutic approaches for this challenging disease.
Excellence: What makes this project exceptional?
These interrelated projects address important questions:
How do insulin resistance and diabetes increase the risk of
developing Alzheimer's disease and other dementias? Once
potential mechanisms have been identified that appear to play a
role in this risk, what therapies might be effective to improve
the symptoms of Alzheimer's disease, or perhaps even delay or
prevent its development?
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The importance of these questions is underscored by the
current pandemic of conditions associated with insulin
resistance, such as obesity, diabetes, hypertension and
cardiovascular disease. The proliferation of these conditions,
in the context of a rapidly aging society, may significantly
increase the prevalence of dementia.
Effectiveness: What is the impact and/or application of
this research to older persons?
This area offers one of the few potential approaches to
preventing or at least delaying the onset of dementia, by
diagnosing and treating insulin resistance prior to its onset.
Innovativeness: Why is this research exciting or
newsworthy?
The approach used to address these questions is innovative,
working with safe yet informative experimental models of
insulin resistance in human patients that are then translated
into novel therapies. The innovativeness of this work has been
recognized by the National Institute of Aging, who awarded a
MERIT grant for excellence in aging research to Dr. Craft. The
newsworthiness of this work has been acknowledged in a number
of media reports, and as well as through its inclusion in an
upcoming HBO series on Alzheimer's disease in March 2009.
U.S. Department of Veterans Affairs: REACH VA
REACH VA is an effective intervention to decrease dementia
caregiver stress and improve the management of dementia patient
behaviors that can be implemented throughout the VHA system and
in community health care settings.
Lead Agency: Department of Veterans Affairs.
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: Pauline Sieverding, MPA, JD, PhD,
Scientific Program Manager, Health Services Research and
Development, 810 Vermont Ave., NW., Washington DC 20420.
Partner Agency: National Institute on Aging (NIA), National
Institute of Nursing Research (NINR).
General Description:
RESOURCES FOR ENHANCING ALZHEIMER'S CAREGIVERS HEALTH (REACH) VA
In 2000, 4.5 million individuals in the United Stated had
Alzheimer's disease. Currently, informal caregivers provide the
majority of care for those with dementia, on average 16-20
hours/day. As part of Congressional funding for caregiver
assistance pilot programs to provide needed training and
resources for caregivers who assist disabled and aging veterans
in their homes, VHA funded REACH VA as a clinical translation
of the successful Resources for Enhancing Alzheimer's
Caregivers Health (REACH II) study. REACH II, funded by the NIA
and the NINR, was the first national randomized clinical trial
of a behavioral intervention to decrease stress and burden for
racially and ethnically diverse dementia caregivers. The REACH
VA program translates the REACH II intervention into clinical
practice, which is the goal of research.
The REACH VA intervention provides education, a focus on
safety for the patient, support for the caregiver, and skills
building to help caregivers manage difficult patient behaviors
and decrease their own stress. It includes 12 individual
sessions in the home and by telephone, and five telephone
support groups over six months. Across the country, 24 Home
Based Primary Care (HBPC) programs, which treat frail dementia
patients and their caregivers in the home, are participating,
providing the intervention as part of clinical care to families
and patients. VA Medical Center at Memphis serves as the
coordinating center for this program, providing training to the
clinical sites, certification of staff to provide the
intervention, and evaluation of the results.
The goal of REACH VA is to implement an effective
intervention to decrease caregiver stress and improve the
management of patient behaviors throughout the VHA system.
REACH VA is being discussed as an option to provide services to
caregivers participating in VHA Adult Day Health Care. Specific
objectives include: (1) improve emotional well-being and
depression, burden, health, social support, and management of
patient dementia-related behaviors for family caregivers of
dementia patients; (2) decrease health care utilization,
including unanticipated admissions, unscheduled outpatient
visits, emergency room visits, and placement, for dementia
patients; (3) decrease time spent ``on duty'' and time
providing actual care for caregivers; (4) assess caregiver
satisfaction with the services provided; (5) assess VHA
clinical staff satisfaction with the intervention; and (6)
determine the cost of the intervention for VHA.
Excellence: What makes this project exceptional?
The goal of research is to translate research findings into
clinical practice and personal behavior. The VA system has made
it possible to implement the REACH II research findings
broadly, through funding of REACH VA as the first national
clinical translation of a proven dementia caregiver behavioral
intervention. Clinical staff from 24 HBPC programs in more than
29 cities and 17 states have volunteered their time to train
for and to deliver the intervention to stressed caregivers of
dementia patients. Based on their dedication and their desire
to provide the best possible care for their patients and their
families, these staff are implementing the program as part of
their clinical workload. Their goal is to raise the standard of
care provided to dementia caregivers and patients using
evidence based interventions. REACH VA materials are a
practical resource for clinicians beyond the confines of the
program, providing knowledge and materials to be used with
other caregivers and patients.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Caregiving is a national and growing concern. Approximately
54 million people provided care in the past year and 59% of
adults are now or expect to be family caregivers in the future.
Unpaid family caregivers are the largest source of long-term
care services in the U.S. The value of ``free'' services
provided by family members is $257 billion annually (in 2000
dollars), more than nursing home and home health care combined.
Factoring in all lost productivity and $36.5 billion in
absenteeism, dementia costs American businesses $61 billion per
year. REACH VA is designed to help caregivers cope with the
stresses of caregiving.
Effectiveness: What is the impact and/or application of
this research to older persons?
Although most dementia caregivers express a desire to
provide care in the home, the emotional and physical costs are
enormous. The REACH II intervention has been shown to
significantly improve caregiver quality of life--caregiver
burden, depression/emotional well-being, self-care and healthy
behaviors, social support, and management of care recipient
problem behaviors. It also provides that most scarce commodity
for caregivers--time--in an additional hour per day not
providing direct care at an intervention cost of $5.00 per day.
This intervention will now be available across the VHA system.
In addition, the VA is a testing ground for the intervention to
be used nationally with community agencies. The Roslynn Carter
Institute for Caregiving has selected REACH VA as one of its
National Caregiver Quality Programs.
Innovativeness: Why is this research exciting or
newsworthy?
An editorial in the Annals of Internal Medicine on REACH II
suggested that if the intervention was a drug, it would be on
the fast track to approval. The VA system has provided a means
to implement this first national clinical translation of a
dementia caregiver behavioral intervention. REACH VA is also an
example of the efforts of two federal agencies, the National
Institutes of Health and the Department of Veterans Affairs,
working together to translate research into clinical practice.
REACH VA showcases the efforts of Congress, through the
Department of Veterans Affairs, to provide support for family
caregivers. Their funding for VHA Caregiver Pilot Assistance
Programs was designed to identify programs that would enhance
the quality of life of veterans and reduce the strain on
veterans' caregivers and then be replicated beyond the
demonstration site.
U.S. Department of Veterans Affairs: Family Assessment of Treatment
This unique project has created a way for the VA to improve
the care that it provides to veterans near the end of life by
asking veterans' families whether the veteran received the best
possible care and, if not, how that care could be improved.
Lead Agency: U.S. Department of Veterans Affairs (VA),
Veterans Health Administration (VHA), Philadelphia VA Medical
Center.
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: David J. Casarett, MD, Chairperson,
Ethics Advisory/Faculty Leader End of Life Care/Staff
Physician, VAMC Philadelphia, Office of Geriatrics, University
and Woodland Avenue, Philadelphia, PA 19104.
General Description:
FAMILY ASSESSMENT OF TREATMENT AT END-OF-LIFE (FATE) SURVEY DEVELOPMENT
Over the past 10 years, growing attention has focused on
opportunities to improve the care that older adults receive
near the end of their lives. For instance, previous studies
have found that symptoms like pain, nausea, constipation, and
shortness of breath are very common, but that clinicians are
often unable to recognize these symptoms and manage them
adequately. Other studies have found that clinicians do not
communicate with patients about their health care preferences,
and that treatment decisions are not always consistent with
those preferences. In particular, patients often receive
aggressive life-sustaining treatment that is not consistent
with their preferences.
The goal of this VA-funded project, the FATE study, was to
develop and test a telephone survey that will allow the family
members of veterans to evaluate the care that the veteran
received near the end of his/her life. This survey allows
family members to rate various aspects of the veteran's care
including management of pain and other symptoms, and the
availability of practical assistance (e.g. home care) and
emotional and spiritual support. Families also are asked
whether the veteran's preferences were respected, whether
clinicians provided adequate information, and whether the
veteran was treated with respect.
This survey is currently being implemented in eight
Veterans Integrated Service Networks (VISN) as a measure of the
quality of care that they are providing to veterans near the
end of life and their families. These surveys are then used to
produce quarterly reports that are made available to VISN and
hospital leaders. These reports highlight each hospital's
strengths, as well as opportunities for improvement.
Excellence: What makes this project exceptional?
This is the first-ever successful project to measure and
improve the quality of end of life care across an entire health
care system. VA is the nation's largest integrated health care
system, and offers unique opportunities both to identify
opportunities for improving end-of-life care and, more
importantly to identify those hospitals that provide excellent
care. This project is the first of its kind to measure and
improve the quality of end-of-life care on such a large scale.
Significance: How is this research relevant to an older
person, populations and/or an aging society?
As the population ages, it will become increasingly
important to ensure that we are providing the best possible
care to older adults throughout their lives, and this includes
the care that they receive near the end of their lives, when
they are most vulnerable. Just as it is essential to preserve
older adults' function and independence as long as possible,
for instance, when they reach the last months of their lives,
then attention turns toward maintaining comfort and preserving
dignity. It is especially important to ensure that older adults
receive high quality compassionate care during this period not
only for the patient's sake, but also for the sake of family
members.
Effectiveness: What is the impact and/or application of
this research to older persons?
This survey, which is currently being rolled out with a
plan for national implementation in the VA health care system,
will provide unique insights into the care that the VA is able
to provide to patients near the end of life and their families.
For instance, the results of these surveys have already begun
to identify areas of care (e.g., pain management) that need to
be improved. In addition, these results have begun to identify
hospitals and nursing homes that are providing excellent care,
both with respect to pain management and in all aspects of
care. By understanding what makes these hospitals so
successful, we are able to take the lessons learned and apply
them to improve care throughout the VA health care system.
Finally, this survey has begun to provide the VA with important
data to guide policy. For instance, the finding that veterans
receive better care from dedicated hospice or ``palliative
care'' teams supports the VA's commitment to ensure that all
veterans have access to this specialized care.
Innovativeness: Why is this research exciting or
newsworthy?
This is the first national effort to measure and improve
the quality of care that older adults receive near the end of
life across a health care system. This project offers important
opportunities to identify opportunities for improvement and to
identify hospitals and nursing homes whose successes can be
shared.
U.S. Department of Veterans Affairs: Aging Veterans Health Policy Model
HSR&D investigators, working with VHA policy and operations
groups, and National Institute on Aging (NIA) investigators,
combined VHA data on enrolled veteran demographics and health
care use with similar data from the NLTCS and other federal
survey to create a LTC projection model, validate the
projections prospectively with data from CMS on nursing home
use, and coordinate data collection with NIA in order to update
the model for all veterans, both enrolled and non-enrolled.
Lead Agency: U.S. Department of Veterans Affairs (VA).
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: Bruce Kinosian, MD, Director of
Community Options Program/Medical Director Hospital Home Care/
Staff Physician, VAMC Philadelphia, Office of Geriatrics,
University and Woodland Avenue, Philadelphia, PA 19104.
General Description:
AGING VETERANS HEALTH POLICY MODEL
The VA Aging Policy Model has been a collaboration between
VA's Health Services Research and Development Service (HSR&D),
the Assistant Deputy Under Secretary for Health Policy and
Planning, the VA's Office of the Actuary, and the Office of
Geriatrics and Extended Care; and investigators from the
University of Pennsylvania, Duke University, and the University
of Michigan. The group undertook to revise VA's original long
term care planning model in 2003, using data from the National
Long Term Care Survey (NLTCS) and other federal surveys,
including linking the NLTCS to the VA enrollment file. These
investigators then used Center for Medicare and Medicaid
Services (CMS) data on national nursing home (NH) use (the
``Minimum Data Set'' or MDS), matched with VHA's enrollment
file, to determine the actual number of veterans in NHs.
Adjusting for methodologic differences, the LTC planning model
accurately predicted total NH use among enrolled veterans. This
was confirmed by using a subsequent round of the NLTCS (in
2004) to validate the projections based on the prior round.
These investigators combined all health care use by
veterans in the NLTCS from CMS and VHA data files from 1994-
2004, in order to estimate an updated model based on combined
health care and LTC use in 1994-2002, with validation of use
for 2003-2004.
Concurrently, these investigators used sophisticated
regression techniques (CART) to map disability questions from
the National Health Interview Survey to the U.S. Census
detailed survey, in order to create county-level estimates of
the prevalence of A disability among veterans.
These investigators coordinated the 2004-2005 rounds of the
VHA Survey Of Enrollees (SOE) and the NLTCS in order to (a)
validate the SOE, (b) extend enrolled veteran disability
estimates to the Veterans Integrated Service Network (VISN) and
market levels, and (c) to comprehensively survey all veterans,
to determine differences in disability between enrolled and
non-enrolled veterans, and the role of enrollment in altering
those differences. This coordination involved using same
functional status question set in both surveys, and altering
the NLTCS screening procedure so that every participant
received the screen in 2004, and every participant was queried
on veteran status. For the 3,727 veterans in the 2004 survey,
it would have cost $5.6 M for VHA to have replicated the direct
data collection, using per capita survey costs for the NLTCS.
The modifications to the NLTCS provide the first comprehensive
examination of functional and cognitive changes in an aging
veteran population, how those changes segregate among enrollees
and non-enrolled veterans, and the change over time in
disability levels among the two groups. In contrast to the
conventional finding of declining disability, which is true for
all veterans, among enrolled veterans disability prevalence
increased between 1999 and 2004, with relatively more disabled
veterans continuing to enroll in VHA through 2004.
Future work includes validating the county-level disability
projections, finishing updating the LTC projection model using
the combined 2004 data, extending the projection validation to
2007 NH data, and re-surveying the NLTCS panel to determine
continued enrollment and disability trends.
This research is exceptional in its breadth of topic, data,
and participants over time. Investigators from outside and
within VA worked with VA research, operations, and policy staff
to leverage a variety of Federal data resources from the
Census, the National Center for Health Statistics, VHA, and NIA
to create a long term care planning model for both
institutional and home and community based care in 2003, using
data from 1999 and 2000 surveys, and linking the NIA survey
directly to VHA data. This same group then coordinated the
2004/2005 rounds of VHA and NIA surveys in order to correct
data gaps found in the first model, as well as to
comprehensively characterize the entire veteran population, not
just those who are enrolled in VHA. This process provided a
test of the accuracy of the VHA survey of enrollees, finding
that the VHA methodology resulted in a significant undercount
of high-level impairments relative to the direct interviews of
the NLTCS. By comprehensively surveying the entire veteran
population, from a panel of male Medicare beneficiaries
surveyed in 1999 and again in 2004, the study demonstrated a
strong trend of increasing disability among enrolled veterans
that continued to be driven by more disabled new enrollees in
every age group >65 years of age. This coordinated survey found
VHA with prevalences of functional disability and cognitive
impairment from 1.5-2 times those found in the general veteran
population, depending upon region, with significant regional
variation in the concentration of disability and impairment.
The investigators then used data from CMS to identify every
veteran in a NH in 2003 and 2004, confirming the accuracy of
the model's NH projections.
The new data are being used to update the current long-term
care model, and improve its precision in projecting specific
home and community care services at a regional level. Future
developments include embedding the VHA long-term care demand
model within the general U.S. long-term care supply, in order
to incorporate enrollment decisions of disabled, aged veterans
in VHA.
This work has demonstrated that VA is not experiencing the
decline in functional disability found in the general
population and the general veteran population, because of
adverse enrollment: a significant exception to prior planning
assumptions, and an exception to the major finding in aging
demography of the past 30 years. The earlier model was used to
determine the target for VHA's supply of home and community-
based services, resulting in a planned tripling of such
services for aged veterans. The updated model will help target
those investments to regions with greater demand, and
distinguish the portion of total demand met by VHA and other
payors for home and community based care. Characterization of
cognitive and functional differences between the general
elderly population that uses long-term care and those of
enrolled veterans suggests that current VHA programs support
veterans with greater levels of disability in the community
than their non-veteran counterparts. Those comparisons also
suggest the need for more creative programs to continue
transitioning institutionalized veterans to supportive
community settings.
Excellence: What makes this project exceptional?
Working across agencies and groups.
Significance: How is this research relevant to older
person, populations and/or an aging society?
Demonstrated increased needs for home and community-based
care (HCBC) services, and effectiveness of current services.
Effectiveness: What is the impact and/or application of
this research to older persons?
Resulted in tripling of HCBC services provided by VHA in
setting to reliance targets.
Innovativeness: Why is this research exciting or
newsworthy?
Overturns conventional assumptions about future needs, puts
VA on a realistic planning path and highlights opportunities to
leverage resources to areas of greatest need (both
programmatically and geographically).
U.S. Department of Veterans Affairs: Shingles Prevention Study
Shingles causes substantial pain and suffering in older
adults. This study showed that a vaccine reduced the incidence
of shingles by 51 percent, the pain severity of the illness by
61 percent and the incidence of postherpetic neuralgia by 66
percent.
Lead Agency: U.S. Department of Veterans Affairs (VA);
Veterans Health Administration VA (VHA), Cooperative Trials and
Durham VA Geriatric Research, Education and Clinical Center
(GRECC).
Agency Mission: ``To care for him who shall have borne the
battle and for his widow and his orphan.''
Principal Investigator: Michael Oxman, MD, Professor of
Medicine, SPS 111F-1 San Diego VA Medical Center, 3350 La Jolla
Village Drive, San Diego, CA 92161.
Partner Agency: National Institute of Allergy and
Infectious Diseases; Merck & Co.
General Description: The Shingles Prevention Study is a VA
Cooperative Study, carried out in collaboration with the NIAID
and Merck & Co., to determine if the zoster vaccine would
decrease the occurrence and/or severity of shingles (scientific
name is herpes zoster) and postherpetic neuralgia, the painful
condition that may persist afterwards. This disease mainly
affects older adults. It is caused by the varicella-zoster
virus (VZV) which also causes chickenpox. After a person has
had the childhood infection, the virus persists in a dormant
state in nerve cells. As resistance to VZV weakens with age,
the virus can reactivate, causing a blistering rash. There is
acute pain due to shingles but many older individuals
experience pain for months or years, a condition called
postherpetic neuralgia. The acute and chronic pain of shingles
markedly interferes with quality of life and daily living. All
older adults are at risk for shingles. Half of people who live
to age 85 will get shingles, and it is estimated that more than
a million new cases of shingles occur in the United States each
year.
The Shingles Prevention Study was a randomized, double-
blind, placebo-controlled study of the zoster vaccine in 38,546
adults *60 years of age enrolled at 16 VA and 6 University
sites across the U.S. Over the 5 years of the study, there were
a total of 957 confirmed cases of herpes zoster (315 among
vaccine recipients and 642 among placebo recipients) and 107
cases of postherpetic neuralgia (27 among vaccine recipients
and 80 among placebo recipients). The zoster vaccine reduced
the incidence of herpes zoster by 51 percent, the pain severity
of the illness by 61 percent and the incidence of postherpetic
neuralgia by 66 percent. Of individuals who developed herpes
zoster, the severity of illness was less in persons who
received the vaccine. The vaccine was safe and well tolerated.
This landmark study showed that the zoster vaccine markedly
reduced the suffering from herpes zoster and postherpetic
neuralgia among older adults. Studies are ongoing to determine
the durability of the response to the vaccine.
Excellence: What makes this project exceptional?
The scientific basis, the methodology, and the results of
the Shingles Prevention Study make it truly exceptional.
Shingles (herpes zoster) is caused by the reactivation of
varicella-zoster virus (VZV) from a dormant or latent infection
of sensory nerve cells. This reactivation occurs when the
immune system is too weak to contain the virus. Almost all
adults in the U.S. are latently infected with VZV and therefore
at risk for shingles. The Shingles Prevention Study is unique
in that is was the first study to determine that a vaccine can
successfully prevent a reactivated infection. All other
vaccines (e.g., measles, mumps, rubella, influenza,
pneumococcal, etc.) prevent primary infections. The Shingles
Prevention Study was the largest vaccine study ever conducted
in older adults with over 38,000 participants. The follow-up in
the study was outstanding with only 0.7 percent of persons lost
to follow-up and it used an innovative computerized telephone
response system to stay in touch with participants. The
diagnosis of shingles was done using state-of-the-art DNA
detection methods whereas all prior shingles clinical drug
trials relied on clinical diagnosis which may not be fully
accurate.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The occurrence of shingles increases dramatically with
aging particularly after the age of 60 years. The increase in
incidence with aging is due to a progressive decline in
immunity to VZV with aging. The main problem with shingles is
pain. The persistent pain that may follow shingles, known as
postherpetic neuralgia, is much more common and severe in older
adults. Shingles pain diminishes the quality of life and
functional capacity of older adults, and markedly reduces their
enjoyment of life. The zoster vaccine is relevant to older
adults in that it can reduce the pain and suffering from
shingles and improve quality of life.
Effectiveness: What is the impact and/or application of
this research to older persons?
The zoster vaccine reduced the incidence of herpes zoster
by 51 percent, the pain severity of the illness by 61 percent
and the incidence of postherpetic neuralgia by 66 percent,
demonstrating that the vaccine markedly reduced suffering from
shingles and postherpetic neuralgia among older adults. Even
among individuals who developed shingles, the severity of
illness was less in persons who received the vaccine. If the
zoster vaccine was used in all older adults in whom it was
recommended, approximately 283,000 cases of shingles and 46,000
cases of postherpetic neuralgia would be eliminated by
vaccination each year in the United States.
Innovativeness: Why is this research exciting or
newsworthy?
The zoster vaccine research adds a powerful new weapon in
our armamentarium against shingles and the suffering that is
causes in older adults. The science and methodology of the
study as conducted by VA investigators was world-class. On the
basis of the results of this one study, the U.S. Food and Drug
Administration (FDA) approved the zoster vaccine for use in
persons 60 years of age and older for the prevention of herpes
zoster. The Advisory Committee on Immunization Practices (ACIP)
of the Centers for Disease Control and Prevention (CDC)
recommends that individuals *60 years of age receive the zoster
vaccine to prevent herpes zoster and postherpetic neuralgia. In
October 2007, the zoster vaccine was added to the CDC's
Schedule of Recommended Adult Immunizations. Their final
recommendations for the use of the zoster vaccine was published
in the CDC's Morbidity and Mortality Weekly Report, June 6,
2008 (MMWR Volume 57, No. RR-5 ``Prevention of Herpes
Zoster'').
U.S. Environmental Protection Agency: Aging Initiative
EPA's ``Aging Initiative,'' a research program focused on
the environmental health of older adults, has increased our
understanding of exposure to--and health effects of--
environmental contaminants on older adults to enhance the
Agency's efforts in health promotion and risk assessment.
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Andrew Geller, PhD, Assistant
Laboratory Director for Human Health and Computational
Toxicology, National Health and Environmental Effects
Laboratory, Office of Research and Development, U.S.
Environmental Protection Agency, MD B305-02, Research Triangle
Park, NC 27711.
Partner Agencies: Environmental and Occupational Health
Science Institute, Research Triangle Institute, Hamner
Institute, University of Mississippi, University of North
Carolina at Chapel Hill.
General Description: EPA's ``Aging Initiative,'' a research
program focused on the environmental health of older adults,
has increased our understanding of the environmental
contaminants to which older adults are exposed and their
resulting health effects. The program is identifying key aging-
related factors that contribute to variability in environmental
exposures and responses to those exposures that could result in
adverse health outcomes. By soliciting and incorporating input
from individuals in the community, advocacy groups, and
scientific experts to derive a creative and comprehensive
action plan based on sound science, EPA is helping to enhance
and protect the health of aging Americans.
The rapid growth in the number of older Americans has many
implications for public health, including the need to better
understand the health risks posed by environmental exposures to
older adults. Biological capacity declines with normal aging
and with diseases of aging. This decline can result in
compromised responses to environmental exposures encountered in
daily activities, resulting in adverse health outcomes.
In recognition of these factors, and consistent with EPA's
mandate to protect the health of vulnerable Americans, EPA
developed the ``Aging Initiative.'' This research program is
designed to answer the following questions to insure that EPA's
regulations and educational outreach programs promote the
health of older Americans:
Where do older adults live and what are the
important pollution sources in those locations?
What activities are older adults engaged in that
bring them into contact with these pollutants?
What happens to those pollutants inside the body?
What are the critical adverse health effects and
adverse outcomes?
How do we link all of the above for effective risk
assessment, management, and communication?
EPA pioneered this research program so that the Agency and
its stakeholders will be able to anticipate, accommodate, and
manage the environmental risks associated with this inevitable
shift in American demographics toward an aging society. The
program is generating data, models, and guidance to incorporate
the susceptibility of this heterogeneous population into health
promotion and intervention strategies to ameliorate risk from
environmental exposures.
Excellence: What makes the project exceptional?
EPA's Aging Initiative is exceptional because it solicits
and incorporates input from individuals in the community,
advocacy groups and scientific experts to derive a creative and
comprehensive action plan, based on sound science, to enhance
and protect the health of aging Americans.
Significance: How is this research relevant to older
persons, populations and/or aging society?
EPA's program to protect the health of older Americans is a
unique combination of intra- and extramural research and public
outreach. The two efforts have a common goal of identifying the
pollutants that are most hazardous to older adults and the
reasons why some older adults are more susceptible than others.
This information can lead to more informed decisions in setting
exposure standards for the public that insures protection of
the aging population. The information is also valuable to the
community in their efforts to improve environmental quality and
minimize the hazards they encounter.
Effectiveness: What is the impact and/or application of
this research to older persons?
EPA's Aging Initiative has highlighted the importance of
the aging population's vulnerability to pollutants through data
generation and publications in peer-review scientific journals,
communication with older adult stakeholder groups, and
presentation of research findings in scientific conferences.
Innovation: Why is this research exciting or newsworthy?
EPA has mounted a program on susceptibility of the aging
population that combines laboratory, clinical, and social
research together with public outreach education. This
multifaceted program insures that research findings can be
quickly and accurately translated into regulatory decisions as
well as public awareness and action.
U.S. Environmental Protection Agency: Air Quality and Its Effect on
Heart Rates
Particulate matter and ozone levels are associated with
alterations in heart rate variability, a measure of autonomic
or involuntary nervous system control of cardiac function,
among individuals living in eastern Massachusetts.
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Joel Schwartz, PhD, Harvard School
of Public Health, 665 Huntington Avenue, Boston, MA 02115.
Partner Agency: Harvard School of Public Health.
General Description: The EPA-funded Harvard Particulate
Matter Center conducted a series of studies that focused on how
air particles or particulate matter (PM) affect the rhythm of
the human heart. The Harvard researchers found that particulate
matter and ozone levels were associated with alterations in
heart rate variability, a measure of cardiac function that is
under autonomic or involuntary control, among individuals
living in eastern Massachusetts. Harvard PM Center researchers
have begun to examine different biologic control pathways that
may play a role in the effect of PM on the heart. In addition,
they are investigating the specific sources of PM that may be
most important in influencing health responses in this study
population, participants in the Normative Aging Study (NAS), a
large longitudinal study established in 1963 by the U.S.
Veterans Administration, because different types of particles
may affect different biological pathways.
Heart rate variability reflects autonomic control of the
rhythmic activity of the heart. The 2280 men enrolled in the
Normative Aging Study were originally confirmed to be free of
known chronic medical conditions, and active, continuing
participants are examined every three years. This study
analyzed information for 603 persons examined between 2000 and
2003. Ambient fine air particles (PM2.5) and black
carbon measurements were obtained from a monitoring site
located 1 kilometer from the clinic and were evaluated in
relation to the clinical measurements. Researchers found that
ozone and ambient PM2.5 and black carbon
concentrations, averaged over the previous 4 hours to 48 hours,
were associated with reductions in heart rate variability. The
greatest reductions were observed among hypertensive
individuals and those with ischemic heart disease. Ambient
black carbon concentrations were further found to be associated
with increased C-reactive protein and fibrinogen levels in
blood samples. These results suggest that the effects caused by
PM could be brought about through pathways involving the
autonomic nervous system and systemic inflammation.
More recent studies in the Normative Aging Cohort found
that the effects of traffic-related PM are modulated by
biologic markers of specific pathways that may be involved in
the disease process. Particle exposure could increase adverse
responses including oxidative stress, inflammation, and
thrombosis (blood clots), leading to alterations in cardiac
autonomic function and cardiovascular problems such as heart
attacks. Researchers examined these effects using white blood
cell counts, C-reactive protein, sediment rate, and fibrinogen
from blood samples collected from study participants. Traffic-
related PM components, black carbon, and particle number were
related to increased levels of inflammatory and thrombotic
markers, with associations most consistent for the blood
clotting factor, fibrinogen. The association was strongest when
exposures were averaged over the 4-weeks prior to the
measurement.
Excellence: What makes this project exceptional?
This project has shown that markers of PM from traffic are
associated with alterations in autonomic control of heart
rhythms, which may increase the risk of cardiovascular disease
and death from heart disease. The relation between particle
pollution and cardiac effects was determined in the Normative
Aging Study which provides very strong evidence for the
observed link because new clinical data and information on risk
factors is collected on the participants every 3 to 5 years.
Subsequent studies in this cohort have confirmed the original
observations and provided stronger evidence that traffic-
related particle pollution is associated with cardiac autonomic
control and inflammation.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Reductions of heart rate variability over long periods has
been associated with increased risk of mortality in middle-aged
and elderly subjects, in patients with diabetes, and in
survivors of heart attacks and other cardiovascular diseases.
Researchers found that ozone and ambient PM2.5 and
black carbon concentrations and particle number, averaged over
the previous 4 hours to 48 hours, were associated with
reductions in heart rate variability. The greatest reductions
were observed among hypertensive individuals and those with
ischemic heart disease. Individuals with these pre-existing
conditions appear to be more susceptible to the adverse effects
of PM exposure.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research indicates that older people, especially
people with pre-existing health conditions, should be very
cautious about their time spent outside on days when the air
quality is poor. It reinforces the need for alerts on days with
large amounts of fine particle pollution in the air. It also
underscores the need to rigorously enforce and periodically re-
evaluate the National Ambient Air Quality Standards for
particulate matter.
Innovativeness: Why is this research exciting or
newsworthy?
This project has shown that markers of PM from traffic are
associated with alterations in autonomic control of heart
rhythms, which may increase the risk of cardiovascular disease
and death from heart disease. The relation between particle
pollution and cardiac effects was determined in the Normative
Aging Study which provides very strong evidence for the
observed link because new clinical data and information on risk
factors is collected on the participants every 3 to 5 years.
Subsequent studies in this cohort have confirmed the original
observations and provided stronger evidence that traffic-
related particle pollution is associated with cardiac autonomic
control and inflammation.
U.S. Environmental Protection Agency: Air Quality and Cardiovascular
Diseases
Older women living in areas with high levels of fine
particles or particulate matter (PM) pollution have a greater
risk of developing cardiovascular disease and subsequently
dying from cardiovascular causes.
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Joel Kaufman, M.D., Principal
Investigator, Univ. of WA Dept. Env. & Occ. Health Sciences,
P.O. Box 357234, Seattle, WA 98195.
Partner Agency: University of Washington.
General Description: EPA-funded research at the University
of Washington found that older women living in areas with high
levels of fine particles or particulate matter (PM) pollution
have a greater risk of developing cardiovascular disease and
subsequently dying from cardiovascular causes. Scientists
studied more than 65,000 women, aged 50 to 79, with no history
of cardiovascular disease. These postmenopausal women lived in
36 U.S. metropolitan areas throughout the United States and
were part of the Women's Health Initiative Observational Study,
initiated by the National Institutes of Health. Researchers
found that long-term exposure to fine particulate air pollution
was strongly associated with cardiovascular disease and death
among postmenopausal women. Each 10 g/m\3\ increase in the
level of fine particulate matter in ambient air was linked to a
76 percent increase in the risk of death from cardiovascular
disease, after taking into account known risk factors such as
blood pressure, cholesterol, and smoking. Increased average
levels of fine particulate matter were associated with a 24
percent increased risk of cardiovascular disease problems,
including stroke and heart attack. Finally, the study found
that obese individuals, defined as having a high body mass
index or high waist-to-hip ratio, were more susceptible to the
health effects linked to increased particulate matter levels.
These are intriguing new findings that have spurred additional
research studies to verify and understand the link with
obesity.
The people in this study were ideally suited for the
investigation of the links between long-term air pollution
exposure and cardiovascular disease and mortality. The very
large cohort or population was established between 1994 and
1998, and study participants were followed for up to nine years
to see who had heart attacks, stroke, coronary bypass surgery,
or died from cardiovascular causes. Participants resided in 36
cities throughout the United States, allowing for comparisons
of cities with a variety of air pollution levels and with
different atmospheric composition. To estimate people's
exposure to fine particles or PM2.5, the researchers
used the average PM2.5 level recorded in the year
2000 (the midpoint of follow-up in the study) recorded by a
monitor located closest to a participant's residence. Most
women lived within 6 miles of a monitor. In addition, the
investigators were able to explore differences in risk
associated with particulate matter concentrations in the cities
where participants lived and compare them to between-city
effects. For cardiovascular events, the within-city effect was
larger than the between-city effect.
Excellence: What makes this project exceptional?
This is the first study to follow, over time, the
development of new cases of cardiovascular disease in a healthy
population. Previous studies have relied solely on reviews of
death records. The scientists studied air pollution exposure
among participants of a longitudinal study established by the
National Heart Lung and Blood Institute of NIH which has
produced other important research on heart disease, cancers,
and osteoporosis. The study was designed to document specific,
first, cardiovascular ``events'' such as heart attacks. Study
scientists conducted annual questionnaires to ascertain
cardiovascular diagnoses and then reviewed medical records to
confirm and classify them. Deaths were identified through
family members and the National Death Index.
This is also one of the first studies to look at local air
pollution levels within metropolitan areas. Local differences
in particulate matter levels within a city, as well as exposure
differences between cities, translate to a higher or lower risk
of cardiovascular disease and related death. In previous
studies of the long-term effects of air pollution, scientists
averaged pollutant concentrations from monitors located in a
city and then compared health effects between cities. The
assignment of particulate matter concentrations measured at the
monitor closest to the participants' homes probably resulted in
more accurate estimates of PM exposure for each individual
compared to previous studies.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This study establishes a stronger association between long-
term exposure to fine particulate air pollution and death from
coronary heart disease, one of the leading causes of illness
and mortality among older adults, than was found in earlier
studies. The finding that health risks associated with within-
city differences in pollutant concentrations are higher than
risks associated with between-city pollution levels suggests
that, as pollution exposure estimates assigned to study
participants become more precise, studies may find that health
risks associated with fine particulate air pollution are higher
than previously estimated.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research indicates that older people, especially
people with pre-existing health conditions, should be very
cautious about their time spent outside on days when the air
quality is poor. It reinforces the need for alerts on days with
large amounts of fine particle pollution in the air. It also
underscores the need to rigorously enforce and periodically re-
evaluate the National Ambient Air Quality Standards for
particulate matter.
Innovativeness: Why is this research exciting or
newsworthy?
This research is the first to look at fine air pollution
levels in major metropolitan areas around the U.S. and connect
exposure to pollution with the development of new cases of
cardiovascular disease in a healthy population.
U.S. Environmental Protection Agency: Air Quality and Respiratory
Diseases
Researchers at The Johns Hopkins Bloomberg School of Public
Health found that hospital admission rates for cardiovascular
and respiratory diseases were significantly associated with
short-term, fine particle exposure in air in individuals over
65 years of age.
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Francesca Dominici, PhD., Johns
Hopkins University, Bloomberg School of Public Health, 615 N.
Wolfe Street, Baltimore, MD 21205.
Partner Agency: Johns Hopkins Bloomberg School of Public
Health.
General Description: A large study, funded by the EPA and
published in the Journal of the American Medical Association in
2006, looked at Medicare recipients across the country and
found that short-term exposure to fine particles or particulate
matter (PM) is related to a greater risk of hospitalizations.
Researchers at The Johns Hopkins Bloomberg School of Public
Health found that hospital admission rates for cardiovascular
and respiratory diseases were significantly associated with
short-term, fine PM exposure in individuals over 65 years of
age. The study used Medicare data for 11.5 million people
living in 204 urban counties in the United States. This is one
of the first studies to use an expanded, nationwide, monitoring
network for ambient particulate matter less than 2.5 m in
diameter (PM2.5). Interestingly, the average ambient
concentration of fine PM in the locations during the study
period was lower than the PM levels that existed during many
previous studies. Region-specific differences in PM-associated
deaths between the eastern and western United States also were
reported.
Researchers compiled a data set of daily hospitalization
admission rates for cardiovascular and respiratory disease and
injuries between 1999 and 2002 from the billing claims of
Medicare participants across the United States. The data were
paired with ambient PM2.5 concentrations in the same
county on the date of hospitalization and up to two days prior.
The resulting data set encompassed 204 urban counties in the
United States and 11.5 million Medicare participants living
within an average of 5.9 miles of a PM2.5 monitor.
Hospital admission rates increased in relation to increases in
PM2.5 concentration on the same or immediately
preceding days for all outcomes studied except injuries. The
health outcomes found to be associated with PM2.5
concentration were cerebrovascular disease including stroke,
peripheral vascular disease, ischemic heart disease (where the
blood supply to heart muscle is reduced), heart rhythm, heart
failure, chronic obstructive pulmonary disease, and respiratory
tract infection.
The study investigators also compared the mortality risks
associated with fine particulate air pollution across seven
regions of the United States. The risk for air pollution-
related cardiovascular disease was highest in counties located
in the eastern United States. In contrast, the risk of
hospitalization for respiratory causes was consistent across
all the counties. The regional differences seen by the
researchers have focused their efforts to identify what factors
are responsible. This is a complex question and may involve
regional differences in the composition of PM in the atmosphere
from specific sources of PM.
The research was conducted as part of a four-year project
funded through a grant from the EPA to the Johns Hopkins
University Bloomberg School of Public Health. The project
started in 2003 and examined the effect of annual average and
daily PM2.5 concentration on illness and death among
Medicare recipients. The study researchers are continuing to
follow the Medicare study population as part of the Johns
Hopkins Particulate Matter Center, one of five research centers
established by the EPA to study particulate air pollution and
health effects.
Excellence: What makes this project exceptional?
This was one of the first studies to show the effects of
fine particles on Medicare recipients across the nation,
comprising nearly all members of the U.S. population over the
age of 65 years.
The size of the Medicare population allowed the researchers
to assess risks pertaining to specific cardiovascular
diagnoses. The findings have led to more specific
investigations concerning the biologic pathways that are
affected by exposure to particulate matter.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
For the first time, nationwide Medicare data were analyzed
to assess the health effects of fine particulate matter (PM).
EPA-funded grantees from Johns Hopkins University found that
increases in hospital admission rates for cardiovascular and
respiratory diseases were significantly associated with short-
term changes in ambient levels of PM2.5. When the
risk estimates were evaluated for individuals in different age
categories, the oldest group, aged 75 years and older, was at
highest risk for several outcomes including ischemic heart
disease, heart rhythm disturbances, heart failure, and chronic
obstructive pulmonary disease.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research indicates that older people, especially
people with pre-existing health conditions, should be very
cautious about their time spent outside on days when the air
quality is poor. It reinforces the need for alerts on days with
large amounts of fine particle pollution in the air. It also
underscores the need to rigorously enforce and periodically re-
evaluate the National Ambient Air Quality Standards for
particulate matter.
Innovativeness: Why is this research exciting or
newsworthy?
For the first time, nationwide Medicare data were analyzed
to assess the health effects of fine particulate matter (PM).
EPA-funded grantees from Johns Hopkins University found that
increases in hospital admission rates for cardiovascular and
respiratory diseases were significantly associated with short-
term changes in ambient levels of PM2.5. When the
risk estimates were evaluated for individuals in different age
categories, the oldest group, aged 75 years and older, was at
highest risk for several outcomes including ischemic heart
disease, heart rhythm disturbances, heart failure, and chronic
obstructive pulmonary disease.
U.S. Environmental Protection Agency: Air Pollution and Chronic
Diseases
EPA scientists have developed tools that use air pollution
levels and activities of older adults to estimate the exposure
of older individuals to air pollution. These estimates, in
turn, can be used to evaluate whether air pollution can
exacerbate diseases of aging, such as heart attack, stroke,
chronic obstructive pulmonary disease (COPD), and asthma in
older adults.
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Andrew Geller, PhD, Assistant
Laboratory Director for Human Health and Computational
Toxicology, National Health and Environmental Effects
Laboratory, Office of Research and Development, U.S.
Environmental Protection Agency, MD B305-02, Research Triangle
Park, NC 27711.
Partner Agency: Research Triangle Institute, University of
North Carolina at Chapel Hill, Environmental and Occupational
Health Science Institute.
General Description: Measuring air pollution levels at
pollution sources, or even at monitoring sites around the
nation, does not tell us what individuals are actually exposed
to. This research helps EPA estimate the real, personal
exposure of older individuals to environmental pollutants by
taking into account their micro-environments and personal
activities through the day.
EPA scientists have developed tools and information to
estimate air pollution exposure to older individuals. These
tools use air pollution levels measured at ambient (or
background) monitoring sites plus information about where older
adults spend their time and what they do. These estimates, in
turn, can be used to evaluate whether air pollution can
exacerbate diseases of aging, such as heart attack, stroke,
chronic obstructive pulmonary disease (COPD), and asthma in
older adults. This research has given EPA the ability to
incorporate information on pollution sources, ambient air
pollution levels, and personal micro-environments to produce
estimates of real-world exposure to potentially hazardous
environmental compounds.
Estimates of personal or population-group exposure tell EPA
where to intervene with their risk mitigation efforts. These
estimates are also used to evaluate whether or not air
pollution can exacerbate diseases of aging. Importantly, EPA
can thereby consider the health of older adults when setting
National Ambient Air Quality Standards.
Excellence: What makes this project exceptional?
This research received EPA's highest level Science and
Technical Achievement Award, an internal award given to
excellent, scientific, peer-reviewed publications.
Significance: How is this research relevant to older
persons, populations and/or aging society?
Measurement of air pollution levels at pollution sources,
or even at monitoring sites distributed throughout the nation,
does not tell us what individuals are exposed to. This research
helps the Agency estimate the real, personal exposure of older
individuals to environmental pollutants by taking into account
their micro-environments and personal activities through the
day.
Effectiveness: What is the impact and/or application of
this research to older persons?
Estimates of personal or population-group exposure derived
from ambient monitoring data tells the EPA where to intervene
with risk mitigation efforts. These estimates are also used to
evaluate whether air pollution can exacerbate diseases of
aging. EPA can thereby consider the health of older adults when
setting National Ambient Air Quality Standards.
Innovation: Why is this research exciting or newsworthy?
This research helps EPA estimate the real, personal
exposure of older individuals to environmental pollutants by
taking into account their micro-environments and personal
activities through the day.
U.S. Environmental Protection Agency: Environmental Risk Factors for
Older Adults
EPA researchers have developed the first publically-
available database that can be used to model the physiology and
metabolism of older adults to determine whether environmental
pollutants put them at risk. This peer-reviewed database can be
used to produce environmental health risk assessments that help
protect older adults from environmental health hazards while
still recognizing the need for the use of chemicals and
pharmaceuticals in commerce.
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Bob Sonawane, PhD, Chief, Effects
Identification and Characterization Group, National Center for
Environmental Assessment, Office of Research and Development,
U.S. Environmental Protection Agency.
General Description: EPA researchers have developed the
first publically-available database that can be used to model
the physiology and metabolism of older adults to determine
whether environmental pollutants put them at risk. This peer-
reviewed database can be used to produce environmental health
risk assessments that help protect older adults from
environmental health hazards while still recognizing the need
for the use of chemicals and pharmaceuticals in commerce.
EPA engaged the world's top experts to collect the factors
to produce this resource. Before this database was developed
and made available to the public, risk assessors had to rely on
physiological data that were scattered throughout the
scientific literature. In addition, mathematical models that
incorporated older adult susceptibilities to environmental
health hazards did not exist in the scientific or risk
assessment literature. This database allows these critical
models to be generated, enhancing the science-based evaluation
of risk for older adults. This single, reviewed source
standardizes risk assessment models while using the best
available data. Importantly, it captures factors determined
scientifically rather than using default factors which may
underestimate or overestimate risk. This, in turn, ensures that
these environmental health risk assessments provide better
protection for older adults.
Although this database was only recently unveiled to the
public, it has already attracted attention from the
environmental health, occupational health, and pharmaceutical
communities because of its general applicability to the
concerns of older adults. Combined with information from
similar databases providing parameters for young children and
adults, this database will be instrumental in enhancing risk
assessment across the entire human lifespan.
Excellence: Why is this project exceptional?
EPA engaged the world's top experts to collate factors to
produce this peer-reviewed publically-available resource, the
first of its kind to address the physiology of older adults.
Significance: How is this research relevant to older
persons, populations and/or aging society?
Physiological factors are scattered throughout the
scientific literature. This single, reviewed source provides
for standardization of models and the use of the best available
data. Science-based factors replace default uncertainty factors
to produce environmental health risk assessments that provide
better protection for older adults from environmental health
hazards while recognizing the need for the use of chemicals in
commerce.
Effectiveness: What is the impact and/or application of
this research to older persons?
This database, only recently unveiled to the public, has
already attracted attention from the environmental health,
occupational health and pharmaceutical communities because of
its general applicability to concerns of older adults. Taken
together with information from similar databases providing
parameters for young children and adults, risk assessment is
enhanced across the entire lifespan.
Innovation: Why is this research exciting or newsworthy?
Mathematical models that incorporate older adult
susceptibility to environmental health hazards do not exist in
the scientific or risk assessment literature. This database
will allow these critical models to be generated, enhancing the
science-based evaluation of risk for older adults from
environmental contaminants.
U.S. Environmental Protection Agency: Environmental Pollution and Liver
Function
Lead Agency: U.S. Environmental Protection Agency.
Agency Mission: The mission of the U.S. Environmental
Protection Agency (EPA) is to protect public health and
safeguard the natural environment.
Principal Investigator: Andrew Geller, PhD, Assistant
Laboratory Director for Human Health and Computational
Toxicology, National Health and Environmental Effects
Laboratory, Office of Research and Development (ORD), U.S.
Environmental Protection Agency, MD B305-02, Research Triangle
Park, NC 27711.
General Description: EPA scientists are beginning to
understand how the liver response changes with aging and
exposure to environmental chemicals. The liver is both the most
important part of the body for protecting individuals from
toxic chemicals and the target organ for many environmental
pollutants. Understanding how the liver responds to exposure to
environmental chemicals is critical to characterizing risk to
older adults.
Experimental models demonstrate that aging is accompanied
by mild decreases in the capacity to detoxify and eliminate
environmental pollutants. These models help the Agency
understand how much of the toxic response is attributable to
changes in metabolism and how much is due to other changes in
biological capacity with aging.
This important research allows risk assessors to better
understand how exposure to toxic chemicals can affect older
adults' health. In addition, data generated by this study is
helping the EPA include polypharmacy--the use of two or more
drugs together, which is common in the older adult population--
in its consideration of risk and its design of risk mitigation
efforts.
This research complements EPA's efforts to address the
scientific goals laid out by the National Academies of Science
in their report on ``Toxicity Testing in the 21st Century.'' An
important aspect of this work is that it is helping EPA produce
more efficient models that predict how to better protect older
adults while reducing the use of animal testing.
Excellence: Why is this project exceptional?
U.S. EPA scientists have been invited to present this
research at invited symposia for Health Canada, California EPA,
and Society of Toxicology.
Significance: How is this research relevant to older
persons, populations and/or aging society?
The liver is both the most important part of the body for
protecting individuals from toxic chemicals and the target
organ for many environmental pollutants. Understanding how the
liver response changes with aging is critical to characterizing
risk to older adults. EPA research suggests that there are
decreases in liver detoxification capacity in older adults.
These changes, in combination with other changes in the aging
body's capacity to respond to toxicity, are likely responsible
for increased sensitivity to environmental chemicals in the
older adults.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research allows risk assessors to better understand
how toxic exposures affect older adults' health. It allows the
Agency to consider factors such as polypharmacy, common in the
older adult population, in its consideration of risk and its
design of risk mitigation efforts.
Innovation: Why is this research exciting or newsworthy?
This research complements EPA's efforts to address
scientific goals laid out by the National Academies of Science
in their report on ``Toxicity Testing in the 21st Century.''
The work will allow EPA to produce predictive models to better
protect older adults while increasing efficiency and reducing
the use of animals in testing.
U.S. Environmental Protection Agency: Building Healthy Communities for
Active Aging Award Program
The principal goal of the Building Healthy Communities for
Active Aging Award program is to raise awareness across the
nation about healthy synergies that can be achieved by
communities combining Smart Growth and Active Aging concepts.
Awards are presented to communities that demonstrate the best
and most inclusive overall approach to implementing smart
growth and active aging at the neighborhood, tribe,
municipality, county, and/or regional levels.
Lead Agency: U.S. Environmental Protection Agency (EPA).
Agency Mission: The mission of the U.S. Environmental
Protection Agency is to protect public health and safeguard the
natural environment.
Principal Investigator: Kathy Sykes, MA, Senior Advisor,
Aging Initiative, Office of Children's Health Protection and
Environmental Education, Division of Child and Aging Health
Protection, U.S. Environmental Protection Agency, Mail Code
1107A, Room 2512N (Ariel Rios North), 1200 Pennsylvania Ave.,
NW., Washington, DC 20460.
Partner Agencies: National Council on Aging, National
Blueprint, Centers for Disease Control, Active for Life,
President's Council for Fitness and Sports.
General Description: Communities built for healthy aging
are characterized by development patterns that emphasize ease
of getting around, with convenient housing options, walking and
biking paths, and abundant green space to create an attractive
environment. Conversely, unbridled growth or haphazard
development harms not just the environment, but healthy and
quality of life. As our population 85 years and older grows,
many may no longer be driving. Communities that plan ahead and
provide a variety of transportation options or housing
developments situated near public transit will be better
prepared to meet the needs of those who choose not to or no
longer can drive their own automobile. Smart growth is a term
used to control the spread of auto dependent development away
from cities and traditional suburbs by revitalizing urban areas
to be more attractive and healthy places to live. Older adults
can play a critical role in making smart growth possible by
getting involved in local planning efforts.
Chronic health conditions such as heart disease, stroke and
diabetes result in adverse human costs and impacts. Lifestyle
changes are a critical component of effective health promotion
strategies. Obesity is reaching epidemic proportions and soon
will pass smoking as a major cause of preventable disease and
premature death. Daily physical activity is vital for keeping
fit and controlling chronic conditions. Walkable communities, a
principle of smart growth, encourage active aging and are
essential to prevention and management of chronic diseases.
Smart growth practices that promote walkable communities and
shorter trips to work, to shop and to do other activities help
protect the environment and the ability of people to maintain
their independence and quality of life as they age. An added
advantage is that walking through one's neighborhood increases
awareness of neighbors, and expands social contacts and
potential support networks.
Impervious surfaces will cause storm water runoff to bypass
soil filtration, potentially affecting drinking water sources.
Traveling long distances can be not only a barrier for elders
seeking care, but also contributes to air pollution. Many
studies have found an association between air pollution and
aggravation of heart and lung diseases, resulting in increased
medication use, more visits to health care providers and
admissions to emergency rooms. Involvement in local planning
efforts at the community level is critical for the
implementation of smart growth principles.
In May 2007, EPA announced, with its partners, CDC, the
President's Council for Fitness and Sports, the National
Council on Aging, Active for Life, (funded by the Robert Wood
Johnson Foundation) and the National Blueprint, a new awards
program that encourages communities to adopt smart growth
principles and encourage active aging, ``Building Healthy
Communities for Active Aging.'' In 2008, seven communities were
recognized for their excellence in smart growth and active
aging. The awards program is a voluntary effort allowing
communities to lead by example and showcase their successes in
building a health community for active aging.
SMART GROWTH
Older persons are a susceptible population with respect to
air and water pollution, and research has demonstrated links
between development and environmental degradation. Increases in
impervious surfaces result in more storm water runoff that
directly enters surface waters without being filtered through
the soil, potentially contributing to contaminants in drinking
water. Increasing distances between where people live, work,
and play can contribute to longer trips, increasing motor
vehicle emissions and air pollution. Smart growth practices
combined with active aging provide choices that both protect
the environment and help people maintain their independence as
they age, resulting in environmental benefits and enhanced
quality of life.
HEALTHY COMMUNITIES
The EPA Aging Initiative and a coalition of federal and
non-governmental partners recognized that community design
directly affects our health. Considerable attention has been
paid to risk factors predicting longevity and quality of life.
This award focuses our attention on the built environment. For
example, encouraging communities to design neighborhoods for
walking and biking is also directly influencing the quality of
one's life and the livability of the community.
Cities will become healthier for Americans as they work to
preserve their natural environment, reduce air pollution and
improve water quality--key smart growth benefits. Those who
move to the edge of towns expect amenities such as
transportation, health care, shopping and recreation along with
safe drinking water, waste water treatment and solid waste
disposal, but they may not realize that those demands stress
their environment. The location, configuration and scale of
homes and communities within a watershed not only increase
risks to wildlife, but also threaten environmental
sustainability. Efforts to assure smart growth will produce
huge dividends for communities that want to retain a reputation
for being a good place to live.
BUILDING HEALTHY COMMUNITIES FOR ACTIVE AGING
In February 2008, the EPA announced the seven winners and
two communities received the highest awards, the achievement
awards: the Atlanta Regional Commission and Kirkland, WA.
The Atlanta Regional Commission (ARC) launched Aging
Atlanta, a partnership of 50 organizations focused on meeting
the needs of the region's growing older adult population. Aging
Atlanta's pilot projects laid the foundation for the Lifelong
Communities Initiative. The Initiative works with local
governments to create housing and transportation options that
enable older adults to ``age in place.'' To improve housing
developments located close to services and connected to
existing neighborhoods. With more than 90% of Atlanta's older
adults relying on automobiles for transportation, ARC has taken
steps to decrease auto dependency by promoting ride sharing
through its six voucher programs and working to improve bus
stops and routes. These efforts increase quality of life and
offer environmental benefits. ARC and its partners converted
traditional senior centers to wellness centers, emphasizing
physical activity and social interaction. Currently, 46 of
these centers offer programs for the 400,000 older adults in
the metro area, and approximately 1,000 individuals have joined
walking clubs. Through community involvement, ARC has
incorporated older adults' needs into parks, trails and
pedestrian paths. Work with city and county staff, ARC is
integrating age-appropriate features into local sidewalk audits
and plans.
The city of Kirkland, WA has succeeded in making its
physical activities more accessible for its 19,000 older
residents by organizing exercise opportunities and improving
infrastructure. The city offers more than 50 physical activity
programs specifically designed for older adults. The Kirkland
Steppers Walk Program, which is free for adults over age 50,
organizes group walks through downtown twice a week during the
summer.
Over the next six years, the city of Kirkland will invest
$6 million to improve sidewalk connections between commercial
and residential developments to make the city more walkable. In
addition, Kirkland is the first city in the state of Washington
to adopt a Complete Streets Ordinance to design streets for the
needs of walkers, bicyclists and drivers. It has adopted two
innovative programs: the ``PedFlag'' Program, which has placed
flags at 63 crosswalks to remind drivers to yield to
pedestrians, and the Flashing Crosswalk Program, which has
incorporated flashing lights into the pavement of 30
crosswalks. Both programs promote a safe pedestrian
environment. By listening to the good counsel and
recommendations from the Active Living Task Force and the
Kirkland Senior Council, the city of Kirkland has and will
continue to enhance the quality of life for its older
residents.
HHS/FDA/Center for Biologics Evaluation and Research (CBER): Joint
Studies for Potential Treatments of Joint Disorders for Americans
Using human gene studies as well as mouse and amphibian
embryos, we discovered several proteins involved in the growth
and development of joints that appear to have great potential
as treatments for joint disorders caused by structural damage.
Lead Agency: HHS/FDA/Center for Biologics Evaluation and
Research (CBER).
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigator: Malcolm Moos Jr., M.D., Ph.D., 1401
Rockville Pike, Suite 200N, HFM-730, Rockville, MD 20852.
Partner Agencies: National Institute of Dental and
Craniofacial Research (NIDCR). NIDCR is one of the National
Institutes of Health (NIH).
General Description: Trauma (accident or injury), normal
wear and tear, disease, and cancer surgery can all damage
specific tissues and organs. The ideal treatment for repairing
this damage would restore the tissue or organ to ``like new''
condition.
But before researchers can design such treatments, they
must first have a detailed understanding of the biochemical
processes the body itself uses to make these specific
structures.
Among the most important elements that guides the growth of
tissues and organs are biochemical signals called growth
factors--proteins that trigger specific, immature cells to
mature into a cell that is committed to a particular identity,
such as a bone cell rather than a cartilage cell. The body uses
dozens of different growth factors that cooperate under normal
circumstances to direct proper formation of developing embryos
as well as to repair tissues during the life of an individual.
Our laboratory uses a combination of experimental
approaches to understand the role of growth factors in
triggering growth and repair of tissues in the joints. We use a
variety of strategies to identify and study several previously
unknown growth factors crucial to the development of joints in
vertebrates (e.g., humans). Specifically, we use conventional
rodent models for studying bone and cartilage formation and use
the embryos of the South African clawed frog (Xenopus) to work
out the detailed biology of the growth factors that control
joint development and other processes. In addition, we analyzed
DNA from families affected by genetic disorders that lead to
short stature and deformed limbs to identify the specific DNA
sequence changes that caused two different clinical syndromes,
thus confirming the role of the factors identified in human
disease.
Our work has led to the discovery of several novel growth
factors, the most important of which are Cartilage-Derived
Morphogenetic Proteins (CDMP) 1, 2, and 3, and Frzb.
CDMPs 1 and 2 are found only in joint cartilage, and appear
to be required for normal joint formation. For example,
individuals who lack a functioning gene for CDMP1 are very
short and have deformed limbs. Therefore, CDMP growth factors
are now being evaluated to determine if they offer potential as
therapies for joint disorders.
Unlike the CDMPs, the job of Frzb is to block the activity
of other growth factors that belong to a group of molecules
called Wnts. The family of Wnt growth factors is crucial to the
formation and repair of many tissues, including joints; but
when these growth factors are overexpressed (i.e., the genes
that code for them are too active and make too much growth
factor) the Wnt proteins sometimes trigger uncontrolled growth,
that is, they cause cancer. Therefore, our work with Frzb and
Wnts has the potential to lead to new strategies for repairing
joints as well as for diagnosing and treating certain forms of
cancer.
While both CDMPs and Frzb growth factors might prove useful
as stand-alone therapies, it is more likely that they will be
most valuable when used in combination with other growth
factors, living cells, and various natural or synthetic
biomaterials to manufacture various tissue-engineered medical
products.
We are currently trying to identify at the molecular level
other crucial biochemical steps that make up the signaling
systems triggered by these growth factors. We hope this work
will help us better understand these pathways that become
active ``downstream,'' after the initial growth factor signal.
The outcome of these studies would likely contribute to the
design of improved products to repair joint disease. In
addition, our finding could help improve techniques for testing
products under clinical development in order to predict how
well they will work in the clinic.
We are currently preparing for submission to scientific
publications several manuscripts that describe our work in
these areas.
Excellence: What makes this project exceptional?
We suggested, years ahead of most investigators in the
field, that the processes controlling many types of tissue
repair-especially skeletal repair-was generally similar to the
processes that control embryonic development.
We tested the idea in two ways. First, we tested the
activity of growth factors that we identified in newborn
mammals to determine their effects in developing frog embryos;
and then we searched both frog and fish embryos for growth
factors that might be useful therapies for human joint
diseases.
Both approaches were successful and enabled FDA researchers
and their colleagues at the National Institutes of Health to
obtain patents for molecules now proposed for testing in human
clinical trials for the repair of damaged joints.
Also of interest is the fact we combined laboratory
research techniques commonly used in embryology (in our case,
frog embryos) with genetic studies of both mice and human
families afflicted with certain short stature syndromes. This
rather unconventional approach to the study enabled us to find
key growth factors more efficiently and economically than would
have been possible with conventional approaches.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Since virtually all older individuals develop joint damage,
this work is relevant to a large and growing population of
Americans.
Effectiveness: What is the impact and/or application of
this research to older persons?
New therapies based on our growth factor discoveries could
significantly improve the quality of life of the many older
persons who develop joint damage (e.g., osteoarthritis), and
help them retain their independent functioning.
Innovativeness: Why is this research exciting and
newsworthy?
The findings hold promise for more effective treatments to
repair, or perhaps even completely reconstruct, damaged joint
tissues, eliminating the need for artificial joints.
U.S. Department of Health and Human Services/Food and Drug
Administration: Neurodegenerative Diseases
Using mouse models of neurodegeneration disease in the
aging brain, we showed that loss of normal connections between
neurons precedes nerve death; and we are studying the impact of
accumulating abnormal protein deposits in neurodegenerative
disease.
Lead Agency: U.S. Department of Health and Human Services
(HHS), Food and Drug Administration (FDA)
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigator: Pedro Piccardo, M.D., Biologist,
Senior Investigator 5516 Nicholson Lane, NLRC B1, Room 126
(HFM-313), Kensington, Maryland 20895.
Partner Agencies: Center for Biologics Evaluation and
Research (CBER), Office of Blood Research and Review (OBRR),
Division of Emerging and Transfusion-Transmitted Diseases
(DTTD), Laboratory of Bacterial, Parasitic and Unconventional
Agents (LBPUA), National Institutes of Health (NIH), USA,
Biotechnology and Biological Sciences Research Council (BBSRC),
UK.
General Description: Transmissible spongiform
encephalopathies (TSEs or prion diseases) are neurodegenerative
diseases that affect humans and animals. The most common human
TSE is Creutzfeldt-Jakob disease (CJD), which the Centers for
Disease Control and Prevention estimates strikes about one in
9,000 persons. Patients with TSEs become progressively demented
and develop movement disorders.
Although TSEs are different from the more common
Alzheimer's disease (AD), doctors sometimes find it difficult
to tell the two diseases apart. Patients with AD tend to
survive much longer; and unlike CJD, AD is not associated with
a transmissible agent that could infect others. Therefore, it
is critical to develop better criteria to diagnose the two
dementing diseases of adults correctly.
Investigators in LBPUA, DETTD, OBRR, CBER, FDA, developed a
quantitative system that might assist in the laboratory
diagnosis of TSE. Currently, under the auspices of the National
Institute of Allergy and Infectious Diseases (NIAID)
interagency agreement, we are leading a project entitled
``Potential of Candidate Cell Substrates for Vaccine Production
to Propagate the Agents of Transmissible Spongiform
Encephalopathies.'' In both TSEs and AD, aggregates of
abnormally folded proteins called ``amyloids'' (that in some
instances form microscopically visible plaques) accumulate in
the brain--prion protein (PrP) in CJD and A% protein in AD. It
has long been thought that amyloid plaques are accumulations of
toxic proteins that cause neurodegeneration. A collaborative
research project between an FDA staff member with investigators
from Indiana University, Washington University, and the
University of Edinburgh (funded in part by NIAID-NIH-FDA
Interagency Agreement [see above]), has developed lines of
transgenic mice with various genetic mutations implicated in
the pathogenesis of some TSEs. These mice have already yielded
useful information for better understanding basic mechanisms of
human neurodegenerative diseases. Recent results indicate that
specific alterations in connections between nerve cells of the
brain (synaptic damage) preceded cell death and might be a
common feature in the pathogenesis of neurodegenerative
diseases. Others have proposed that, because some degenerating
nerve cells show evidence of the phenomenon termed programmed
cell death (``cell suicide'') or apoptosis, treatments to
inhibit apoptosis might be clinically useful. However, we found
that such treatments failed to rescue mice with neurological
disease. Thus, it seems unlikely that anti-apoptotic therapies
alone will have a beneficial effect in human neurodenerative
diseases unless combined with other treatments aimed at
preventing synaptic damage and neuronal dysfunction. In a
related project, we found that substantial amounts of amyloid
proteins accumulated in brains of transgenic mice that
developed no overt illness, no tissue changes of ``spongiform''
degeneration--the pathologic hallmark of TSEs--and contained no
transmissible infectious agent. We propose that amyloid plaques
may form as part of a ``protective'' mechanism that sequesters
small toxic proteins; if that is true, then therapies designed
to disrupt amyloid plaques might paradoxically enhance disease
rather than reversing it. We are now investigating
abnormalities in the brain that take place early in the course
of neurodegeneration, seeking both a better understanding of
the process and more promising targets for possible therapy.
Excellence: What makes this project exceptional?
This research program is based on our previous work
(published in peer-reviewed, high-impact scientific journals)
that showed that transgenic mice we developed have faithfully
reproduced some of the same clinical and pathologic features
found in patients with dementing diseases of aging. The ongoing
research program takes advantage of a close collaboration
between laboratories at FDA and academic institutions in the
United States and the United Kingdom. The importance of our
published studies was recently recognized by the editorial
board of the Proceedings of the National Academy of Science,
USA, which selected a publication for special editorial comment
in the area of neuroscience.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Converging lines of evidence suggest that progressive
accumulation of misfolded proteins in the brain plays a central
role in causing neurodegenerative diseases of aging, such as
Alzheimer's disease, as well as some forms of transmissible
spongiform encephalopathies. Our work is shedding light on the
causes of those diseases and suggesting new ways to treat them.
Effectiveness: What is the impact and/or application of
this research to older persons?
A number of important questions about neurodegenerative
diseases affecting older people cannot be answered by studies
in cell culture systems and require animal models. We developed
several lines of transgenic mice as models for human
neurodegenerative diseases in which abnormal forms of prion
protein accumulate in the brain. Those models have been useful
for better understanding basic processes causing
neurodegeneration and offer an opportunity for testing effects
of new therapies.
Innovativeness: Why is this research exciting and
newsworthy?
Our work challenges the long-held assumption that amyloid
plaques are toxic and trigger the neurodegeneration that
ultimately damages the aging brain. Instead, our findings
suggest those conclusions might not be true.
Future studies aim to better explain the basic mechanisms
of amyloid formation and neuronal cell death and to seek new
targets for therapeutic intervention in neurodegenerative
diseases of the aging brain.
U.S. Food and Drug Administration/Center for Drug Evaluation and
Research (CDER): Parkinson's Disease Research and Drug Development
With increases in the aging population, the prevalence of
neurodegenerative diseases such as Parkinson's disease will
increase. Drugs that can slow the worsening of symptoms are
clearly needed, but tools to guide the design of clinical
trials which can measure the effect of a drug on disease
progression are not available. Our research has used existing
clinical trial data to develop publicly available quantitative
models that may aid in the successful design of clinical trials
that support evaluation of the disease modifying potential of
newly developed therapies for Parkinson's disease.
Lead Agency: U.S. Department of Health and Human Services,
Food and Drug Administration, Center for Drug Evaluation and
Research (CDER).
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigators: Dr. Venkatesh A. Bhattaram, 10903
New Hampshire Ave., Bldg 51, Rm. 3160, Silver Spring, MD 20993-
0002; Dr. Ohidul Siddiqui, 10903 New Hampshire Ave., Bldg 21,
Rm. 4606, Silver Spring, MD 20993-0002; Dr. Leonard Kapcala,
10903 New Hampshire Ave., Bldg 22, Rm. 4368, Silver Spring, MD
20993-0002.
Partner Agencies: National Institute of Health, University
of Rochester, NY, Parkinson's Study Group, Michael J. Fox
Foundation for Parkinson's Disease, Parkinson's Action Network.
General Description: With an increasing aging population,
the number of Americans who suffer from neurodegenerative
diseases such as Parkinson's disease will increase. Parkinson's
disease is a debilitating movement disorder that severely
curtails the quality of life for patients and may lead to other
serious secondary complications. Available drugs to treat this
disease primarily provide symptomatic relief, but do not slow
the disease progression. Drugs which may provide symptomatic
relief when Parkinson's disease is first diagnosed become less
effective as the disease progresses. Pharmaceutical companies
are now developing drugs intended to slow the disease
progression. Success of these development programs will have a
major impact on public health. The scientific challenges
associated with drug development programs are paralleled by
scientific challenges associated with the development of
objective evaluation tools to gauge the effectiveness of
disease modifying treatments. Clearly, the trial designs,
endpoints and analyses currently used for evaluating the
effectiveness of drugs for symptomatic benefit are not
applicable for testing whether a drug slows the progression of
a disease. Thorough scientific research on the appropriate
endpoints for discerning symptomatic and disease modifying
effects is imperative if new therapies are to be successfully
developed and evaluated.
A group of FDA scientists initiated the Parkinson's disease
research project with the goal of developing objective models
and tools to aid in the design and evaluation of clinical
trials intended to demonstrate a disease-modifying effect. The
approach focused on using previously collected clinical trial
data to develop a quantitative description of multiple factors
important to predicting disease progression in clinical trials.
Patient level disease, demographic, trial design and other
relevant data from several clinical trials within the FDA files
and a NIH sponsored trial were collected and quantitative
disease-drug-trial models for Parkinson's disease were
developed. These models described the natural progression of
the disease, patient disposition in terms of baseline disease
severity, patient's age at disease onset, projected drug
effects on disease progression, and reasons for patient
discontinuation. Subsequently, the models were employed to
explore competing endpoints and analyses that could demonstrate
a disease-modifying effect. The results of the research were
presented at the FDA Clinical Pharmacology Advisory Committee
meeting (October 2006), and later at a public conference
sponsored by FDA, Michael J. Fox Foundation, Parkinson's Study
Group, and American Association of Pharmaceutical Scientists
(April 2008).
The generalized mathematical model is a useful tool which
may support the effective design of clinical trials by clinical
investigators/researchers in the pharmaceutical industry and
academia, thus advancing the public health by helping to speed
innovations in drug development.
Excellence: What makes this project exceptional?
1. High public health value: Parkinson's disease is
debilitating and patients need new therapies that not only
provide relief of symptoms, but that retard the rate of disease
progression. However, FDA and industry have little experience
with drug development programs for drugs with this indication.
Clear guidelines on how to develop such drugs and demonstrate
disease-modification (i.e., slowing disease worsening) are
lacking. FDA took a proactive step in leading the scientific
thinking and building knowledge on how to efficiently develop
and evaluate such drugs.
2. Objective use of prior knowledge: The first step in
developing guidelines for future development is to accrue prior
knowledge. FDA scientists evaluated prior trials submitted as
part of New Drug Applications and a NIH sponsored study to
appreciate the key features of the underlying disease.
Specifically, the research set out to answer questions such as:
How fast does a patient's disease worsen? What patient
characteristics, if any, control the pace of the disease's
progression? Do patients discontinue treatments because of
toxicity or due to lack of effectiveness? Answering these
questions was crucial to explore strategies to test if a new
drug indeed modifies the pace of the disease. FDA is in a
unique position to address these questions with its access to
vast archive of clinical trial data and expertise in
pharmacometrics, clinical trial design and biostatistics.
Leveraging that knowledge is in the best interest of public
health.
3. Effective collaboration across institutions/disciplines
towards public health advancement: FDA scientists recognized
the need for a collaborative approach to this research. The
Offices of Clinical Pharmacology, Biostatistics and New Drugs
within FDA collaborated actively in seeking answers to the
above questions. At different stages of the research, different
organizations/groups were engaged, which included: FDA, Michael
J. Fox Foundation for Parkinson's Disease, University of
Rochester, NY, Parkinson's Study Group, Parkinson's Action
Network, several pharmaceutical industry representatives, and
FDA advisors.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Parkinson's disease is a debilitating disease, which occurs
mostly in the elderly. These aging patients need better drugs,
which not only provide relief of symptoms, but retard disease
progression.
Effectiveness: What is the impact and/or application of
this research to older persons?
Developing guidelines on testing for drugs developed to
slow disease progression is important to promote the design of
efficient clinical trials that will provide for a clear and
objective evaluation of new therapies which seek a disease
modifying claim.
Innovativeness: Why is this research exciting and
newsworthy?
This is an example of FDA scientists recognizing the
tremendous public health benefit that can be realized by
proactively leveraging prior knowledge in a systematic manner
to aid future drug development. The creativity and dedication
of the scientists involved is illustrated by the fact that much
of the work was accomplished outside of their regular work
assignments. This project exemplifies the tremendous potential
of FDA's Critical Path Initiative to improve the public health
by providing tools that can reduce the uncertainties
surrounding development of urgently needed new therapies.
U.S. Food and Drug Administration, National Center for Toxicological
Research: Safety and Bioactivity of Estrogenic Dietary Supplements
Americans of all ages can be exposed to potent estrogenic
compounds in dietary supplements, foods, and drugs, but many of
the products are specifically marketed to older individuals,
such as menopausal or postmenopausal women for their perceived
health benefits and potential to relieve menopausal symptoms.
This research project has critically investigated the role of
dose, target tissue, and life stage timing of exposure in
producing physiological effects, because both beneficial and
detrimental effects are possible in mammary, adipose tissue,
and the central nervous system.
Lead Agency: U.S. Department of Health and Human Services,
U.S. Food and Drug Administration, National Center for
Toxicological Research (NCTR).
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigator: Daniel R. Doerge, Ph.D., Research
Chemist, 3900 NCTR Road, Jefferson, AR 72079.
Partner Agencies: University of Illinois--CRADA
(Cooperative Research and Development Agreement).
General Description: The overall goal of this project has
been to evaluate the safety and bioactivity of estrogenic
dietary supplements. The component projects are aimed
collectively at defining the activity of estrogenic dietary
supplements in various target tissues (including mammary gland,
adipose tissue, and central nervous system) in which estrogens
are known to have diverse--sometimes beneficial and sometimes
detrimental--effects. All of the investigations were also
designed to critically evaluate the important issue of safety,
which with hormonal agents such as estrogens is typically
complex, because it depends on dosage and exposure, metabolism,
and age, and often can vary from target tissue to target
tissue. Americans of all ages are exposed to these potent
estrogenic compounds, but many of the products are specifically
marketed to older individuals, such as menopausal or
postmenopausal women for their perceived health benefits and
potential to relieve menopausal symptoms. Therefore, the
research has focused in particular on the benefits and risks
from the use of these products by older individuals.
Excellence: What makes this project exceptional?
The overall goal of this research project was to evaluate
the safety and bioactivity of estrogenic dietary supplements
through the combined effort of several experienced
investigators, who have a long-standing track record of
scientific excellence and well-developed collaboration among
them. Together, these investigators have organized a series of
interdependent research projects that collectively are aimed at
defining the activity of estrogenic dietary supplements in
mammary, adipose tissue, and the central nervous system, in
which estrogens are known to have diverse effects.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The FDA has severely limited regulatory authority over
dietary supplements, and, as a result, the safety and efficacy
of most of these products are unknown. A significant proportion
of the estrogenic dietary supplements currently on the market
contain soy isoflavones. Many of the beneficial effects of
isoflavones are associated with their estrogenic action. This
presents a paradox--because dietary estrogens, like endogenous
and hormone-replacement therapy, have both potential risks and
benefits. Many of these products are specifically marketed to
older individuals, particularly menopausal or postmenopausal
women for their perceived health benefits and potential to
relieve menopausal symptoms. Based on research from this
project in appropriate animal models, consumption of dietary
estrogens could affect growth of estrogen-dependent breast
cancer, the development of adipose tissue and obesity, and
affect cognitive function in the elderly.
Effectiveness: What is the impact and/or application of
this research to older persons?
These studies contain important direct estrogenic
comparisons of effects from purified isoflavones, which occur
in dietary supplements, with more complex soy ingredients that
occur in whole-soy foods and other commercial products. In this
way, critical guidance can be provided to older Americans about
the healthiest practices regarding consumption of soy-based
products.
Innovativeness: Why is this research exciting and
newsworthy?
Breast cancer is the second leading cause of cancer death
in U.S. women, most breast cancer cases ( 75%) occur in
postmenopausal women, and most ( 70%) are estrogen-dependent.
The stimulatory effect of estrogens on the growth of breast
cancers can be blocked by two manipulations: competitive
binding interactions at the estrogen receptor (ER) by anti-
estrogens like tamoxifen, and competitive inhibition of
estrogen synthesis by aromatase inhibitors. These adjuvant
endocrine therapies have proven to be highly effective and have
led to significant improvements in survival for postmenopausal
women with early-stage estrogen-dependent breast cancer. This
research project has shown that dietary soy isoflavones can
negate the inhibitory effects of tamoxifen and aromatase
inhibitors on the growth of human breast tumors in a mouse
xenograft model. These studies suggest that such diet-drug
interactions have the potential to reduce the effectiveness of
frontline endocrine therapy for breast cancer in postmenopausal
women.
U.S. Food and Drug Administration/National Center for Toxicological
Research (NCTR): Effects of Dietary Supplements in Aging Individuals
This research project is designed to investigate the
possible toxic effects of the consumption of large doses of the
over-the-counter dietary supplements glucosamine and
chondroitin sulfate on the metabolism of sugar by aging
individuals who may have Type II diabetes. The project will
also evaluate the effects that glucosamine or glucosamine and
chondroitin sulfate in combination have on blood glucose,
insulin, cholesterol, and triglycerides. Organ systems that
will be investigated include liver, kidney, and eyes.
Lead Agency: U.S. Department of Health and Humans Services,
U.S. Food and Drug Administration, National Center for
Toxicological Research (NCTR).
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigator: Julian Leakey, Ph.D., Research
Biologist, 50 RM647 HFT-030, 3900 NCTR Road, Jefferson, AR
72079.
Partner Agencies: National Toxicology Program (NIEHS).
General Description: This research project is designed to
investigate the chronic effects of the long-term use of
glucosamine and chondroitin sulfate, over-the-counter dietary
supplements commonly used for inflammation and chronic joint
pain relief, and the possible interference of sugar metabolism
in individuals who may have Type II diabetes. Approximately 40
million Americans have been reported to suffer from
osteoarthritis; annual retail sales of these dietary
supplements approached $750,000,000 in 2004. Use of these
dietary supplements continues to increase among an aging U.S.
population that seeks to maintain hip, knee, and spinal health
and, therefore, preserve mobility and productive activity.
Data indicate that the subpopulation of consumers using
these compounds for chronic joint or arthritic pain management
is in its 50s or beyond, are usually overweight, and may
consume doses in excess of manufacturer's recommended levels.
It is thought that the compounds in question could accelerate
the development of vascular degeneration and other
physiological and clinical effects associated with Type II
diabetes. The potential for kidney degeneration may also prove
to be an increased risk for Type II diabetes when these drugs
are used for extended periods of time. The primary concern is
for the individuals in this sub-group who are not aware they
are Type II diabetics. The lack of dietary control has been
shown to be a contributing factor in the development of this
disease. Joint pain is increased as the level of obesity rises,
which tends to cause these self-medicated individuals to
routinely increase the dose of dietary supplements to offset
the discomfort. When one considers that most of this treatment
is without the knowledge or advice of a medical professional,
these individuals could be endangering their future health to
the point of loss of limbs, blindness, vascular disease, or
even death. The data from this project will provide much needed
information for the education of this aging population.
Excellence: What makes this project exceptional?
While use of the dietary supplements, glucosamine and
chondroitin sulfate, continues to increase in the aging U.S.
population, there is currently no long-term toxicology data on
these compounds. The depth and breadth of this study will
provide insight as to whether glucosamine or glucosamine and
chondroitin sulfate in combination, dosed at various
concentrations, will have a lasting effect on organ systems
that are also affected by diabetes. Of particular interest is
investigating whether these dietary supplements can cause
kidney damage in normal or diabetic animal models. The use of
lean (normal) and diabetic (obese) rat models in this study act
as surrogates of two human populations of individuals. The
models will allow a comparison of the effects of these drugs
under both physiological conditions and whether these
supplements will cause kidney damage in either or both rat
strains. The obese, diabetic rat begins to develop kidney
sclerosis at 20 weeks of age; osteoarthritis also begins to
develop at an early age in the obese rat. We therefore have a
model that develops signs of disease at an early age, and a
normal animal to which we can compare that disease development.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Data indicate that the likely consumers of these readily
available, over-the-counter dietary supplements, who use these
compounds for chronic joint or arthritic pain management,
comprise a large segment of the aging U.S. population.
Frequently these individuals are overweight and likely
candidates for development of Type II diabetes. It is further
thought that these supplements have the potential to accelerate
the development of vascular degeneration, kidney degeneration,
and other physiological and clinical effects known to be
associated with Type II diabetes.
Effectiveness: What is the impact and/or application of
this research to older persons?
Glucosamine or glucosamine and chondroitin sulfate in
combination are dietary supplements promoted and purchased to
relieve the symptoms of chronic inflammation and joint pain.
Consumers are predominately the middle-aged or older segment of
our population; many are obese and at risk for the development
of Type II diabetes. Significant numbers of these individuals
self-medicate independent of medical supervision, to routinely
increase the dosage to offset increased discomfort. There are
currently no data to guide individuals on short- or long-term
use of these dietary supplements. The data from this project
will provide much needed information for the education of this
aging population.
Innovativeness: Why is this research exciting and
newsworthy?
As our population ages and becomes limited in mobility and
productive activity, dietary supplements that are promoted to
alleviate the pain and discomfort of inflammation, joint pain,
and arthritis are used with greater frequency and at higher
doses. Sound guidelines for use and appropriate dosages do not
exist. As life expectancy of aging populations in the U.S.
increases, the potential for long-term use of glucosamine or
glucosamine and chondroitin sulfate in combination also
increases. Currently, there is no toxicology data on the
effects of these drugs on multiple organ systems or on the
potential for associated diabetes risk among aging, obese
populations. This study promises to provide sound scientific
data for such risk assessment.
U.S. Food and Drug Administration/Office of Women's Health: Impact of
Gender Analysis and Pharmacogenomics on Clinical Efficacy, Safety, and
Pharmocokinetics of Drugs Used for the Treatment of Alzheimer's Disease
The objectives of this project were to examine the
representation of women in Alzheimer's disease trials and to
identify whether gender and ApoE genotype are predictive
factors of the response to Alzheimer's disease drugs.
Lead Agency: U.S. Department of Health and Human Services
(HHS), U.S. Food and Drug Administration (FDA), Office of
Women's Health (OWH).
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigator: Angela Men, Ph.D., Staff Fellow,
Division of Clinical Pharmacology V, OCP, OTS/OCP/DCP5 Center
for Drug Evaluation and Research, 10903 New Hampshire Avenue,
Silver Spring, MD.
Partner Agencies: Center for Drug Evaluation and Research
(CDER), Office of Clinical Pharmacology (OCP), Division of
Neurology Products (DNP), Office of Drug Evaluation I (ODEI),
Office of New Drugs (OND), Office of Pharmacoepidemiology and
Statistical Science (OPASS), Office of Biostatistics (OB),
Divison of Biometrics I (DBI).
General Description: Impact of Gender Analysis and
Pharmacogenomics on Clinical Efficacy, Safety, and
Pharmacokinetics of Drugs Used for the Treatment of Alzheimer's
Disease. Alzheimer's disease (AD) is the most common cause of
dementia in the elderly. Risk factors for AD include one form
of the apolipoprotein E (ApoE) genotype and gender: females and
ApoE4 carriers are at higher risk for AD. Several literature
reports showed that certain patients respond better to the
treatment than others. Thus, it will be very helpful to
identify whether gender and ApoE genotype are predictive
factors of the response to AD.
The medications approved at the time of the study are
cholinesterase inhibitors and drugs regulating glutamate.
This project examined the clinical trials associated with
AD for gender-based analysis. Historically females have been
underrepresented in clinical research and thus have examined
these clinical trials determine if the number of women enrolled
is adequate. Further, since AD affects 1.5 to 3 times as many
women as men and because there are studies that suggest gender
is likely to be a more powerful determinant of outcome of
cholinesterase inhibitor treatment than ApoE status in the
short term, it was of increased importance that we track the
inclusion of women and investigate the roles that gender may
play.
Large strides have been made to ensure that women were not
underrepresented in these clinical trials. Issues of
insufficient enrollment are no longer significant in AD
clinical trials. Available genomic data show that AD patients
with homozygous ApoE4 responded more positively to treatment of
these two drugs on the cognitive function than ApoE4 negative
and heterozygous ApoE4 patients. This work shows that
pharmacogenomic information in FDA submissions is useful for
examining efficacy in important AD disease subgroups. To better
understand the impact of ApoE on clinical efficacy, collection
of pharmacogenomic information in the IND and NDA submission is
recommended.
Excellence: What makes this project exceptional?
Alzheimer's disease (AD) is characterized by progressive
impairment in memory, language, visual-spatial perceptions, and
judgment. Risk factors for AD include one form of the
apolipoprotein E (APOE) genotype and gender. Females are at
higher risk for AD. Although AD affects both men and women,
studies show that 1.5 to 3 times as many women suffer from AD
as do their male counterparts. The results from the study
showed that the ratios of women to men ranged from as low as
1.3 to 2.1. This study also explored the relationship between
ApoE biomarker and clinical outcome of AD patients when treated
with approved drugs. Since there is no cure for AD, any
progress that can be made in understanding the disease is a
tremendous step forward.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Alzheimer's Disease (AD), an age-related neurodegenerative
disorder, is the most common cause of dementia in elderly
people. There are two types of AD, early onset and late onset.
In early onset AD, symptoms first appear before age 65. Early
onset AD is much less common, accounting for only 5-10% of
cases. Late-onset AD, the more common form, develops after age
65. Although AD affects both men and women, studies show that
1.5 to 3 times as many women suffer from AD as do their male
counterparts. In 1992, researchers found that certain forms of
the apolipoprotein E (ApoE) gene can influence AD risk. The
ApoE4 is the main known genetic risk factor for AD. The ApoE4
alleles decrease and the ApoE2 alleles increase age at onset of
AD. It is estimated that the number of AD patients will reach 9
million by the year 2040 if there are no curative treatments
developed.
Effectiveness: What is the impact and/or application of
this research to older persons?
One of the objectives of this project was to determine
whether enrollment of women in AD clinical trials is sufficient
and fairly representative of the disease demographic. Based on
the obtained results, it can be said that large strides have
been made to ensure that women were not underrepresented in
these clinical trials. The results of the study demonstrate the
importance of collecting pharmacogenomic data in AD trials.
Innovativeness: Why is this research exciting and
newsworthy?
Tracking inclusion of women in these clinical trials and
identifying the gender and the genomic effects on the
pharmacokinetic/pharmacodynamic of drugs used to treat AD will
help achieve the goal of personalized medicine.
U.S. Food and Drug Administration/Office of Women's Health: Evaluating
the Effectiveness of Vertebroplasty for Improving the Mechanical
Properties of the Spine in Patients With Osteoporosis
The objective of this project was to help surgeons identify
osteoporosis patients for vertebroplasty surgery, optimize the
quantity of cement being injected and provide information to
FDA to facilitate regulatory decision making process on the use
of cements for vertebroplasty surgery.
Lead Agency: U.S. Department of Health and Human Services
(HHS), U.S. Food and Drug Administration (FDA), Office of
Women's Health (OWH).
Agency Mission: The FDA is responsible for protecting the
public health by assuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical
devices, our nation's food supply, cosmetics, and products that
emit radiation. The FDA is also responsible for advancing the
public health by helping to speed innovations that make
medicines and foods more effective, safer, and more affordable;
and helping the public get the accurate, science-based
information they need to use medicines and foods to improve
their health.
Principal Investigator: Jove Graham, Ph.D., Mechanical
Engineer, Materials Engineering Branch (MEB), Office of Science
and Technology (OST), Center for Devices and Radiological
Health, Mail Code: HFZ-150.
Partner Agencies: University of California, Berkeley
(Department of Bioengineering, Department of Mechanical
Engineering, Department of Orthopaedic Surgery, Medical
Polymers and Biomaterials Laboratory), and University of
California, San Francisco (Engineering Systems).
General Description: Vertebral compression fractures are
estimated to affect 33% of women over age 65, causing pain,
disability, and increased mortality risk. An emerging surgical
treatment is vertebroplasty, or injection of acrylic bone
cement into the vertebral body. Previous work has suggested
that bone porosity can have a significant effect on the
integrity of cement fixation in joint replacement, so the
potential benefit of vertebroplasty may depend on a patient's
degree of osteoporosis. The hypothesis was to test whether bone
mineral density (BMD) can be used to predict mechanical
strength and stiffness of the vertebral body after cement
injection. A corollary hypothesis was to test whether the
relationship between mechanical properties and BMD varies with
amount of cement injected. Vertebral columns from thirteen
adult Caucasian female cadavers were obtained and bone mineral
density was measured with DEXA. Vertebrae were randomly
assigned to five groups: intact, untreated, 4%, 12% and 24%
cement fill treatment. Specimens were first compressed to
simulate a vertebral wedge fracture and then treated with
cement. Strength and stiffness of all specimens were measured.
The results suggest that there may be significant differences
between patients with high and low bone density in terms of the
relative improvement in strength that vertebroplasty can offer
them. In the study, only the highest cement dose used (24%
fill) had any effect on mechanical strength or stiffness. More
importantly, samples with very low bone density (i.e., highly
osteoporotic) did not how as great an improvement in stiffness
as high-density samples even when cement volume was increased
to 24% fill. This study suggests that clinicians may be able to
use DEXA to select a cement volume and to predict the
mechanical integrity after vertebroplasty for a specific
patient based on bone mineral density.
Excellence: What makes this project exceptional?
Among persons over 65, fracture rates are three times
higher in women than in men, and women with osteoporosis are
more likely to suffer vertebral compression fractures.
Vertebral compression fractures are the most common injury
resulting from osteoporosis, with an estimated incidence of
700,000 per year in the U.S. These fractures, if untreated,
have been shown to cause acute and chronic back pain,
disability, and increased mortality risk. In a 2000 study of
6,459 women with osteoporosis followed for 3.8 years, those
women who sustained a spine fracture were 8.7 times more likely
to die than those women who did not experience a fracture. One
treatment for these fractures is vertebroplasty, or injection
of acrylic bone cement into the vertebral body to restore its
strength. This minimally-invasive approach is expected to
result in earlier recovery times than other more conservative
options, and it is used for severe, intractable cases where
non-surgical treatments are not sufficient to relieve the pain
and deformity caused by the fracture. Acrylic bone cement,
normally reserved for joint replacement surgery, has not been
FDA-approved for this procedure, but the cement is used ``off-
label'' for vertebroplasty at the surgeon's discretion. The
objective of this project was to test two important hypotheses
related to the safety and effectiveness of vertebroplasty
surgery. The first hypothesis is that, by diagnosing a
patient's degree of osteoporosis with non-invasive clinical
techniques, we will be able to predict the success of
vertebroplasty as measured by improvement in mechanical
strength of the vertebral body. The second hypothesis was that
the volume of cement injected can be optimized to restore
strength without causing an excessive stiffness of the
vertebral body that might lead to secondary fractures.
This study suggests that clinicians may be able to use DEXA
to select a cement volume and to predict the mechanical
integrity after vertebroplasty for a specific patient based on
bone mineral density.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Vertebral compression fractures are estimated to affect 33%
of women over age 65, causing pain, disability, and increased
mortality risk. An emerging surgical treatment is
vertebroplasty, or injection of reinforcing acrylic bone cement
into the vertebral body. Cements have not been FDA-approved for
this procedure, but they are used ``off-label'' at surgeons'
discretion.
Effectiveness: What is the impact and/or application of
this research to older persons?
Recent studies performed by FDA investigators have
established that bone porosity can have a significant effect on
the quality of cement fixation in joint replacement, so it was
hypothesized that there might also be limitations to the
benefits of vertebroplasty surgery depending on a patient's
degree of osteoporosis. A secondary long term complication of
the surgery is that adjacent vertebrae may fracture due to a
redistribution of loads following the repair of the original
fracture. It may be important to optimize the quantity of
cement being injected in order to avoid excessive stiffening of
the repaired segment relative to the adjacent bone. Such an
optimization technique has not yet been studied or reported in
the literature until this study was conducted.
As the off-label use of existing bone cements for
vertebroplasty becomes more popular, the FDA anticipates a
surge in submissions for new cement devices specific to this
application. It is a very recent, emerging area with a lack of
published data from the industry and very limited clinical
follow-up data from surgeons. The results of this project could
help FDA/ODE to develop a model for preclinical testing that
could evaluate safety and effectiveness without the need for
human studies. This project could provide important information
to ODE reviewers about the proper clinical indications for
these devices, thus reducing uncertainty in the review process
and leading to faster review times. The results of this study
should be beneficial to OSB by helping them to make informed
decisions about actions that the FDA should or should not take
in regulating these devices.
Innovativeness: Why is this research exciting and
newsworthy?
Public health will be enhanced by helping surgeons use
existing diagnostic tools to make better-informed decisions
about benefits and limitations of vertebroplasty surgery for a
specific patient.
Health Resources and Services Administration: Access to Health Care in
Rural America
This research addresses issues of access to formal home
health care in rural areas.
Lead Agency: U.S. Department of Health and Human Services
(HHS), Health Resources and Services Administration (HRSA).
Agency Mission: HHS Mission: The HHS mission is to enhance
the health and well-being of Americans by providing for
effective health and human services and by fostering sound,
sustained advances in the sciences underlying medicine, public
health, and social services.
HRSA Mission: HRSA provides national leadership, program
resources and services needed to improve access to culturally
competent, quality health care. As the Nation's Access Agency,
HRSA focuses on uninsured, underserved, and special needs
populations in its goals and program activities.
Principal Investigator: William J. McAuley, Ph.D.,
Communication Department, George Mason University, Center for
Social Science Research, 9201 Chain Bridge Road, Suite B100-MSN
1H5, Fairfax, VA 22030.
General Description:
ACCESS TO FORMAL HOME HEALTH CARE IN RURAL AREAS
This research addresses issues of access to formal home
health care in rural areas, and examines the use of formal home
health care in such areas. It also examines the impact of the
Balanced Budget Act (BBA) of 1997 and other recent policies on
the staffing characteristics of Medicare-certified home health
agencies (HHAs) across rural and urban counties from 1996 to
2002, a period encompassing changes of the BBA and related
policies.
Excellence: What makes this project exceptional?
This research highlighted the policy impact on use of
formal home health care in both small rural counties and remote
counties. The risk of any formal home care use is significantly
higher for Medicaid enrollees residing in small rural counties
(i.e., with no town larger than 10,000). Use of Medicare home
health care is significantly greater for residents of the most
remote counties. There were substantial population-adjusted
decreases in home health aides based in HHAs in all counties,
including remote counties.
Significance: How is this research relevant to older
persons, populations and or an aging society?
Results suggest that for the elderly in rural counties,
Medicaid coverage, especially of case-management services, may
facilitate access to acute and chronic care services,
especially Medicare home health care. The limitedpresence of
stable HHA staff in certain rural counties, especially in
remote counties, has been exacerbated since implementation of
the BBA.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research provides information for decision-makers
about the impact of Medicaid in rural places as an important
mechanism for linking the elderly to formal home care,
especially to Medicare formal home health care. The loss of
home health aides in more rural counties may limit the
availability of home-based long term care in these locations.
Formal home health care may substitute for less available forms
of care in the most rural counties.
Innovativeness: Why is this research exciting or
newsworthy?
This research is newsworthy because it suggests that
policies that limit access to formal home care could lead to
increased service-related vulnerabilities among the elderly in
rural areas.
U.S. Department of Health and Human Services: Medicare Advantage Plans
This research focuses on the analysis of Medicare Advantage
plan choices for rural beneficiaries.
Lead Agency: U.S. Department of Health and Human Services
(HHS), Health Resources and Services Administration (HRSA).
Agency Mission: HHS Mission: The HHS mission is to enhance
the health and well-being of Americans by providing for
effective health and human services and by fostering sound,
sustained advances in the sciences underlying medicine, public
health, and social services.
HRSA Mission: HRSA provides national leadership, program
resources and services needed to improve access to culturally
competent, quality health care. As the Nation's Access Agency,
HRSA focuses on uninsured, underserved, and special needs
populations in its goals and program activities.
Principal Investigator: Keith Mueller, Ph.D, Director,
RUPRI Center for Rural Health Policy Analysis, University of
Nebraska Medical Center, Department of Health Services Research
and Administration, 987835 Nebraska Medical Center, Omaha, NE
68198.
General Description:
IMPACT OF MEDICARE ADVANTAGE PLAN CONCENTRATION ON CHOICES AND
COMPETITION IN RURAL AREAS
This research focuses on the analysis of Medicare Advantage
(MA) plan choices for rural beneficiaries and what the
concentration of plan choices in rural areas may mean in the
context of how rural beneficiaries are making their choices.
Using measures of concentration from the economics literature,
this project explores the relationship between market
concentration in MA plans and the generosity of MA plans, and
how it varies by the location of residence of Medicare
beneficiaries.
Excellence: What makes this project exceptional?
This research is exceptional because of its emphasis on
assisting the elderly in rural America to obtain the benefits
of the Medicare Advantage program.
Significance: How is this research relevant to older
persons, populations and or an aging society?
This research is relevant because it examines the need for
outreach and education of the rural elderly about the
usefulness of the Medicare Advantage program.
Effectiveness: What is the impact and/or application of
this research to older persons?
The research provides information for decision-makers
concerned with the slow start in enrollment in rural areas to
review policies concerning Medicare Advantage in rural areas.
Innovativeness: Why is this research exciting or
newsworthy?
This research is exciting because it shows that enrollment
in Medicare Advantage in rural areas, which was off to a slow
start, is now growing rapidly so rural elderly can take
advantage of the extra benefits provided by Medicare Advantage.
Congressional Research Service: Affordable Housing for the Elderly
This report gives a detailed history of how the Department
of Housing and Urban Development (HUD) has funded, and
continues to fund, housing for older households. The report
describes how HUD supportive services programs can assist
elderly residents to stay in their residential units as they
age.
Lead Agency: Congressional Research Service.
Agency Mission: The Congressional Research Service
provides, exclusively to the United States Congress, objective,
non-partisan assessments of legislative options for addressing
the public policy problems facing the nation.
Principal Investigator: Libby Perl, Analyst in Housing.
General Description: The Department of Housing and Urban
Development (HUD) operates a number of programs that provide
assisted housing specifically for low-income ``elderly''
households (defined by HUD as those with a head of household or
spouse age 62 or older). Together with housing assistance, HUD
also funds several programs that provide supportive services
for residents to allow them to remain in their apartments as
they age. This report describes those programs, along with
current developments in the area of housing for elderly
households.
This report also describes current issues involving HUD-
assisted housing for elderly residents. Among the issues
described is the preservation of affordable housing for low-
income elderly households. At the time affordable housing
projects were developed, building owners entered into contracts
with HUD in which they agreed to maintain affordability for a
certain number of years. The duration of these contracts were
generally between 20 and 50 years. In recent years, these
contracts have begun to expire or, in some cases, property
owners have chosen to pay off their mortgages early and end the
use restrictions. When this occurs, owners may charge market-
rate rents for the units, and the affordable units are lost. In
coming years, more and more property owners will be in a
position to opt out of affordability restrictions and thousands
of units could be lost.
This report will be updated in the future to provide more
information about HUD developments, in particular Section 202
developments, with updated data from HUD. The report will also
discuss the new Intergenerational Housing Demonstration Project
through HUD that has just begun to accept grant applications.
Excellence: What makes this project exceptional?
The report explains complicated concepts in a way that
policymakers unfamiliar with the programs discussed as well as
the complexities of housing finance can understand. The report
chronicles Congressional efforts over nearly fifty years to
develop housing for elderly households. These efforts began in
1959, when Congress created the Section 202 Supportive Housing
for the Elderly program, which at the time was targeted to
underserved, moderate income households (low-income households
at the time were served through the Public Housing program).
The report focuses on the Section 202 program because it is the
only program devoted exclusively to serving elderly households
and because its history is complex. The program has had many
incarnations; the system of providing financing for
developments has changed from loans to grants, the tenant
population targeted has moved from moderate-income elderly
households to very low-income elderly households, and the
program has gone from serving only elderly households to
serving elderly and disabled households, and then back to
serving elderly households exclusively. This history of Section
202 is important to policymakers because many projects
developed in the early years of the program continue to operate
under the rules in place at the time they were built, and
changes to the law must take account of those rules.
The report also discusses four programs that provide
housing devoted to elderly households, but that do not receive
as much attention as Section 202. Two of these programs,
Section 221(d)(3) and Section 236, were created in 1961 and
1968 respectively, however they have not been used to build new
housing since the 1970s. As a result, there is not much
information available about the way in which these programs
developed and currently operate. These sections of the report
are therefore a good source of information that is otherwise
difficult to find. The report also details how buildings
developed through the Section 8 project based rental assistance
program and Public Housing program may be dedicated to elderly
residents exclusively and the rules involved in dedicating
these facilities. Finally, the report brings in a discussion of
HUD supportive services programs and how they work together
with HUD-assisted housing. These programs are the Service
Coordinator program, Congregate Housing program, Assisted
Living Conversion program, and the Resident Opportunity and
Self Sufficiency program.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This report unifies the discussion of how the federal
government supports affordable housing for Older Americans.
Numerous funding streams for both housing and supportive
services exist, and the way in which they interact to serve
``elderly'' households, defined by the Department of Housing
and Urban Development (HUD) as those with a head of household
or spouse age 62 or older, is not always clear. Over the years,
HUD has developed assisted housing through multiple programs,
and the structure of those programs, the financing
arrangements, and the populations that they serve all differ to
some degree. For example, some of these programs have not
funded new housing developments since the 1970s, and others
have changed their financing schemes as well as the
characteristics of households eligible to live there.
Effectiveness: What is the impact and/or application of
this research to older persons?
The report's purpose is to inform Congressional staff and
Members of Congress about how existing programs operate as they
consider future policy approaches to this issue. Knowing the
evolution of the Section 202 program is important background
for understanding pending legislation, since its provisions
would affect Section 202 developments differently depending on
which version of the program financed their construction.
Innovativeness: Why is this research exciting or
newsworthy?
This report takes a comprehensive and detailed approach to
chronicling these varied and complex housing programs. Although
other existing reports may present information about the
history of the Section 202 program, for example (both HUD and
AARP have done this), this report differs in that it also
discusses four other HUD programs that provide housing for
elderly households in an attempt to cover the spectrum of
assisted housing. Unlike the Section 202 program, these
programs--Section 236, Section 221(d)(3), Section 8 project-
based housing, and Public Housing--also provide housing for
non-elderly households, but building owners may choose to
dedicate their facilities to elderly residents. Nor do other
existing reports include discussions of how HUD supportive
services programs interact with HUD housing programs so that
residents may remain in their units as they age.
Congressional Research Service: Long-Term Family Caregiving
This report describes the role of family caregivers in
providing long-term care to older individuals; federal programs
and initiative that directly and indirectly assist family
caregivers; and, selected policy issues that would provide
direct assistance to family caregivers.
Lead Agency: Congressional Research Service.
Agency Mission: The Congressional Research Service
provides, exclusively to the United States Congress, objective,
non-partisan assessments of legislative options for addressing
the public policy problems facing the nation.
Principal Investigator: Kirsten J. Colello, Analyst in
Gerontology.
General Description:
FAMILY CAREGIVING TO THE OLDER POPULATION: BACKGROUND, FEDERAL
PROGRAMS, AND ISSUES FOR CONGRESS
This report describes the role of family caregivers in
providing long-term care to older individuals; federal programs
and initiatives that directly and indirectly assist family
caregivers; and, selected policy issues that would provide
direct assistance to family caregivers. These policy issues,
which have been the subject of discussion among federal
policymakers and other interested stakeholders, include the
following: caregiver services and supports, flexible workplace
accommodations and income security, and additional tax credits.
Family caregiving to older individuals in need of long-term
care encompasses a wide range of activities, services, and
supports. Caregiving can include assistance with personal care
needs, such as bathing, dressing, and eating, as well as other
activities necessary for independent living, such as shopping,
medication management, and meal preparation. In addition,
family caregivers may arrange, supervise, or pay for formal or
paid care to be provided to the care recipient.
Family caregivers fulfill the majority of the need for
long-term care among older persons with chronic disabilities in
the United States. As a result of increases in life expectancy,
as well as the aging of the baby-boom generation, demand for
family caregiving to the older population is likely to
increase. However, demographic trends such as reduced
fertility, increased divorce rates, and greater labor force
participation among women may limit the number of available
caregivers to older individuals, as well as the capacity for
caregivers to provide needed care.
Excellence: What makes this project exceptional?
This report assists Congress in identifying and describing
the various federal programs and initiatives that provide both
direct and indirect assistance to family caregivers.
Recognizing family caregivers as an important part of the
nation's long-term care delivery system, the federal government
has established programs and initiatives that provide direct
supports to caregivers, such as respite care, education and
training, tax relief, and cash assistance. This report
summarizes federal programs and initiatives that provide both
direct and indirect support to family caregivers. Benefits that
are targeted directly at family caregivers help to reduce
stress and financial hardship, and to improve caregiving
skills, among other things. Other federal programs and
initiatives provide home-and community-based long-term care
services and supports to the care recipient. These programs can
indirectly benefit caregivers in relieving caregiver burden by
either supplementing the informal care they are providing or
substituting with paid support. This report assists federal
policymakers by describing these federal programs and
initiatives. The report also summarizes key policy issues for
family caregivers to the older population that have been the
subject of discussion among federal policymakers and other
interested stakeholders.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The need for long-term care increases with advancing age.
Family caregivers fulfill the majority of the need for long-
term care among older persons with chronic disabilities in the
United States. As a result of increases in life expectancy, as
well as the aging of the baby-boom generation, demand for
family caregiving to the older population is likely to
increase. However, demographic trends such as reduced
fertility, increased divorce rates, and greater labor force
participation among women may limit the number of available
caregivers as well as the capacity for caregivers to provide
needed care to older individuals. Given these competing
factors, it is likely that family caregiving to the older
population will remain an important topic for consideration
among policymakers.
Effectiveness: What is the impact and/or application of
this research to older persons?
About 5.5 million adults aged 65 and older--about 16% of
the U.S. population aged 65 and older--receive long-term care
services and supports. Of those receiving services, the
majority (70%, or 3.8 million) live in the community; the
remaining 30% (1.7 million) live in institutional settings. It
is estimated that between 7 and 54 million Americans provide
assistance with personal care and other activities necessary
for individuals to function independently in their own homes
and communities. The majority of these individuals providing
care to older relatives are family members, such as a spouse or
adult child. Many do so willingly out of a sense of
responsibility or personal obligation to their family member.
As a result, some do not identify themselves as caregivers.
However, researchers have increasingly paid more attention to
the issue of family members providing unpaid care to older
relatives, many of whom provide assistance with long-term care
needs for extended periods of time. It is estimated that family
caregivers provide on average, 46 hours of care per week for
over 4 years. Family caregivers seeking information on
available public and private long-term care services and
supports for their older relative may be overwhelmed with what
is often described as a fragmented and confusing system.
Innovativeness: Why is this research exciting or
newsworthy?
Family caregivers will continue to play an important role
in the delivery of long-term care services and support to the
older population. Researchers are continuing to examine ways in
which education, training, and other services and supports can
best assist family caregivers. Policymakers will continue to
debate ways in which the federal government can further assist
family caregivers providing long-term care to older
individuals.
Social Security Reform: Possible Effects on the Elderly Poor and
Mitigation Options
This report analyzes the projected effects of four possible
options to mitigate the effects of Social Security (SS) benefit
reductions on elderly poverty. The four options examined are
(1) a poverty-line SS minimum benefit; (2) a sliding-scale SS
minimum benefit; (3) a poverty-line Supplemental Security
Income (SSI) benefit; and (4) a poverty-line SSI benefit with
liberalized eligibility.
Lead Agency: Congressional Research Service
Agency Mission: The Congressional Research Service
provides, exclusively to the United States Congress, objective,
non-partisan assessments of legislative options for addressing
the public policy problems facing the nation.
Principal Investigator: Kathleen Romig, Analyst in Income
Security.
General Description:
SOCIAL SECURITY REFORM: POSSIBLE EFFECTS ON THE ELDERLY POOR AND
MITIGATION OPTIONS
This report analyzes the projected effects of four possible
approaches to mitigating the effects of Social Security benefit
reductions on elderly poverty in 2042, the first full year of
projected trust fund insolvency. The options are compared to a
payable baseline, which assumes current-law benefits would need
to be cut across the board to balance Social Security's annual
income and spending at the point of insolvency. The four
options examined are (1) a poverty-line Social Security minimum
benefit; (2) a sliding-scale Social Security minimum benefit;
(3) a poverty-line SSI benefit; and (4) a poverty-line SSI
benefit with liberalized eligibility.
Major findings include the following:
Each of the four options would reduce elderly
poverty compared to the payable baseline--ranging from a
negligible reduction in the elderly poverty rate for the option
to create a sliding-scale Social Security minimum benefit to a
reduction of three percentage points for the poverty-line SSI
benefit with liberalized eligibility.
The elderly poverty rate under all of the options
would be higher than under the current law scheduled baseline,
which assumes the current benefit formula can be maintained
with no reductions.
The SSI options examined would target the
additional spending more efficiently toward the poor elderly
than would the Social Security options.
The Social Security options examined would reduce
the incomes of some elderly because of interaction effects; the
SSI options would not create such interactions.
Excellence: What makes this project exceptional?
This program uses a microsimulation model to simulate the
impact of alternative Social Security reform proposals on the
elderly poor. This research can be distinguished from other
research as it focuses on the poor elderly specifically and is
able to simulate the interaction of Social Security and
Supplemental Security Income (SSI). Most other research has
focused on only the effects of Social Security on the low,
median and high-wage earner. This information should help
policymakers identify any potential unintended consequences
through the interaction of these effects.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The Social Security system faces a long-term financing
problem. The Social Security Trustees project cash-flow
deficits beginning in 2017 and trust fund insolvency in 2041.
Many recent proposals to improve system solvency would reduce
Social Security benefits in the future. Benefit reductions
could affect the low-income elderly, many of whom rely on
Social Security benefits for almost all of their income. Such
potential benefit reductions could lead to higher rates of
poverty among the elderly compared to those projected under the
current benefit formula. Because the low-income elderly are
especially vulnerable to benefit reductions, many recent Social
Security reform proposals have included minimum benefits or
other provisions that would mitigate the effect of benefit cuts
on the elderly poor. This report is significant in that it
quantifies the effect of four possible options for mitigating
the effect of Social Security reform on the elderly poor.
Effectiveness: What is the impact and/or application of
this research to older persons?
Congress will be faced with the addressing Social Security
reform in the next few years and will be looking at many
options. Since Social Security has played a unique role in
reducing elderly poverty over time, the findings from this
research can inform policymakers as they consider reforming the
program.
Innovativeness: Why is this research exciting or
newsworthy?
When discussing changes to public policy, it is important
to keep in mind the possible unintended consequences of
potential changes. This research uses a microsimulation model
and provides an advantage in that it can identify unexpected
interactions between policy options and existing program rules.
Social Security is a complex program, and changes to its
structure could lead to unexpected results--both within Social
Security and in the relationship of Social Security to
Supplemental Security Income (SSI). In the most extreme case,
an increase in Social Security benefits could actually make
some low-income beneficiaries worse off because they would lose
eligibility for other programs as a result.
Congressional Research Service: Retirement Savings: How Much Will
Workers Have When They Retire?
This report shows how varying the age at which households
begin to save for retirement, the percentage of their earnings
that they save, and the rate of return on investment can affect
the amount of retirement savings the household will have
accumulated by age 65.
Lead Agency: Congressional Research Service.
Agency Mission: The Congressional Research Service
provides, exclusively to the United States Congress, objective,
non-partisan assessments of legislative options for addressing
the public policy problems facing the nation.
Principal Investigator: Patrick Purcell, Specialist in
Income Security.
General Description:
RETIREMENT SAVINGS: HOW MUCH WILL WORKERS HAVE WHEN THEY RETIRE?
This report presents the results of an analysis of the
amount of retirement savings that households might be able to
accumulate by age 65 under a number of different scenarios. The
analysis shows how varying the age at which households begin to
save for retirement, the percentage of their earnings that they
save, and the rate of return on investment can affect the
amount of retirement savings the household will accumulate.
Based on Monte Carlo simulations of the variability of
investment rates of return, a married-couple household that
contributes 8% of pay annually for 30 years beginning at age 35
to a retirement plan invested in a mix of stocks and bonds
could expect to accumulate $468,000 (in 2004 dollars) by age 65
if rates of return were at the median over the 30-year period.
Nevertheless, given the variability of rates of return, there
is a 5% chance that the couple would have $961,000 or more and
a 5% chance that the couple would have $214,000 or less. Higher
contribution rates and longer investment periods lead to higher
account balances, but also increase the impact of the
variability of investment rates of return. At a 10%
contribution rate over 30 years, the household could expect to
accumulate $594,000, with a 90% probability that account would
total between $301,000 and $1.2 million. Saving 8% of pay over
40 years, the household could expect to accumulate $844,000,
with a 90% probability that the account would total between
$370,000 and $2 million.
Excellence: What makes this project exceptional?
Rather than estimating future retirement account balances
based on average historical rates of return on stocks and
bonds, the estimates presented in this report are based on
Monte Carlo analysis, which simulates thousands of possible
outcomes. The results of the analysis provide estimates of
retirement account balances under favorable and unfavorable
market conditions as well as the average outcome.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Over the past 25 years, although the percentage of the
workforce who participate in employer-sponsored retirement
plans has remained relatively stable at approximately half of
all workers, the type of plan by which most workers are covered
has changed from defined benefit (DB) pensions to defined
contribution (DC) plans. The responsibilities of managing a DB
plan--making contributions, investing the assets, and paying
the benefits to retired workers and their survivors--lie mainly
with the employer. In a typical DC plan, the worker must decide
whether to participate in the plan, how much to contribute, how
to invest the contributions, and what to do with the money in
the plan when he or she changes jobs or retires. As a result of
the shift from DB plans to DC plans, workers today bear more
responsibility for preparing for their financial security in
retirement. This report illustrated the impact of those
decisions on retirement savings.
Effectiveness: What is the impact and/or application of
this research to older persons?
The impact of this report on older persons would be
indirect, as a result of informing the Congress on this issue.
The oldest members of the ``baby boom''--the 78 million
Americans who were born between 1946 and 1964--are 62 years old
in 2008. The youngest members of the baby boom, however, are
just 44 years old. The report illustrates how those who have
postponed saving for retirement until after age 40 can still
accumulate substantial retirement savings, but that it requires
a substantially higher savings rate than would have been needed
if they had begun to save for retirement at an earlier age.
Innovativeness: Why is this research exciting or
newsworthy?
The research is innovative in the application of Monte
Carlo simulation techniques that clearly illustrate the effects
of the variability in rates of return on retirement savings.
The Human Research Program: Astronaut Health and Elderly Treatment
Because some of the effects of space flight on astronauts
have similarities to the effects of human aging, NASA's
research can illuminate the mechanisms behind the effects
common to both.
Lead Agency: The Human Research Program, Advanced
Capabilities Division, Exploration Systems Mission Directorate,
of the National Aeronautics and Space Administration.
Agency Mission: The Human Research Program (HRP) is
instrumental in carrying out the Vision for Space Exploration
(VSE), by developing and delivering research findings, health
countermeasures, and human systems technologies for spacecraft
that will support crews on missions to the moon, Mars, and
beyond.
Principal Investigator: Jacob Bloomberg, Ph.D., Brian
Crucian, Ph.D., Judith Hayes, M.S., Lauren Leveton, Ph.D.,
William Paloski, Ph.D., Steven Platts, Ph.D., Scott Smith,
Ph.D., Human Research Program, NASA Johnson Space Center,
Houston, TX 77058.
Partner Agencies: NASA's HRP funds research with a large
number of academic institutions and collaborates with many
national and international government agencies and commercial
entities.
General Description: NASA's Human Research Program
undertakes biomedical research and develops technologies to
assure human health, safety, and performance during space
exploration missions to the moon and Mars. Because some of the
effects of space flight on astronauts have similarities to the
effects of human aging, NASA's research on astronaut health may
offer significant utility for treatment of the elderly. The
following research areas demonstrate this linkage:
Balance and Gait Control: Falls in astronauts and the
elderly can be caused by problems with the sense of balance.
Astronaut's nervous systems adapt to weightlessness in ways
that disturb balance and gait when they return to Earth or land
on another planet. The human nervous system has evolved
components that optimize body movements and posture control
under Earth's gravity. Both space flight and aging affect the
performance of the components. NASA is investigating ways to
help astronauts ``learn how to learn'' to adapt to new
gravitational environments. This involves techniques that
systematically test and challenge the balance and gait control
systems. (References: BG-1 to BG-12)
Orthostatic Hypotension: The decrease of blood pressure
while standing upright may lead to fainting, falls and thus
injuries in astronauts and the elderly. Astronauts' orthostatic
hypotension has been shown to be related to dehydration and
blunted functioning of the cardiovascular control system, and
there is evidence of similar mechanisms in elderly hypotensive
patients. NASA's work in understanding this problem in
astronauts has suggested treatments ranging from mechanical
support, to oral rehydration, to a medication named Midodrine
that augments the nervous system's control of the circulation.
(References: OH-1 to OH-4)
Osteoporosis and Bone Fracture Risk: The injuries from
falls in the elderly are often manifested in bone fractures,
which are also a significant risk to astronauts if they occur
during stressful missions on another planet, at a great
distance from definitive medical care on Earth. Osteoporosis is
perceived as a disease of the elderly because the inevitable
loss of bone mass with aging occurs by a slow, chronic process
that does not display symptoms until a low-trauma fracture
occurs. But loss of bone strength happens in young, fit
astronauts at a much faster rate than in the elderly, in a
process that NASA calls premature osteoporosis. This is a long-
term health risk to astronauts after a space flight, as well as
a risk during the mission. (References: B-1 to B-4)
Impaired Nutrition and Vitamin D Metabolism: Many of NASA's
nutritional biochemistry efforts have important applications to
the elderly, foremost among them NASA's vitamin D research.
This involves astronauts in spaceflight, scientists in the
Antarctic, and the self-neglecting elderly. NASA collaborated
with the Surgeon General's Office in 2004 and 2005 in
conferences titled ``Vitamin D and Bone Health Conference: An
Update from Earth and Outer Space.'' (References: N-1 to N-2,
VD-1 to VD-3)
Reduced Immunological Response: Innate immunity, the first
line response to bacterial infections, is diminished in up to
20% of adults over age 65 who do not develop fevers in response
to infections. Immunity has been found to be altered during and
following space flight. In particular, the reversible nature of
the space flight effects offers hope for slowing or even
reversing the effects of aging. Specifically, astronauts have
exhibited altered number and function of immune cells and
reactivation of latent herpesviruses. (References: I-1 to I-7)
Noninvasive Behavioral Health Techniques: There are
neurobehavioral and psychosocial factors that influence both
the elderly and astronauts including risk of depression, sleep
disorders, and cognitive function changes that can benefit from
noninvasive techniques. These noninvasive behavioral health
techniques can aid physicians to provide treatments for
individuals at risk, to enable them to continue leading
productive and healthy lives, whether in space or on Earth.
Excellence: What makes this project exceptional?
Unique perspective and contributions to aging research are
resulting from NASA's space biomedical research program.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Balance and Gait Control importance to Aging: Falls in the
elderly are a significant (and growing) public health problem
because they lead to death, injury, and activity restrictions.
Approximately one-third of community-dwelling persons over age
65 falls at least once per year. As a result, 40% of all
nursing home admissions are due to fall-related injuries. The
risk is greater in women.
Orthostatic Hypotension Importance to Aging: This risk
increases rapidly with age and resulted in 164,000
hospitalizations in 1994 alone.
Osteoporosis and Bone Fracture Risk importance to Aging
Research: The injuries from falls in the elderly are often
manifested in bone fractures, which can lead to hospitalization
and subsequent decline.
Nutrition and Vitamin D Research Importance to Aging:
Insufficient exposure to the ultraviolet light in sunshine,
through immobility or confinement whether on Earth or in a
spacecraft, leads to decreased production of Vitamin D. This
can increase the risk of diseases such as Alzheimer's and
diabetes in the elderly, as well as depression, cancer,
impaired physical performance, weakened immune function and
decreased bone health which the elderly on Earth may have in
common with astronauts on long, hazardous space missions.
Reduced Immunological Response importance to Aging: Immune
system dysregulation is observed in both the elderly and
astronauts during space flight. Innate immunity, the first line
response to bacterial infections, is diminished in up to 20% of
adults over age 65 who do not develop fevers in response to
infections.
Noninvasive Behavioral Health Techniques importance to
Aging: There are neurobehavioral and psychosocial factors that
influence both the elderly and astronauts including risk of
depression, sleep disorders, and cognitive function changes
that can benefit from noninvasive techniques.
Effectiveness: What is the impact and/or application of
this research to older persons?
Balance and Gait Control Results/Application of Research:
Some of these techniques were applied to community-dwelling
participants in a study associated with John Glenn's second
space flight in 1998. The techniques applied in spaceflight
could also be used in rehabilitation of patients with balance
disorders, and for fall prevention training in the elderly.
Orthostatic Hypotension Practical Applications of Research:
The most beneficial discovery in this area for astronauts and
the elderly in the form of a warning. It came from a study that
determined that Midodrine may interact badly with Promethazine
(Phenergan%), a medication used to control severe motion
sickness whether due to space flight, radiation treatment,
chemotherapy or surgical anesthesia. The effects may include
twitching, anxiety and even violent behavior.
Osteoporosis and Bone Fracture Risk Results/Application of
Research: NASA has just started funding a collaborative study
with the Mayo Clinic to evaluate factors such as ethnicity,
gender, genetics, age, nutritional status and fitness level and
their importance on bone health in astronauts. This will have
obvious implications for the elderly.
Nutrition and Vitamin D Results/Application of Research:
NASA-funded research evaluated the ability of diet modification
to mitigate bone loss, based on extensive ground research (N1-
N2). Vitamin D is a dietary factor related to diseases such as
cancers and diabetes, as well as bone health, in people on
Earth and in space. The 2005 USDA Dietary Guidelines for
Americans specifically called out the need for supplementation
of vitamin D in at risk populations, including the elderly, and
those with insufficient exposure to the ultraviolet light in
sunshine, due to limited mobility and confinement in the
elderly (ref. VD-3), or to being in a small spacecraft without
many windows that protects astronauts from the unfiltered sun
(refs. VD-1 to VD-2). On-going NASA research will determine
safe and effective vitamin D dosing regimens in individuals
with insufficient ultraviolet light exposure.
Reduced Immunological Response Results/Application of
Research: A recent study has demonstrated that the elderly
suffer higher levels of latent herpesvirus reactivation, which
is usually associated with reduced immune function. NASA
studies of astronaut immunity during space flight have revealed
similar observations (ref. I-7). The flight of John Glenn (age
77) in 1998 specifically revealed differences in white blood
cells and in stress hormone levels between him and his younger
crewmates.
Noninvasive Behavioral Health Techniques Results/
Application of Research: NASA is funding research at the
National Space Biomedical Research Institute designed to
address behavioral health risks including: (1) use of
noninvasive near-infrared neuro-imaging technology to identify
biomarkers indicating a tendency to depression, (2) development
of speech monitoring technologies that can indicate damage to
portions of the central nervous system that can result from
radiation exposure or hypoxia (in astronauts) or the early
stages of Alzheimer's disease (in the elderly), (3) use of blue
light to maintain circadian rhythms and alertness, and (4)
developing systems that can provide feedback to astronauts on
long, stressful missions to warn them if their cognitive
function is changing, so they can seek appropriate treatments
and counseling, which could also be made available to the
elderly on Earth.
Innovativeness: Why is this research exciting or
newsworthy?
In many forms and areas, NASA's research into the causes of
maladaptation to weightlessness, and the development of
treatments and preventions for them, may offer significant
utility and importance for the elderly. The opportunity to
provide tangible benefits to the segment of the population who
initiated and supported the development of America's
exploration of space is a demonstration of the potential of
space exploration to improve the lives of all Americans while
extending our reach further into the universe.
National Space Biomedical Research Institute Ultrasound Technology in
Assisted Living Facilities
This project trains non-medical personnel to use ultrasound
to assess health situations for a space mission. These
techniques can be applied on earth, e.g. staff at assisted
living facilities, ambulance crews, rural medical caregivers
and military medics.
Lead Agency: National Space Biomedical Research Institute
(funded through a cooperative agreement with NASA).
Agency Mission: The National Space Biomedical Research
Institute leads a national effort for accomplishing the
integrated, critical path, biomedical research necessary to
support long-term human presence, development and exploration
of space and to enhance life on Earth by applying the resultant
advances in human knowledge and technology acquired through
living and working in space.
Principal Investigator: Scott A. Dulchavsky, M.D., Ph.D.,
Henry Ford Health System, 2799 W. Grand Boulevard, CFP 110,
Detroit, MI 48202.
Partner Agency: Henry Ford Health System.
General Description: In spaceflight, a number of crew
health situations, such as severe abdominal pain, tooth
abscess, sinus infection, muscle and bone loss, broken or
fractured bones, and eye, knee or shoulder trauma, could
severely impact the success of long-duration missions. These
same injuries are common in the elderly. Diagnosing and
managing acute health problems in remote locations or non-
hospital environments, including space, is challenging due to
availability of equipment and trained personnel. Dr. Scott
Dulchavsky's project, funded by National Space Biomedical
Research Institute, assessed the ability to use ultrasound in
health situations which would have a high impact on mission
success.
This project uses training regimens and CD-ROM refresher
modules to teach non-medical personnel to easily perform
ultrasound imaging. Trainees learn to use miniaturized
ultrasound to assess health situations that could impact all
aspects of a space mission. These same training techniques are
transferable to Earth-based medicine, including staff at
assisted living facilities, ambulance crews, rural medical
caregivers and military medics.
The program gave trainees the tools to assess injuries
using real-time remote assistance from medical experts,
enabling persons working in a remote environment to assess and
manage an emergency medical condition. His team developed
training regimens and refresher modules that allowed non-
physicians to operate ultrasound as if they were technicians.
It normally takes 200 hours plus yearly updates to learn to
operate ultrasound, but Dr. Dulchavsky and his team developed
training methods that cut the time to two-three hours a year.
The training program consists of a computer-based instructional
presentation on the basics of ultrasound examination and
examples of remote guidance. Trainees then participate in a
hands-on session where they perform abdominal and
musculoskeletal ultrasound scans.
With remote guidance, a modestly trained operator is
coupled with an experienced medical expert, essentially making
the non-physician the hands of the expert. The diagnostic,
treatment, and training protocols developed in this study will
also provide information which can be used in rural care,
assisted living care, military conflicts, and third world
medicine on Earth. The methods have been used with professional
sports teams, in research projects studying athletes at the
Olympics in Italy, and during a recent Mount Everest
expedition.
Excellence: What makes this project exceptional?
This portable technology facilitates training of lay
individuals in a complex medical task that results in improved
disease detection and the potential to save lives.
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Because many elderly individuals are immobile or living in
confined conditions, this technique allows the technology to
come to the patient, without the patient having to come to the
clinic or hospital.
Effectiveness: What is the impact and/or application of
this research to older persons?
This technology provides improved capabilities for
diagnosis of medical problems by a portable means that can be
used by non-medical personnel.
Innovation: Why is this research exciting or newsworthy?
This ultrasound training concept is global in nature, in
that it has no boundaries.
National Aeronautics and Space Agency: Surgical Implant Technology
Research
Orthopedic implant decontamination is an application
developed from NASA research on combating the corrosive effects
of atomic oxygen in space. Understanding this corrosive gas has
resulted in new methods to decontaminate surgical implants.
Lead Agency: National Aeronautics and Space Agency (NASA).
Agency Mission: NASA's mission is to pioneer the future in
space exploration, scientific discovery and aeronautics
research.
Principal Investigator: Bruce Banks, Senior Physicist,
Consultant to Alphaport supporting NASA Glenn Research Center,
21000 Brookpark Road, M/S 309-2, Cleveland, OH 44135.
Partner Agency: Case Western Reserve University Department
of Orthopedics and DePuy Orthopedics, Inc.
General Description: Orthopedic implant decontamination is
a spinoff application that has been developed as a direct
result of NASA's research on low Earth orbital atomic oxygen
interactions with spacecraft materials. The contribution
consists of a process for removal of biologically active
contaminants from the surfaces of orthopedic implants.
Currently most orthopedic implants have endotoxins on their
surfaces, which cause inflammation and pain. Such responses can
lead to joint loosening and implant failure. Sterilization does
not remove endotoxins because they are non-living chemicals
consisting of mostly bacterial cell wall fragments. Implant
surface exposure to atomic oxygen has been demonstrated to
fully remove all endotoxins thus minimizing the chances of
inflammation in the patient after surgery.
The technology that inspired the spinoff applications was
NASA's investigation of low Earth orbital atomic interaction
with materials. All hydrocarbon materials and hydrocarbon
polymers have been found to erode though oxidation when exposed
to the low Earth orbital environment. As a result of this
reactive environment polymers used for solar array blankets and
thermal control materials can be eroded away unless protective
coatings could be used to prevent chemical reactions from
occurring. Protective coatings were developed to protect such
polymers. Validation of protective coating solutions to atomic
oxygen erosion needed to be performed in ground laboratory
facilities. To address NASA's mission needs, ground based
atomic oxygen facilities were developed and used to validate
full mission durability for International Space Station (ISS)
solar array blanket materials. Protective coatings developed
for ISS solar array blankets are now used on all the USA
supplied ISS solar arrays. The resulting knowledge of atomic
oxygen interaction with materials and being made aware of
specific biomedical needs provided the inspiration for the
innovation of this biomedical application.
Excellence: What makes this project exceptional?
Exposure to atomic oxygen is the only known method that
fully removes all endotoxins on surgical implants, thus
minimizing the chances of inflammation in the patient after
surgery.
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Osteoarthritis affects between 20% and 30% of the people in
the USA over 70 years old and 32 million people of all ages.
There are 350,000 hip fractures in the USA each year that
require orthopedic implants for repair. It is estimated that by
the year 2050 there will be 1,800 hip fractures per day that
will require surgery. Almost all such surgeries will require
implantation of orthopedic devices that are currently
contaminated with biologically active chemicals which can cause
inflammation. The quality of life and financial cost associated
with inflammation resulting from implant contamination is
enormous. As the average life expectancy increases along with
weight of Americans the incidence of restorative orthopedic
surgery will obviously increase. Surveys indicate that the
worldwide orthopedic implant market was $4.5 billion in 2002
and is expected to be $7 billion in 2007. The quality of life
improvements and reduction in corrective orthopedic operations
enabled by reduction in inflammation through use of atomic
oxygen removal of biologically active contaminants would be
significant.
Effectiveness: What is the impact and/or application of
this research to older persons?
The value of this technology will increase as the life
expectancy increases and average weight of adults increases.
Although this nomination deals with orthopedic implants many
other surgical implant surfaces may cause adverse biological
responses which lead to functional compromises due to presence
of biologically active contaminants. One example is titanium
vascular stents which may occlude if there is a presence of
organic contaminants which are used in the machining process
during fabrication.
Innovation: Why is this research exciting or newsworthy?
Recent tests of commercially produced, sterilized and
packaged bone screws from four different orthopedic supplier
companies indicated that three quarters of the screws showed
presence of endotoxins on their surface.
National Aeronautics and Space Administration: BioWatch Monitors
Originally designed to monitor astronaut health, BioWATCH
monitors multiple vital signs and transmits data to doctors. It
can monitor various diseases across levels of acuity, which
makes it ideal for patients at home. BioWATCH can dramatically
increase a patient's quality of life.
Lead Agency: National Aeronautics and Space Administration
(NASA).
Agency Mission: NASA's mission is to pioneer the future in
space exploration, scientific discovery, and aeronautics
research.
Principal Investigator: Alan Chmiel, Vice President, ZIN
Technologies, 6745 Engle Road, Cleveland, Ohio 44130.
General Description: Biomedical Wireless and Ambulatory
Telemetry for Crew Health (BioWATCH) is a wireless biometric
monitoring system originally designed to monitor astronaut
health in space. It can measure heart rate, blood pressure,
glucose, temperature, joint angle, ECG, and blood oxygenation,
and then send the information to doctors on Earth in real time.
BioWATCH was developed by ZIN Technologies and The Cleveland
Clinic Foundation under NASA Glenn's Small Business Innovation
Research Program.
The commercial version of BioWATCH transmits data to
doctors wirelessly via cell phone, wireless internet or
Bluetooth. It can be configured to monitor various conditions,
which makes it ideal for post-surgery patients, participants in
clinical drug trials, and home healthcare patients.
Based on the success of the initial prototypes, ZIN and the
Cleveland Clinic teamed to deploy BioWATCH in an application
monitoring heart rhythm in patients following a procedure
designed to eliminate a heart rhythm irregularity known as
atrial fibrillation. BioWATCH can be used in applications to
monitor patients with histories of heart disease, arterial
disease, hypertension, diabetes, pulmonary disease, stroke,
myocardial infarction, or sleep apnea.
The technology of BioWATCH allows for transmission of
patient data from the patient to a health professional in real
time. Since BioWATCH is a small wearable monitor, it can travel
with the patient. All of these features allow for a substantial
improvement in quality of life.
Ten percent of Americans over age 70 have a heart condition
known as atrial fibrillation (AF), which is treated with
anticoagulation drugs that require regular screenings.
Typically, patients on these drugs are tested twice monthly for
potentially fatal side effects. With BioWATCH patients can be
tested daily, and results are available to the doctor
instantaneously, reducing the risks. Also, patients facing long
rehabilitation from orthopedic surgery can use BioWATCH to
track their progress, thereby reducing rehabilitation time and
readmission rates.
BioWATCH is a single solution that can affect the quality
of life of millions of Americans.
Excellence: What makes this project exceptional?
BioWATCH is the only technology platform that can be used
across various diseases and acuteness of symptoms. The real-
time data transmission expedites diagnosis and treatment by
keeping medical professionals accurately informed about a
patient's specific symptoms and conditions. BioWATCH can
measure a patient's pulse, blood pressure, glucose,
temperature, joint angles and more, and then send the
information to a doctor in another location in real time. Its
batteries have an operating life more than four times longer
than current monitoring systems. It is also much lighter than
other systems. Its battery life, small size, and wireless
transmission are a few of many factors that make the BioWATCH
exceptional.
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
Existing monitors allow for only one parameter to be
monitored at a time. However, 40 percent of patients who need
monitoring have multiple symptoms or complications, which is
why BioWATCH's adaptability is so valuable.
The wearable monitor can be used in the car, at home, or
outside to monitor cardiac, orthopedic, diabetic, or
neurological disease. Remote monitoring technology will allow
for increased efficiency of the over-tasked nursing population.
Because many older adults take an active role in monitoring
their health, the BioWATCH is a significant product that allows
comfortable at-home wellness and peace of mind for any adult
concerned about their medical history. Rather than reacting to
severe medical emergencies after a patient is already in
distress, a patient and his or her doctor may be alerted to
potentially dangerous conditions far earlier, enabling the
patient to feel empowered while taking a pro-active approach to
health and longevity.
Effectiveness: What is the impact and/or application of
this research to older persons?
BioWATCH can be prescribed without the need for outside
laboratories or technicians. It can reduce the cost or need for
hospitalization, improve patient compliance with treatment,
improve quality of life, and improve life expectancy.
Innovation: Why is this research exciting or newsworthy?
BioWATCH is the application of a flexible technology to the
aging population. Unlike other monitoring products, BioWATCH's
innovative technology allows a single monitor to be used in a
variety of settings and disease severity. Results can be
transmitted easily and wirelessly, without the patient needing
to visit a lab or clinic; it allows for a better quality of
life by increasing patient freedom, allowing patients to visit
family or travel without missing routine medical testing.
National Aeronautics and Space Administration: Blood Glucose Monitoring
NASA technology for Earth orbital atomic oxygen
interactions is being applied to advanced concepts for blood
glucose monitoring which would use blood analyte-responsive
detection method in which blood only contacts the end of an
optical fiber.
Lead Agency: National Aeronautics and Space Administration
(NASA).
Agency Mission: NASA's mission is to pioneer the future in
space exploration, scientific discovery and Aeronautics
research.
Principal Investigator: Bruce Banks, Senior Physicist,
Consultant to Alphaport, NASA Glenn Research Center, 21000
Brookpark Road, M/S 309-2, Cleveland, OH 44135.
Partner Agency: QuestStar Medical Inc.
General Description: This is a spinoff application that has
been developed as a direct result of NASA's research on low
Earth orbital atomic oxygen interactions with spacecraft
materials. The contribution consists of a practical and
effective method of constructing microscopic cones on the
surface of optical fibers that are necessary for a fiber optic
blood glucose monitoring device to function. Blood glucose
monitoring for diabetics is typically performed by piercing the
skin of a finger with a lance and applying a droplet of blood
on a reagent pad or test strip. The quantity of blood that is
required to perform the test determines size and depth of the
cut required. The amount of blood required for blood glucose
monitoring could be significantly reduced using this new
technology. Advanced concepts for blood glucose monitoring are
being considered which would use blood analyte-responsive
detection method in which blood only contacts the end of an
optical fiber. The process makes use of knowledge space
environmental interactions and the atomic oxygen test
facilities that exist at NASA's Glenn Research Center.
Excellence: What makes this project exceptional?
The technology developed by NASA Glenn Research Center to
produce inexpensive glucose monitoring devices that require
much smaller quantities of blood than conventional lance and
absorbent strip devices will invite more frequent monitoring
and thus better potential for control of blood glucose levels
because of affordability and the fact that samples can be taken
from almost anywhere on the body with reduced pain associated
with blood sampling.
Significance: How is this research relevant to older
persons, populations, and/or an aging society?
The National Institutes of Health reports that 7% of the
U.S.A. population has diabetes (14.6 million diagnosed and 6.2
million undiagnosed) in 2005. For the same year 20.9% of the
population aged 60 years or older is reported to have diabetes.
Diabetes was the 6th leading cause of death in 2002. The total
cost of diabetes in the U.S.A. in 2002 was a staggering $132
billion for direct medical costs and indirect costs
(disability, work loss, and premature mortality).
Effectiveness: What is the impact and/or application of
this research to older persons?
The surface modification technique used for the blood
glucose optical fibers cannot be accomplished by conventional
chemical or mechanical means because of the small scale and
high aspect ratio (cone height-to-width ratio) shape of the
morphology required. However, NASA technology developed for
space simulation is both applicable and potentially cost
effective to produce a glucose monitor that can function on an
order of magnitude less blood than conventional monitors. It is
for this reason that the development of the blood glucose
monitor by QuestStar Medical has had numerous Reimbursable
Space Act Agreements with NASA Glenn Research Center to assist
in the development of the monitor.
Innovation: Why is this research exciting or newsworthy?
The U.S. population developing diabetes is growing.
National Council on Disability: Promoting Self Sufficiency of People
Living With Disabilities
Federal indicator systems should include people with
disabilities to ensure effective enforcement, program
monitoring, evaluation, and performance reporting. Indicators
and data need to inform decision makers about quality of life
status across all citizens.
Lead Agency: National Council on Disability.
Agency Mission: The mission of the National Council on
Disability is to promote the full inclusion, independent
living, and economic self-sufficiency of people with
disabilities of all ages and backgrounds by providing advice,
analysis, and recommendations on disability policy to the
President, Congress, and other federal agencies.
Principal Investigator: Martin Gould, Ed. D., Director of
Research, National Council on Disability, 1331 F Street, NW.,
Suite 850, Washington, DC 20004-1138.
General Description: Through this research, NCD sought to:
(a) ensure appropriate Federal Government monitoring, program
evaluation, and supports for people with disabilities, without
duplicating ongoing efforts, and (b) determine how the Federal
Government can contribute effectively to improve performance
reporting across major social programs for Americans with
disabilities and their families.
Nationally, a major reporting mechanism has been the use of
indicator systems; yet, few adequately address (or even
include) outcome data related to people with disabilities. Most
indicator systems also are domain-specific (e.g., addressing
health while omitting other areas of people's lives). On one
hand, better information that presents a full picture can
benefit people with disabilities, business, and government. On
the other hand, some of the proposed changes might require
regulatory and legislative action.
NCD's research identifies valid federal indicators and data
focused on people with disabilities. It also describes the
status of the U.S. population of Americans with disabilities
and points to knowledge gaps. NCD's report makes
recommendations for transforming the existing indicator system
and contributing to the knowledge base. This includes the
prospect of gaining useful information about the extent that
federal programs are beneficial to people with disabilities.
Excellence: What makes this project exceptional?
No other federal research report exists which has examined
the issues of improving federal statistics, outcome data and
indicator systems, and proposed a set of quality-of-life
indicators for the United States based on extant, reliable and
valid statistical data.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The research conducted for this report included a review of
federal aging data collection, indicator projects, and
statistical reports. The proposed set of quality-of-life
indictors offered by this report are applicable to people up to
64 years of age.
Effectiveness: What is the impact and/or application of
this research to older persons?
One impact is that this report has demonstrated the ability
to use existing federal statistical data to depict the quality
of life of people with disabilities who are aging. Extant
federal indicator systems for older persons could adopt and/or
adapt specific items from NCD's set of 18 for the purpose of
enhancing the extant systems.
Innovativeness: Why is this research exciting or
newsworthy?
There has been an almost immediate demonstration of public
excitement and newsworthiness about this research. On June 4,
2008, less than two months after the report's public release,
the U.S. House Committee on Oversight and Government Reform,
Subcommittee on Information Policy, the Census, and National
Archives conducted a hearing on the topic.
National Council on Disability: Consumer Directed Health Reports
Non-government and government-wide reform should expand
consumer-directed health care options/choices available for
people with disabilities and/or who are aging. Consumers need
cross-disability involvement from the planning to evaluation
phases.
Lead Agency: National Council on Disability.
Agency Mission: The mission of the National Council on
Disability is to promote the full inclusion, independent
living, and economic self-sufficiency of people with
disabilities of all ages and backgrounds by providing advice,
analysis, and recommendations on disability policy to the
President, Congress, and other federal agencies.
Principal Investigator: Martin Gould, Ed.D, Director of
Research, National Council on Disability, 1331 F Street, NW.,
Suite 850, Washington, DC 20004-1138, Telephone (Voice): (202)
272-2004; (TTY): (202) 272-2074.
Partner Agency: Health and Disability Working Group, School
of Public Health, Boston University.
General Description: NCD reviewed the literature on
consumer-directed care, obtained guidance from a key informants
and a Consumer Advisory Board, evaluated relevant policies,
identified practices in consumer-directed health care for
people with disabilities. The agency also made recommendations
for improving how health care planning, services and outcomes
are established, implemented, and/or evaluated.
In the health and supportive services arena, people's
desire for independence and control is more likely to be
satisfied when health care systems have several factors in
place. First, such systems are consumer directed and provide
care coordination. Second, they seek to eliminate barriers to
care and give consumers choice about the location and type of
services provided. Third, the favored health care systems
provide high-quality, seamless, consumer-centered, and
continuous care across settings and providers. Fourth, these
systems provide support services linked to housing to increase
the availability and efficiency of service provision. A fifth
factor is that people with disabilities and their caregivers
need and want access to timely, understandable, and culturally
appropriate information. Combined, the factors help people
navigate the maze of services and make informed choices.
The report informs policy discussions among policymakers,
practitioners, researchers, consumers, and advocates for health
reform. The report also examines current laws; program and
policy trends in financing; outcomes; implementation of models;
barriers to and facilitators of consumer-direction; the role of
federal agencies; and includes recommendations for
improvements.
Key NCD recommendations imply that shifts are needed in
government and non-government strategies for organizing,
locating, and managing health care for people with
disabilities. The recommendations include replacing a narrow
diagnosis-focused approach and limited service options with a
cross-disability, lifespan approach that: (a) considers
consumer input and (b) includes funding to meet individual
needs. The role of government should change from the oversight
of tightly defined program options. Broader responsibility of
government should include ongoing assessments of consumer needs
and a continuum of choices, provision of resources directed to
fill gaps in the service continuum, and incorporation of
programs and practices that meet rigorous evaluation standards
for clear consumer-defined outcomes.
Excellence: What makes this project exceptional?
This report is based on a one-of-a-kind systematic analysis
of federal policy, program, and research initiatives regarding
the interaction of consumer-directed health care and the needs
of individuals with disabilities including people who are
elderly. Taken as a whole, the methodology, findings and
recommendations in this report imply a major shift in the way
government, private agencies, and even to some extent consumer
organizations think about organizing and locating, and managing
health care for people with disabilities and people who are
elderly.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The systematic analysis relied on in this report included
evidenced-based federal and state level research available
regarding people who are elderly and people with disabilities.
The evidence-based research captured for analysis involved
seminal demonstration projects (e.g., Cash and Counseling),
traditional federal initiatives (e.g., Medicaid Waivers), and
programs that provide a continuum of community-based care
(e.g., Programs of All-Inclusive Care for the Elderly (PACE).
Effectiveness: What is the impact and/or application of
this research to older persons?
Federal agencies play an important role in promoting
research on consumer-directed and consumer-oriented health
care. The Centers for Medicare and Medicaid Services, the
Office of the Assistant Secretary for Planning and Evaluation,
and the National Institute on Disability and Rehabilitation
Research play leading roles in this area. This report's
findings support federal initiatives needed to expand the
implementation of consumer-directed and -oriented care, as
demonstrated through:
Streamlining of the Waiver process and improved
communication with states through Independence Plus;
Real Choice Systems Change and Medicaid Infrastructure
Grants; and
The proposed Money Follows the Person Rebalancing
Initiative.
CMS has implemented the Real Systems Change Grant
Initiative to help states implement community-based care
systems through partnership with community organizations. These
grants support the development of programs that enable
individuals to move out of institutions into the most
integrated community setting appropriate to their individual
needs and preferences. Real Systems Change programs also offer
consumers choice in regard to living environments, care
providers, the types of services they use, and the way these
services are delivered (CMS Web site, 2004). This was the first
major federal initiative to support consumer-oriented and
directed care across the spectrum of disability and across the
lifespan, and as such has facilitated the implementation of
community-based care systems.
The joint support of CMS and the Administration on Aging of
Aging and Disability Resource Centers in 40 states is intended
to help those states develop ``one-stop shopping'' programs.
These programs, which work at the community level to help
people make informed decisions about their service and support
options, serve as the entry point to the long-term care system.
Eligible populations for these programs include people over 65
and at least one additional population (such as people with
serious mental illness, developmental disabilities, or physical
disabilities). Funds are used to coordinate or redesign
information systems, to provide consumer education, or to
facilitate access to care across multiple federal, state, and
local programs (CMS Web site, 2004). This program has the
potential to address some of the consumer education barriers to
community-based care, and it also begins to break down some of
the age-related barriers to care.
Innovativeness: Why is this research exciting or
newsworthy?
The report, Consumer-Directed Health Care: How Well Does It
Work?, offers a clear picture of the strengths and limitations
of our Federal Government's current research agenda related to
consumer-directed health care for Americans with disabilities.
It sheds light on the relationship between consumer-directed
health care and practice. It also provides a basis for
policymakers who use health research evidence to make informed
policy decisions in keeping with the intent of the New Freedom
Initiative.
National Council on Disability: Livable Communities
Livable communities promote adult well-being, independence,
and inclusion of people with disabilities and seniors in daily
living. Coordinated government planning and funding can be
useful to break barriers, establish, and sustain positive
changes.
Lead Agency: National Council on Disability.
Agency Mission: The mission of the National Council on
Disability is to promote the full inclusion, independent
living, and economic self-sufficiency of people with
disabilities of all ages and backgrounds by providing advice,
analysis, and recommendations on disability policy to the
President, Congress, and other federal agencies.
Principal Investigator: Penny Feldman, Mia Oberlink, Michal
Gursen & Colleagues, Visiting Nurse Service of New York, Center
for Home Care Policy and Research, 107 East 70th Street, New
York, NY 10021, http://www.vnsny.org/research.
Partner Agency: The Center for Home Care Policy and
Research.
General Description: NCD began this project with the
premise that full community integration recognizes the needs of
people with disabilities. Among those needs are safe and
affordable housing; access to transportation; access to the
political process; and the right to enjoy services, programs,
and activities that public and private entities offer to all
members of the community.
Livable communities enable citizens who choose to reside in
their homes and communities to do so, regardless of age or
disability. However, across America, many communities face
difficult choices and decisions about how to grow, plan for
change, and improve the quality of life for all citizens.
Researchers for this NCD project adapted characteristics of a
model or framework originally established to help communities
measure and improve their livability by people who are aging.
The resulting ``livable communities'' framework identifies
elements that a number of communities around the country have
incorporated in their approaches to inclusion.
NCD's project shines the spotlight on inclusive community
practices that are working. Attention to common needs among
people who are growing older and other adults with disabilities
were not surprising. The project identifies and provides
examples of the strategies used to transfer policy into
actions. Broadly, the strategies address identifiable elements
focused on environmental inclusion, safety and affordability.
The project also makes recommendations for consideration by
other entities.
Excellence: What makes this project exceptional?
This unique report clearly describes how communities can
improve the quality of life for adults with disabilities, as
well as for the growing population of seniors who may develop
disabilities later in life. The report is organized around six
key goals: (1) providing affordable, appropriate, accessible
housing; (2) ensuring accessible, affordable, reliable, safe
transportation; (3) adjusting the physical environment for
inclusiveness and accessibility; (4) providing work, volunteer,
and education opportunities; (5) ensuring access to key health
and support services; and (6) encouraging participation in
civic, cultural, social, and recreational activities. A number
of model programs from around the United States are
highlighted. Individual's stories of livability are described.
And one community's regional approach to incorporating
livability principles for long-term planning and growth is
presented.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This report is based on the research and the community
model of livability as constructed by the American Association
for Retired Persons (AARP). This research is organized around
six key goals necessary for community living for people with
disabilities and people who are elderly. The key goals involve:
(1) providing affordable, appropriate, accessible housing; (2)
ensuring accessible, affordable, reliable, safe transportation;
(3) adjusting the physical environment for inclusiveness and
accessibility; (4) providing work, volunteer, and education
opportunities; (5) ensuring access to key health and support
services; and (6) encouraging participation in civic, cultural,
social, and recreational activities.
Effectiveness: What is the impact and/or application of
this research to older persons?
Communities across the country are aging. By the year 2030,
one out of five people in America will be over 65. Those 85 and
older are the fastest-growing segment of the population. As
they grow older, the overwhelming majority of Americans will
remain in their homes and communities. In fact, contrary to
popular perception of older adults relocating to retirement
communities, people aged 65 to 85 are the least likely of any
age group to move. The active involvement of vital, independent
older citizens--those ``aging in place''--can enhance the
social and civic life of communities. At the same time,
communities will need to provide services to a growing number
of their frail and disabled elders. To prepare for this so-
called ``Age Boom,'' many communities need help in creating an
environment that will support older people's health and well-
being as they age.
Comprehensive regional planning approaches such as the one
described in Livable Communities for Adults with Disabilities
address at a macro level what community planners, policy
makers, funders, home builders and remodelers, and citizens
know at the local level--i.e., that lifespan planning may not
have been a priority for Boomers in their financing of
retirement but it has certainly begun to catch on. In many
respects, these planning approaches call for new and achievable
configurations of services for older adults that imitate what
Centers for Independent Living for people with disabilities
have refined over decades--i.e., that the goal of living
independently is possible and of the highest priority.
Innovativeness: Why is this research exciting or
newsworthy?
The discussion of livable community components in this
research report includes many examples of communities across
the United States that have successfully implemented measures
to improve the quality of life for people of all ages and
abilities. Communities large and small are increasingly looking
toward the livable community concept to help them address some
of the most challenging issues that they face today, such as a
growing population of older residents, an increasing number of
persons with disabilities from diverse cultures, rising housing
costs, limited transportation alternatives, lack of
coordination among agencies, and limited and ``silo'' funding.
The examples demonstrate what is possible when stakeholders
work together and make livability a priority in their
community.
National Council on Disability: Long Term Support Service
Seniors and people with disabilities need a coherent and
comprehensive framework of long-term services and supports
across states. Congress should authorize federal interagency
coordination of essential public policies, programs, and
funding.
Lead Agency: National Council on Disability.
Agency Mission: The mission of the National Council on
Disability is to promote the full inclusion, independent
living, and economic self-sufficiency of people with
disabilities of all ages and backgrounds by providing advice,
analysis, and recommendations on disability policy to the
President, Congress, and other federal agencies.
Principal Investigator: Michael Morris, Director National
Disability Institute, Johnette Hartnett, Ed.D., NCD Capitol
Impact, National Cooperative Bank Development Corporation,
National Disability Institute, 1667 K Street, NW., Suite 640,
Washington, DC 20006.
Partner Agency: National Disability Institute.
General Description: The NCD report called attention to
America's changing demographics--growing numbers of people age
65 and people with disabilities. More than 20 federal agencies
and nearly 200 programs with varying policy objectives provide
assistance and services. Elders (people who are seniors) and
people with disabilities need choices when seeking assistance
with daily living that maintains their self-determination and
maximum dignity and independence. Significant reform should
explore possibilities of a universal approach to the design and
financing before existing financing mechanisms become
unsustainable. NCD (1) analyzed the state of long-term services
and supports, future market demand and system reform needs; (2)
surveyed promising state practices and local innovations; (3)
solicited suggestions and comments from an expert panel of
public and private stakeholders; and offered the following
recommendations to Congress:
Decouple eligibility for Home- and Community-Based
Services (HCBS) under an HCBS waiver from a determination of
nursing home eligibility. Remove the institutional bias in the
Medicaid program to give Medicaid beneficiaries greater choice
in how financial assistance is provided to cover a range of
LTSS.
Increase support for families and significant
others in their role as informal and unpaid caregivers.
Eligibility for LTSS and the scope and intensity of covered
services varies significantly from state to state. Despite
state variability in criteria for Medicaid eligibility and
scope of benefits, in all states, individuals with disabilities
are dependent on informal caregivers, including parents, family
members, and significant others. The estimated benefit of
informal caregiving exceeds $200 billion annually. Services
should be designed to support, not supplant, the role of the
family and actions of informal caregivers.
Improve the supply, retention, and performance of
direct support workers to meet increasing demand. Authorize
funding for collaborative demonstration projects between the
U.S. Departments of Labor and Health and Human Services that
promote collaboration between community colleges and
disability-related organizations to develop a high-quality set
of competencies to be taught in a new support worker
certificate program that expands supplies of quality workers to
meet market demand in home- and community-based settings.
Mandate coordination and collaboration among
federal agencies to align public policy and transform
infrastructure to be responsive to consumer needs and
preferences for a comprehensive system of LTSS. Congress should
consider holding hearings to evaluate possible options for
improvement of multiple department collaboration to provide
access to information and supports and services to meet the
long-term needs of people with disabilities. Congress should
also consider establishing an Interagency Council on Meeting
the Housing and Service Needs of Seniors and Persons with
Disabilities.
Excellence: What makes this project exceptional?
This is the most comprehensive policy analysis of LTSS that
evaluates federal LTSS laws, regulations, policies, and
programs for people over 65 years of age (with and without
disabilities) and people with disabilities under 65 years of
age who use LTSS.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
NCD undertook research for this report because it had grown
increasingly concerned about the (a) lack of a coherent
national long-term services and supports (LTSS) public policy
for all people with disabilities; (b) fragmented nature of
service and support delivery systems, with uneven access and
services provisions; and (c) LTSS costs of 22 percent or more
of state budgets, which are fast becoming unsustainable.
Additionally, NCD noted in undertaking research for this report
that no single federal program, federal agency, or
congressional committee was charged with the responsibility for
the management, funding, and oversight of LTSS; however, 23
federal agencies were actively involved in LTSS using the NCD
definition.
Effectiveness: What is the impact and/or application of
this research to older persons?
As demonstrated in the findings of this NCD report, the
United States needs a coherent and comprehensive framework for
its LTSS policies, programs, and funding based on five inter-
related realities. First, that people who are elderly and
people with disabilities both desire and deserve choices when
seeking assistance with daily living that maintains their self-
determination and maximum dignity and independence. Second, the
current financing mechanisms (public and private) will become
unsustainable in the near future without significant reform.
The system must be affordable to all Americans regardless of
income levels and must consider opportunities to leverage
public and private support in new ways without impoverishing
beneficiaries. Third, there is an opportunity with the changing
demographic picture of the United States to explore the
possibilities of a universal approach to the design and
financing of supports that is responsive to individuals under
the age of 65, as well as Americans over 65 who may or may not
have disabilities, without sacrificing individual choice and
flexibility. Fourth, formal and informal care giving must be
sustained, including examination of family needs and workforce
recruitment and retention challenges. Fifth, the approach to
quality must include consumer direction and control of
resources in addition to traditional external quality assurance
mechanisms.
Innovativeness: Why is this research exciting or
newsworthy?
This is the first federal analysis of the issue of long-
term services and supports (LTSS) which is based on an
operational definition of LTSS identical to the one used by the
American Association for Retired Persons. It is the first
federal analysis that looks at LTSS for people over 65 years of
age (with and without disabilities) and people with
disabilities under 65 years of age who use LTSS. It is the
first to review federal government LTSS policies, laws, and
programs for both population groups. And it is the first to
codify Executive Branch and Congressional operations involving
LTSS initiatives.
National Council on Disability: Livable Communities
Livable communities promote adult well-being, independence,
and inclusion of people with disabilities and seniors in daily
living. Coordinated government planning and funding can be
useful to break barriers, establish, and sustain positive
changes.
Lead Agency: National Council on Disability.
Agency Mission: The mission of the National Council on
Disability is to promote the full inclusion, independent
living, and economic self-sufficiency of people with
disabilities of all ages and backgrounds by providing advice,
analysis, and recommendations on disability policy to the
President, Congress, and other federal agencies.
Principal Investigator: Penny Feldman, Mia Oberlink, Michal
Gursen & Colleagues, Visiting Nurse Service of New York, Center
for Home Care Policy and Research, 107 East 70th Street, New
York, NY 10021, http://www.vnsny.org/research.
Partner Agency: The Center for Home Care Policy and
Research.
General Description: NCD began this project with the
premise that full community integration recognizes the needs of
people with disabilities. Among those needs are safe and
affordable housing; access to transportation; access to the
political process; and the right to enjoy services, programs,
and activities that public and private entities offer to all
members of the community
Livable communities enable citizens who choose to reside
their homes and communities to do so, regardless of age or
disability. However, across America, many communities face
difficult choices and decisions about how to grow, plan for
change, and improve the quality of life for all citizens.
Researchers for this NCD project adapted characteristics of a
model or framework originally established to help communities
measure and improve their livability by people who are aging.
The resulting ``livable communities'' framework identifies
elements that a number of communities around the country have
incorporated in their approaches to inclusion.
NCD's project shines the spotlight on inclusive community
practices that are working. Attention to common needs among
people who are growing older and other adults with disabilities
were not surprising. The project identifies and provides
examples of the strategies used to transfer policy into
actions. Broadly, the strategies address identifiable elements
focused on environmental inclusion, safety and affordability.
The project also makes recommendations for consideration by
other entities.
Excellence: What makes this project exceptional?
This unique report clearly describes how communities can
improve the quality of life for adults with disabilities, as
well as for the growing population of seniors who may develop
disabilities later in life. The report is organized around six
key goals: 1) providing affordable, appropriate, accessible
housing; 2) ensuring accessible, affordable, reliable, safe
transportation; 3) adjusting the physical environment for
inclusiveness and accessibility; 4) providing work, volunteer,
and education opportunities; 5) ensuring access to key health
and support services; and 6) encouraging participation in
civic, cultural, social, and recreational activities. A number
of model programs from around the United States are
highlighted. Individual's stories of livability are described.
And one community's regional approach to incorporating
livability principles for long-term planning and growth is
presented.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This report is based on the research and the community
model of livability as constructed by the American Association
for Retired Persons (AARP). This research is organized around
six key goals necessary for community living for people with
disabilities and people who are elderly. The key goals involve:
(1) providing affordable, appropriate, accessible housing; (2)
ensuring accessible, affordable, reliable, safe transportation;
(3) adjusting the physical environment for inclusiveness and
accessibility; (4) providing work, volunteer, and education
opportunities; (5) ensuring access to key health and support
services; and (6) encouraging participation in civic, cultural,
social, and recreational activities.
Effectiveness: What is the impact and/or application of
this research to older persons?
Communities across the country are aging. By the year 2030,
one out of five people in America will be over 65. Those 85 and
older are the fastest-growing segment of the population. As
they grow older, the overwhelming majority of Americans will
remain in their homes and communities. In fact, contrary to
popular perception of older adults relocating to retirement
communities, people aged 65 to 85 are the least likely of any
age group to move. The active involvement of vital, independent
older citizens--those ``aging in place''--can enhance the
social and civic life of communities. At the same time,
communities will need to provide services to a growing number
of their frail and disabled elders. To prepare for this so-
called ``Age Boom,'' many communities need help in creating an
environment that will support older people's health and well-
being as they age.
Comprehensive regional planning approaches such as the one
described in Livable Communities for Adults with Disabilities
address at a macro level what community planners, policy
makers, funders, home builders and remodelers, and citizens
know at the local level--i.e., that lifespan planning may not
have been a priority for Boomers in their financing of
retirement but it has certainly begun to catch on. In many
respects, these planning approaches call for new and achievable
configurations of services for older adults that imitate what
Centers for Independent Living for people with disabilities
have refined over decades--i.e., that the goal of living
independently is possible and of the highest priority.
Innovativeness: Why is this research exciting or
newsworthy?
The discussion of livable community components in this
research report includes many examples of communities across
the United States that have successfully implemented measures
to improve the quality of life for people of all ages and
abilities. Communities large and small are increasingly looking
toward the livable community concept to help them address some
of the most challenging issues that they face today, such as a
growing population of older residents, an increasing number of
persons with disabilities from diverse cultures, rising housing
costs, limited transportation alternatives, lack of
coordination among agencies, and limited and ``silo'' funding.
The examples demonstrate what is possible when stakeholders
work together and make livability a priority in their
community.
National Endowment for the Arts: Involvement in Arts & Health Promotion
The Creativity and Aging in America study evaluated the
effects of active involvement in the arts on the physical
health, mental health, and social functioning of adults ages
65-103, as compared to a Control Group. Results showed striking
positive results relevant to health promotion and cost savings.
Lead Agency: National Endowment for the Arts.
Agency Mission: The National Endowment for the Arts is a
federal agency dedicated to supporting excellence in the arts,
both new and established; bringing the arts to all Americans;
and providing leadership in arts education.
Principal Investigators: Gene D. Cohen, M.D., Ph.D, George
Washington University, Center on Aging, Health & Humanities.
Partner Agencies: National Endowment for the Arts (Lead
Sponsor), U.S. Department of Health and Human Services (DHHS),
Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Mental Health Services, National Institute
of Health (NIH), National Institute of Mental Health (NIMH),
AARP, National Retired Teachers Association, Stella and Charles
Guttman Foundation, International Foundation for Music
Research.
General Description: In 2001, the National Endowment for
the Arts engaged George Washington University to conduct a
multi-site, national study with the aim of measuring the impact
of professionally conducted community-based cultural programs
on the general health, mental health, and social activities of
older persons, age 65 and older. The study measured
participants engaged in on-going, weekly programs in creative
writing, visual arts, music, and theater. Referred to as the
Creativity and Aging Study, the project's formal title is ``The
Impact of Professionally Conducted Cultural Programs on Older
Adults.'' No previous study of this nature using an
experimental or related scientific design and a control group
had been carried out.
The study took place in three different sites across the
country:
The Levine School of Music, Washington, DC;
Elders Share the Arts, Brooklyn, New York;
and
Center for Elders and Youth in the Arts,
Institute on Aging, San Francisco, California.
Each site involved two groups--(1) the Intervention Group,
comprised of older individuals who were involved in a weekly
participatory art program, and (2) a Control Group, comprised
of individuals involved in their ongoing activities as usual.
Each site recruited at least 100 older persons--50 participants
in the Intervention Group and Control Group alike. The overall
study had 300 participants--150 in the Intervention Groups, 150
in the Control Groups. The average age in all three sites and
all Intervention and Control Groups, was approximately 80 years
old, which is older than the average American's life
expectancy. Approximately 30 percent of the groups reflected
racial and ethnic minorities.
The groups were very well matched in level of functioning
at the start of the Study, with very similar physical health,
mental health, and level of activity profiles. Participants
were each interviewed three times by George Washington
University research assistants:
(1) at the start of the Study to establish a
baseline;
(2) a year later; and finally;
(3) two years after the baseline assessment.
Results reveal strikingly positive differences in the
Intervention Group (those involved in intensive, weekly
participatory art programs) as compared to the Control Group.
The Intervention Group at the one-and two-year follow-up
assessments, reported:
(1) better health, fewer doctor visits, and less
medication usage;
(2) more positive responses on mental health
measures; and
(3) more involvement in overall activities.
Since the study collected so much rich data, analyses of
existing data are expected to continue through 2010.
In conclusion, the results suggest sharply positive
intervention effects of these community-based art programs run
by professional artists. The Study points to true health
promotion and disease prevention effects. It also shows
significant cost savings through fewer doctor visits and
reduced medication usage. In that they also show stabilization
and actual increase in community-based activities in general
among those in the cultural programs, the Study reveals a
positive impact on maintaining independence and reducing
dependency. This latter point demonstrates that these
community-based cultural programs for older adults appear to be
reducing risk factors that drive the need for long-term care.
Excellence: What makes this project exceptional?
The Creativity and Aging study is the first theory-driven,
multi-site, national study with an experimental or related
scientific design and a control group that sought to assess the
impact of active involvement in community-based art programs on
the physical health, mental health, and social functioning of
older adults. Moreover, for a study cohort with an average age
of 80, most scientists would expect that any positive effects
would take the form of merely a slower decline in health.
Instead, what makes this Study truly noteworthy are evidence-
based, statistically significant findings that show actual
improvement in overall health among those participating in the
art programs, versus declines in the Control Group.
The partnership that supported the study is unique in
itself. The study was conducted and supported by a diverse
group of government agencies and private sector organizations
in the scientific and arts fields with individual and common
goals for older Americans--brought together by the National
Endowment for the Arts through a series of interagency
agreements and contracts.
For example, one of goals of the National Endowment for the
Arts is to make the best art available to all Americans. Over
the years, the Endowment and many of its grantees have observed
how involvement in quality arts programming, including dance,
creative writing, theater, painting, and music, appear to make
a remarkable difference in participants' lives. However, there
was no substantive data to validate the observation. The
National Institutes of Health have long been concerned with
improving the mental and physical health of older adults. And
the AARP is dedicated to positive social change and enhancing
the quality of life for people as they age. The International
Foundation on Music Research works to advance active
participation in music making across the lifespan. This effort
addresses all of these important missions.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This research is highly relevant because it has shown,
among older adults, clear health promotion and prevention
effects. The Study results reflect a reduction in risk factors
that drive the need for long-term care. It has also
demonstrated important cost-saving outcomes highly relevant to
an aging society. The arts programs in the Study can be
replicated in urban, suburban, and rural settings across the
country.
Effectiveness: What is the impact and/or application of
this research to older persons?
The positive impact of this research on the physical
health, mental health, independent social functioning, and
health care cost-savings for older persons is of high relevance
to older adults, their families, their communities, and
society. In the two years following start-up Federal funding
for the Levine School's Senior Chorale, the program doubled in
size because of public demand and recognition of its
effectiveness.
Innovativeness: Why is this research exciting and
newsworthy?
The Creativity and Aging research is exciting and
newsworthy because it illustrates surprising health
improvements in a population group with an average age greater
than normal life expectancy, when one would typically
anticipate noticeable declines in health. It also reveals
dramatic cost-saving ramifications without causing an added
burden to Medicare or Medicaid programs. This study and
participation by the Levine School's Senior Chorale were
featured with in-depth coverage on the CBS Evening News with
Dan Rather.
One year after the study began, Medicare D went into
effect. The study had been measuring medication usage. In the
Medicare D-eligible population, a savings of a mere 8 cents a
day--extrapolated to the 36.5 million persons in this age
group--comes to $1 billion per year in savings.* On
the other hand, a dollar a day in savings nets $13 billion a
year in total savings. In fact, the results from the just-
completed cost analysis of the Senior Chorale reflect a savings
close to a dollar a day. At the same time, doctor visits,
though essentially the same in number among those in the Senior
Chorale and the control group at the start of the study, had
grown to an average of 3.56 visits per year for the control
group two years later. Extrapolating this finding to all
Medicare-eligible Americans would mean a yearly savings of $6.3
billion a year by being in a chorale similar to the one in the
Intervention Group. The Study reveals the profound role on
healthcare cost savings that is played by creative engagement
through involvement in community-based arts.
*Medicare data found under ``Statistics''
at:\1\ www.cms.hhs.gov.
Factors That Impact the Determination by Medical Examiners of Elder
Mistreatment as a Cause of Death in Older People
The professionals best equipped to determine that elder
abuse caused an individual's death are medical examiners and
coroners. However, medical examiners rarely deem elder
mistreatment as a cause of death; this is likely due to a lack
of research and evidence to support this determination. In
response, this project was undertaken to begin to develop
primary data and a literature base on the topic of death due to
elder mistreatment.
Lead Agency: National Institute of Justice, Office of
Justice Programs.
Agency Mission: NIJ is the research, development, and
evaluation agency of the U.S. Department of Justice and is
dedicated to researching crime control and justice issues. NIJ
provides objective, independent, evidence-based knowledge and
tools to meet the challenges of crime and justice, particularly
at the State and local levels.
Principal Investigator: Dr. Carmel B. Dyer, Professor and
Director of the Division of Geriatric and Palliative Medicine,
University of Texas Health Center, Health Science Center at
Houston, P.O. Box 20708, Houston, TX 77225.
Partner Agencies: U.S. Department of Justice's Elder
Justice and Nursing Home Initiative.
General Description: The professionals best equipped to
determine that elder abuse caused an individual's death are
medical examiners and coroners. However, medical examiners
rarely deem elder mistreatment as a cause of death; this is
likely due to a lack of research and evidence to support this
determination. In response, this project was undertaken to
begin to develop primary data and a literature base on the
topic of death due to elder mistreatment. The research team
conducted four distinct projects to evaluate these three
aspects of death determination by medical examiners:
Phase I was a survey exploring the views of
medical examiners, which showed that medical examiners
infrequently determine elder mistreatment as a cause of death
in older decedents even when the signs are there to do so.
Phase II evaluated scene investigation and medical
records and toxicology by studying the medical examiners' case
conferences and case records. This study showed that while the
medical examiners are expert at performing autopsies,
interpreting toxicology and determining the cause and manner of
death, they are not versed (nor should they be expected to be)
in the standard of care of older persons.
Phase III was a study of the scene investigation,
which showed that the scene investigation is not necessarily
geared to the detection of forensic markers and risk factors
for elder mistreatment and that the training of investigators
in the specifics of elder mistreatment may be helpful.
Phase IV explored autopsy and physical examination
findings, which found that in cases where dementia was
documented or pressure ulcers were present, the decedents were
more likely to have been contacted by Adult Protective Services
prior to their death.
Excellence: What makes this project exceptional?
This project was the first to examine the ability of
medical examiners to determine whether someone died of elder
mistreatment rather than the natural health complications and
degeneration associated with old age. The results of each of
these studies offers pilot data that inform readers of the
factors that account for the low rate of determination of elder
mistreatment as a cause of death in older persons. These
studies not only increase understanding of elder mistreatment
death determinations but also lay the groundwork for future
research by a wide variety of disciplines including
prosecutors, police officers, protective service workers and
medical examiners.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
As the American elderly population expands exponentially
over the coming decades, law enforcement will need new tools
and knowledge to detect signs of abuse of these members of this
vulnerable population. These two projects lay the groundwork
for the production and communication of such guidance.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research expands our knowledge of the signs of elder
abuse and the ability (or inability) of medical and criminal
justice personnel to detect such abuse in this population.
These findings will lead to an increased ability of caretakers
and law enforcement to detect and respond to these crimes,
which are currently under-reported and go largely unaddressed.
Innovativeness: Why is this research exciting or
newsworthy?
This project demonstrated the need for training for medical
examiners in the area of elder mistreatment, as many are
currently unable to distinguish between signs of elder abuse
and other natural byproducts of aging. Such training would
greatly increase detection of homicides of elderly individuals.
Bruising as a Forensic Marker of Physical Elder Abuse
Very little is known regarding the ``red flags'' that law
enforcement and caretakers can use to look for signs of
physical abuse of elderly people. This project will provide
practical information to medical, forensic and law enforcement
personnel on how bruises that are caused by abuse appear in the
elderly population. In addition, it will greatly advance the
science on physical signs and injuries that result from elder
abuse.
Lead Agency: National Institute of Justice, Office of
Justice Programs.
Agency Mission: NIJ is the research, development, and
evaluation agency of the U.S. Department of Justice and is
dedicated to researching crime control and justice issues. NIJ
provides objective, independent, evidence-based knowledge and
tools to meet the challenges of crime and justice, particularly
at the State and local levels.
Principal Investigator: Dr. Laura Mosqueda, Professor of
Clinical Family Medicine and Director of Geriatrics, UCI
Medical Center, Pavilion III, ZC1150, 101 The City Drive,
Orange County, CA 92868.
Partner Agencies: U.S. Department of Justice's Elder
Justice and Nursing Home Initiative.
General Description: In 2001, NIJ took a significant step
in building the medical forensic literature on elder
mistreatment by funding a project entitled Bruising in the
Geriatric Population. This project systematically documented
the occurrence, location, color, progression, and resolution of
accidental bruising in a sample of adults aged 65 and older.
Using the results of this first study, the research team is now
systematically documenting bruising known to have occurred in
elders who have been physically abused. This project will
provide practical information to medical, forensic and law
enforcement personnel on how bruises that are caused by abuse
appear in the elderly population; and will advance the science
on forensic markers of physical elder abuse.
Excellence: What makes this project exceptional?
This project is the first to attempt to delineate how
injuries (bruises, in this case) that result from abuse differ
from those that occur accidentally. The findings will greatly
aid first responders in determining whether signs of bruising
are cause for concern and additional investigation.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
As the American elderly population expands exponentially
over the coming decades, law enforcement will need new tools
and knowledge to detect signs of abuse of these members of this
vulnerable population. These two projects lay the groundwork
for the production and communication of such guidance.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research expands our knowledge of the signs of elder
abuse and the ability (or inability) of medical and criminal
justice personnel to detect such abuse in this population.
These findings will lead to an increased ability of caretakers
and law enforcement to detect and respond to these crimes,
which are currently under-reported and go largely unaddressed.
Innovativeness: Why is this research exciting or
newsworthy?
This project will give the field its first solid piece of
evidence that bruises that result from abuse differ from those
that result from accidental injury. This information has
already changed investigative practices in Orange County, CA,
and will hopefully influence the law enforcement practices
across the country once results are reviewed and disseminated.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE)
The ACTIVE study showed that certain mental exercises can
offset some of the expected decline in older adults' thinking
skills and show promise for maintaining cognitive abilities
needed to do everyday tasks such as shopping, making meals and
handling finances.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Sharon L. Tennstedt, Ph.D., New
England Research Institute, Inc., Institute for Studies on
Aging, 9 Galen Street, Watertown, MA 02472.
Partner Agency: National Institute of Nursing Research
(NINR).
General Description: Results from the NIH-supported
Advanced Cognitive Training for Independent and Vital Elderly
(ACTIVE) study demonstrated, for the first time in a
randomized, controlled trial, that certain mental exercises can
offset some of the expected decline in older adults' thinking
skills and show promise for maintaining cognitive abilities
needed to do everyday tasks such as shopping, making meals and
handling finances. Some of the benefits of the short-term
training tested in this study lasted for as long as five years.
Excellence: What makes this project exceptional?
The ACTIVE study is the first randomized, controlled trial
to demonstrate long-lasting, positive effects of brief
cognitive training in older adults, and the only trial to date
in which the effects of mental exercises were assessed after
five years for both cognitive and functional status.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Some studies suggest that as many as 22.2 percent of
Americans age 71 and older--some 5.4 million people--display
some level of cognitive impairment that does not reach the
threshold for a diagnosis of dementia. This study offers hope
that cognitive training may be useful, demonstrating that
relatively brief targeted exercises can produce durable
changes.
Effectiveness: What is the impact and/or application of
this research to older persons?
Although these findings are promising, further research is
needed to determine how these and similar interventions can
best be employed in real-world settings.
Innovativeness: Why is this exciting or newsworthy?
This is the first randomized, controlled trial to
demonstrate long-lasting, positive effects of cognitive
training in older adults. Cognitive exercises are potentially
less expensive than pharmacological interventions, with fewer
side effects.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
The Dynamics of Health, Aging, and Body Composition
The Health ABC study will identify how increases in body
fat and declines in lean mass and bone mineral yield a body
susceptible to multiple diseases contributing to disability in
old age. 3,075 men and women between the ages of 70-79 who are
free of disability were selected for this study. Body weight,
lean body mass, and body fat are quantified from computed
tomography images using software developed by CIT's Biomedical
Imaging Research Services Section (BIRSS), Division of
Computational Bioscience (DCB).
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Tamara B. Harris, M.D., M.S.,
Senior Investigator, Intramural Research Program, National
Institute on Aging, Laboratory of Epidemiology, Demography, and
Biometry, Gateway Building, 3C309, 7201 Wisconsin Avenue,
Bethesda, MD 20892.
Partner Agency: NIH Center for Information Technology
(CIT), National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), National Research
Council of Italy, American Heart Association, American Diabetes
Association, and Hologic Inc.
General Description: The Center for Information Technology
is collaborating with the National Institute of Aging to assist
in image segmentation and quantification in a clinical research
study, the Dynamics of Health, Aging and Body Composition
(Health ABC). The Health ABC study will identify how increases
in body fat and declines in lean mass and bone mineral yield a
body susceptible to multiple diseases contributing to
disability in old age. 3,075 men and women between the ages of
70-79 who are free of disability were selected for this study.
CIT is augmenting the analysis from computerized tomography
scans. Lean body mass, and body fat are quantified from
computed tomography images using software developed by CIT's
Biomedical Imaging Research Services Section (BIRSS), Division
of Computational Bioscience (DCB). Manual image segmentation is
laborious and subject to inter and intra-observer variability
when performing volumetric analysis. An extension of BIRSS'
MIPAV software provides researchers with a multistage
semiautomatic process for image segmentation, quantification,
and visualization.
Excellence: What makes this project exceptional?
The Health ABC study will identify how increases in body
fat and declines in lean mass and bone mineral yield a body
susceptible to multiple diseases contributing to disability in
old age. This should help to address questions of morbidity
related to body weight and weight related health conditions in
old age.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Older people incur multiple health conditions as they age
that affect multiple organ systems. Most studies of aging that
had been performed prior to 1998 tended to emphasize the
function of one organ system: heart, brain, bone rather than a
comprehensive assessment. Health ABC used the principle of
weight-related health conditions to organize a multi-
dimensional study.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research has shown that the same risk factors that
cause early declines in function contribute to later, major
losses in function and the onset of frailty. This is a powerful
prevention message for aging.
Innovativeness: Why is this exciting or newsworthy?
Early interventions on weight, heart disease, diabetes,
inflammation, and depression may prevent later declines to
frailty in old age.
National Center for Complementary and Alternative Medicine Acupuncture
Relieves Pain and Improves Function in Knee Osteoarthritis
Acupuncture provides pain relief and improves function for
people with osteoarthritis of the knee and serves as an
effective complement to standard medical care.
Lead Agency: National Center for Complementary and
Alternative Medicine (NCCAM)/National Institutes of Health
(NIH).
Agency Mission:
Explore complementary and alternative healing
practices in the context of rigorous science.
Train complementary and alternative medicine
researchers.
Disseminate authoritative information to the
public and professionals.
Principal Investigator: Brian M. Berman, M.D., Family
Medicine, University of Maryland School of Medicine, 419 W.
Redwood Street, Suite 470B, Baltimore, MD 21201-1734.
General Description:
ACUPUNCTURE RELIEVES PAIN AND IMPROVES FUNCTION IN KNEE OSTEOARTHRITIS
The multi-site study team, including rheumatologists and
licensed acupuncturists, enrolled 570 patients, aged 50 or
older with osteoarthritis of the knee. Participants were
randomly assigned to receive one of three treatments:
acupuncture; sham acupuncture; or participation in a control
group that followed the Arthritis Foundation's self-help course
for managing osteoarthritis. Patients continued to receive
standard medical care from their primary physicians, including
anti-inflammatory medications, such as COX-2 selective
inhibitors, non-steroidal anti-inflammatory drugs, and opioid
pain relievers.
After enrolling in the study, patients' pain and knee
function were assessed using standard arthritis research survey
instruments and measurement tools, such as the Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC).
Patients' progress was assessed at 4, 8, 14, and 26 weeks. By
week 8, participants receiving acupuncture were showing a
significant increase in function and, by week 14, a significant
decrease in pain, compared with the sham and control groups.
These results, shown by declining scores on the WOMAC index,
sustained through week 26. Overall, those who received
acupuncture had a 40 percent decrease in pain and a nearly 40
percent improvement in function compared to baseline
assessments.
Excellence: What makes this project exceptional?
This study is a well-designed phase 3 clinical trial that
demonstrated the safety and efficacy of Traditional Chinese
Acupuncture as a complementary treatment for osteoarthritis of
the knee.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
More than 20 million Americans have osteoarthritis, which
is one of the most frequent causes of physical disability among
adults. Acupuncture provides a non-pharmacologic, complementary
treatment for osteoarthritis of the knee.
Effectiveness: What is the impact and/or application of
this research to older persons?
These results demonstrate that acupuncture is an effective
non-pharmacologic complementary treatment for osteoarthritis of
the knee, potentially resulting in a higher-quality of life and
functioning for individuals with osteoarthritis.
Innovativeness: Why is this research exciting or
newsworthy?
A survey conducted by the Centers for Disease Control and
Prevention showed that, in 2002, acupuncture was used by an
estimated 2.1 million U.S. adults. This trial provides evidence
that acupuncture is an effective non-pharmacologic complement
to conventional treatment for osteoarthritis, and can be
utilized successfully as a part of an integrated approach to
treating the symptoms of osteoarthritis.
The National Institute of Environmental Health Sciences: Powerful
Techniques for Studying DNA Damage Recognition and Repair
This research project uses very powerful electron
microscopic techniques to study DNA repair and DNA damage
recognition. The researchers also study telomeres, which are
structures of repetitive DNA sequences at the ends of
chromosomes.
Lead Agency: The National Institute of Environmental Health
Sciences (NIEHS)/National Institutes of Health (NIH).
Agency Mission: The mission of the NIEHS is to reduce the
burden of human illness and disability by understanding how the
environment influences the development and progression of human
disease.
Principal Investigator: Jack D. Griffith, Professor,
Department of Microbiology/Immunology, CB# 7295, RM 11-119,
Lineberger Comprehensive Cancer Center, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-
7295.
General Description:
POWERFUL TECHNIQUES FOR STUDYING DNA DAMAGE RECOGNITION AND REPAIR
Single molecule electron microscopy provides a powerful
approach for studying the way in which damaged DNA is remodeled
by proteins. The focus of this application is to understand how
a number of central human DNA repair and telomere binding
proteins interact at large, complex DNA structures containing
damage, and how they carry out repair or signal the presence of
lesions. This is a highly interactive program which represents
longstanding fruitful collaborations with Dr. Paul Modrich
working on human mismatch factors, Dr. Aziz Sancar working on
human repair signaling factors, and with Dr. Titia deLange
working on telomere binding proteins. Together from our own
work on this topic and through these collaborations we have
published over 20 papers in the past 5 years. This is a highly
propitious time to carry out these studies since we have
developed two powerful new EM methods: nano-scale biopointers
that provide a means of identifying the location of proteins
within multi-protein complexes and glycerol spray/low voltage
EM that provide a more gentle means of preparing samples for
EM. Further, as substrates for these studies, we have produced
large natural DNAs containing replication forks or Holliday
junctions with nearby mismatched bases and a model telomere
DNA. Work on the mismatch repair proteins will take advantage
of the recent in vitro reconstitution of nick directed excision
repair by the Modrich laboratory. Work on Claspin and the Rad
9- Husl-Radl complex will focus on learning how these proteins
interact with replication forks containing damage. Studies of
the remodeling of telomeres will take advantage of the recent
discovery of discrete multi protein complexes at telomeres.
Finally continuing work from our laboratory will focus on p53
as a facilitator of DNA damage recognition. Each system offers
a unique window into basic questions of DNA protein remodeling
at sites of damage and telomeres and information garnered from
one study is immediately applied to the others.
Excellence: What makes this project exceptional?
The research team has discovered a fundamental difference
between the telomeres of the roundworm C. elegans and those of
mammals. Telomeres act like buffers preventing chromosomes from
fusing together or rearranging. Those types of abnormalities
can lead to cancer. The team found that roundworm telomeres are
rich in the compound cytosine as opposed to mammalian telomeres
which are rich in guanine.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
As humans and all higher organisms age, the telomeres at
the ends of their chromosomes shorten. Very short telomeres,
reached after several cell divisions, signal the cell to go
through programmed cell death, thus preventing the chromosomes
from rearranging in ways that have been associated with the
development of cancer. However, in some forms of cancer, the
death signal is not sent and the tumor cells continue to divide
allowing the cancer to grow and spread.
Effectiveness: What is the impact and/or application of
this research to older persons?
For the most part, cancer is a disease associated with
aging. In fact, most people, if they live long enough, will
develop some form of cancer in their lives. By identifying
methods to prevent or treat cancer, we can extend the healthy
years of life for all people.
Innovativeness: Why is this research exciting or
newsworthy?
This research team will now search for cytosine-rich
telomeres in mammalian cells. If they are found, they could
play a role in extending telomere maintenance and in cancer
prevention. The research team hopes to exploit these findings
in stopping cells from becoming cancerous or killing early
stages of cancer by blocking an enzyme critical in telomere
synthesis.
Office of Portfolio Analysis and Strategic Initiatives:
Interdisciplinary Research Consortium in Geroscience
The Roadmap Interdisciplinary Research Program is intended
to address significant research and health challenges by
bringing together researchers from different fields to develop
new approaches to solve problems. The Interdisciplinary
Research Consortium in Geroscience will foster
interdisciplinary collaborations that will help unravel the
reasons why we age so that we can better understand what goes
wrong in age-related diseases and disorders. Many avenues will
be explored including how dietary restriction affects aging and
why the aging brain recovers less easily from traumatic brain
injury.
Lead Agency: Office of Portfolio Analysis and Strategic
Initiatives (OPASI)/Common Fund, NIH Office of the Director.
Agency Mission: Strategic planning and implementation of
trans-NIH initiatives that seek to transform the way health
research is conducted.
Development and distribution of tools and methodologies to
NIH Institutes and Centers for analysis and evaluation of NIH
programs.
Principal Investigator: Dr. Gordon J. Lithgow, Associate
Professor, Buck Institute for Age Research, 8001 Redwood Blvd.,
Novato, CA 94945.
Partner Agencies: All NIH Institutes and Centers
participate in the planning and implementation of NIH Common
Fund/Roadmap Programs. The NIDCR plays a lead role in
implementing the Interdisciplinary Research Program. The
Geroscience research program at the Buck Institute for Age
Research is one of nine interdisciplinary research consortia
funded by the NIH Director's Roadmap program.
General Description: The Roadmap Interdisciplinary Research
Program brings together scientists from numerous fields to
develop new approaches that will address significant research
and health challenges. The Interdisciplinary Research
Consortium in Geroscience will foster interdisciplinary
collaborations between cell and molecular biologists,
biochemists, geneticists, endocrinologists, physiologists,
bioinformaticians, and chemists that will elucidate the
fundamental mechanisms of aging in order to better understand
what goes awry in age-related diseases and disorders. The
research will be carried out at the Buck Institute for Age
Research, which is an NIH-designed Center of Excellence, and
the only independent research institute in the United States
focused solely on aging research. The Geroscience Consortium
will synergize research on the basic mechanisms of aging with
research on age-associated diseases and with designing and
optimizing new technologies that may be of great value to the
geroscience community.
The research will include determining how cellular
signaling pathways (e.g., TOR) increase longevity in response
to environmental cues (e.g., dietary restriction) and how the
same genes that control cell division and thereby suppress
cancer (e.g., HUR) also promote neurodegeneration. Chemical
compounds will be searched for that increase lifespan and also
protect mammalian neurons from stressors. How proteins interact
and how they change shape in an aging cell vs. a diseased cell
will be explored since these processes are fundamental to the
development of several neurodegenerative diseases. The role of
histone deacetylase in aging and neurodegeneration will be
investigated since this enzyme plays a critical role in
modifying the epigenome of many cell types and may play a role
in the development of Huntington's Disease and Parkinson's
Disease. In addition, the research will explore why it is
harder for the aged brain to recover from injury.
Excellence: What makes this project exceptional?
The nine interdisciplinary research consortia including the
Geroscience Consortium were chosen through an incredibly
competitive process. Each proposed consortium had to have a
team of exceptionally accomplished scientists drawn from many
disciplines who could address significant research challenges
not amenable to existing uni- or multidisciplinary approaches.
The Geroscience Consortium is located at a premier aging
research institute--The Buck Institute for Age Research in
Novato, CA--which has no academic departments and is therefore
ideal for fostering interdisciplinary research at the interface
of different fields. The Geroscience Consortium will integrate
research on the molecular mechanisms of aging with age-
associated disease research and with designing and optimizing
new technologies of great potential value to the geroscience
community.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This research directly targets older persons. By
determining what constitutes the ``normal'' aging process, one
can better understand what biological processes go awry in age-
related diseases and disorders, and find therapeutic agents to
target these processes.
Effectiveness: What is the impact and/or application of
this research to older persons?
Finding out how aging occurs at the molecular and cellular
level will result in a better understanding of pathological
processes associated with disease. The Geroscience Consortium
has taken a multi-pronged approach to understanding aging and
addressing age-related diseases from examining changes in the
DNA (regulated epigenetic changes and stochastic oxidative
damage), to looking at changing protein dynamics (including the
formation of protein aggregates in Huntington's Disease and
Parkinson's Disease), to why aging brains do not recover well
from trauma (may be a paucity of stem cells). Knowing the
molecular players in the aging process and the factors that
modulate their functions normally and during disease
progression will allow for the development of therapeutic
agents or adoption of lifestyle changes to increase longevity
and combat disease.
Innovativeness: Why is this research exciting or
newsworthy?
Much has yet to be elucidated with respect to the molecular
pathways underlying aging in order to begin to get at what goes
awry in these pathways during the development of age-related
disease and to identify which molecules can be targeted by
therapeutic agents or can be modulated by lifestyle choices--
e.g., in diet.
National Institute on Aging: Health and Retirement Study (HRS)
The Health and Retirement Study (HRS) surveys more than
22,000 Americans over the age of 50 every two years. Survey
results and analyses paint an emerging portrait of an aging
America's physical and mental health, insurance coverage,
financial status, family support systems, labor market status,
and retirement planning. The data contain unique and innovative
features and are designed for cross-national comparisons with
international counterparts that allow analysts to consider
important research questions relating to aging societies.
Lead Agency: National Institute on Aging (NIA)/National
Institutes of Health (NIH).
Agency Mission: Support and conduct genetic, biological,
clinical, behavioral, social, and economic research related to
the aging process, diseases and conditions associated with
aging, and other special problems and needs of older Americans.
Foster the development of research and clinician scientists
in aging.
Communicate information about aging and advances in
research on aging to the scientific community, health care
providers, and the public.
Principal Investigator: David Weir, PhD, Institute for
Social Research, University of Michigan, 426 Thompson Street,
Ann Arbor, Michigan 48106-1248.
Partner Agency: Social Security Administration.
General Description:
HEALTH AND RETIREMENT STUDY (HRS)
Since 1992, the NIH-supported Health and Retirement Study
(HRS) has painted a detailed portrait of America's older
adults, helping us learn about this growing population's
physical and mental health, insurance coverage, financial
situations, family support systems, work status, and retirement
planning. Through its unique and in-depth interviews with a
nationally representative sample of adults over the age of 50,
the HRS provides an invaluable, growing body of
multidisciplinary data to help address the challenges and
opportunities of aging. During each 2-year cycle of interviews,
the HRS team surveys more than 20,000 people who represent the
Nation's diversity of economic conditions, racial and ethnic
backgrounds, health, marital histories and family compositions,
occupations and employment histories, living arrangements, and
other aspects of life. Since the inception of the HRS, more
than 27,000 people have given 200,000 hours of interviews. The
design and content of the HRS provides opportunities to analyze
individual aging and population trends and subgroup
differences, develop and test causal models, and simulate
policy. The data have proven to be a valuable scientific and
policy resource to both academic and federal researchers--there
are over 7,000 registered users of the data and nearly 1,000
researchers have employed the data to publish more than 1,300
reports, including more than 600 peer-reviewed journal articles
and book chapters, and 70 doctoral dissertations. The HRS is
managed jointly through a cooperative agreement between the
National Institute on Aging (NIA) and the Institute for Social
Research (ISR) at the University of Michigan. The study is
designed, administered, and conducted by the ISR, and decisions
about the study content are made by the investigators. The
principal investigators at the University of Michigan are
joined by a cadre of co-investigators and working group members
who are leading academic researchers from across the United
States in a variety of disciplines, including economics,
medicine, demography, psychology, public health, and survey
methodology. In addition, a Data Monitoring Committee is
charged with maintaining HRS quality, keeping the survey
relevant and attuned to the technical needs of researchers who
use the data and ensuring that it addresses the information
needs of policymakers and the public. The development of
international longitudinal aging studies using the HRS as a
model is leading to the production of a network of cross-
nationally comparable data sources to conduct timely research
on population aging.
Excellence: What makes this project exceptional?
The Health and Retirement Study (HRS) has provided an
invaluable, long-term look at the complex interplay of health,
work, and economic status of Americans age 51 and older. Over
the years, the study has been recognized for its high level of
innovation and unique approaches within the social science
research arena and has become the premier source of retirement
data. The data is widely used by both academic and federal
researchers. In terms of budget, sample size, number of
interview hours, and number of researchers involved, the HRS
ranks among the largest and most ambitious social and
behavioral studies ever undertaken. Rather than being a
narrowly controlled investigation of the hypotheses of a small
group of scientists, it provides a laboratory for many
researchers to explore their theories. The HRS has served as a
model for other countries to develop harmonized cross-
nationally comparable surveys.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The HRS is widely recognized as the leading data source for
research on the health and retirement behavior of older
populations. The data are being used by federal and academic
researchers to address critical questions facing aging
populations. Broad national representation in the study allows
it to look at the older population in general as well as the
great diversity and variability of aging. The structure of the
data allows researchers to investigate both current issues and
changes over time. The HRS tracks the health of respondents
over time allowing researchers to probe the impacts of
unexpected health events on other aspects of individuals'
lives. The HRS, along with harmonized international companion
studies, allows for comparisons of trends in aging and
retirement worldwide.
Effectiveness: What is the impact and/or application of
this research to older persons?
The HRS has enabled a significant amount of research
supported by the federal government and private institutions of
aging. Data and analyses from HRS have been used to publish
more than 1,300 reports, including more than 600 peer-reviewed
journal articles and book chapters and 70 doctoral
dissertations on health and retirement.
Innovativeness: Why is this research exciting or
newsworthy?
The HRS contains many survey innovations, including:
Providing improved measurement of key concepts
like assets using random entry bracketing, which reduces the
number of non-responses by eliciting ranges of values from
respondents who would otherwise give no information at all.
Innovative concepts like participants' future
expectations such as how long people expect to work in the
future, their estimates of how long they will live, the
likelihood of giving major financial assistance to family
members in the future, whether or not they expect to leave a
bequest and the amount of that bequest, and whether they think
they will enter a nursing home or move to a new home or other
living arrangement in the future.
Short experimental modules administered to
randomly selected subgroups of participants to test new
concepts and explore narrowly focused topics such as
physiological capacity, early childhood experiences,
personality, quality of life, and employment opportunities.
The largest national study of the prevalence of
dementia in the United States using in-home assessments (the
Aging, Demographics, and Memory Study--ADAMS).
Collection of biomarker data including grip
strength, lung capacity, walking ability, blood pressure, blood
spot samples to assay for some common disease markers and
salivary DNA samples.
Consumption and time-use data.
Linkages to administrative records on benefits and
earnings from federal programs like Social Security and
Medicare as well as employers to better understand pension
plans.
International data collections modeled after the
HRS provide opportunities for comparable data for cross-
national analyses.
National Eye Institute (NEI)/National Institutes of Health (NIH): Age-
Related Eye Disease Study: Women Interagency HIV Study (WIHS)
AREDS investigators reported on clinical trial findings
that a daily, high-dose combination of antioxidant vitamins C,
E, and beta-carotene, and the trace element zinc reduced the
risk of developing advanced AMD by 25% over a five-year period.
Lead Agency: National Eye Institute (NEI), National
Institutes of Health (NIH).
Agency Mission: The National Eye Institute (NEI) was
established by Congress in 1968 to protect and prolong the
vision of the American people. As one of the Federal
government's National Institutes of Health (NIH), the NEI
conducts and supports research that helps prevent and treat eye
diseases and other disorders of vision. This research leads to
sight-saving treatments, reduces visual impairment and
blindness, and improves the quality of life for people of all
ages. NEI-supported research has advanced our knowledge of how
the visual system functions in health and disease.
Principal Investigators: Dr. Frederick Ferris, Address: 10-
CRC--Hatfield Clinical Research Center, 3-2531, 10 Center
Drive, Bethesda, MD 20892.
General Description:
AGE-RELATED EYE DISEASE STUDY (AREDS)
The two most common eye diseases associated with aging are
lens opacities (cataract), a leading cause of worldwide
blindness, and age-related macular degeneration (AMD), the
leading cause of irreversible vision loss in the United States
among persons over 65 years of age. Cataract surgery replaces
the opaque, natural lens with a clear, synthetic lens and is
highly successful in the United States. However, in developing
countries, the procedure is costly and not readily available.
There are no cures for AMD, which causes the loss of light
sensing photoreceptor cells in the central portion of the
retina (macula) that provides us with sharp visual acuity and
color vision. In the initial phases of the disease, patients
experience trouble reading fine print and seeing in dim light.
During the advanced stages, the disease destroys the macula,
resulting in severe vision loss and legal blindness. Patients
with advanced AMD can no longer read, recognize faces, drive a
car, or perform simple daily tasks that require hand-eye
coordination. AMD greatly diminishes mobility, independence and
the quality of life. A delay in the progression of AMD would
provide improved visual function for afflicted individuals. As
the U.S. population ages, the prevalence of AMD and cataracts
is expected to rise sharply, placing ever greater burdens on
healthcare and social services.
The NEI initiated the Age-Related Eye Disease Study (AREDS)
to evaluate, in part, the effects of antioxidants on the
development and progression of AMD and cataracts. AREDS
included a large, multi-center clinical trial involving 4,757
participants, 55 to 80 years of age, in 11 clinical centers
nationwide. Researchers found that people at high risk of
developing advanced stages of AMD lowered their risk of
progression by about 25 percent over a five-year period when
treated with a daily, high-dose combination of antioxidant
vitamins C, E, and beta-carotene, and the trace element zinc.
No effect of these nutrients on cataract formation was
observed. This nutritional therapy represents the first
treatment to slow the progression of AMD and delay the onset of
severe and debilitating vision loss. Based on published
prevalence data, an estimated 8 million Americans at least 55
years old are at high risk to develop advanced AMD. Based on
results from the AREDS, 1.3 million of these people would
develop advanced AMD over the next five years if no treatment
were given to reduce their risk. If this at-risk population
avails themselves of the AREDS nutritional formulation
(vitamins C, E, beta-carotene, and zinc), greater than 300,000
would avoid advanced AMD and its associated vision loss over
the next five years.
AREDS also added to our understanding of the epidemiology
of AMD and cataract. Data from AREDS and other studies
suggested that lutein/zeaxanthin and omega-3 long chain
polyunsaturated fatty acids might also have benefit in AMD and
cataract. Leveraging these findings, NEI began AREDS 2 in 2005,
a multicenter study that will include up to 100 clinical sites
to evaluate these supplements and other modifications of the
original AREDS formulations on AMD and cataract.
WOMEN INTERAGENCY HIV STUDY (WIHS)
The Women's Interagency HIV Study (WIHS) was established in
August 1993 to investigate the impact of HIV infection on women
in the United States. Approximately 3,700 women have been
enrolled, of which 2,400 are still attending visits every six
months (the remaining have either died or lost to follow-up).
The core portion of this NIH-supported study includes a
detailed and structured interview, physical and gynecologic
examinations, and laboratory testing. The WIHS participants are
also asked to enroll in various sub-studies, including
cardiovascular, metabolic, and physical functioning.
Excellence: What makes this project exceptional?
AREDS offers the first treatment to slow the progression of
AMD.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
AMD is the leading cause of blindness in older Americans in
the United States.
Effectiveness: What is the impact and/or application of
this research to older persons?
If the more than 8 million older Americans at high risk of
developing advanced AMD took the AREDS formulation, more than
300,000 would avoid severe vision loss over the next 5 years.
Innovativeness: Why is this exciting or newsworthy?
AREDS offers a valuable therapy to prevent severe vision
loss simply by taking a relatively low-cost antioxidant
supplement.
National Center for Complementary and Alternative Medicine: Turmeric
and Rheumatoid Arthritis Symptoms
Using an experimental animal model of rheumatoid arthritis,
NCCAM-supported investigators demonstrated that a curcuminoid-
containing turmeric extract, similar to that found in turmeric
dietary supplements, significantly inhibited joint inflammation
and joint destruction.
Lead Agency: National Center for Complementary and
Alternative Medicine (NCCAM)/National Institutes of Health
(NIH).
Agency Mission:
Explore complementary and alternative healing
practices in the context of rigorous science.
Train complementary and alternative medicine
researchers.
Disseminate authoritative information to the
public and professionals.
Principal Investigator: Barbara Timmermann, Ph.D.,
Department of Medicinal Chemistry, University of Kansas, School
of Pharmacy, 4070 Malott Hall, 1251 Wescoe Hall Dr., Lawrence,
KS 66045-7582.
Partner Agencies: Office of Dietary Supplements (ODS),
Office of the Director/National Institutes of Health.
General Description:
TURMERIC AND RHEUMATOID ARTHRITIS SYMPTOMS
Rheumatoid arthritis (RA) is an autoimmune disease that
causes inflammation in the joints, resulting in pain, swelling,
stiffness, and loss of function in the affected joints.
Scientists estimate that about 2.1 million people in the United
States have RA, which occurs in all races and ethnic groups.
The financial and social impact of this disease is substantial:
the medical and surgical treatment costs and the wages lost
because of disability add up to billions of dollars annually.
Using an experimental animal model of arthritis, NCCAM-
supported investigators demonstrated that a curcuminoid-
containing turmeric extract, similar to that found in turmeric
dietary supplements, significantly inhibited joint inflammation
and joint destruction. These findings suggest a mechanism for
turmeric's protective, antiarthritic effect. The investigators
documented the chemical composition of a curcumin-containing
compound tested in an animal model for antiarthritic activity;
provided evidence of antiarthritic efficacy of a turmeric
extract similar to turmeric dietary supplements; and proposed a
mechanism of action of curcumin-containing extracts in
arthritis treatments.
The centuries-old practice of Ayurvedic medicine supports
the use of turmeric as an anti-inflammatory agent. Turmeric, a
botanical supplement, has been widely promoted in the United
States as a treatment for arthritis, despite the lack of
standardization of over-the-counter products and paucity of
scientific efficacy data. This scientific advance builds on and
extends previous findings that turmeric can prevent joint
inflammation in an animal model of RA. It also demonstrates the
application of sophisticated research techniques to assess the
potential therapeutic benefits of botanicals. Thus, these
results lay the foundation for further clinical evaluation of
turmeric dietary supplements in the treatment of RA.
Excellence: What makes this project exceptional?
More than 2 million Americans suffer from rheumatoid
arthritis (RA), a condition in which the body's immune system
attacks the joints, causing pain, swelling, stiffness, and loss
of function. Using an animal model, this project provided
evidence of antiarthritic activity of a turmeric extract,
similar to that in turmeric dietary supplements.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Rheumatoid arthritis affects the middle-aged and occurs
with increased frequency in older individuals. This study has
demonstrated that a turmeric extract, similar to that found in
turmeric dietary supplements, significantly inhibited joint
inflammation and joint destruction. The successful translation
of these results from an animal model to human use would
provide another effective treatment for arthritis and,
potentially, other inflammatory diseases.
Effectiveness: What is the impact and/or application of
this research to older persons?
These investigators demonstrated in vivo efficacy and
identified the mechanism of action for a well-characterized
turmeric extract, which lays the groundwork for clinical
evaluation of turmeric dietary supplements for the treatment of
RA.
Innovativeness: Why is this research exciting or
newsworthy?
A variety of medical and lifestyle approaches are used to
treat RA-associated pain and inflammation, and slow down or
halt the subsequent joint damage. This study lays the
foundation for the clinical evaluation of a potentially new
treatment for a painful and debilitating disease that affects
older adults. In addition, the research results provide a
proof-of-concept for the potential use of a botanical to treat
other inflammatory diseases, such as inflammatory bowel
disease, asthma, and multiple sclerosis.
National Center for Complementary and Alternative Medicine: Tai Chi
Boosts Immunity to Shingles Virus in Older Adults
This is the first rigorous clinical trial to suggest that a
mind-body intervention, tai chi, alone or together with a
vaccine, can help protect older adults from the varicella
virus, which causes both chickenpox and shingles.
Lead Agency: National Center for Complementary and
Alternative Medicine (NCCAM)/National Institutes of Health
(NIH).
Agency Mission:
Explore complementary and alternative healing
practices in the context of rigorous science.
Train complementary and alternative medicine
researchers.
Disseminate authoritative information to the
public and professionals.
Principal Investigator: Michael R Irwin, M.D., University
of California, Los Angeles, Neuropsychiatric Institute, 300
UCLA Medical Plaza, Suite 3109, Los Angeles, CA 90095-7076.
General Description:
TAI CHI BOOSTS IMMUNITY TO SHINGLES VIRUS IN OLDER ADULTS
In a randomized, controlled clinical trial, NIH-supported
researchers demonstrated that tai chi increases the immunity of
older adults to the varicella zoster virus that causes both
chickenpox and shingles and boosts their immune responses to
the chickenpox vaccine. Tai chi, developed in China around the
12th century as a martial art, is a low-impact form of exercise
and moving meditation that can improve physical condition,
muscle strength, coordination, and flexibility.
One hundred twelve healthy adults, ages 59 to 86, took part
in a 16-week program in which they received either a tai chi
intervention or participated in a health education control
group. After completing the program, both groups received a
single injection of VARIVAX%, the chickenpox vaccine. Periodic
blood tests determined levels of viral immunity during the
program and nine weeks following vaccine administration. Prior
to vaccination, tai chi was found to increase pre-existing
immunity to varicella. Following vaccination, the level of
immunity to varicella was significantly higher in the tai chi
group, about a 40 percent increase, compared to the education
group.
The researchers further showed that the tai chi group's
rate of increase in immunity over the course of the study was
double that of the control group. The tai chi group also
reported significant improvements in physical functioning, body
pain, vitality, and mental health.
Excellence: What makes this project exceptional?
Tai chi, a traditional Chinese form of exercise, may help
older adults avoid getting shingles by increasing immunity to
varicella-zoster virus (VZV) and boosting the immune response
to varicella vaccine in older adults. This study is the first
rigorous clinical trial to suggest that a behavioral
intervention, alone or in combination with a vaccine, can help
protect older adults from VZV, which causes both chickenpox and
shingles.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
One in five people who have had chickenpox will get
shingles later in life, usually after age 50, and the risk
increases as people get older. More research is needed, but
this study suggests that the tai chi intervention tested, in
combination with immunization, may enhance protection of older
adults from this painful condition.
Effectiveness: What is the impact and/or application of
this research to older persons?
Tai chi, developed in China around the 12th century as a
martial art, is a low-impact form of exercise and moving
meditation that can improve physical condition, muscle
strength, coordination, and flexibility. It is also said to
improve balance, which may lower the risk of falls, especially
in the elderly, and to ease pain and stiffness caused, for
example, by arthritis. Tai chi is considered to be particularly
suitable for older people because it is low-impact and can be
modified easily to accommodate health limitations.
Innovativeness: Why is this research exciting or
newsworthy?
This is the first rigorous clinical trial to suggest that a
mind-body intervention, tai chi, alone or together with a
vaccine, can help protect older adults from the varicella
virus, which causes both chickenpox and shingles.
National Cancer Institute: Elderly Medicaid Patients Less Likely To
Receive Chemotherapy for Colorectal Cancer
A study using data from the Michigan Tumor Registry and the
Centers for Medicare and Medicaid Services showed that elderly
Medicaid-insured patients in the state are less likely to
initiate or complete chemotherapy for colorectal cancer
compared with Medicare-insured patients. Previous studies have
shown that Medicaid-insured patients have worse survival rates
for colorectal cancer, but it had not been known if they
receive less treatment than patients with other forms of
insurance.
Lead Agency: National Cancer Institute (NCI)/National
Institutes of Health (NIH).
Agency Mission: The National Cancer Institute coordinates
the National Cancer Program, which conducts and supports
research, training, health information dissemination, and other
programs with respect to the cause, diagnosis, prevention, and
treatment of cancer, rehabilitation from cancer, and the
continuing care of cancer patients and the families of cancer
patients. Specifically, the Institute:
Principal Investigator: Cathy J. Bradley, Virginia
Commonwealth University, 1008 East Clay St., Richmond, VA.
General Description: Elderly Medicaid Patients Less Likely
to Receive Chemotherapy for Colorectal Cancer. While major
improvements have been made in the collection of epidemiologic
data, special populations such as minorities and the medically
underserved have been excluded. No accurate epidemiologic
information exists on the cancer incidence, diagnosis, and
treatment of these populations. The investigators collected
data from 4,765 patients aged 65 or older who were diagnosed
with colorectal cancer between January 1997 and December 2000
and insured through Medicaid, Medicare, or both. In addition to
data on chemotherapy initiation and completion, the
investigators compared whether patients were evaluated by an
oncologist, subsequently hospitalized, and experienced
comorbidities; demographic variables including age, race, sex,
household income, and whether patients lived in a metropolitan,
urban, or rural area were also studied.
Patients insured through Medicaid were more likely to be
African American or of another minority race, female, and to
live in a low-income area. For all patients, those with
Medicaid insurance were less likely to initiate or complete
chemotherapy and less likely to be evaluated by a medical
oncologist. Older patients were also less likely to initiate
chemotherapy, even though studies have shown that these
patients benefit from adjuvant treatment. Future projects using
the data can include the prevention of disease or disability,
the restoration or maintenance of health, and interventions for
more effective health care.
Excellence: What makes this project exceptional?
This research provides evidence that elderly patients with
Medicaid are less likely to initiate or complete chemotherapy
for colorectal cancer. Previous studies have shown that
Medicaid-insured patients have worse survival rates for
colorectal cancer, but it had not been known if they receive
less treatment than patients with other forms of insurance.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Between 2001 and 2005 the median age at diagnosis for
colorectal cancer was 71, and approximately 66% of those
diagnosed were over 65. This research shows that older patients
with Medicaid are less likely to initiate chemotherapy, even
though studies have shown that these patients benefit from
adjuvant treatment.
Effectiveness: What is the impact and/or application of
this research to older persons?
Medicaid enrollment is associated with disparate colon
cancer treatment, which likely compromises the survival of
these patients. Recognizing the deficiencies in the quality of
care Medicaid patients with colorectal cancer receive will
hopefully encourage the changes in policies and practices
needed to reduce this trend.
Innovativeness: Why is this research exciting or
newsworthy?
This research demonstrates the substantially disparate
treatment uptake and compliance received by Medicaid patients.
Ensuring access to appropriate care for Medicaid recipients
with colorectal cancer has the potential to greatly improve the
quality of life, and life expectancy of these patients,
especially if similar trends are seen in other states around
the nation.
National Cancer Institute: Survival With Treatment vs. Observation of
Localized Prostate Cancer in Elderly Men
Prostate-specific antigen screening has led to an increase
in the diagnosis and treatment of localized prostate cancer.
However, the role of active treatment of low- and intermediate-
risk disease in elderly men is controversial. This study
estimates the association between treatment (with radiation
therapy or radical prostatectomy) compared with observation and
overall survival in men with low- and intermediate-risk
prostate cancer. This study suggests a survival advantage is
associated with active treatment for low- and intermediate-risk
prostate cancer in elderly men aged 65 to 80 years.
Lead Agency: National Cancer Institute (NCI)/National
Institutes of Health (NIH).
Agency Mission: The National Cancer Institute coordinates
the National Cancer Program, which conducts and supports
research, training, health information dissemination, and other
programs with respect to the cause, diagnosis, prevention, and
treatment of cancer, rehabilitation from cancer, and the
continuing care of cancer patients and the families of cancer
patients.
Principal Investigator: Dr. Timothy Rebbeck, Center for
Clinical Epidemiology and Biostatistics, University of
Pennsylvania School of Medicine, 904 Blockley Hall, 423
Guardian Drive, Philadelphia, PA 19104-6021.
General Description: Survival with Treatment vs.
Observation of Localized Prostate Cancer in Elderly Men.
Prostate-specific antigen screening has led to an increase in
the diagnosis and treatment of localized prostate cancer.
However, the role of active treatment of low- and intermediate-
risk disease in elderly men is controversial. This study
estimates the association between treatment (with radiation
therapy or radical prostatectomy) compared with observation and
overall survival in men with low- and intermediate-risk
prostate cancer using the US cohort from Surveillance,
Epidemiology, and End Results Medicare data. A total of 44,630
men aged 65 to 80 years who were diagnosed between 1991 and
1999 with organ-confined, well- or moderately differentiated
prostate cancer and who had survived more than a year past
diagnosis. Patients were followed up until death or study end
and were classified as having received treatment if they had
claims for radical prostatectomy or radiation therapy during
the first 6 months after diagnosis. They were classified as
having received observation if they did not have claims for
radical prostatectomy, radiation, or hormonal therapy. Patients
who received only hormonal therapy were excluded. At the end of
the 12-year study period, 37% of men in the observational group
23.8% in the treatment group had died. The treatment group had
longer 5- and 10-year survival than the observation group.
After using propensity scores to adjust for potential
confounders (tumor characteristics, demographics, and
comorbidities), there was a statistically significant survival
advantage associated with treatment. A benefit associated with
treatment was seen in all subgroups examined, including older
men (aged 75-80 years at diagnosis), black men, and men with
low-risk disease. This study suggests a survival advantage is
associated with active treatment for low- and intermediate-risk
prostate cancer in elderly men aged 65 to 80 years. Because
observational data cannot completely adjust for potential
selection bias and confounding, these results must be validated
in randomized controlled trials of alternative management
strategies in elderly men with localized prostate cancer.
Excellence: What makes this project exceptional?
This observational study suggests a reduced risk of
mortality associated with active treatment for low- and
intermediate-risk prostate cancer in the elderly Medicare
population examined. Although a randomized controlled trial
design is needed to confirm these findings, they help begin to
answer the long-standing questions regarding treatment
decisions for older men.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This study is relevant to older populations because
prostate cancer primarily affects older men. In fact, from
2001-2005, the median age at diagnosis for cancer of the
prostate was 68 years of age, with over 62% of all persons
diagnosed over 65. This study supports the use of treatment to
prolong life for these older men.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research is especially applicable to older men because
of the large percentage of prostate cancer cases in this
population. Upon further study, confirmation of these results
will lead to the more effective treatment of older men.
Innovativeness: Why is this research exciting or
newsworthy?
This study suggests a survival advantage is associated with
active treatment for low- and intermediate-risk prostate cancer
in elderly men aged 65 to 80 years. By helping to answer long-
standing questions about appropriate types of treatment for
prostate cancer, especially for older men, these findings
propel researchers to begin to confirm these findings. Through
future randomized studies the finding that treatment is
effective for older men can be confirmed and put into practice
holding the promise to affect countless older men diagnosed
with this disease.
National Cancer Institute: Integrating Aging and Cancer Research at
NCI-Designated Cancer Centers
The goal of this program is to expand the capacity of the
NCI-designated Cancer Centers to carry out research that
concentrates on aging and age-related aspects of human cancer
through support of new investigators, pilot projects, and
shared resources focused on aging and cancer. Grantees are
expected to develop a formal research program that would become
a stable component of the cancer center dedicated to
collaborative research in aging and cancer and translation of
findings into the clinical and population settings.
Lead Agency: National Cancer Institute (NCI)/National
Institutes of Health (NIH).
Agency Mission: The National Cancer Institute coordinates
the National Cancer Program, which conducts and supports
research, training, health information dissemination, and other
programs with respect to the cause, diagnosis, prevention, and
treatment of cancer, rehabilitation from cancer, and the
continuing care of cancer patients and the families of cancer
patients.
Principal Investigator: Richard H. Weindruch, Ph.D.,
University of Wisconsin, VA Hospital (GRECC-4D), 2500 Overlook
Terrance, Madison, Wisconsin 53705-2286.
Partner Agency: National Institute on Aging (NIA)/National
Institutes of Health (NIH).
General Description: Planning and Development Grants
Integrating Aging and Cancer Research at NCI-Designated Cancer
Centers. The goal of this program is to expand the capacity of
Cancer Centers to engage in pioneering research that
concentrates on aging- and age-related aspects of human cancer
through support of new investigators, pilot projects, and
shared resources focused on aging and cancer. Grantees are
expected to design and coordinate a research effort in a five-
year project period that will result in a formal aging/cancer
``Program'' or an equally effective integrated research
activity that becomes a component of the NCI-funded Cancer
Center. A solid, focused infrastructure for the conduct and
continued development of an aging/cancer research program,
allowing for incorporation of multiple disciplines and creative
exploration of new approaches to cancer, is also expected.
A broad range of cancer research falls under this
scientific initiative, based on seven thematic areas defined in
a 2001 NIA/NCI Workshop Report: Treatment Efficacy and
Tolerance; Effects of Comorbidity; The Biology of Aging and
Cancer; Patterns of Care; Prevention, Risk Assessment, and
Screening; Psychosocial and Medical Effects; and Palliative
Care, End-of-Life Care, and Pain Relief.
Excellence: What makes this project exceptional?
It was specifically designed to build research capability
in aging-and age-related aspects of human cancer through the
NCI-designated Cancer Centers, building upon their abilities to
work across organizational boundaries, foster transdisciplinary
research, create long-term stability for scientists and
research programs, provide extensive core resources to
investigators, and link to their communities.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
There is a clear need to encourage research which draws
from expertise in many disciplines to focus on the problems of
cancer in older persons. This initiative is an effort to
mobilize expertise through a planning and implementation effort
that accelerates research at the aging/cancer interface. The
research initiative provides the initial resources to develop
and create an integrated, interactive research capability with
a significant base of externally funded, peer reviewed research
projects in NCI-designated Cancer Centers that focuses on
problems of cancer in the elderly. The unique cancer center
infrastructure and its critical mass of multidisciplinary
expertise provide an ideal research setting for meeting the
challenges inherent in integrating aging and cancer research.
Cancer Centers have well-established interactive research
environments, and they have the leadership, space, equipment,
structure and resources available to take advantage of new
research directions as opportunities arise.
Effectiveness: What is the impact and/or application of
this research to older persons?
Persons 65 and older are at highest risk for cancer and
have a higher mortality rate than younger persons. This
initiative is still underway and it will be some time before
the true and long-term impact can be assessed. However, it
should accelerate research specifically focused on in cancer
and aging research.
Innovativeness: Why is this research exciting or
newsworthy?
This program is the culmination of several years of effort
by NIA and NCI and extramural scientists with expertise in many
areas relevant to cancer and aging. It should stimulate
research capability in this area in the funded institutions and
visibility for aging/cancer issues, build a cadre of future
investigators at the cancer/aging research interface, and
identify important focal areas for further research and
infrastructure support, thus serving as a platform for
additional efforts in the future.
National Human Genome Research Institute: Hutchinson-Gilford Progeria
Syndrome
The gene responsible for the rare and deadly accelerated
aging syndrome known as progeria is called LMNA, which is
translated into a mutant form of a protein called progerin. The
research aims to understand the specific dysfunctions of
mutated progerin in the cell by observing cell division,
creating a mouse model, testing inhibitors, and starting the
first ever human clinical trial. Understanding the variations
in the gene and protein product can potentially help treat
children with progeria, as well as shed light on the normal
aging process.
Lead Agency: National Human Genome Research Institute
(NHGRI)/National Institutes of Health (NIH).
Agency Mission: The National Human Genome Research
Institute (NHGRI) led the National Institutes of Health's (NIH)
contribution to the International Human Genome Project, which
had as its primary goal the sequencing of the human genome.
This project was successfully completed in April 2003. Now, the
NHGRI's mission has expanded to encompass a broad range of
studies aimed at understanding the structure and function of
the human genome and its role in health and disease.
To that end, NHGRI supports the development of resources
and technology that will accelerate genome research and its
application to human health. A critical part of the NHGRI
mission continues to be the study of the ethical, legal, and
social implications (ELSI) of genome research. NHGRI also
supports the training of investigators and the dissemination of
genome information to the public and to health professionals.
Principal Investigator: Francis S. Collins, MD, PhD,
Director, NHGRI, Building 31, Room 4B09, 31 Center Dr, MSC
2152, Bethesda, MD 20892-2152.
General Description: Hutchinson-Gilford progeria syndrome
(HGPS) is the most dramatic human syndrome of premature aging.
Children with this rare condition are normal at birth, but by
age 2 they have stopped growing, lost their hair, and shown
skin changes and loss of subcutaneous tissue that resemble the
ravages of old age. They rarely live past adolescence, dying
almost always of advanced cardiovascular disease (heart attack
and stroke). The classic syndrome has never been observed to
recur in families. The laboratory conducting this research
discovered that nearly all cases of HGPS harbor a de novo point
mutation in codon 608 of the LMNA gene. This mutation causes
disease by creating an abnormal splice donor, generating a mRNA
with an internal deletion of 150 nt. This is translated into a
mutant form of the lamin A protein (referred to now as
progerin) that lacks 50 amino acids near the C-terminus. This
research has shown that progerin acts as a dominant negative to
disrupt the structure of the nuclear membrane scaffold. Recent
data has also demonstrated that progerin interferes with proper
chromosome segregation during mitosis. A mouse model for HGPS
has been developed. Animals carrying a human BAC transgene
bearing the codon 608 mutation show progressive loss of smooth
muscle cells in the media of large vessels, with replacement by
proteoglycan. Thus, the mouse model nicely replicates the
cardiovascular phenotype of HGPS.
This project has also explored the possibility that
farnesyl transferase inhibitors (FTIs) might be beneficial in
HGPS, since lamin A is a farnesylated protein. Treatment of
progeria fibroblasts growing in cell culture demonstrates that
FTIs are capable of reversing the dramatic nuclear blebbing
that is the hallmark of the disease. Based on this data, the
research team is conducting a trial of FTIs in the progeria
mouse model. A clinical trial of FTIs in children with the
disease is planned to be initiated shortly.
Finally, it is hypothesized that other structural or
regulatory variants in the LMNA gene might actually be
protective against the normal aging process. Accordingly, the
lab is also comparing haplotypes in well-matched cohorts of
controls and individuals who have achieved exceptional
longevity.
Excellence: What makes this project exceptional?
The research team has uncovered remarkable findings about
the syndrome as well as its basic biological malfunctions. In
addition to discovering the gene responsible and its regulatory
pathway inside the cell, the team has discovered that drugs
known as farnesyltransferase inhibitors (FTIs), which are
currently being tested in people with myeloid leukemia,
neurofibromatosis and other conditions, might also provide a
potential therapy for children suffering from Hutchinson-
Gilford Progeria Syndrome.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Progeria studies are crucial to understand the normal aging
process. Understanding the biology of progeria and the mutated
form of the LMNA protein also helps researchers understand the
normal process that happens in the rest of us.
Effectiveness: What is the impact and/or application of
this research to older persons?
If the mutated progerin proteins are able to be slowed down
by drugs, the research may provide potential ways to extend
longevity and health in the normal population as well.
Innovativeness: Why is this research exciting or
newsworthy?
Not only does this research hold promise for children and
families affected by progeria by initiating the first ever
clinical trial, it also sheds light on the biology of aging and
common elderly conditions such as atherosclerotic disease.
National Human Genome Research Institute: Understanding of the
Molecular Mechanisms of Cardiovascular Diseases
This innovative laboratory team seeks to identify the
molecular, cellular, and genetic mechanisms that cause vascular
disorders. In particular, their research focuses on defining
the pathways that regulate cell growth in the vasculature,
remodel the vasculature after injury, and lead to genetic
susceptibility to vascular diseases. Taken together, these
studies focus on the molecular genetics of vascular diseases,
with an emphasis on cell cycle regulation of proliferation,
inflammation, and apoptosis.
Lead Agency: National Human Genome Research Institute
(NHGRI)/National Institutes of Health
Agency Mission: The National Human Genome Research
Institute (NHGRI) led the National Institutes of Health's (NIH)
contribution to the International Human Genome Project, which
had as its primary goal the sequencing of the human genome.
This project was successfully completed in April 2003. Now, the
NHGRI's mission has expanded to encompass a broad range of
studies aimed at understanding the structure and function of
the human genome and its role in health and disease.
To that end NHGRI supports the development of resources and
technology that will accelerate genome research and its
application to human health. A critical part of the NHGRI
mission continues to be the study of the ethical, legal and
social implications (ELSI) of genome research. NHGRI also
supports the training of investigators and the dissemination of
genome information to the public and to health professionals.
Principal Investigator: Elizabeth G. Nabel, M.D., Director,
NHLBI, Building 50, Room 4525, 50 South Dr, MSC 8016, Bethesda,
MD 20892-8016.
General Description:
UNDERSTANDING THE MOLECULAR MECHANISMS OF CARDIOVASCULAR DISEASES
Cardiovascular diseases are the leading cause of morbidity
and mortality in industrialized countries. Most cardiovascular
diseases result from complications of atherosclerosis, which is
a chronic and progressive inflammatory condition characterized
by excessive cellular proliferation of vascular smooth muscle
cells, endothelial cells, and inflammatory cells that leads to
occlusive vascular disease, myocardial infarction, and stroke.
Recent studies have revealed the important role of cyclins,
cyclin-dependent kinases (CDKs), and cyclin-dependent kinase
inhibitors (CKIs) in vascular and cardiac tissue injury,
inflammation, and wound repair. This research seeks to
understand the circuitry of the cyclin-CDK-CKI interactions in
normal physiology and disease pathology, providing a better
understanding of the molecular mechanisms of cardiovascular
diseases. This approach will hopefully lead to the rational
design of new classes of therapeutic agents.
Given the role of cyclins in vascular health, a major focus
of the study is CKIs, which are primarily involved in
inhibiting the proliferation of a variety of normal cell types.
Previous research identified a particular CKI, known as
p27Kip1, as a major regulator of vascular cell
proliferation during arterial remodeling. In one set of
studies, her group found that p27Kip1 plays a major
role in cardiovascular disease through its effects on the
proliferation of bone marrow-derived immune cells that migrate
into vascular lesions. To demonstrate whether
p27Kip1 regulates arterial wound repair, NHGRI
Investigators recently subjected p27-/- (homozygous
knockout), p27+/- (heterozygous knockout), and
p27+/+ (wild-type) mice to a wire injury in the
femoral artery and examined subsequent cell proliferation and
lesion formation. Cell proliferation was significantly
increased in the innermost lining of the blood vessels of
p27-/- mouse arteries compared with
p27+/+ arteries. Arterial lesions also were markedly
increased in the p27-/- mice compared with those of
p27+/+ mice. The heterozygous knockout mice
(p27-/+) had an intermediate phenotype. These
findings suggest that vascular repair and regeneration are
regulated by the proliferation of hematopoietically and
nonhematopoietically derived cells through a
p27Kip1-dependent mechanism, with immune cells
largely mediating these effects.
A related area of study focuses on the structural and
functional analysis of a serine-threonine kinase called kinase
interacting stathmin, or KIS. A nuclear protein that binds the
C-terminal domain of p27Kip1, KIS phosphorylates a
serine residue at position 10 (Ser 10) in the sequence and
thereby promotes its export to the cytoplasm. KIS is activated
by mitogens during G0/G1, and expression of KIS overcomes
growth arrest induced by p27Kip1. Depletion of KIS
with small interfering RNA (siRNA) inhibits Ser 10
phosphorylation and enhances growth arrest. In addition,
treating p27-/- cells with KIS siRNA causes them to
grow and progress to S/G2, similar to control-treated cells,
implicating p27Kip1 as the critical target for KIS.
Previous research cloned and characterized the gene encoding
this kinase and is studies are now examining its structure and
function, including the transcriptional control of the KIS
promoter, the phenotypic consequences of knockout out the KIS
gene in mice, and the effect of knock-in mutations at different
phosphorylation sites of p27.
NHGRI investigators are also involved in a clinical study
of the genetics of restenosis, which is the recurrence of a
blockage in an artery after it has been manually reopened with
an artificial stent. Restenosis is a major limitation of stent
therapy for coronary artery disease. In this study, the
investigators are following patients who have received bare
metal stents for the treatment of a blocked coronary artery and
then comparing the genetic profiles of patients with restenosis
with those of patients with no restenosis. The genetic analyses
include gene expression profiling, serum proteomics, and
genotyping using candidate gene and genome-wide scanning
approaches. The goal is to identify gene, RNA, and protein
profiles of patients with recurrent restenosis, so as to
advance our understanding of the pathogenesis of this problem
and to target potential therapies.
Excellence: What makes this project exceptional?
This project utilizes both cardiovascular and genetic
medicine to create innovative therapeutic targets for
conditions that affect millions worldwide.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Cardiovascular disease remains the leading cause of death
and disability in the elderly population, and cardiovascular
risk increases steadily with age.
Effectiveness: What is the impact and/or application of
this research to older persons?
Understanding the molecular pathophysiology of vascular
diseases, such as in-stent restenosis, is critical to the
design and development of novel therapeutics.
Innovativeness: Why is this research exciting or
newsworthy?
This research has the potential to identify key genetic
variants responsible for cardiovascular inflammation, a wide-
spread condition, with the aim of eventually tailoring
therapies specifically for each group.
National Heart, Lung, and Blood Institute: Action To Control
Cardiovascular Risk in Diabetes (ACCORD)
ACCORD (Action to Control Cardiovascular Risk in Diabetes)
is evaluating approaches to decrease the occurrence of major
CVD events--heart attack, stroke or death from CVD--among high-
risk patients with type 2 diabetes.
Lead Agency: National Heart, Lung, and Blood Institute
(NHLBI)/National Institutes of Health (NIH).
Agency Mission:
Provide leadership for a national program in
diseases of the heart, blood vessels, lung, and blood; blood
resources; and sleep disorders.
Plan, conduct, foster, and support an integrated
and coordinated program of basic research, clinical
investigations and trials, observational studies, and
demonstration and education projects related to the causes,
prevention, diagnosis, and treatment of heart, blood vessel,
lung, and blood diseases; and sleep disorders.
Conduct educational activities for health
professionals and the public with an emphasis on prevention.
Support research training and career development
of new and established researchers in fundamental sciences and
clinical disciplines.
Principal Investigator(s):
Coordinating Center PI: Robert Byington, Ph.D, Email:
bbyingto@wfubmc.edu, Phone: 336-716-2885.
Steering Committee Chairman: William Friedewald, M.D.,
Email: william.cushman@med.va.gov, Phone: 212-305-3017.
NHLBI Project Officer: Denise Simons-Morton, M.D., Ph.D,
Email: simonsd@nhlbi.nih.gov, Phone: 301-435-0384.
Partner Agencies: National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK), National Center on
Minority Health and Health Disparities (NCMHD), National
Institute on Aging (NIA), National Eye Institute (NEI), Centers
for Disease Control and Prevention (CDC), and Sanofi Aventis
(Conditional gift fund).
General Description:
ACTION TO CONTROL CARDIOVASCULAR RISK IN DIABETES (ACCORD)
ACCORD (www.accordtrial.org) is a large clinical trial of
adults with established type 2 diabetes who are at especially
high risk of cardiovascular disease (CVD). Type 2 diabetes is a
complex metabolic disease characterized by high blood glucose
(sugar) levels. People with this form of diabetes have insulin
resistance and a progressive loss of the ability to produce
insulin.
Type 2 diabetes increases the risk of a number of
complications, especially CVD. Adults with type 2 diabetes are
two to four times more likely to die of heart disease and
stroke than adults without diabetes; about 65 percent of people
with diabetes succumb to these diseases. Many people with type
2 diabetes are overweight and have high blood pressure and
undesirable cholesterol levels--conditions that further add to
CVD risk.
ACCORD is testing approaches to decrease the high rate of
major CVD events--heart attack, stroke, or death from CVD--
among high-risk patients with type 2 diabetes. Three treatment
approaches are being evaluated: intensive lowering of blood
sugar levels compared with lowering to the conventional target
level, intensive lowering of blood pressure compared with
lowering to the conventional target level, and modification of
blood cholesterol levels using a fibrate plus a statin compared
with a statin alone.
The study began enrolling participants in 2001 at 77
clinical sites across the United States and Canada. A total of
10,251 adults with established type 2 diabetes are
participating. At enrollment, they were 40-79 years of age
(average age, 62), had diabetes for an average of 10 years, and
either had diagnosed CVD or had at least two CVD risk factors
(high LDL cholesterol, high blood pressure, smoking, obesity)
in addition to type 2 diabetes.
In addition to CVD, outcomes of interest include
microvascular diseases, cognition, and quality of life.
Treatment is scheduled to end in 2009, with final results
reported in 2010.
Excellence: What makes this project exceptional?
ACCORD is testing aggressive strategies to reduce the
burden of CVD among highly vulnerable patients with type 2
diabetes.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Type 2 diabetes primarily affects older persons, and its
prevalence is growing as the population ages and risk factors
such as obesity affect increasing numbers of people.
Effectiveness: What is the impact and/or application of
this research to older persons?
Recently, ACCORD found that intensively lowering blood
sugar to near-normal levels did not significantly reduce the
risk of major CVD events, such as fatal or non-fatal heart
attacks or strokes. In fact, when compared with standard
treatment this approach appeared to increase the risk of death.
This is important evidence to help guide treatment of adults
with type 2 diabetes who already have CVD or are at high risk
of developing it. For such individuals, intensively lowering
blood sugar may be too risky.
Innovativeness: Why is this research exciting or
newsworthy?
The research addresses an important clinical problem for
which no effective preventive strategies have heretofore been
identified.
National Heart, Lung, and Blood Institute: Home Oxygen Therapy Trial
for Chronic Obstructive Pulmonary Disease?
The LOTT will determine the effectiveness and safety of
long-term, home-administered oxygen therapy in patients with
moderate COPD. Findings will inform decision-making about
extending coverage for home oxygen treatment to such patients.
Lead Agency: National Heart, Lung, and Blood Institute
(NHLBI)/National Institutes of Health (NIH).
Agency Mission:
Provide leadership for a national program in
diseases of the heart, blood vessels, lung, and blood; blood
resources; and sleep disorders.
Plan, conduct, foster, and support an integrated
and coordinated program of basic research, clinical
investigations and trials, observational studies, and
demonstration and education projects related to the causes,
prevention, diagnosis, and treatment of heart, blood vessel,
lung, and blood diseases; and sleep disorders.
Conduct educational activities for health
professionals and the public with an emphasis on prevention.
Support research training and career development
of new and established researchers in fundamental sciences and
clinical disciplines.
Principal Investigator:
Steering Committee Chairman: William Bailey, M.D., UAB
Hospital 1802 6th Avenue South, Birmingham, AL 35249.
NHLBI Project Officer: Thomas Croxton, M.D., Ph.D.
Partner Agencies: The Centers for Medicare and Medicaid
Services (CMS).
General Description:
HOME OXYGEN THERAPY TRIAL FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
The NHLBI, in collaboration with the Center for Medicare
and Medicaid Services (CMS), has launched a large randomized
clinical trial of the effectiveness and safety of long-term,
home oxygen therapy for COPD (chronic obstructive pulmonary
disease). The six-year, $28 million project will study patients
with moderate disease.
COPD, a lung disease that severely impairs the ability to
breathe, is the fourth most common cause of death in the United
States. In the Long-Term Oxygen Treatment Trial (LOTT),
researchers at 14 clinical centers across the United States
will study approximately 3,500 COPD patients to determine
whether supplemental oxygen will improve longevity, exercise
capacity, and quality of life.
The results will provide a scientific basis for decisions
about whether to extend Medicare coverage for home oxygen
treatment to patients with moderate disease. Currently,
coverage of home oxygen therapy is limited to beneficiaries
with severe COPD (very low blood oxygen levels while resting).
Excellence: What makes this project exceptional?
LOTT is the largest randomized clinical trial of the
effectiveness and safety of long-term, home oxygen therapy for
COPD.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Approximately 12 million adults in the United States have
been diagnosed with COPD, and it is believed that another 12
million have the disease but are unaware of it. COPD typically
develops in older persons after years of cigarette smoking. It
is a major cause of disability and death.
Effectiveness: What is the impact and/or application of
this research to older persons?
If the LOTT determines that home oxygen treatment is
beneficial for patients with moderate COPD, it is likely that
Medicare coverage for this therapy will follow.
Innovativeness: Why is this research exciting or
newsworthy?
Many individuals with COPD are desperate for approaches to
alleviate symptoms and improve function, and they are largely
dependent on Medicare coverage to pay for treatment.
National Heart, Lung, and Blood Institute (NHLBI)/National Institutes
of Health (NIH): Women's Health Initiative (WHI): Hormone Replacement
Therapy
The WHI is a 15-year study of strategies for preventing
heart disease, breast and colorectal cancers, and osteoporosis
in postmenopausal women.
Lead Agency: National Heart, Lung, and Blood Institute
(NHLBI), National Institutes of Health (NIH).
Agency Mission:
Provide leadership for a national program in
diseases of the heart, blood vessels, lung, and blood; blood
resources; and sleep disorders.
Plan, conduct, foster, and support an integrated
and coordinated program of basic research, clinical
investigations and trials, observational studies, and
demonstration and education projects related to the causes,
prevention, diagnosis, and treatment of heart, blood vessel,
lung, and blood diseases; and sleep disorders.
Conduct educational activities for health
professionals and the public with an emphasis on prevention.
Support research training and career development
of new and established researchers in fundamental sciences and
clinical disciplines.
Principal Investigators: Dr. Marcia Stefanick, Steering
Committee Chair, National Heart, Lung, and Blood Institute,
NIH, Bethesda, MD 20892-2482.
Partner Agency: National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), Office of Research
on Women's Health (ORWH), Health Resources and Services
Administration (HRSA), and National Cancer Institute (NCI).
General Description: The WHI is a 15-year study of
strategies for preventing heart disease, breast and colorectal
cancers, and osteoporosis in postmenopausal women. Launched by
the NIH in 1991, it has been administered by the NHLBI since
fiscal year 1998. More than 160,000 women from across the
United States, who were between 50 and 79 years of age at the
time of their recruitment, enrolled in the WHI clinical trials
and observational study; almost 30,000 of them are minorities.
The clinical trial component, now completed, consists of three
prevention studies examining the effects of postmenopausal
hormone therapy on risk of coronary heart disease (CHD),
osteoporosis, and breast cancer; the effects of a low-fat diet
on risk of breast and colorectal cancers and CHD; and the role
of calcium and vitamin D supplementation in preventing
fractures and colorectal cancer. The Observational Study
component has focused on identifying predictors of disease. In
addition, a Community Prevention Study was conducted in
collaboration with the Centers for Disease Control and
Prevention to examine strategies for enhancing adoption of
healthful behaviors, particularly among minority and under-
served women.
Excellence: What makes this project exceptional?
The WHI is the largest disease prevention study ever
undertaken in postmenopausal women.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Given the remarkable increases in life expectancy that have
occurred in recent years, the average American woman can expect
to live more than a third of her life after menopause and,
thus, experience a high risk of developing CHD, breast and
colorectal cancer, and osteoporosis. Effective strategies are
needed to prevent these chronic diseases and thereby enhance
longevity and quality of life.
Effectiveness: What is the impact and/or application of
this research to older persons?
The WHI postmenopausal hormone trials produced startling
results that had an immediate effect on prescribing practices.
They included two placebo-controlled components--a study of
estrogen plus progestin in women who had an intact uterus and a
study of estrogen alone in women who had undergone a
hysterectomy. Both studies were designed to test the hypothesis
that long-term use of hormone therapy could reduce risk of CHD.
The estrogen-plus-progestin trial was halted ahead of
schedule in July 2002. Compared with women taking a placebo,
study participants taking hormones experienced higher rates of
heart attack, stroke, blood clots, and invasive breast cancer.
Although the women taking hormones also had a lower incidence
of colon cancer and fewer hip fractures, the overall balance of
risks and benefits was unfavorable.
In March 2004, the second hormone trial component also was
halted ahead of schedule. With an average of nearly 7 years of
follow-up completed, the trial revealed that estrogen-alone
therapy had no effect on CHD risk, but it increased risk of
stroke and of blood clots in the legs. No evidence of elevated
breast cancer risk was found, and a favorable effect on bone
health emerged. On balance, however, the trial indicated that
postmenopausal hormone therapy should not be prescribed for
chronic disease prevention, but only for short-term relief of
menopausal symptoms.
The WHI hormone trials also failed to find evidence of
other putative benefits of hormone therapy--on cognitive
function, urinary incontinence, or quality of life, for
example.
A follow-up study published in 2008 found that the
unfavorable balance of risk versus benefit associated with
long-term use of estrogen-plus-progestin therapy persisted even
after the drugs were stopped. Although the increased risk of
CHD diminished three years after halting treatment, overall
risks including stroke, blood clots, and cancer, remained
elevated.
Innovativeness: Why is this exciting or newsworthy?
For many years postmenopausal hormones were prescribed to
women not only because they alleviate symptoms (e.g., hot
flashes) but also because they were believed to be helpful in
preventing CHD and other chronic conditions. The surprising
findings of the WHI trials fundamentally changed perceptions of
the role of hormone therapy in health promotion among
postmenopausal women.
National Institute on Aging: Alzheimer's Disease Research Centers
Much of the progress in Alzheimer's disease research in the
United States over the past 20 years has been made through the
NIH-supported Alzheimer's Disease Centers, where ADC scientists
have conducted exemplary research and provided rich resources
to investigators across the community of Alzheimer's disease
researchers.
Lead Agency: National Institute on Aging (NIA)/National
Institutes of Health (NIH).
Agency Mission: Support and conduct genetic, biological,
clinical, behavioral, social, and economic research related to
the aging process, diseases and conditions associated with
aging, and other special problems and needs of older Americans.
Foster the development of research and clinician scientists
in aging.
Communicate information about aging and advances in
research on aging to the scientific community, health care
providers, and the public.
Principal Investigator: Creighton Phelps, Ph.D., National
Institute on Aging, Division of Neuroscience, 7201 Wisconsin
Avenue, Bethesda, MD 20892.
General Description:
ALZHEIMER'S DISEASE RESEARCH CENTERS
Much of the important progress made in Alzheimer's disease
(AD) research in the United States over the past 20 years has
come through studies conducted by the NIH-supported Alzheimer's
Disease Centers (ADCs). For example, ADC scientists have
conducted much of the research on protein processing related to
plaque and tangle formation--the hallmark of AD. Other studies
are examining changes in brain structure at different clinical
stages of AD, developing brain imaging technologies, and
conducting neuropathology autopsy evaluations. ADC researchers
have also focused on evaluating cognitive changes associated
with normal aging, the transitions to mild cognitive impairment
and early dementia, and factors that contribute to changes in
cognitive abilities. Relationships and commonalities between
Alzheimer's and other neurodegenerative diseases are also
emphasized as well as the contributions of non-neurological co-
morbid conditions such as cardiovascular disease, diabetes, and
inflammation.
By pooling resources and working cooperatively, the ADCs
have produced research findings and developed resources
resulting in accomplishments that could not have been achieved
by individual investigators. In addition, the ADCs have
provided resources for hundreds of research projects conducted
outside of the ADC network. Shared resources include biological
samples and data from longitudinal studies on the development
of dementia in particular populations, brain and specimen banks
comprised of well-characterized specimens collected under
standardized protocols, and a National Cell Repository for
Alzheimer's Disease which collects and stores blood, well-
documented phenotypic data, DNA, and cell lines from families
that have multiple affected members. The repository is part of
the NIA AD Genetics Initiative to identify genetic risk factors
for late onset AD. Other ADC collaborative efforts that have
led to the establishment of other research resources such as
the Consortium to Establish a Registry for Alzheimer's Disease,
the National Alzheimer's Coordinating Center, the Alzheimer's
Disease Cooperative Study, and the Alzheimer's Disease
Neuroimaging Initiative.
Excellence: What makes this project exceptional?
The ADC program has brought together the top experts in the
country to accelerate progress in developing a more
comprehensive understanding of the mechanisms that underlie the
development of AD. The program has also greatly enhanced the
work of many more researchers by providing much needed
resources to the larger community of AD researchers as they
search for better strategies to prevent and treat the disease.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Alzheimer's disease (AD) is the most common form of
dementia among older people. It is a neurodegenerative disease
that damages the parts of the brain controlling thought,
memory, and language. AD is estimated to affect approximately
4.5 million older people in the United States. Although
occasionally it is diagnosed in patients in their forties and
fifties, AD most frequently is associated with advancing age.
The disease doubles in prevalence with every 5 years past the
age of 65; thus, extending life by 10 years quadruples the
probability of the disease occurring. AD is the most frequent
cause of institutionalization for long-term care. It destroys
the active productive lives of its victims and devastates their
families financially and emotionally.
Effectiveness: What is the impact and/or application of
this research to older persons?
The ADCs have produced research findings and developed
resources that could not have been achieved by individual
investigators working alone. Biological samples from
Alzheimer's patients have provided the materials for hundreds
of non-ADC funded projects including genetic projects currently
underway. Several major longitudinal studies on the development
of dementia in particular populations rely on ADC core
facilities, and integrate their findings with those of the
centers.
Innovativeness: Why is this research exciting or
newsworthy?
It has been estimated that the United States spends as much
as $148 billion per year for the direct and indirect costs of
care for patients with AD. With the rapidly increasing
percentage of the population over the age of 65, the number of
people with AD will increase proportionately, as will the toll
it takes. If interventions cannot be found, the large number of
people who will develop AD will overwhelm the health care
system. As we learn about the causes of AD, we are better
positioned to finding new interventions and, ultimately, a cure
for this devastating disease.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
The Dynamics of Health, Aging, and Body Composition
The Health ABC study will identify how increases in body
fat and declines in lean mass and bone mineral yield a body
susceptible to multiple diseases contributing to disability in
old age. 3,075 men and women between the ages of 70-79 who are
free of disability were selected for this study. Body weight,
lean body mass, and body fat are quantified from computed
tomography images using software developed by CIT's Biomedical
Imaging Research Services Section (BIRSS), Division of
Computational Bioscience (DCB).
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Tamara B. Harris, M.D., M.S.,
Senior Investigator, Intramural Research Program, National
Institute on Aging, Laboratory of Epidemiology, Demography, and
Biometry, Gateway Building, 3C309, 7201 Wisconsin Avenue,
Bethesda, MD 20892.
Partner Agency: NIH Center for Information Technology
(CIT), National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), National Research
Council of Italy, American Heart Association, American Diabetes
Association, and Hologic Inc.
General Description: The Center for Information Technology
is collaborating with the National Institute of Aging to assist
in image segmentation and quantification in a clinical research
study, the Dynamics of Health, Aging and Body Composition
(Health ABC). The Health ABC study will identify how increases
in body fat and declines in lean mass and bone mineral yield a
body susceptible to multiple diseases contributing to
disability in old age. 3,075 men and women between the ages of
70--79 who are free of disability were selected for this study.
CIT is augmenting the analysis from computerized tomography
scans. Lean body mass, and body fat are quantified from
computed tomography images using software developed by CIT's
Biomedical Imaging Research Services Section (BIRSS), Division
of Computational Bioscience (DCB). Manual image segmentation is
laborious and subject to inter and intra-observer variability
when performing volumetric analysis. An extension of BIRSS'
MIPAV software provides researchers with a multistage semi-
automatic process for image segmentation, quantification, and
visualization.
Excellence: What makes this project exceptional?
The Health ABC study will identify how increases in body
fat and declines in lean mass and bone mineral yield a body
susceptible to multiple diseases contributing to disability in
old age. This should help to address questions of morbidity
related to body weight and weight related health conditions in
old age.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Older people incur multiple health conditions as they age
that affect multiple organ systems. Most studies of aging that
had been performed prior to 1998 tended to emphasize the
function of one organ system: heart, brain, bone rather than a
comprehensive assessment. Health ABC used the principle of
weight-related health conditions to organize a multi-
dimensional study.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research has shown that the same risk factors that
cause early declines in function contribute to later, major
losses in function and the onset of frailty. This is a powerful
prevention message for aging.
Innovativeness: Why is this exciting or newsworthy?
Early interventions on weight, heart disease, diabetes,
inflammation, and depression may prevent later declines to
frailty in old age.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Exemplary Research Conducted through the Edward R. Roybal Centers
Investigators at the Edward R. Roybal Centers for
Translational Research in the Social and Behavioral Sciences
are working to improve the health, quality of life, and
productivity of middle-aged and older people by translating
findings from the social and behavioral sciences into practical
outcomes.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Tamara Jones, Ph.D., National
Institute on Aging, 7201 Wisconsin Avenue, Bethesda, MD 20892,
NIA Legislative Officer.
General Description: The Edward R. Roybal Centers for
Translational Research in the Social and Behavioral Sciences,
first authorized by Congress in 1993, are designed to improve
the health, quality of life, and productivity of middle-aged
and older people by facilitating the translation of knowledge
learned in the social and behavioral sciences into practical
outcomes. Investigators at the Roybal Centers have made a
number of key discoveries in the emerging field of
translational behavioral and social research. For example:
The Roybal Center at the University of
Alabama at Birmingham has developed tools and
technologies for identifying older adults at risk for
automobile crash involvement, and is working with
industry partners to develop and disseminate products
based on these tools.
The Roybal Center at the University of
Illinois at Chicago (UIC) has developed two evidence-
based interventions from its in-depth work on physical
activity for older adults. One program, Fit and
Strong!, is targeted to older adults with lower
extremity osteoarthritis, and one is targeted to older
adults with developmental/intellectual disabilities
(primarily Down syndrome). Both programs are currently
being used in several states; in addition, the Center
has partnered with the National Arthritis Foundation
(NAF) to replicate Fit and Strong! through NAF chapters
nationwide.
Another investigator at the UIC Roybal
Center has developed instruments for self-efficacy
appropriate for use with older adults with
developmental/intellectual disabilities, and these have
been adopted internationally.
The Oregon Center for Aging and Technology
(ORCATECH), a Roybal Center, has developed a ``living
laboratory'' model methodology for in-home assessment
of activity to facilitate early detection of changes in
health or memory. This new technology provides a
continuous data stream, which provides a more complete
view of real-world function and an improved
understanding of the variability of in-home activity.
Other companies have used the ORCATECH model to develop
related products, and the model has spurred several new
grant-funded research projects, including the
development of a new medication tracker for older
adults.
Excellence: What makes this project exceptional?
As recent years have seen an explosion of fundamental
insights in the basic social and behavioral sciences,
translating this knowledge into practical advances to benefit
the health and well being of older Americans has increasingly
become a priority for the NIH. Since 1993, the Roybal Centers
have been at the forefront of the NIH's efforts in
translational behavioral and social science aimed at older
Americans.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
The development and testing of interventions that will
benefit the health and well being of older Americans, and the
effective translation of these interventions into routine
practice, is becoming increasingly important: Between now and
2030, the number of individuals age 65 and older will likely
double, reaching 71.5 million and comprising a larger
proportion of the entire population, up from 13 percent today
to 20 percent in 2030.
Effectiveness: What is the impact and/or application of
this research to older persons?
Because the mission of the Roybal Centers is the
translation of scientific and technological findings into
practical applications for older adults, their findings may be
expected to have a widespread impact. For example, the tools
for identifying at-risk older drivers (referenced above) are
currently being translated into practice in several states, and
the Roybal-developed instruments for self-efficacy among
intellectually disabled older adults (also referenced above)
are being used internationally.
Innovativeness: Why is this exciting or newsworthy?
By identifying ways to move interventions from the clinic
to the mainstream, the Roybal Centers are poised to make a
real-world difference in the lives of everyday Americans.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Useful Field of View Test for Older Drivers
A new test of visual function may ultimately help older
adults, their families, and physicians decide when it's okay
for an older person to continue driving or when it may be time
to hang up the car keys. Using a novel ``useful field of view''
measure to assess how drivers process visual information,
researchers at the University of Alabama at Birmingham found
that poor performance on the test was linked to an increased
risk of car crashes. Drivers who showed a 40 percent or greater
impairment in their useful field of view were more than twice
as likely to be involved in a crash within 3 years of testing.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological,
clinical, behavioral, social, and economic research
related to the aging process, diseases and conditions
associated with aging, and other special problems and
needs of older Americans.
Foster the development of research and
clinician scientists in aging.
Communicate information about aging and
advances in research on aging to the scientific
community, health care providers, and the public.
Principal Investigators: Karlene Ball, Ph.D., University of
Alabama at Birmingham, Campbell Hall/Suite 415, 1300 University
Blvd., Birmingham, AL 32594-1170.
General Description: A new test of visual function may
ultimately help the elderly, their families, and physicians
decide when it's okay for an older person to continue driving
or when it may be time to hang up the car keys. Using a novel
``useful field of view'' (UFOV) measure to assess how older
adults process visual information, researchers at the
University of Alabama at Birmingham (UAB) found that poor
performance on the test was linked to an increased risk of car
crashes. Drivers who showed a 40 percent or greater impairment
in their useful field of view were more than twice as likely to
be involved in a crash within 3 years of testing.
The study marks the first time that scientists have
attempted to find out whether or not a visual processing test
can predict the likelihood of future crashes for individual
older adults. The test differs substantially from standard eye
exams, which measure acuity or visual function or the ability
to see an object at a given distance. To assess their visual
processing abilities, participants in this study looked at a
computer screen with figures of cars, trucks, and other
objects. The drivers were asked to identify a particular object
amid different kinds of visual distractions on the screen. The
useful field of view was defined as the area in which rapidly
presented visual information can be used. People who had
measured difficulty with the task were considered to have an
impaired useful field of view.
Some 294 drivers ranging in age from 55 to 87 participated
in the study. In addition to being tested for visual function,
information was collected on the participants' general health,
mental status, and how often they drove so that the researchers
could determine the factors involved in crashes over the three-
year follow-up period from 1990 to 1993. Crash reports
involving the participants were collected from a state agency,
and researchers compared the useful field of view scores and
results from the other types of vision tests with the crash
information.
Performance on the useful field of view test was found to
be directly related to involvement in a crash. People with a 40
percent or greater impairment in their useful field of view
were more than twice as likely to be involved in a crash. For
every 10 points of reduction in a driver's useful field of view
measure, his or her crash risk rose by 16 percent, regardless
of age. Other vision tests did not predict the risk of future
crashes.
Excellence: What makes this project exceptional?
The test used in this study differs substantially from
standard eye exams, which measure acuity or visual function or
the ability to see an object at a given distance. To assess
their visual processing abilities, participants were asked to
identify a particular object amid different kinds of visual
distractions on a computer screen with figures of cars, trucks,
and other objects. The useful field of view was defined as the
area in which rapidly presented visual information can be used.
People who had measured difficulty with the task were
considered to have an impaired useful field of view.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Older drivers are over-represented in fatal crashes per
mile driven, and those in oldest age groups are the fastest-
growing group in the United States. However, age alone is not a
very good predictor of driving ability. There are large
differences in the skills and abilities of older drivers, and
denying an older adult a driver's license can have significant
implications for their mobility and quality of life.
Effectiveness: What is the impact and/or application of
this research to older persons?
This evidence-based UFOV test is being effectively
translated into practice in the motor vehicle departments in
three states to date: California, Maryland, and Florida. State
Farm Auto Insurance Company is also using the test and offering
insurance discounts for people who take the UFOV test and
``qualify'' for a discount.
Innovativeness: Why is this exciting or newsworthy?
The useful field of view test is a demonstrated method of
screening high-risk older drivers and may be a more appropriate
way to address individual differences than using age-based
restrictions on driving.
National Institute on Aging: Restricting Caloric Intake May Improve the
Body's Metabolic Efficiency
NIH-supported investigators demonstrated that restricting
caloric intake may improve the body's metabolic efficiency, an
effect that could contribute to slowing of adverse changes that
often accompany aging.
Lead Agency: National Institute on Aging, National
Institutes of Health (NIH).
Agency Mission: Support and conduct genetic, biological,
clinical, behavioral, social, and economic research related to
the aging process, diseases and conditions associated with
aging, and other special problems and needs of older Americans.
Foster the development of research and clinician scientists
in aging.
Communicate information about aging and advances in
research on aging to the scientific community, health care
providers, and the public.
Principal Investigator: Eric Rauvussin, Louisiana State
University, Pennington Biomed Research, 6400 Perkins Rd., Baton
Rouge, LA 70808.
General Description:
RESTRICTING CALORIC INTAKE MAY IMPROVE THE BODY'S METABOLIC EFFICIENCY
Calorie restriction (CR) is the most robust, nongenetic
intervention that increases lifespan and reduces the rate of
aging in a variety of species. Mechanisms responsible for the
antiaging effects of CR remain uncertain but effects on
efficiency of energy metabolism and mitochondria (subunits
within cells that are the primary source of cellular energy)
remains a major focus of research. To understand CR's effects
in energy metabolism and mitochondrial function in humans, NIH-
supported researchers studied its effects over six months in
overweight people. They found that CR lowered body temperature
and lowered metabolic rate by more than would be expected based
on weight loss alone. They also found evidence of new
mitochondria. Combined, these results suggest that CR may cause
the body to shift to more ``efficient'' mitochondrial function,
resulting in less energy expenditure and cooler body
temperature. The latter is of particular interest because in
one study, cooler body temperature was associated with longer
human lifespan.
Excellence: What makes this project exceptional?
Numerous studies in laboratory animals have shown that
chronic caloric restriction extends lifespan by as much as 40
percent and delays age-related pathologies correspondingly.
However, little has been known about the effects of CR in
humans. This study is a first step in understanding whether
CR's effects in people resemble those found in laboratory
animals.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
By understanding the effects of caloric restriction in
people, we may gain insights into interventions to slow the
development of age-related diseases.
Effectiveness: What is the impact and/or application of
this research to older persons?
There are no immediate clinical or public health
applications. We need to learn more about the effects of
caloric restriction in humans before evaluating its potential
for improving health, aging, or lifespan.
Innovativeness: Why is this research exciting or
newsworthy?
Caloric intake is a topic of broad interest as concerns
increase regarding obesity and weight gain. This study sheds
new light on the effects of decreased caloric intake on
metabolic processes.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Clinical Practice Guidelines for Comorbidities
Clinical practice guidelines (CPGs) are based on clinical
evidence and consensus of experts to guide physicians and
standard care. Most CPGs focus on a single disease, and don't
always address the needs of the approximately half of persons
65 years and older who have three or more concurrent medical
conditions. An NIH-supported study demonstrated that for older
patients with co-occurring medical problems, adherence to CPGs
for individual diseases may be counterproductive and sometimes
harmful.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and
advances in research on aging to the scientific
community, health care providers, and the public.
Principal Investigator: Linda P. Fried, M.D., Johns Hopkins
University, Department of Medicine/Suite 2-700, 2024 E.
Monument Street, Baltimore, MD 21205.
General Description: In recent years, Clinical Practice
Guidelines (CPGs), which are based on clinical evidence and the
consensus of experts, have been developed to guide physicians
regarding the management of common medical problems, thus to
standardize care and improve its quality for many chronic
conditions. However, most CPGs focus on a single disease, and
approximately half of persons 65 years or older have three or
more concurrent medical conditions. To explore the
applicability of current CPGs to the care of older individuals
with several co-occurring diseases, NIH-supported researchers
identified the most common chronic medical problems among older
adults and assessed whether the corresponding CPGs addressed
issues relevant to older patients with combinations of co-
occurring diseases. Issues included goals of treatment, burden
to patients and caregivers, patient preferences, and quality of
life. Researchers discovered that most CPGs did not modify or
discuss the application of their recommendations for older
patients with comorbidities, did not comment on short- or long-
term goals of treatment or the burden of care associated with
treatment, did not give guidance about incorporating patient
preferences into the treatment plan, and in general did not
``fit together'' well for patients with multiple medical
problems. Overall, this study demonstrated that, for older
patients with co-occurring medical problems, adherence to CPGs
for individual diseases may be counterproductive and even
sometimes harmful.
Excellence: What makes this project exceptional?
This research provides crucial information to better
understand the special clinical care needs of older patients
and improve their quality of care.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
This research is specific to the clinical care of patients
65 years or older and addresses a crucial issue for the
treatment of older patients with comorbidities for whom
appropriate practice guidelines could lead to improved health.
Effectiveness: What is the impact and/or application of
this research to older persons?
Addressing the clinical management problems identified by
this research could greatly improve the clinical care of older
patients.
Innovativeness: Why is this exciting or newsworthy?
This research provides a dramatic illustration of the need
to expand guidance for the management of health care specific
to the needs of older patients.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Translating Resources for Enhancing Alzheimer's Caregiver Health to
Community Settings
REACH was a multi-site randomized clinical trial for family
caregivers of patients with Alzheimer's disease or related
disorders. The intervention is now being translated into
various community settings and could provide a valuable and
potentially cost-saving resource for caregivers and their care
recipients.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological,
clinical, behavioral, social, and economic research
related to the aging process, diseases and conditions
associated with aging, and other special problems and
needs of older Americans.
Foster the development of research and
clinician scientists in aging.
Communicate information about aging and
advances in research on aging to the scientific
community, health care providers, and the public.
Principal Investigators: Richard Schultz, Ph.D., University
of Pittsburgh, University Center for Social and Urban Research,
121 University Place, Room 607, Pittsburgh, PA 15213.
Partner Agency: National Institute of Nursing Research
(NINR), Department of Veterans' Affairs, Administration on
Aging.
General Description: Resources for Enhancing Alzheimer's
Caregiver Health to Community Settings (REACH) was a multi-site
randomized clinical trial for family caregivers of patients
with Alzheimer's disease or related disorders funded by NIA and
the National Institute of Nursing Research. The intervention is
designed to provide education, support, and skill building to
help caregivers manage patient behaviors and their own stress.
It includes 12 individual sessions in the home and by telephone
and five telephone support groups over a six-month period.
The Department of Veterans Affairs (VA) will provide nearly
$4.7 million for eight ``caregiver assistance pilot programs''
across the country to expand and improve health care education
and provide needed training and resources for caregivers who
assist disabled and aging veterans in their homes. One of these
programs will be a translation of the REACH intervention. The
VA Medical Center (VAMC) at Memphis/University of Tennessee,
one of the participating sites for REACH, will serve as the
Coordinating Center for this program, providing evaluation and
training to the clinical sites, with the assistance of the
REACH investigators. Across the country, 17 Home Based Primary
Care (HBPC) programs for treating frail dementia patients and
their caregivers in the home are providing the intervention to
200 caregivers. The VA Palo Alto Health Care System, which was
also one of the REACH sites, will also participate, providing
services to 150 caregivers.
Specific objectives for the REACH VA translation are to:
Assess the feasibility of translating a multi-
component, community-based intervention for family caregivers
of patients with dementia in VA settings.
For patients with dementia, evaluate the
intervention's efficacy in decreasing health care utilization,
including unanticipated admissions, unscheduled outpatient
visits, ER visits, and placement.
For family caregivers of patients with dementia,
evaluate the intervention's efficacy in improving clinical
outcomes relating to quality of life as measured by (1)
emotional well-being and depression, burden, health, social
support, and management of patient dementia-related behaviors
and (2) time spent ``on duty'' and time providing actual care.
Assess caregiver satisfaction with the services
provided.
Determine the cost of the intervention for VHA
clinical staff.
Materials and protocols from REACH have also been adapted
for wide-spread community use by the Administration on Aging
for use in their Area Agencies on Aging and the Alzheimer's
Association through their ongoing contact with caregivers.
Implementation at the community level can enhance the lives of
caregivers, potentially delay institutionalization of care
recipients, and decrease the need for professional intervention
for both caregiver and care recipient. Cost analysis of the
outcomes is ongoing and may provide additional evidence of the
cost savings. By making such an intervention available, REACH
implementation in community settings, with physician referral,
can provide a valuable resource for caregivers and their care
recipients.
Excellence: What makes this project exceptional?
The project involves a thoroughly tested and proven
intervention that is being implemented through collaborative
efforts across public and private organizations.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Family members and friends provide most of the care for
millions of people with dementia who live at home, often facing
challenges that can seriously compromise their own quality of
life. REACH tells us that a well-designed, tailored
intervention can make a positive, meaningful difference in
caregivers' lives.
Effectiveness: What is the impact and/or application of
this research to older persons?
The intervention is being translated into practice.
Innovativeness: Why is this exciting or newsworthy?
This novel research demonstrates that an intervention can
readily address a significant need and benefit the diverse
communities of people who provide care to individuals with
Alzheimer's disease.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Hospital Quality and Racial Differences in Heart Attack Treatment and
Outcomes
Differences between black and white heart attack patients
in quality of care received are due in part to the quality of
the hospital in which they are treated. These results suggest
that hospital-level interventions to improve quality of care
may be needed.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Jonathan Skinner, Ph.D., Center
for Evaluative Clinical Sciences, Dartmouth Medical School, HB
7251, Hanover, NH 03755; Amber E. Barnato, MD, MPH, MS, Center
for Research on Health Care, University of Pittsburgh, 230
McKee Place, Suite 600, Pittsburgh, PA 15213.
Partner Agency: The Robert Wood Johnson Foundation.
General Description: Black patients who have suffered a
heart attack or are at risk are less likely than white patients
to receive invasive procedures such as percutaneous coronary
interventions (PCI) and coronary artery bypass grafts (CABG),
and much evidence suggests that they are also less likely than
whites on average to receive effective low-intensity treatments
such as aspirin and beta blocker prescriptions. A key
unresolved question is the extent to which these racial
disparities result from physicians and hospitals providing
poorer quality care for their black patients than for whites,
or from black patients more often than whites being treated in
facilities providing lower quality care for all their patients.
In a recent study, NIH-supported researchers analyzed the
records of more than one million adults who were treated for
acute myocardial infarction (AMI) at over 4,000 non-federal
hospitals from 1997 to 2001. They found that patients of all
races were at higher risk of mortality in hospitals with a
disproportionate share of African-American heart attack
patients. Patients treated at largely minority-serving
hospitals were not sicker and did not have more severe heart
attacks than patients at other hospitals. The differences in
outcomes also were not explained by patients' income, the
hospitals' AMI patient volume, region of the country, or urban
status.
In related work, NIH-supported investigators reviewed data
on Medicare patients treated for AMI in 1994 and 1995 to assess
the extent to which differences in the actual hospitals where
blacks and whites were treated explain the differences observed
in the frequency of specific treatments and in subsequent
mortality. They used statistical techniques that allowed them
to study whether black and white patients treated at the same
hospital received different care and had different outcomes,
rather than--as in previous studies--whether patients treated
at hospitals with similar measurable characteristics had
similar outcomes. They found that the overall black-white gap
in lower-intensity medical procedures such as prescription of
beta-blockers and ACE inhibitors was entirely explained by
differences in hospitals. However, blacks were given fewer
surgical treatments requiring complex referrals and follow-up,
such as catheterization, PCI, and CABG than whites attending
the same hospitals. Both of these studies suggest that black-
white differentials in medical procedures known to be effective
would be greatly reduced by hospital-level interventions to
improve quality of care.
Excellence: What makes this project exceptional?
Previous studies have documented racial disparities in
heart attack treatment among Medicare beneficiaries. However,
it has not been clear whether these differences are due
primarily to differential treatment of black and white patients
within the same institutions or to differences in the quality
of care across hospitals. These studies suggest that quality
differences between hospitals (as opposed to differential
treatment of races within the hospitals) accounts for the
larger share of these disparities.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Age is a risk factor for heart disease, and over a million
Americans have heart attacks each year and approximately half
of these individuals die from the attacks. Heart attack is most
common among African-American men and is more common among
African-American women than white women.
Effectiveness: What is the impact and/or application of
this research to older persons?
Understanding the origins of health disparities is the
crucial first step toward eliminating them. The development of
effective hospital-level interventions to eliminate disparities
in heart attack treatment may lead to improved outcomes for
vulnerable groups.
Innovativeness: Why is this exciting or newsworthy?
This research helps explain treatment differences between
black and white heart attack patients observed at the aggregate
level and offers insight into avenues--i.e., hospital-level
interventions--to ameliorate these differences.
National Institute on Aging (NIA)/National Institutes on Health (NIH):
Improving the Quality of Health Care for Older Adults: Doctors May Not
Diagnose and Manage Coronary Heart Disease As Actively for Women As for
Men
Researchers used video vignettes to assess how primary care
doctors' diagnostic questions differed significantly by patient
gender. Results suggest that doctors' actions may contribute to
gender disparities in health and health care. Investigators
observed no influence of social class or race.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Dr. Sara Arber, Department of
Sociology, Centre for Research on Ageing and Gender, University
of Surrey, Guildford, Surrey GU2 7XH, UK.
General Description: Previous studies have established that
women are less likely than men to receive thorough diagnostic
investigations and surgical treatments for coronary heart
disease (CHD). Few studies have focused on the exact points in
the process at which disparities arise (initial access,
interactions with physicians, hospitalizations) and few have
examined the possibility of age-by-gender interactions in the
process. The authors examined the influence of gender, age,
race and social class, singly and in combination, on diagnostic
and management decisions for patients presenting with symptoms
of CHD. They trained professional actors to portray patients on
videos in realistic first consultations with a doctor,
presenting with symptoms either of CHD or of depression.
Participating primary care physicians (256, selected randomly
in Massachusetts and two regions in England) watched the 7-8-
minute tapes and answered questions about how they would
diagnose and manage the patient. In the two countries combined,
physicians reported fewer follow-up questions for women (mean
5.7) than for men (7.0); proposed fewer examinations for women
(4.3 compared with 5.1); proposed fewer diagnostic tests for
the CHD diagnosis (80 percent for women; 90 percent for men),
and were less likely to prescribe medications appropriate for
treating heart disease for women than for men (52% of women;
64% for men). In both countries, the female patient reported to
be age 55 was less likely to have a medication prescribed, and
doctors were less sure of the CHD diagnosis, than for men the
same age. But even with lower certainty, in England (though not
in the US) doctors reported that they would ask fewer questions
of the woman aged 55 than of a man, and fewer than for a woman
aged 75. The black patients and those portraying working-class
men and women were not treated differently than white and
middle-class patients in these simulations.
This analysis was based on ``video vignettes,'' and the
correspondence of self-reports to actual behavior is unknown.
The clinical significance of differences in diagnosis and
management after a first consultation is also not clear. But
the finding of significant differences between the diagnostic
and management activities that physicians think appropriate for
women and for men warrants further research.
Excellence: What makes this project exceptional?
Previous studies have established that women are less
likely than men to receive thorough diagnostic investigations
and surgical treatments for coronary heart disease. This
research represents an important step in clarifying the nature
of these disparities, as well as the circumstances under which
the disparities arise.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Coronary heart disease is the leading cause of death among
both women and men in the United States and is particularly
common in individuals over age 65. One in four American women
die of heart disease.
Effectiveness: What is the impact and/or application of
this research to older persons?
This research was based on ``video vignettes,'' and the
extent to which physicians' reactions to the vignettes
correlate with their actual behavior in the clinic remains
unknown. However, this finding does underscore the need for
women and their physicians to become aware of the risk factors
and symptoms of heart disease and for physicians to ensure
thorough diagnostic and treatment efforts for both men and
women.
Innovativeness: Why is this exciting or newsworthy?
Few studies have focused on the exact points in the
diagnostic process for CHD where disparities arise (initial
access, interactions with physicians, hospitalizations) and few
have examined the possibility of age-by-gender interactions in
the process.
National Institute on Aging (NIA)/National Institutes of Health (NIH):
Integrating Effective Strategies to Prevent Falls Into Community
Settings
Two recent studies funded by the National Institute on
Aging and the Administration on Aging on integrating fall risk
evaluation and prevention strategies into community programs
show promise for future development of public health and
medical practice education, reducing barriers or obstacles to
pursue fall risk evaluation, and application into practice
settings.
Lead Agency: National Institute on Aging (NIA), National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.
Foster the development of research and clinician
scientists in aging.
Communicate information about aging and advances
in research on aging to the scientific community, health care
providers, and the public.
Principal Investigators: Mary E. Tinetti, M.D., Director of
Yale Program on Aging, School of Medicine, 20 York Street, New
Haven, CT 06504.
Partner Agency: U.S. Administration on Aging (AoA).
General Description: NIH-supported researchers tested the
ability to integrate effective strategies to prevent falls in
older persons into community care settings. The studies found
that practitioners could adopt these strategies, although
organizational and financial barriers limited the ability to
implement them fully.
Excellence: What makes this project exceptional?
Translation to practice.
Significance: How is this research relevant to older
persons, populations and/or an aging society?
Among older adults, falls are the number one cause of
fractures, hospital admissions for trauma, loss of independence
and injury-related deaths. Only half of older adults
hospitalized for a broken hip return home or live on their own
after the injury, which is why prevention of falls is so
important. Previous clinical trials showed that fall risk
evaluation and management programs can lessen risk of falls in
older persons, but application of these findings to the ``real
world'' of health care practice faces significant challenges in
integrating and organizing activities of health care providers
from a variety of specialties and care settings.
Effectiveness: What is the impact and/or application of
this research to older persons?
The results of these studies show that the fall risk
evaluation and management strategies can be integrated into
existing programs, although significant obstacles to full
integration remain.
Innovativeness: Why is this exciting or newsworthy?
This research is an excellent example of evidenced-based
outcomes translated to the community. This project is also an
example of prevention research to address an important health
risk for seniors and demonstrates an effective collaboration
among federal agencies.
National Institute on Aging: Understanding the Genetic Underpinnings of
Parkinson's
NIA intramural scientists have successfully identified
mutations of the LRRK2 gene that cause Parkinson's disease,
first in five families in Spain and England and later in
approximately 1 percent of sporadic PD and 5 percent of cases
of PD with a positive family history in the United States and
Canada, making it the most common genetic cause of PD
identified to date. Ongoing work from NIA scientists is aimed
at turning this genetic discovery into new avenues for
treatment.
Lead Agency: National Institute on Aging (NIA)/National
Institutes of Health (NIH).
Agency Mission:
Support and conduct genetic, biological, clinical,
behavioral, social, and economic research related to the aging
process, diseases and conditions associated with aging, and
other special problems and needs of older Americans.