compare nursing home use by African. Americans and Whites while controling for social support, economic status, and physical and cognitive function and (2) as ...
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Predictors of Nursing Home Admission in a Biracial Population Marcel E. Salve, MD, MPH, Karen S. Collins, MD, MPH, Daniel J. Foley, MS, and Linda K George, PhD
Inm dudion Older adults seek nursing home care
primarily because of physical or mental impairment secondary to illness in advanced age and the lack of informal care.1-3 Racial disparities have been reported such that 27% of African Americans can expect to use nursing homes in their lifetime, as compared with 38% of
Whites.4 This analysis was designed to (1) compare nursing home use by African Americans and Whites while controling for social support, economic status, and physical and cognitive function and (2) assess the relative importance of selected predictors of institutionalization within each racial group.
Medhods Swdy Population The data were derived from the fivecounty North Carolina community of the Established Populations for Epidemiologic Studies of the Elderly, a collaborative longitudinal study of men and women 65 years of age or older. Details of the methods have been published.5'6 During 1986 and 1987, trained interviewers conducted household surveys to collect baseline information from 4163 people (80%o of eligible respondents). This study includes 4074 community-dwelling persons, classified by the interviewer as Black (55%) or White, who were followed for up to 3 years. Other races and persons without adequate follow-up to assess subsequent institutionalization were excluded. Annual interviews ascertained interval admission to intermediate or skilled nursingfacilities and personal care homes. Follow-up rates were greater than 95% each year among those initially interviewed. If a participant died, institutionalization since the last interview was ascertained from a proxy. During the initial interview, information on age, gender, education, household income, marital status, household composition, types of medical insurance, urban or rural residence, and prior use of health services (home health aide, visiting nurse,
or nursing home) was obtained. Social support was measured as perceived availability of support and instrumental support.7 Physical function was measured as limitations in activities of daily living8'9 and in instrumental activities of daily living.10 Cognitive impairment was defined as four or more errors on the modified Short Portable Mental Status Question-
naire.11,12
StatfkticalAnalysis The baseline population was used to directly adjust the incidence of nursing home admission by age.'3 Logistic regression models used nursing home admission as the dependent variable in multivariate analyses examinin the hypothesis that racial differences could be explained by demographic characteristics and social and
functional status.14"15 Logistic regression models stratified by race were examined to evaluate whether the factors associated with institutionalization differed by race. Sampling weights were used in all analyses to represent population estimates for the five counties.
Resus During the follow-up, 311 (7.6%) persons reported at least one nursing home admission. Blacks were institutionalized 24% less than Whites (3-year age-adjusted incidence rates of 6.4% and 8.5%, respectively; Table 1). Among those 85 years of age or older, Black women had the lowest rates. Marcel E. Salive, Karen S. Collins, and Daniel J. Foley are with the Epidemiology, Demography and Biometry Program, National Institute on Aging, Bethesda, Md. Karen S. Collins is alsowith the General Preventive Medicine Residency Program, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Md. Linda K George is with the Center for the Study of Aging and Human Development, Duke University, Durham, NC. Requests for reprints should be sent to Marcel E. Salive, MD, MPH, Epidemiology, Demography and Biometry Program, National Institute on Aging, National Institutes of Health, 7201 Wisconsin Ave, Gateway Bldg, Suite 3C309, Bethesda, MD 20892. This paper was accepted April 26, 1993.
American Journal of Public Health 1765
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Whites to be institutionalized (relative odds = 0.50, 95% CI = 0.35, 0.72) after these variables were controlled. Among elderly Whites, urban residence, iving alone, low perceived social support, impaimen activities of dailyliving, cognitive mpaiment, and having fewer chfldren were signiicantl (P < .05) associated with nursing home use (Table 2). Among Whites, l s in three or more
activities of daily livg and cogitive impainnent inreased the risk of institutional-
ization apprommmately fivefold. Among African Americans, nursing home a ion was sificantly associated with fewer predictors, specficlly prior nursing home use, impairment in instrumental activities of daily living, and perceived social support.
Discussion This longitudinal analysis of nursing home use in a biracial North Carolina community serves to clarify and challenge some long-standing beliefs about explanations for racial differences in institutionalization. In 3 years of follow-up, African Americans were admitted to nursing homes about half as often as Whites after adjustment for several confounding factors. Although this population is geographically based, these differences have been reported nationally,1 and the explanation may, in part, cut across regional
lines.16 Our results highlight specific differences in predictors of institutionalization between these two racial groups. Among Whites, urban residents were more likely to be institutionalized than were their rural neighbors. Furthermore, physical and cognitive impairment were leading risk factors for admission of Whites but not African Americans. This may reflect dif-
Based on a model for the entire cohort, the following characteristics were significantly (P < .05) associated with nursing home use: age, White race, impairment in activities of daily living, cog1766 American Journal of Public HealthD
nitive impairment, Medicaid eligibility, urban residence, prior nursing home use, living alone, unmarried, low perceived availability of support, and having fewer children. Blackswere only half as likely as
fering cultural attitudes toward disability, a need to have the person at home regardless of impairment,17,18 or limited knowledge of the long-term care system. Moreover, the Short Portable Mental Status Questionnaire may have divergent ability to accurately screen for impairment across racial groups. Although research in this area is limited, lifetime experiences such as segregated schools and job discrimination may contnbute to poor performance on mental status questionnaires, leading to unreliability of such screening tests across cultures or ethnic groups.19 Evaluation of more sensitive and specific screening instruments in the appropriate population is needed to address this issue. In African Americans, instrumental activities of dail living and prior nursing home December 1993, Vol. 83, No. 12
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use may also reflect underlying physical and cognitive impairment. We found siant unexplained differences in institutionalization rates between African Americans and Whites in this population. Therefore, eitherwe were not able to capture one or more additional factors that influence this difference at the individual or community level or the measures that we used as confounders were incomplete. The baseline data coliection was extensive but did not include personal or caregiver attitudes toward institutionalization. Also, we did not measure precisely the use of home care as an alternative for institutionalization. These results suggest that, in addition to physical and cognitive changes that occur with aging, underlying social and historical differences may, at some level, influence current patterns of nursing home use. This analysis cannot address whether African Americans at home are better or worse off than their White counterparts. Our results do question, however, the way in which racial differences have been explained in the past without complete information. Future work should examine the current and future needs of Afican Americans and other minorities for access to long-term care services. l
Acknowledgments This study was supported in part by contract N01-AG-1-2102 from the National Institute on
Aging.
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