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5 Health Promotion and Disease Prevention INTRODUCTION Health promotion and disease prevention are a major emerging theme in geriatric medicine and health care generally. Although efforts have typically been targeted at younger persons, there is growing evidence that this approach is both appropriate and feasible for those age 65 and over (Office of Technology Assessment, 1985b). The health promotion and disease prevention approach is one of a number of possible strategies to deal with what has increasingly become a hallmark of current times: the prevalence of chronic illness and multiple chronic illnesses or functional impairments among the elderly. While it will not replace medical care either for the treatment of acute diseases or for acute flare-ups of chronic illness, this approach has promise for reducing the incidence and prevalence of chronic and acute disease among both the general population and the elderly. (See Office of Technology Assessment, Chapters 4 and 5, 1985b; and Kane et al., 1985, for a review of the state of the art in health promotion and disease promotion in the elderly.) In addition, of course, both long-term medical treatment and care for many diseases and illnesses, as well as research to improve diagnosis, treatment, and prevention of chronic and acute disease, are a continuing need. Selected policy questions relating to health promotion and dis- ease prevention include: Should more resources be allocated to increasing our scientific and clinical knowledge base on the efficacy of many health 108

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HEALTH PROMOTION AND DISEASE PREVENTION 109 promotion and prevention activities for the elderly popula- tion? To what extent should public and private programs be devel- oped to motivate older persons who are still asymptomatic to health-maintaining behavior? What success rate in modifying health behavior can we antic- ipate for older patients with various forms of chronic illness or disability? What institutions and what professions should be responsible for health promotion? Should health professionals be trained, and should their training be publicly supported? How can we move toward a more balanced relationship be- tween the minuscule national investment in health education and other aspects of preventive medicine and the overwhelm- ing resources devoted to medical care directed to reducing the duration and severity of disease and disability? Should public and private health insurance programs pay for health promotion and disease prevention interventions? DEFINITIONS, FEDERAL INITIATIVES, AND GOATS What is health promotion and disease prevention? Simply stated, health promotion involves "the development of behaviors that im- prove bodily functioning and enhance an individual's ability to adapt to a changing environment" (Ward, 1984:6~. Disease prevention in- volves actions to reduce or eliminate exposure to risks that might increase the chances that an individual or group will incur disease, disability, or premature death. Some risk factors for disease and dis- ability are mutable or amenable to change (such as personal habits), while others (such as genetic endowment and family history) are not (Kane et al., 1985~. A major goal of the health promotion and disease prevention approach both for individuals and for an entire population is "to identify the health problems for which preventive efforts can result in more appropriate utilization of health services and improvements in health status" (Lee, 1985:784~. This approach to health emphasizes the importance of lifestyle and personal behavior in improving personal health status and in maintaining health and functioning, both physical and mental. It also recognizes that the extent to which health care interventions and behavior change or channeling can be effective in promoting health and preventing disease depends in part on current health

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110 AGING POPULATION IN THE TWENTY-FIRST CENTURY status and the stage in the life cycle in which particular interventions are introduced. Both concepts underscore the need for individuals and family units to accept personal responsibility for their own health and to take the initiative in managing their health care. Three types of prevention activities can affect health and well- being of the elderly. Primary prevention refers to efforts to eliminate health or functional problems at their source-that is, preventing their occurrence or to procedures (such as immunizations, improv- ing nutritional status, and increasing physical fitness and emotional well-being) that reduce the incidence of disease or render a popula- tion at risk not vulnerable to that risk. Secondary prevention involves efforts to detect adverse health conditions early in their course and to intervene promptly and effectively, or to curtail the spread of disease to others. Tertiary prevention aims to reduce the duration and severity of potentially disabling sequelae of disease and disabil- ity, to reduce complications of disease once established, to minimize suffering, and to assist the individual in adjusting to irremediable conditions (see Lowy, 1983; Office of Technology Assessment, 1985b; World Health Organization, 1986; and Chapter 6 of this report). Federal Initiatives Interest in health promotion and disease prevention activities nationwide, and in particular for older Americans, has been stimu- lated by federal initiatives. The first major step was publication of the report by the U.S. Department of Health, Education, and Wel- fare entitled Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention in 1979. Noting that individual behavior and lifestyle, as well as the environment, are major deter- minants of health and illness that are amenable to change, the report contends that health promotion and disease prevention are critical to further improvements in health status. The report laid out a set of 5 broad national goals and 15 priority areas for improving the health of the American people during the 1980s. Each goal targeted an age group of the population, from infants to older adults. Health promotion activities initiated before people become elderly would tend to improve their health status in old age. For older adults, the stated goal was "To improve the health and quality of life for older adults and, by 1990, to reduce the average annual number of days of restricted activity due to acute or chronic conditions by 20 percent, to fewer than 30 days per year for people aged 65 and older" (U.S.

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HEALTH PROMOTION AND DISEASE PREVENTION 111 Department of Health, Education, and Welfare, 1979~. Among the 15 priority areas were high blood pressure control, immunization, surveillance and control of infectious diseases, smoking control, im- proved nutrition, and physical fitness and exercise. All of these have relevance for the elderly. The perspective for health promotion and disease prevention obviously extends far beyond these goals for 1990. Subsequent to the publication of the surgeon general's report, the Public Health Service published Promoting Bealth/Preventing Disease: Objectives for the Nation (U.~. Department of Health and Human Services, 1980a), which included separate reports on each of the 15 priority areas. A total of 226 measurable national objec- tives were presented under 5 major headings: improved health sta- tus, reduced risk factors, increased public or professional awareness, improved services or protection, and improved surveillance and eval- uation systems. Implementation plans for achieving these objectives were presented in the supplement to the September-October 1983 issue of Public Health Reports, entitled Promoting Heatth/Preventing Disease: Public Health Service Implementation Plans for Attaining the Objectives for the Nation. (U.S. Department of Health and Hu- man Services, 1984~. A more recent federal initiative in the area of health promo- tion and disease prevention is the establishment in 1984 of the U.S. Preventive Services Task Force within the Public Health Service to develop recommendations for the appropriate use of preventive services in clinical settings (see U.S. Department of Health and Hu- man Services, 1984~. Another initiative was mandated by the U.S. Congress under P.~. 98-551. This law authorized the Department of Health and Human Services, through its Centers for Disease Control, to establish, maintain, and operate centers for research and demon- stration with respect to health promotion and disease prevention (U.S. Congress, 1984~. In accordance with this congressional man- date, the Centers for Disease Control in spring 1986 approved the creation of such centers at the Schools of Public Health of the Univer- sity of North Carolina, the University of Texas, and the University of Washington. In contrast to the other two schools, the Univer- sity of Washington's center is to focus on the elderly. Although the preceding discussion emphasizes federal initiatives, there are obvious implications for the private sector, for example, in the organization and delivery of services and the financing of medical care.

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112 AGING POPULATION IN TlIl3 TWENTY-FIRST CENTURY Goals Most statements of health promotion and disease prevention goals for the elderly acknowledge that expected outcomes for older persons especially those who already have chronic illnesses or dis- abilities may be different from those for younger persons who do not yet have such illnesses or disabilities. Cure, or full restoration of health or function, may not be a realistic general goal for the elderly. More realistic goals might involve tertiary prevention efforts such as maintenance or stabilization of existing health and function, amelioration of the effects of disease and disability, and postpone- ment or delay of further disability and functional lirn~tation. Even small gains in the ability to maintain current health and to reduce functional disability may make a major difference in the quality of life experienced by an older person. For the elderly population as a whole, shifting or delaying the average age of onset of particular diseases and disabilities, such as hip fracture, may make survival to old age more pleasant, as active life expectancy is increased and morbidity is shifted to the end of the life span. Preservation of per- sonal independence and avoidance of institutionalization may also be viewed as legitimate goals of a health promotion and disease pre- vention strategy for the elderly, as they are so intimately related to quality of life. Broadly stated, the goal of health promotion and disease pre- vention for the elderly may be viewed as the avoidance or delay of "the potentially reversible . . . physical, mental, or social factors that lead to unnecessary functional dependence and institutionalization" (Filner and Williams, 1981~. HEALTH PROMOTION AND DISEASE PREVENTION FOR THE ELDERLY A note of caution is required before the development of health promotion and disease prevention strategies for the elderly popula- tion is enthusiastically endorsed. Attempts to improve the quality of old age require an understanding of the risk factors for common dis- ease among the elderly and the efficacy of strategies to decrease the risk of morbidity. Simplistic generalizations from studies of young and middle age adults to the elderly in this realm are frequently invalid. Middle aged adults and the elderly differ in their patterns of disease and disease presentation. Furthermore, the elderly represent a select group of survivors,

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HEALTH PROMOTION AND DISEASE PREVENTION 113 with physiologic alterations that may influence pathophysiologic processes. For instance, the widely cited Alameda County study (Wingard et al., 1982) reported reduced mortality in young and middle-aged adults who never smoked, drank little alcohol, were physically active, and slept seven or eight hours nightly. In con- trast, however, ~ a similar analysis of elderly Massachusetts residents (Branch and Jette, 1984) it was found that five-year mortality rates were not influenced by alcohol intake, physical activity, or sleeping habits, indicating the age modification of risk factors. Similarly, a recent study suggests that more overweight elderly subjects have a lower rather than a higher mortality rate from coronary disease (Ja- jich et al., 1984~. This controversial finding is difficult to explain in view of the known adverse ejects of obesity on diabetes, hyperten- sion, and hyperlipidemia and indicates a need for detailed evaluation of the potential protective effect of moderate overweight in old age (the two preceding paragraphs closely parallel Rowe, 1985:8283. There are several reasons for adopting a health promotion and disease prevention approach for the elderly, despite legitimate cau- tions. Among them are the plasticity of the aging process; the possibility of modifying physiologic or pathologic conditions that, although associated with so-called normal aging, also entail risks to health; and the high incidence of chronic disease among the elderly, which increases the importance of pi stponing additional disability. Furthermore, life expectancy is increasing and it is desirable to en- hance health status during these additional years of life. The Plasticity of the Aging Process The health ejects of deleterious habits and lifestyles are typically cumulative, and for this reason often viewed as nonremediable- making primary prevention among younger members of the popula- tion appear as a preferable strategy for improving the nation's health. There is, however, increasing evidence to suggest that some harmful habits and behaviors are capable of modification and even reversal, sometimes when interventions and changes occur late in life. Recent studies on osteoporosis, for example, indicate that moderate exer- cise can retard age-related bone loss and even in some cases increase bone density in elderly women, including women in their nineties and those living in institutions (Aloia et al., 1978; Smith and Reddan, 1976; Smith et al., 1981~.

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114 AGING POPULATION IN THE TWBNTY-FIRST CENTURY Risks Associated With Normal Aging There is evidence to suggest that physiologic or pathologic chang- es so common with advancing age as to be considered normal by clinicians may not be without risk. Although systolic blood pressure increases with age among the American elderly population, it is also clear that increases in systolic blood pressure are associated with marked increases in the risk of stroke and coronary heart disease (Rowe, 1983~. Just because a finding is considered normal among the elderly does not mean that it is also harmless. Perhaps the term usual aging should be substituted for normative aging, to recognize the possibility of adverse effects associated with typical age-related change and the importance of considering techniques to modify these usual, but not necessarily harmless, characteristics. The High Incidence of Chronic Disease and BInese Among the Elderly While persons of any age may have chronic disease or disabil- ity (e.g., both children and adults become deaf or blind, acquire permanent orthopedic disabilities and develop degenerative diseases requiring continuing treatment and care), the elderly are particularly vulnerable to chronic disease and disability. An estimated 86 per- cent of persons over age 65 have one or more chronic diseases (Office of Technology Assessment, 1985b). Among the noninstitutionalized elderly, who have a much lower prevalence of severe limitations and dependency than the institutionalized elderly, some 46 percent had arthritis, 37 percent had hypertension, 28 percent had a hearing Toss, and 28 percent had a heart condition in 1981 (Office of Technology Assessment, 1985b; Rice, 19863. Therefore, efforts to maintain ex- isting health and well-being, to ameliorate the effects of illness and disability, and to delay or postpone further disability are particularly important for the elderly population. Increases In Average Life Expectancy and Individual Variability The life expectancy of the elderly is increasing. Those currently age 65 can expect on average to live another 16 years (more than 14 for men and 18 for women) (Office of Technology Assessment, 1985b:10~. With increasing longevity, current elderly cohorts, as well as younger age groups, can be expected to live through longer periods of exposure to risk factors, including those posed by the

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HEALTH PROMOTION AND DISEASE PREVENTION 115 environment, diet and nutrition, and personal behavior and lifestyle, and will have more time to develop symptoms than past generations. Furthermore, as with other age groups, there is great variability in the health and functional status of older persons. While some are severely debilitated or ill and can benefit minimally if at all from preventive interventions, others are thriving and show no evidence of disease or disability. CRITICAL ISSUES Five issues are of current concern in the health promotion and disease prevention approach to health care: (1) the inconclusiveness of the scientific and clinical evidence of the efficacy of many promo- tion and prevention activities, (2) the need for additional knowledge concerning factors that facilitate behavior modification among per- sons of all ages, (3) the shortage of health care personnel trained in this approach, (4) the potential impact that accelerating growth in the number and utilization of health maintenance organizations and other systems with prepaid capitation fees will have on this ap- proach to health care, and (5) the effect that prospective payment systems, as exemplified by diagnosis-related groups for the elderly under Medicare, will have on the services received. The scientific basis for many of the health promotion and disease prevention activities currently in vogue is inadequate. With respect to the elderly in particular, there is only modest evidence that par- ticular behaviors and interventions can prevent disease or retard the impact of illness and disability, once established. For example, the role of exercise in reducing the risk of coronary heart disease and stroke for women and the elderly is not yet known (Office of Technol- ogy Assessment, 1985b). Similarly, it is not yet understood whether current obesity or a history of chronic obesity is a risk factor for coro- nary heart disease (Office of Technology Assessment, 1985b). And the relative risks and benefits of different levels of exercise for older persons particularly those with chronic disease have not yet been established (Office of Technology Assessment, 1985b). Nonetheless, a variety of activities and behavior changes have been widely adver- tised as health promoting and disease preventing- as ways to avoid everything from cancer to heart disease. Private-sector initiatives in the area of physical fitness, nutrition, and diet counseling have

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116 AGING POPULATION IN THE TWENTY-FIRST CENTURY been largely responsible here, although the scientific and clinical ev- idence on which much of the popularized advice to the public and to individuals is based is often inconclusive or conflicting. A related issue is the need for increased knowledge of the factors that facilitate attitude and behavior change among the population as a whole and among segments of it, including the elderly (Franks et al., 1983; Sanazaro, 1985~. An effective national strategy of preven- tion and promotion, such as that established by the Public Health Service initially with the publication of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Department of Health, Education, and Welfare, 1979), depends not only on knowledge of scientific and clinical efficacy of particular in- terventions but also on the ability and willingness of individuals to modify their behavior. A third issue is the shortage of physicians and other health personnel who are trained to provide health promotion and disease prevention services to their patients (Lee, 1985~. One reason for this shortage is the passive structure of the U.S. health care delivery sys- tem, which generally relies on individuals to present themselves to physicians and other providers when and if they have a problem. Un- ti! very recently, health care coverage for most people, and Medicare reimbursement policies for the elderly, have reinforced a system of health care that creates no demand for health promotion and disease prevention practitioners. Medicare has not generally covered individ- uals or compensated providers of care for prevention and promotion activities. Two developments that may affect the rate at which the health promotion and disease prevention approach gains widespread accep- tance are the recent dramatic growth in the number and utilization of prepaid health plans by the general public and by the elderly and the provision of coverage and rennbursement for Medicare enrollees and providers of care involved in health plans that are paid prospectively according to a fixed rate capitation formula. HMOs, one type of cap- itated plan, provide a comprehensive range of medical or health care services within a single organization in exchange for a fixed monthly or annual fee. As their name suggests, HMOs might be expected to encourage their enrollees to maintain health and prevent disease through the particular variety of services they offer and the gatekeep- ing functions they perform to reduce utilization of more expensive forms of care (such as hospitalization). Information on the extent to which these functions are carried out would be important. From June

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HEALTH PROMOTION AND DISEASE PREVENTION 117 1983 to June 1985, enrollment in HMOs increased by 20 percent per year, with an estimated 8 percent of the U.S. population or some 19 million persons enrolled as of June 1985 (TarIov, 1986:29-303. In 1985 the Health Care Financing Administration issued regulations that encourage HMOs to enroll Medicare beneficiaries on a capitation basis (Ginsburg and Hackbarth, 1986~. DATA NEEDS This portion of the chapter discusses existing federal surveys that provide data relevant to health promotion and disease preven- tion for the general population and for the elderly. These surveys are reviewed from two perspectives: the extent to which they pro- vide information about the health promotion and disease prevention knowledge and activities of the general population (including the elderly), and the extent to which they provide information about the health promotion and disease prevention activities of providers of care (such as physicians and nurses). Population-based surveys yield information by surveying samples of individuals selected from the general population or certain segments of it, such as minorities, the elderly, or women of childbearing age. Provider-based surveys sur- vey individual or institutional providers of care, such as physicians or nursing homes. Public Enawledge About Health Promotion and Disease Prevention The success of a health promotion or health maintenance and dis- ease prevention program depends on many things. One is an informed and knowledgeable public, which in turn depends on widespread dis- semination of the known benefits and harmful effects to health and well-being of particular behaviors. Also necessary is a willingness on the part of individuals to change attitudes, habits, and behaviors- often long-standing ones- and the initiative to undertake responsi- bility for one's own health and the health of one's family. More information is needed about the techniques and strategies that are likely to be effective in inducing and maintaining attitude and behavior change, not only among the elderly, but also among the general population. In fact, there is a considerable amount of research in the area of behavior modification techniques under way at present and planned for the future some of it experimental, involving controlled clinical trials, and some of it less rigorous in nature (see, for example, Russell, 1987~.

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118 A GING P OP ULA TI ON IN THE T WENTY-FIRS T CENTURY There is also concrete evidence demonstrating that successful campaigns to educate the public, increase its awareness of the harm- ful effects of particular practices, and motivate individuals to take action can be mounted. A prominent example is the successful Na- tional High Blood Pressure Education Program launched by the National Heart Institute in 1972 to spread the word to physicians, their patients, and to ordinary citizens (U.S. Department of Health and Human Services, 1985~. In 1985, the National Health Interview Survey (National Center for Health Statistics, 1985a) described in Chapter 3 included a health promotion and disease prevention supplement as an effort to obtain information on the knowledge and behaviors of the general public. The supplement includecl questions pertinent to various age groups including the elderly. For example, adult respondents were asked about their knowledge of factors that increase one's chances of de- veloping heart disease and stroke, about foods associated with high blood pressure, about diseases caused by smoking and alcohol, and about activities that prevent tooth decay and gum disease, among others (National Center for Health Statistics, 1985a). The supple- ment thus provides data relevant to the Public Health Service's goals and objectives for promoting health and preventing disease (U.S. Department of Health and Human Services, 1980a) and the imple- mentation plans for attaining the objectives for the nation (U.S. Department of Health and Human Services, 1983~. Despite the obvious importance of health maintenance and dis- ease prevention, data are not routinely available through national data systems on the extent to which the population is informed as to the causes of preventable illnesses and conditions and the actions they might take to reduce their own risks of developing such illnesses and accompanying impairments. As noted earlier, the health needs and concerns of the elderly are somewhat different from those of younger persons, because of their stage in the life cycle, their social circumstances, and the fact that the risk of particular diseases and disabilities changes with age and with the existing health and functional status of the individual. Separate health promotion and disease prevention modules (clusters of items on specific topics) should be developed that are appropriate to the elderly and subgroups of this population, since risk factors and expected health and functional outcomes for particular diseases and disabilities among the elderly vary. Modules should be designed to reflect special conditions among racial and ethnic minorities, the

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HEALTH PROMOTION AND DISEASE PREVENTION 119 poor, residents of rural areas, women, the oIclest-old, the impaired and institutionalized, and those elderly who are at high risk for or who have particular diseases or disabilities. The panel also believes that such modules and items that have a more narrow focus on a particular disease or disability for which the elderly are at greater risk than the rest of the population should also be developed, to be administered in or along with selected population surveys. It would be useful to develop modules and information items for subjects such as breast self-examination and screening, pap tests, and osteoporosis prevention and retardation for women; issues of falling (including items on hip fracture ant] broken bones); primary prevention ac- tivities such as influenza and tetanus shots for the institutionalized and other immunizations and their purposes; incontinence; adverse effects of drugs; social isolation, depression, and other potentially preventable and/or remediable social and emotional conditions; the role of diet, nutrition, and exercise in the prevention or retardation of particular illnesses; and the use of preventive safety measures in the home. Both the National Health Interview Survey and the National Health and Nutrition Examination Surveys would be good vehicles for health promotion and disease prevention items and modules for the general population and for the elderly. Both surveys are de- scribed in Chapter 3 of this report. The NHANES, scheduled to be fielded again in 1988 (NHANES ITI) is a unique opportunity because of its inclusion of physiologic measures in addition to self-reported (interview) information on health and nutrition status and practices. A major policy issue is whether the federal government should fund health promotion and disease prevention activities and, if so, which ones. To clarify this issue, information is needed on the extent to which population subgroups of the elderly are informed about health promotion and disease prevention practices and the degree to which persons of all ages behave in ways known to promote health and prevent illness. Such information is also needed to assess changes in the extent of such activities resulting from public and private initiatives. Recommendation 5.1: The panel recommends (a) that mod ules of health promotion and disease prevention items (in cluding those concerned with attitudes, knowledge, and be havior) be developed that are appropriate for the elderly and subgroups of the elderly population that are at risk for particular diseases, illnesses, disabilities, or conditions,

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120 AGING POPULATION IN THE TWENTY-FIRST CENTURY which can be used with a variety of population-based sur veys; (b) that these health promotion and disease prevention survey modules be tested on relevant segments of the elderly population; and (c) that successful modules be incorporated in population-based surveys such as the National Health Interview Survey and the National Health and Nutrition Examination Survey, or as supplements to them. Development of these modules will require cooperation and coordi- nation of effort by several agencies, including the Office of Health Promotion and Disease Prevention, the National Center for Health Services Research and Health Care Technology, the National Center for Health Statistics, and institutes within the National Institutes of Health. The Role of Physicians Once the scientific basis for particular health promotion and disease prevention interventions and behaviors has been established, and the medical and health care technology to implement them has been developed, physicians and other health care personnel can play important roles in promoting health and preventing disease, with patients of all ages, including the elderly. The elderly, on average, make more visits to physicians annually than middle-aged persons. In 1985, for example, persons ages 65-74 averaged 7.7 physician visits per year, and those age 75 and over had an average of 9.3 visits per year, in contrast with 6.1 visits per year for persons ages 45-64 (National Center for Health Statistics, 1986b). In 1979 elders (age 65 and older) with chronic activity limitation averaged 8.7 physician visits per year, in contrast with 4.3 visits per year for those without activity limitation. Only 5 percent of the elderly had not seen a physician for five or more years (Rice, 1986~. The sheer frequency with which the typical older person visits a physician, particularly since the elderly tend to see the same physician (Rice, 1986), enhances the possibility of physician influence. Although some patients, including elderly patients, do not adhere to physician-prescribed regimens such as drug regimens, it has been shown that in the area of promoting and maintaining attitude and behavior change, physicians-particularly primary care physicians- can be effective (German et al., 1982; U.S. Department of Health ~.nd Human Services, 1986c; GiTson et al., 1984~. This is especially true

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HEALTH PROMOTION AND DISEASE PREVENTION 121 when other intervention techniques, such as providing the patient with written material on the issue in question, are used in conjunc- tion with physician-initiated discussion. This was demonstrated in a recent study conducted at a large Seattle-area health maintenance organization in which researchers examined the relative impact of strategies involving physician-patient discussions and other interven- tion methods on compliance with colorectal screening and smoking cessation (Gilson et al., 1984~. For colorectal screening compliance, the most elective intervention was a three-step strategy consisting of a physician-patient talk about the importance of the screening test, sending a postcard as a reminder, and calling those who failed to return the test within 10 days. With respect to smoking cessation, experimental interventions involving physician discussions with pa- tients, together with the provision of selhelp material, achieved a higher rate of compliance with trying to quit smoking than did other interventions. None of the interventions, however, were notably suc- cessfu] in achieving smoking cessation (Gilson et al., 1984~. A major drawback to fully exploiting the potential influence of physicians in health promotion and disease prevention among their patients has been the paucity of data on the extent to which physi- cians currently do engage in prevention activities. Such activities might include screening examinations and inoculations, discussion and counseling, and therapeutic measures and follow-up where effi cacy measures have been scientifically and clinically established. The mechanism being used to determine some aspects of physi- cian behavior in this area is the National Ambulatory Medical Care Survey (also discussed in Chapter 9~. This survey, conducted an- nually from 1973 through 1981, and again in 1985, with three-year periodicity planned for the future, collects data on office visits made by ambulatory patients to nonfederal physicians who are principally employed in office-based patient care practice. The nature of the physician-patient encounter is recorded for a sample of patient vis- its to a sample of such physicians in the coterminous United States. The physician sample is drawn from files maintained by the American Medical Association and the American Osteopathic Association. In 1985, the latest year for which data are available, some 3,500 physi- cians (70.2 percent of those sampled) participated in the survey. Of the 71,594 physician-patient visits sampled and recorded, 14,700 (20.5 percent) were by people age 65 and over (National Center for Health Statistics, 1987b). At present, the data collected on the physician-patient encounter

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122 AGING POPULATION IN THE TWENTY-FIRST CENTURY include the date and duration of the visit, the reasonts) for the visit (the patient's presenting complaints or symptoms), the physician's diagnoses, whether the major problem Is new or previously addressed by this physician, the diagnostic and therapeutic services ordered or provided, and the action at the end of the visit. The patient record for this survey provides a checklist for the physician that distinguishes between medication and nonmedication therapy (including among other things psychotherapy, diet counseling, and other counseling). The 1985 patient record report of the visit also contains checkoff items on specific tests, e.g., blood pressure, glucose tolerance, visual acuity, and breast examination. These sections need to be reexamined to increase their usefulness in identifying specific health promotion and disease prevention activities. At present, such activities cannot be distinguished from those carried out as a follow-up for previously diagnosed disease or because of suspected disease. The pane! recognizes the space constraints of the form currently being used for the National Ambulatory Medical Care Survey, but we believe that changes can be accommodated in the items currently included and a distinction made between prevention and treatment. The recommendation below recognizes that: . physicians and other health care providers play a critical role in influencing the behavior of their patients, the health needs of the elderly often diner from those of the remainder of the population, and some diseases and illnesses of old age can be modified through prevention and health promotion. Recommendation 5.2: The pane] recommends that the Na- tional Center for Health Statistics: (a) develop questions pertaining to the health promotion and disease prevention practices of health care providers that include categories with special relevance for the elderly to be used in provider- based surveys and that (b) these questions be included in the National Ambulatory Medical Care Survey to obtain information on physician-patient encounters. These questions should ascertain: (1) the activities that physi- cians undertake to change patients' behavior and increase their awareness and understanding of health promotion and disease pre- vention, (2) the specific preventive measures (such as dietary advice and screening for hypertension) taken during the patient visit, and (3) information obtained on changes in patient's behavior.

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HEALTH PROMOTION AND DISEASE PREVENTION 123 A recommendation in Chapter 9 to expand the sampling frame of the National Ambulatory Medical Care Survey to include additional physician types and practice settings is pertinent here as well. Providers of Health Maintenance and Disease Prevention Services to the Elderly Many different kinds of physicians, for example, family prac- titioners, pediatricians, internists, psychiatrists, and cardiologists, engage in some kinds of health promotion and disease prevention ac- tivities with their patients, but the extent to which they do so varies and is currently unknown. A recent report on the 1980-1981 Na- tional Ambulatory Medical Care Survey (National Center for Health Statistics, 1984b) points out some differences by type of physician and age and condition of patient, for instance, in the extent to which a blood pressure reading is taken during an office visit and whether medication or nonmedication therapy (e.g., counseling) is provided. However, this survey, as currently constituted, does not attempt to fully document physician practices in health promotion or mainte- nance and disease prevention. Nor is this survey designed to ascertain the extent to which different physician specialties and other providers of care consider health promotion and disease prevention concerns as among the services they should provide to their patients. Many other types of practitioners, such as nutritionists and social workers, also provide health and health-related services to persons of all ages, including the elderly. Furthermore, health promotion and disease prevention services are also provided in a variety of nonmed- ical settings, including physical fitness centers and senior centers by professional, paraprofessional, and nonprofessional support person- nel. Comprehensive information on the numbers of professionals and allied health personnel who provide health promotion and disease prevention services to the elderly in a variety of settings does not exist. While some federal agencies such as the Bureau of Health Professions of the Health Resources and Services Administration (U.S. Public Health Service) collect data on health manpower and/or health manpower training (see, for instance, Fifth Report to the Pres- ident and Congress: U.S. Department of Health and Human Services, 1986a), none of them collects information on professionals and allied personnel who render health promotion and disease prevention ser- vices to the U.S. population at large or to the elderly. Although some

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124 AGING POPULATION IN THE TWENTY-FIRST CENTURY data exist on members of health maintenance organizations and their enrollment figures (which are in flux because of rapid growth in this area), there are no comprehensive data on the services HMO s pro- vide and the numbers of elderly who receive these services as HMO enrollees. The Health Research Extension Act of 1985, Section 8, called for a study of personnel for health needs of the elderly. It directed the secretary of the U.S. Department of Health and Human Services to "conduct a study on the adequacy and availability of personnel to meet the current and projected health needs (including needs for home and community-based care) of elderly Americans through the year 2020." The National Institute on Aging, in a joint effort with the Health Resources and Services Administration, conducted the study, with its director acting as chair of a committee that includes representatives from several federal agencies (see National Institute on Aging, 1985, and Chapter 9 of this report for more information). The secretary's report, submitted to Congress in fall 1987, includes recommendations related to the number of primary care physicians, dentists, and other health personnel needed to provide adequate care for the elderly; the education and training needs of other physicians, dentists, and health personnel to provide care responsive to the par- ticular needs of the elderly, and the financing of geriatric and training activities (U.S. Department of Health and Human Services, 1987~. While the study addresses the manpower and training needs for many different types of health personnel who provide care to the elderly, it does not focus explicitly on the area of health promotion and disease prevention, although it recognizes it as a special issue area. The Office of Disease Prevention and Health Promotion within the De- partment's Public Health Service also does not routinely collect data on the numbers of health personnel involved in health promotion and disease prevention services to the elderly or on their training in this area. The panel believes such information is important to determine whether there is need for additional trained personnel and training programs for health promotion and disease prevention among the elderly. Recommendation 5.3: The panel recommends that the Bu- reau of Health Professions collect information on health care personnel (including professionals and support staff such as nurse's aides) who focus on health promotion and disease prevention activities and services to the elderly in a variety

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HEALTH PROMOTION AND DISEASE PREVENTION of medical and nonmedical, and institutional and noninstitu- tional, settings. Estimates of the numbers of such personnel and their health promotion and disease prevention activities should be ascertained. 125