Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s Vision Health Initiative November 6, 2015 National Center.

Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s Vision Health Initiative November 6, 2015 National Center for Chronic Disease Prevention and Health Promotion Vision Health Initiative

Quotidian

Outline  Describe public health model  Populate model with vision examples  Surveillance  Introduce WHO ICF Framework  Vision & eye health disparities  Vision and Health-Related Quality of Life  Implications of findings for Vision Rehab  Intervention & intervention design  Begins to tell the complex story of aging and vision impairment

Public Health Monitoring Surveillance Public Health Research Risk/Disparity Public Health Intervention What works? Public Health Impact Implementation Problem Response Public Health Model

Surveillance Surveillance is the foundation of public health Population based Driven by rigor and science Cannot underestimate or over estimate a problem Without sound surveillance, all other decisions may be incorrect 6

How many people experience vision impairment?? 7

Population Estimates Prevalence and estimated population of people who are visually impaired remains problematic 3.3 million (40+) (Eye Diseases Prevalence Research Group, 2004) 5.7 million (65+) (Crews, Jones, & Kim, 2006) 14 million (12+) (Vitale, Cotch, & Sperduto, 2006) 21.2 million (18+) (Pleis & Lethbridge-Cejku, 2007) Desire to have large numbers

Estimate depends on what you ask Disease: macular degeneration, cataract (cataract removed), glaucoma – Self report vs clinical examination Impairment: difficulty seeing Activity performance: read newspaper print, recognize friend across the street Environment: Can you drive at night in unfamiliar neighborhoods? No gold standard question for vision surveys 9

Surveillance Gap No vision surveillance system in the US. Therefore, no systematic effort to harmonize questions, create conceptual clarity, or establish comparability. Consequences: – Vision public health research appears fragmented. – Creates distinct disadvantage to inform decision making. 10

Supplement to American Journal of Ophthalmology Convened national/ international panel of experts Identified strategies to improve vision surveillance in US Papers address disparities Guide investigators and encourage harmonization of vision data

Forecasting studies Cases of cataract expected to increase from 20.5 million to 30.1 million from 2010 to 2020. Glaucoma is expected to increase from 2.2/2.7 million to 7.3 million in 2050. Cases of early macular degeneration expected increase from 9.1 million in 2010 to 17.8 million in 2050. Diabetic retinopathy will triple from 5.5 million cases in 2005 to 16 million in 2050.

Status of Vision Surveillance Recall surveillance is foundation of public health. Substantial knowledge base, but, perhaps, not organized in way to move a public health agenda. Existing knowledge makes case for the magnitude of the problem. 13

Are people with vision impairment different from the general population? 15

Risk/ Disparity/ Effects of Vision Impairment  Second step in the public health model is to determine whether or not a problem is evenly distributed across the population  Age group, gender, race/ethnicity, co-morbidity, health behaviors, health outcomes, SES Status, social outcomes, quality of life, health-related quality of life.  Accounts for much research in vision  Identifies where the action is. Targets interventions.

Self reported no, little, & moderate/severe difficulty seeing by age BRFSS, 2006-2010

Severity of Vision Impairment by Sex for People Aged ≥65 Years BRFSS. 2006-2010

Severity of Vision Impairment by Race/Ethnicity for People Aged ≥ Years BRFSS, 2006-2010

Vision Impairment and Co-morbid Conditions Represents huge emerging issue Represents another range of disparities Vision largely excluded from initiatives to address multiple chronic conditions (MCCs) 20

RankDiseases Present% w/ both 1Arthritis, visual impairment44 2Visual impairment, high blood pressure40 3Arthritis, high blood pressure34 4Any heart disease, visual impairment17 5Visual impairment, hearing loss15 6Any heart disease, hearing loss14 7Any heart disease, HBP13 8Arthritis, hearing loss12 9Diabetes, visual impairment12 10Cancer, visual impairment10 Comorbid Chronic Conditions Among Women aged 65+ Fried, at al, 1999

Findings from NHIS  NHIS Vision Questions:  Do you have any trouble seeing, even when wearing glasses or contact lenses?  Are you blind or unable to see at all?  14.6% report trouble seeing or blind

Prevalence of eight chronic conditions among people aged ≥65 years 23 Data source: NHIS, 2007-2011

Prevalence of eight chronic conditions among people aged ≥65 years 24 Data source: NHIS, 2007-2011

What is the prevalence of vision impairment among people with chronic diseases? 25

Percent of people age ≥65 years with chronic conditions reporting vision impairment 26 Data source: 2007-2011 NHIS

Percent of people with chronic conditions reporting vision impairment 27 Data source: 2007-2011 NHIS

Percent of men & women with chronic conditions reporting vision impairment 28 Differences Significant for hypertension, heart disease, arthritis, asthma, & diabetes. Data source: 2007-2011 NHIS

Percent of men & women with chronic conditions reporting vision impairment 29 Differences Significant for hypertension, heart disease, arthritis, asthma, & diabetes. Data source: 2007-2011 HNIS

Prevalence of vision impairment among people w/ chronic conditions by age group

So... What are the effects of comorbid conditions among people with vision impairment? 31

Prevalence of self-reported fair/poor health among people with chronic conditions w/ and w/o vision impairment 32 Data source: NHIS 2007-2011

International Classification of Functioning, Disability and Health 33

Historical struggle to understand disablement  Social & policy efforts have struggled to describe and respond to disability (cognitive, sensory, & mobility limitations).  Shame, isolation, removal, institutionalization, discomfort, fear  Civil War and WW-I response—institutional care  WW-II—employment, reintegration  Developmental disabilities--removal  Vietnam—civil rights

Models of Disablement  Nagi’s disablement model,1960s  ADLs—Katz: bathing, toileting, dressing, eating  IADLs—Lawton: housework, meds, money, shopping  Disability as consequence of disease/ injury  Linear models; Disability ≠ disease  WHO 2001 International Classification of Functioning, Disability and Health

Experience of Disability led to Social Model of Disability  Disability is dimensional  Disability is dynamic  Disability Research & Interventions must embrace these qualities  Fit between the person and the environment

Goals of public health  Prevent disease, injury, and disability  Uneasy relationship with disability  People with disabilities, including people with vision impairment, are largely viewed as a failure of public health  And therefore, not of interest.

Vision’s Place in This Debate  Vision impairment is generally the negative outcome— to be avoided  Much confusion within the discipline regarding what we mean by “vision” or “vision impairment  Disease, function (20/200), activity (read), work disability (participation)  No gold standard vision questions  If reframed, I can show place of vision impairment in public health

Impairment of Structure or Function Activity Limitation Participation Restriction Disorder/Disease ICD-9/10 Personal Factors Environmental Factors ICF Conceptual Model 17

Functioning at Body, Person, and Societal Levels Disease/Disorder--ICD 9 Body Function and Structures – Impairments focused on body systems Activities – Activity limitations —e.g., self care, mobility, communication, controlling behavior Participation – Participation restrictions—e.g., friends, family, work, school, community, & civic engagement Environmental Factors – Built, Attitudinal, Policy – May be barriers or facilitators (positive or negative) 18

Utility of ICF Common language Can be used for international comparisons Is dimensional Can track dynamic changes Can be used at person, group, or population level Neutral terms Classification system—does not replace survey questions 20

Employ ICF Want to demonstrate utility of ICF framework to better understand effects of vision impairment and effects of vision impairment and comorbid conditions 42

Back to Public Health Model Surveillance—how big is problem Research—what are the disparities? Use ICF to understand disparities. 43

Remember 19.9% of people age 65+ years report diabetes. Of that group, 17.3% of men & 22.2% of women report vision impairment. 45

Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Diabetes and Vision Impairment, Health Interview Survey, 1997-2004 Crews, Jones, & Kim, 2006

Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Diabetes and Vision Impairment, Health Interview Survey, 1997-2004 Crews, Jones, & Kim, 2006

Percent Reporting Worse Health for Adults 65+ w/ & w/o Diabetes and Vision Impairment, Health Interview Survey, 1997-2004 Crews, Jones, & Kim, 2006

The Effects of Stroke and Vision Impairment  Remember, 8.6% of people age 65+ years report stroke.  But of that group, 25.5% report vision problems.

Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Stroke and Vision Impairment, Health Interview Survey, 1997-2004

Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Stroke and Vision Impairment, Health Interview Survey, 1997-2004 Crews, Jones, Kim, 2006

Percent Reporting Worse Health Adults 65+ w/ & w/o Stroke and Vision Impairment, Health Interview Survey, 1997-2004 Crews, Jones, Kim, 2006

Effects of Vision & Comorbid Conditions  Associated with decreased activity  Associated with decreased social roles  Associated with poorer health  Vision and multiple chronic conditions have propelling negative effect.  An effect that requires attention.

Oral Health & Vision Impairment

Data Set: 2008 National Health Interview Survey Established 1957 Samples 35,000 household and 87,500 people annually Multistage area probability design permits representative sample of households 2008 Oral Health Supplement in Adult File 2008 Vision Supplement in Adult File

Definition of Vision Impairment  “Do you have any trouble seeing even with glasses or contacts?”  “Have you EVER been told by a doctor or other health professional that you had any of the following conditions: Macular degeneration, diabetic retinopathy, glaucoma, or cataract?”

Outcome variables  Self-reported perceived oral health (very good to good/ fair to poor),  Teeth problems (toothache/sensitive teeth, bleeding gums, crooked teeth, broken/missing teeth, stained/discolored teeth, loose teeth, broken/missing fillings),  Mouth problems (pain in jaw, sores in mouth, difficult eating, bad breath, dry mouth.)

Self-Reported Oral Health Status  How would you describe the condition of your mouth?  Very good, good, fair, poor

Teeth Problems Question stem: During the past six months, have you had any of the following problems? Toothache/sensitive teeth Bleeding gums, Crooked teeth, Broken/missing teeth, Stained/discolored teeth, Loose teeth not due to an injury, Broken/missing fillings

Mouth Problems Question stem: During the past 6 months, have you had any of the following problems that lasted more than a day? (Y/N) Pain in jaw, Sores in mouth, Difficult eating or chewing, Bad breath, Dry mouth.

RESULTS

Oral Health Age ≥ 40 Years Mouth Condition NHIS, 2008 How would you describe the condition of your mouth? Visually ImpairedNo Vision Impairment Age 40-64Age 65+Age 40-64Age 65+ Fair/Poor45.0%36.3%24.5%23.5%

Oral Health Age ≥ 40 Years Problems with Mouth among those having teeth., NHIS, 2008 Vision Impairment No Vision Impairment Pain in jaw12.3%5.1% Sores in mouth9.2%4.1% Difficulty eating18.6%7.0%

Oral Health Age ≥ 40 Years Problems with Teeth among those having teeth. NHIS, 2008 Vision Impairment No Vision Impairment Toothache/ Sensitive teeth 36.8%21.2% Bleeding Gums17.2%8.5% Broken/Missing Teeth 34.9%18.9% Loose teeth9.9%4.6%

Heath Status among those having teeth. Age ≥ 40 Years, NHIS, 2008 Vision Impairment No Vision Impairment Excellent/ Very good, good 64.6%84.8% Fair/ Poor35.4%15.2%

Odds Ratio of Oral Health Problems among people with vision impairment, Age 40 Years, 2008 NHIS Vision Impairment Age 40-64 years Vision Impairment Age ≥ 65 years Fair/ Poor Oral Health 1.671.23 Mouth Problems2.311.58 Teeth Problems1.791.35

Health Related Quality of Life as Outcome Measure

Health Related Quality of Life Disparities from BRFSS  Health Related Quality of Life  Life Satisfaction  Disability  Self-reported health  Physically unhealthy days  Mentally unhealthy days  Activity limitation days

Vision Questions How much difficulty, if any, do you have reading print in newspaper, magazine, recipe, menu, or numbers on the telephone? How much difficulty, if any, do you have in recognizing a friend across the street? Response categories: No difficulty, little difficulty, moderate difficulty, extreme difficulty, unable to do because of eyesight

HRQoL Questions Self-Rated Health (excellent, very good, good, fair, poor) Physically Unhealthy Days: “Now thinking about your physical health, which included physical illness and injury, for how many days during the past 30 was your physical health not good? Mentally Unhealthy Days: Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”

HRQoL Questions Activity Limitation Days: “During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?” Life Satisfaction: “In general, how satisfied are you with your life?” Disability: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problems that requires you to us special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”

HRQoL Questions Valid indicators of service needs Valid indicators of intervention outcome 91

Life Dissatisfaction by Severity of Vision Impairment among people age ≥ 65 years, BRFSS, 2006-2010 92 Crews, Chou 2014

Disability by Severity of Vision Impairment among people age ≥ 65 years, BRFSS 2006-2010 93 Crews, Chou et al 2014

Fair/Poor Health by Severity of Vision Impairment among people age ≥ 65 years, BRFSS 2006-2010 94 Crews, Chou, et al, 2014

Frequent (14+) unhealthy days by severity of vision impairment among people aged ≥65 years, BRFSS 2006-2010 95 Crews, Chou, et al, 2014

Logistic Regression Fair/ Poor Health Life Dissatisfaction Disability No VI1.0 Little VI1.201.531.47 Moderate/ Severe VI 1.802.212.01 Crews et al, 2012

Potential Solutions  Improved access and utilization of eye care and vision rehabilitation—no “system” of vision care.  Increased engagement of chronic disease providers to address needs of constituents with vision impairment.  Stanford Health Promotion materials, for example, are not accessible to people with vision impairment  Improved tailored efforts to promote health among people with vision impairment  Integrate nutrition (low salt, low fat) into meal preparation  Integrate exercise, conditioning, falls prevention into O&M  Health outcomes are measurable

Vision Rehabilitation Outcomes  Using the ICF model, Vision Rehabilitation Intervention occurs at the activity level; outcomes occur at the social participation level.  Given the evidence, vision rehabilitation has potential to address health and can result in measureable health outcomes.

Next steps in public Health Model The future: Development and implementation of health promoting interventions targeted to people with vision impairment 99

A Game Changer 100

Institute of Medicine Report on Vision and Public Health vision and eye health surveillance vision health disparities prevalence & effects of comorbid conditions access and utilization of eye care, health for people with vision impairment. public and private collaborations at the community, state, and national levels to elevate vision and eye health as a public health issue 102

Vision and Eye Health Surveillance System  Develop, test, and implement a vision and eye health surveillance system using existing surveys, as well as administrative and electronic data sources.  Provide population estimates of vision loss function, eye diseases, as well as barriers and facilitators to access to eye care at the national, state, and community levels.

National Opinion Research Center NORC  Establish standardized vision and eye health indicators (expert advisory panel)  Identify data sources  Estimate the prevalence and disparities in vision, eye health, and eye care utilization

Quotidian 105

Man is the only animal that laughs and weeps; for he is the only animal that is struck with the difference between the way things are and the way they ought to be. --William Haslett

Thank you 107

Thank you very much! 108

For more information, please contact John E. Crews, DPA at Jcrews@cdc.gov 770 488 1116Jcrews@cdc.gov For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Vision Health Initiative

If no convinced, let me share one more piece of evidence  Health related Quality of Life among people age 40-64.  Used same vision and HRQoL questions from BRFSS  Vocational rehabilitation is big business  Outcomes probably not as desirable as we wish  Concerns: education, employer attitudes, transportation, technology,

Life Dissatisfaction, Disability & Fair/Poor Health among People with no, little & severe vision impairment, ages 40-64

Frequent physically unhealthy days, frequent mentally unhealthy days, and frequent activity limitation days by severity of vision impairment, BRFSS, 2006-2010

Findings  Given the findings of HRQoL among those over 65 years, these findings are not unexpected.  Mentally unhealthy days and life dissatisfaction is greater among those 40-64.  What if we look at these data by employment status?

Case definitions  Nine employment questions in BRFSS  Working: working for wages or self employed  Not working: unemployed less than or more than one year  Excluded: student, homemaker, retired, unable to work  Working: No Difficulty: 75%; Little Difficulty: 72%; Severe Difficulty: 59%

Fair/Poor Health by employment status & severity of vision impairment

Life Dissatisfaction by employment status & severity of vision impairment

Frequent Physically Unhealthy Days by employment status & severity of vision impairment

Frequent Activity limitation Days by employment status & severity of vision impairment

Disability by employment status & severity of vision impairment 119

Frequently Mentally Unhealthy Days by employment status & severity of vision impairment 120

What to make of these findings Healthy Worker Effect Same factors that predict health, predict work—education, income Workers may have access to better food, more opportunities for exercise, better healthcare Working may improve mood 121

In addition These finding argue for: Improved access to health care Improved health promoting activities (decreased obesity, decreased smoking, increased exercise, improved nutrition) Better management of chronic conditions— especially diabetes and depression 122

Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s Vision Health Initiative November 6, 2015 National Center.

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Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s Vision Health Initiative November 6, 2015 National Center.

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Presentation on theme: "Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s Vision Health Initiative November 6, 2015 National Center."— Presentation transcript:

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