About The Senior Report

America’s Health Rankings® Senior Report: A Call to Action for Individuals and Their Communities offers a comprehensive analysis of senior population health on a national and state-by-state basis across 35 measures of health. The report is meant to promote discussion around the health of older Americans while driving communities, governments, stakeholders, and individuals to take action to improve senior health.

 

1. Introduction and Purpose

Introduction

In 2010 the median age in the US increased to 37.2 years, a new high[1] that shows how the nation is aging. Our aging population became more discussed in 2011 when the first of 77 million baby boomers turned 65[2] and a remarkable demographic/societal shift in the US population commenced. It marked the start of a surge, a surge that will continue steadily until both the increase in the number of older adults and their percent of the total population flatten by 2050.[3]

Today, 1 in 7 Americans are aged 65 or older. By 2050 this age group is projected to equal 83.7 million, almost double the estimated population of 43.1 million in 2012.[4] This seniors surge and the increasing rates of obesity, diabetes, and other chronic diseases threaten to swamp our health care system at state and national levels. What’s more, the pressure that this aging-of-America shift places on the nation is not evenly distributed among the states. [See Aging Nation].

Seniors are the largest consumers of health care because aging carries with it the need for more frequent care.[5] Adults aged 65 and older spend nearly twice as much on health care yearly as those aged 45 to 64; they spend 3 to 5 times more than all adults younger than 65.[6] The health needs of older adults are not only more costly but are also vastly different than the health needs of the younger population. Nearly 80% of seniors have already been diagnosed with at least 1 chronic condition, and half have been diagnosed with at least 2.[7] The widespread prevalence of chronic disease among older adults leads to increased visits to health professionals, more medications prescribed, and a decline in overall well-being and quality of life.

The projected growth of the senior population will pose challenges to policymakers, Medicare, Medicaid, and Social Security—not to mention the effect it will have on families, businesses, and health care providers. As seniors age, challenges such as limited mobility, social isolation, and the need for long-term care become increasingly common. These issues extend far beyond the health care system, requiring families and communities to offer support, accommodate limited-mobility residents, and provide long-term care.

Purpose

Communities, governments, individuals, and organizations may use this report to assess the status of senior health and build awareness of the breadth of issues facing older adults—and, by extension, communities. They also can use the report to learn where and how to take action to improve the health of current and future seniors. In particular, the report is intended to promote widespread awareness of where states stand on important public health measures and to drive action toward activities proven to improve population health.

Objectives

There are 5 objectives of America’s Health Rankings® Senior Report:

1)  Be a catalyst for comprehensive, balanced, and data-driven discussions of senior health in this country.
2)  Provide a multi-dimensional, comprehensive, and conveniently accessible summary of the overall health of the population aged 65 years and older in all 50 states and the District of Columbia. The summary includes how states match up against each other and the nation as a whole.
3)  Focus attention on the measures that have the most potential to improve senior health—and then drive change in a positive direction.
4)  Using the 2013 edition as a baseline, produce regular updates so the progress and challenges of senior health can be gauged over time.
5)  Stimulate action by the general public, health professionals, and policymakers.

Process

To develop America’s Health Rankings® Senior Report, a panel of experts in senior health was charged with 1) identifying areas of health and well-being most pertinent to the older adult population and 2) creating a model for assessing population health at a state level. Before releasing each annual edition, the panel re-convenes to review the model and measures. For details on this process, see Methodology.

Audience

America’s Health Rankings® Senior Report consolidates public health statistics and senior health information into an easily digestible format for:
1)  The general public so that individuals can understand the components of overall population health for those aged 65 and older, compare their state with others, and learn what they can do to improve health.
2)  Health professionals so that they can effect positive change. These are public health professionals and professionals in the delivery system for senior health. (“Delivery system” is intended in the broadest sense, as in a community-mobility service, an in-home nutrition service, or a health care clinic).
3)  Policymakers to use the report as a reference for sharing successes and challenges related to improving senior health and for providing best practices that can be leveraged across all states.
4)  The media as they come to understand the complex issues underlying senior health and as they search for sources and resources, particularly those focused on disseminating best practices and solutions.

 


[1] US Census Bureau. State and county quickfacts. http://quickfacts.census.gov/qfd/states/00000.html. Updated March 27, 2014. Accessed March 31, 2014.
[2] Colby, Sandra L. and Jennifer M. Ortman. The Baby Boom Cohort in the United States: 2012 to 2060. Current Population Reports, P25-1141. U.S. Census Bureau, Washington, DC. 2014.
[3]Ortman, Jennifer M., Victoria A. Velkoff, and Howard Hogan. An Aging Nation: The Older Population in the United States, Current Population Reports, P25-1140. U.S. Census Bureau, Washington, DC. 2014.
[4]Ortman, Jennifer M., Victoria A. Velkoff, and Howard Hogan. An Aging Nation: The Older Population in the United States, Current Population Reports, P25-1140. U.S. Census Bureau, Washington, DC. 2014.
[5]Alemayehu B,Warner KE. The lifetime distribution of health care costs. Health Services Research. 2004; 39(3): 627-642
[6] Centers for Disease Control and Prevention (CDC). Public health and aging: Trends in aging—United States and worldwide. MMWR. 2003;52(06):101-106.
[7] Centers for Disease Control and Prevention & Merck Company Foundation. The State of Aging and Health in America 2007. Whiteshall Station, NJ: The Merck Company Foundation; 2007. 

 

 

2. Core Measures

Determinants Outcomes

Core Measures Summary - Determinants

Determinants-

Description

Source, Data Year(s)

Behaviors

 

Smoking

Percentage of adults aged 65 and older who are self-reported smokers (smoked at least 100 cigarettes in their lifetime and currently smoke every day or some days)

Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System, 2014

Excessive Drinking

Percentage of adults aged 65 and older who self-report either binge drinking (having five or more [men] or four or more [women] drinks on one occasion in the last month) or chronic drinking (having more than two drinks [men] or more than one drink [women] per day) 

CDC. Behavioral Risk Factor Surveillance System, 2014

Obesity

Percentage of adults aged 65 and older estimated to be obese (body mass index [BMI] of 30.0 or higher) based on self-reported height and weight

CDC. Behavioral Risk Factor Surveillance System, 2014

Underweight

Percentage of adults aged 65 and older with fair or better health status estimated to be underweight (BMI of 18.5 or less) based on self-reported height and weight

CDC. Behavioral Risk Factor Surveillance System, 2014

Physical Inactivity

Percentage of adults aged 65 and older with fair or better health status who self-report doing no physical activity or exercise other than their regular job in the last 30 days

CDC. Behavioral Risk Factor Surveillance System, 2014

Dental Visit

Percentage of adults aged 65 and older who self-report visiting the dentist or dental clinic within the past year for any reason

CDC. Behavioral Risk Factor Surveillance System, 2014

Pain Management*

Percentage of adults aged 65 and older with arthritis who self-report arthritis or joint pain does not limit their usual activities

CDC. Behavioral Risk Factor Surveillance System, 2013

Community and Environment  

 

Community and Environment—Macro

 

Poverty**

Percentage of adults aged 65 and older who live in households at or below 100% of the poverty threshold

US Census Bureau. American Community Survey, 2014

Volunteerism

Percentage of adults aged 65 and older who report volunteering through or for an organization in the past 12 months

Corporation for National & Community Service, 2012-2014

Nursing Home Quality

Percentage of certified nursing home beds rated 4- or 5-stars (2015 revised CMS definition)

Centers for Medicare & Medicaid Services (CMS). Nursing Home Compare, 2016

Community and Environment—Micro

 

Home-Delivered Meals

Number of persons served a home-delivered meal as a percentage of adults aged 65 and older living in poverty

 

 

Numerator: Administration on Aging (AoA). State Program Reports, 2013

Denominator: US Census Bureau. American Community Survey, 2013**

Food Insecurity

Percentage of adults aged 60 and older who face the threat of hunger in the last 12 months

National Foundation to End Senior Hunger. The State of Senior Hunger in America 2013: An Annual Report, April 2015

Community Support

Total expenditures captured by the Administration on Aging per adult aged 65 and older living in poverty

Numerator: AoA. State Program Reports, 2013

Denominator: US Census Bureau. American Community Survey, 2013**

Policy

 

Low-Care Nursing Home Residents

Percentage of nursing home residents who were low-care, according to the broad definition (no physical assistance required for late-loss activities of daily living)

Brown University, Shaping Long Term Care in America Project, 2014

Prescription Drug Coverage

Percentage of adults aged 65 and older who have a creditable prescription drug plan

The Henry J Kaiser Family Foundation, State Health Facts, 2012

SNAP Reach

Number of adults aged 60 and older who participate in Supplemental Nutrition Assistance Program (SNAP) as a percentage of adults aged 60 and older living in poverty

Numerator: US Department of Agriculture, Food and Nutrition Service, 2014

Denominator: US Census Bureau. American Community Survey, 2014**

Geriatrician Shortfall*

Percentage of geriatricians required to meet estimated need

 

 

The American Geriatrics Society, 2015

Clinical Care

 

Dedicated Health Care Provider

Percentage of adults aged 65 and older who self-report having a personal doctor or health care provider

CDC. Behavioral Risk Factor Surveillance System, 2014

Flu Vaccine

Percentage of adults aged 65 and older who self-report receiving a flu vaccine in the last year

CDC. Behavioral Risk Factor Surveillance System, 2014

Health Screenings

Percentage of adults aged 65 to 74 who self-report having a mammogram and/or fecal occult/colonoscopy/sigmoidoscopy screens within the recommended time period

CDC. Behavioral Risk Factor Surveillance System, 2014

Recommended Hospital Care

Percentage of hospitalized patients aged 65 and older who received the recommended care for heart attack, heart failure, pneumonia, and surgical procedures

Improving Healthcare for the Common Good. WhyNotTheBest.org, March 1, 2016 (based on data from Q1/2014-Q4/2014)

Diabetes Management

Percentage of Medicare beneficiaries aged 65 to 75 with diabetes receiving a blood lipids test

The Dartmouth Atlas of Health Care, 2013

Home Health Care

Number of personal care and home health aides per 1000 adults aged 75 or older

Bureau of Labor Statistics & US Census, 2015

Preventable Hospitalizations

Number of discharges for ambulatory care-sensitive conditions per 1,000 Medicare beneficiaries

The Dartmouth Atlas of Health Care, 2013

Hospital Readmissions

Percentage of patients aged 65 and older who were readmitted within 30 days of discharge

The Dartmouth Atlas of Health Care, 2013

Hospice care

Percentage of decedents aged 65 and older who were enrolled in hospice during the last 6 months of life after diagnosis of condition with high probability of death

The Dartmouth Atlas of Health Care, 2013

Hospital Deaths

Percentage of decedents aged 65 and older who died in a hospital

The Dartmouth Atlas of Health Care, 2013

 

 

*The data appearing in this edition are the same that appeared in the 2015 edition. An update was not available at the time of this publication.

**American Community Survey discontinued 3-year estimates. The American Community Survey data used in this edition is based on a single year of data.

Core Measures Summary - Outcomes

Outcomes

Description

Source, Data Year(s)

ICU Use

Percentage of decedents aged 65 and older spending 7 or more days in the intensive care or critical care unit during the last 6 months of life

The Dartmouth Atlas of Health Care, 2013

Hip Fracture

Rate of hospitalization for hip fracture per 1,000 Medicare beneficiaries

The Dartmouth Atlas of Health Care, 2013

Falls

Percentage of adults aged 65 and older who self-report having had a fall in the past 12 months (2012 definition)

CDC. Behavioral Risk Factor Surveillance System, 2014

Health Status

Percentage of adults aged 65 and older who self-report their health is very good or excellent

CDC. Behavioral Risk Factor Surveillance System, 2014

Able-Bodied**

Percentage of adults aged 65 and older with no disability

US Census, American Community Survey, 2014.

Premature Death

Number of deaths per 100,000 adults aged 65 to 74

CDC. National Center for Health Statistics, 2014

Teeth Extractions

Percentage of adults aged 65 and older who self-report having had all teeth removed due to tooth decay or gum disease

CDC. Behavioral Risk Factor Surveillance System, 2014

Frequent Mental Distress

Percentage of adults aged 65 and older who self-report their mental health was not good 14 or more days during the past 30 days

CDC. Behavioral Risk Factor Surveillance System, 2014

 

**American Community Survey discontinued 3-year estimates. The American Community Survey data used in this edition is based on a single year of data.

3. Supplemental Measures

Supplemental Measures

Measure

Description

Source, Data Year(s)

Behaviors

Education

Percentage of adults aged 65 and older with a college degree

US Census Bureau, American Community Survey, 2014**

Clinical Care

Overuse – Mammography

Percentage of female Medicare beneficiaries aged 75 and older who had at least one screening mammogram

The Dartmouth Atlas of Health Care, 2012

Overuse – PSA Test

Percentage of male Medicare beneficiaries aged 75 and older who received a screening PSA test

The Dartmouth Atlas of Health Care, 2012

Outcomes

Multiple Chronic Conditions

Percentage of Medicare beneficiaries aged 65 and older with 4 or more chronic conditions

Centers for Medicare & Medicaid Services, 2014

Cognition**

Percentage of adults aged 65 and older who report having a cognitive difficulty

US Census Bureau, American Community Survey, 2014

Depression

Percentage of adults aged 65 and older who were told by a health professional that they have a depressive disorder

Centers for Disease Control and Prevention (CDC), Behavioral Risk Surveillance Factor System, 2014

Suicide

Number of deaths due to intentional self-harm per 100,000 adults aged 65 and older

CDC, National Center for Health Statistics, 2012-2014

**American Community Survey discontinued 3-year estimates; the data used in this edition are based on single-year estimates.

4. Model Changes

2016 Model Development

 

The measures and model for America’s Health Rankings® Senior Report were developed by a panel of experts in the field of senior health for the inaugural edition in 2013. The panel was charged with identifying the areas of health and well-being most pertinent to the older adult population and developing a model for assessing population health at a state level.

 

In March 2016, the panel convened by telephone and reviewed each measure included in the 2015 edition. Panelists recommended that the following items be explored:

1.Home and Community Based Services (HCBS) waiver waitlists: Waitlists depend heavily on size of state HCBS program and state population, and some states don’t have waivers. This measure is difficult to rank at this time and will be revisited in future years.

2.Out-of-pocket spending. This measure is lacking data at the state level. Consider exploring bankruptcy, medical impoverishment, and other equivalent measures.

3.Overuse of clinical care: Consider adding prostate-specific antigen (PSA) testing among men aged 75 and older and mammography among women aged 75 and older.

4.Wellness visits: Potential issues exist with the definition and data validity. Consider adding as a supplemental measure and explore other possible measures such as the Medicare benefit paid to primary care physicians who counsel seniors with obesity during a 15-minute weight loss visit.

5.Social support, social isolation, medication adherence, and elder abuse: All areas lack comparable state-level data and will be revisited in future years.  

6.Transportation: Explore potential measures (eg, lack of reimbursement).

7.Diet and/or nutrition: Identify improved measure(s).

 

Changes implemented in 2016:

  • Replaced chronic drinking, a core behaviors measure, with excessive drinking—a combined chronic drinking and binge drinking measure (page 26).
  • Replaced poor mental health days, a core outcomes measure, with frequent mental distress (page 72).
  • Added clinical overuse-PSA among men aged 75 and older and clinical overuse-mammography among women aged 75 and older, supplemental clinical care measures, as proxies for overuse of clinical care services (pages 68-69). 
  • The supplemental measure prescription drug plans with a gap is no longer available and was removed.
  • The American Community Survey discontinued 3-year estimates. The measures poverty and able-bodied, as well as the denominators for home-delivered meals, community support, and SNAP reach, are based on a single year of data in this edition.

5. Methodology

Methodology

For each measure, the raw data are obtained from secondary sources and presented as “value”. The score for each state is based on the following formula:

                                                          STATE VALUE – NATIONAL VALUE

                        SCORE =         —————————-----------------------------------------

                                                STANDARD DEVIATION OF ALL STATE VALUES

This “z score” indicates the number of standard deviations a state is above or below the national value. A  0.00 indicates a state has the same value as the nation. States with higher values than the national value have a positive score; states below the national value have a negative score. To prevent an extreme value from exerting excessive influence, the maximum score for a measure is capped at +/- 2.00. If a US value is not available for a measure, the mean of all state values is used with the exception of measures from the Behavioral Risk Factor Surveillance System (BRFSS). For BRFSS measures, the median of the state values is used for the US value to conform to the Centers for Disease Control and Prevention tradition.

Overall score is calculated by adding the scores of each measure multiplied by its assigned weight (the percentage of total overall ranking). Not all changes in rank are statistically significant.

The overall ranking is the ordering of each state according to the overall score. The ranking of individual measures is the ordering of each state according to the measure’s value. Ties in values are assigned equal ranks. Scores for individual measures may not add up to the overall scores due to the rounding of numbers.

Methodology Diagram

Measure Selection

The selection of the 35 measures that make up America’s Health Rankings® Senior Report is driven by these 5 factors:
1.      The overall rankings represent a broad range of issues that affect senior health.
2.      Individual measures use common health-measurement criteria.
3.      Data must be available at a state level.
4.      Data must be current and updated periodically.
5.      The aspect being measured should be amenable to change.

While imperfect, these 35 measures are the best available indicators of the various aspects of senior healthiness.

 

Population Growth Projections

Woods and Poole projections are based on models of county population growth and migration due to economic conditions. The average absolute percent error for Woods and Poole’s 10 year total population projections has been ±4.0% for states. 

 

Comparison of Health Estimates in the Middle-Aged Population Methodology

The prevelance of obesity, diabetes, smoking and very good or excellent health status were examined in the middle-aged population (aduls aged 50-64) using 1999 and 2014 Behavioral Risk Factor Surveillance System (BRFSS) data. The 15 year relative change in these four measures was calculated. Missing data were excluded from this analysis, which includes “don’t know,” “not sure,” “refused,” and blank or missing responses.

 

Limitations

For the chronic disease measures, comparisons between estimates before and after 2011 should be approached with caution  due to changes in BRFSS methodology. I in 2011, BRFSS added cellular telephone-only households and a new method of weighting the data. The addition of cellular telephone only households has disproportionately increased the numbers of certain population groups represented in the survey, and the weighting change has increased prevalence estimates of certain chronic disease estimates, such as diabetes and obesity. Thus, some of the increase seen since 1999 in diabetes and obesity prevalence and some of the decrease seen since 1999 in smoking prevalence and high health status prevelance could be attributed to the new methods implemented in 2011. Please refer to the following CDC website for more information on the 2011 methodological changes. Missing data were excluded from this analysis, which includes “don’t know,” “not sure,” “refused,” and blank or missing responses. 

 

 

6. Measure Weights

Weighting of Measures

The combined weights of all measures total 100%. Determinants account for 75% of the overall ranking, and Outcomes account for 25%. Weights are assigned to each category in the model. Within each category, the individual measures are weighted equally.

The “Total, %” column indicates the weight of each measure in determining the overall ranking. The “Effect on Score” column shows how each measure impacts the overall ranking—either positively or negatively. For example, a high prevalence of smoking among older adults has a negative effect on the score and will lower the state’s ranking, whereas an increase in the percentage of older adults with controlled pain management has a positive effect on score and will raise the state’s ranking.

Measure

 

Total, %

Effect on Score

Determinants

75.0

 

Behaviors

25.0

 

 

Smoking

3.6

Negative

 

Excessive Drinking

3.6

Negative

 

Obesity

3.6

Negative

 

Underweight

3.6

Negative

 

Physical Inactivity

3.6

Negative

 

Dental Visit

3.6

Positive

 

Pain Management

3.6

Positive

Community & Environment—Macro

10.0

 

 

Poverty

3.3

Negative

 

Volunteerism

3.3

Positive

 

Nursing Home Quality

3.3

Positive

Community & Environment—Micro

10.0

 

 

Home-Delivered Meals

3.3

Positive

 

Food Insecurity

3.3

Negative

 

Community Support

3.3

Positive

Policy

15.0

 

 

Low-Care Nursing Home Residents

3.75

Negative

 

SNAP Reach

3.75

Positive

 

Prescription Drug Coverage

3.75

Positive

 

Geriatrician Shortfall

3.75

Negative

Clinical Care

15.0

 

 

Dedicated Health Care Provider

1.5

Positive

 

Flu Vaccine

1.5

Positive

 

Health Screenings

1.5

Positive

 

Recommended Hospital Care

1.5

Positive

 

Diabetes Management

1.5

Positive

 

Home Health Care

1.5

Positive

 

Preventable Hospitalizations

1.5

Negative

 

Hospital Readmissions

1.5

Negative

 

Hospice Care

1.5

Positive

 

Hospital Deaths

1.5

Negative

Outcomes

25.0

 

 

ICU Use

3.1

Negative

 

Falls

3.1

Negative

 

Hip Fractures

3.1

Negative

 

Health Status

3.1

Positive

 

Able-bodied

3.1

Positive

 

Premature Death

3.1

Negative

 

Teeth Extractions

3.1

Negative

 

Frequent Mental Distress

3.1

Negative

 

Overall Ranking                                              

Note: The total of individual weights may not add up to a whole number for each category, and therefore fractions are rounded.

100.0

 

 

7. Senior Health Expert Panel

Senior Health Expert Panel

History

The measures and model for America’s Health Rankings® Senior Report were developed by a panel of senior health experts for the inaugural edition in 2013. The panel was charged with identifying the areas of health and well-being most pertinent to the older adult population and developing a model for assessing population health at a state level.

The panel convened over a series of meetings to establish the broad categories as well as the specific determinant measures and outcomes that are most relevant and amenable to change. Surveys were also sent to each panel member in order to narrow the list of possible measures and establish the current model. The weighting of each category within the model was discussed and agreed upon by the panel in order to reflect the relative importance of each category toward the health of older Americans.

The Senior Health Advisory Group members include:

Soo Borson, MD
Professor Emerita, University of Washington School of Medicine
Dementia Care Research and Consulting

Randy Brown, PhD
Director of Health Research
Mathematica Policy Research

Julie Bynum, MD, MPH
Associate Professor of The Dartmouth Institute
Associate Professor of Medicine
Associate Director, Center for Health Policy Research
The Dartmouth Institute for Health Policy & Clinical Practice
Geisel School of Medicine at Dartmouth

Tom Eckstein, MBA
Principal and author, America’s Health Rankings®
Arundel Metrics, Inc

Sarah Milder, MPH
Epidemiologist and author, America’s Health Rankings®
Arundel Metrics, Inc

Rhonda Randall, DO
Chief Medical Officer
UnitedHealthcare Retiree Solutions

Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP
Professor of Nursing
Chairman of the Board, American Geriatrics Society
Sonya Ziporkin Gershowitz Chair in Gerontology
University of Maryland

Anna Schenck, PhD, MSPH
Professor of the Practice, Associate Dean for Practice
Director, Public Health Leadership Program and the North Carolina Institute for Public Health
UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill

Lynn Shaull, MA
Director, Health Improvement
Association of State and Territorial Health Officials

Denise Tyler, PhD
Assistant Professor of Health Services, Policy and Practice
Brown University

Elizabeth Walker Romero, MS
Senior Director, Health Improvement
Association of State and Territorial Health Officials

8. Team

 

America’s Health Rankings® Senior Report is a team effort in which all contribute a vital part to the creation and dissemination of this report. Members of this team, listed alphabetically by organization, follow:

 

Aldrich Design

Emily Aldrich

Jenna Brouse

Andrea Egbert

Arundel Metrics, Inc

Melanie Buhl

Tom Eckstein

Laura Houghtaling

Jamie Kenealy

Sarah Milder

Mariah Quick

Kristin Shaw

The Glover Park Group

Kate Ackerman

Jane Beilenson

Tulani Elisa

John Gaglio

Craig James

Lee Jenkins

Amanda Keating

Megan Lowry

Rose McLeod

Rachel Millard

Andy Oare

Reservoir Communications Group

Christine Harrison

David Lumbert

Robert Schooling

RoninWare Inc

TJ Kellie

Neven Milakara

United Health Foundation

Michael Birnbaum

Alyssa Erickson

Rachel Medina

Jane Pennington

LD Platt

Rhonda Randall

Kara Smith

Tina Stow

Jodie Tierney

Anne Yau

Ianthe Zabel